Developing pediatric three-dimensional upper airway normative values using fixed and interactive thresholds



To develop and compare pediatric upper airway three-dimensional normative values using the two most commonly used cone beam computed tomography (CBCT) software: Invivo5 (fixed threshold) and Dolphin 3D (interactive threshold).

Study design

Out of 3738 CBCT scans, scans of 81 pediatric patients were utilized after applying strict exclusion criteria. The sample was grouped into two age groups (7–11 and 12–17 years). Intra-class correlation coefficient was used to test intra-rater and inter-rater reliability and showed coefficients greater than 0.9 indicating good reliability of the methods used.


Paired t tests showed that volumetric and area measurements obtained using Dolphin 3D were significantly larger than those obtained using Invivo5 (p < 0.05). The mean minimal cross-sectional areas (MCSA) for Dolphin 3D were 151 mm2 and 177 mm2 for age groups 1 and 2, respectively. The mean MCSA values for Invivo5 for age groups 1 and 2 were 120 mm2 and 145 mm2, respectively.


Pediatric upper airway volumetric, area, and linear measurements were reported after applying strict exclusion criteria including a validated sleep questionnaire. Our goal is that clinicians utilize the proposed-here normative values for screening and assist in the timely diagnosis and management of pediatric sleep apnea.

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  1. 1.

    Aboudara C, Nielsen I, Huang JC, Maki K, Miller AJ, Hatcher D. Comparison of airway space with conventional lateral headfilms and 3-dimensional reconstruction from cone-beam computed tomography. Am J Orthod Dentofac Orthop. 2009;135(4):468–79.

    Article  Google Scholar 

  2. 2.

    Pliska B, Lowe AA, Almeida FR. The orthodontist and the obstructive sleep apnea patient. Int J Orthod. 2012;23(3):19–22.

    Google Scholar 

  3. 3.

    Masoud AI, Jackson GW, Carley DW. Sleep and airway assessment: a review for dentists. Cranio. 2017;35(4):206–22.

    Article  Google Scholar 

  4. 4.

    Massicotte C, Al-Saleh S, Witmans M, Narang I. The utility of a portable sleep monitor to diagnose sleep-disordered breathing in a pediatric population. Can Respir J. 2014;21(1):31–5.

    Article  Google Scholar 

  5. 5.

    El H, Palomo JM. Measuring the airway in 3 dimensions: a reliability and accuracy study. Am J Orthod Dentofac Orthop. 2010;137(4 Suppl):S50 e1–9 (discussion S-2).

    Google Scholar 

  6. 6.

    Garib DG, Calil LR, Leal CR, Janson G. Is there a consensus for CBCT use in Orthodontics? Dental Press J Orthod. 2014;19(5):136–49.

    Article  Google Scholar 

  7. 7.

    Guijarro-Martinez R, Swennen GR. Three-dimensional cone beam computed tomography definition of the anatomical subregions of the upper airway: a validation study. Int J Oral Maxillofac Surg. 2013;42(9):1140–9.

    Article  Google Scholar 

  8. 8.

    Weissheimer A, Menezes LM, Sameshima GT, Enciso R, Pham J, Grauer D. Imaging software accuracy for 3-dimensional analysis of the upper airway. Am J Orthod Dentofac Orthop. 2012;142(6):801–13.

    Article  Google Scholar 

  9. 9.

    Alves M Jr, Baratieri C, Mattos CT, Brunetto D, Fontes Rda C, Santos JR, et al. Is the airway volume being correctly analyzed? Am J Orthod Dentofac Orthop. 2012;141(5):657–61.

    Article  Google Scholar 

  10. 10.

    Athanasiou AE. Orthodontic cephalometry. London: Mosby-Wolfe; 1995.

    Google Scholar 

  11. 11.

    Flegal KM, Ogden CL. Childhood obesity: are we all speaking the same language? Adv Nutr. 2011;2(2):159S–66S.

    Article  Google Scholar 

  12. 12.

    Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med. 2000;1(1):21–32.

    Article  Google Scholar 

  13. 13.

    Aboudara CA, Hatcher D, Nielsen IL, Miller A. A three-dimensional evaluation of the upper airway in adolescents. Orthod Craniofac Res. 2003;6(Suppl 1):173–5.

    Article  Google Scholar 

  14. 14.

    Kim YJ, Hong JS, Hwang YI, Park YH. Three-dimensional analysis of pharyngeal airway in preadolescent children with different anteroposterior skeletal patterns. Am J Orthod Dentofac Orthop. 2010;137(3):306 e1–11 (discussion 7).

    Google Scholar 

  15. 15.

    Schendel SA, Jacobson R, Khalessi S. Airway growth and development: a computerized 3-dimensional analysis. J Oral Maxillofac Surg. 2012;70(9):2174–83.

    Article  Google Scholar 

  16. 16.

    Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714–55.

    Article  Google Scholar 

  17. 17.

    Shprintzen RJ. The origin of speech ease: evolution of the human upper airway and its functional implications for obstructive sleep apnea. Editorial commentary: the great leap forward: the anatomic basis for the acquisition of speech and obstructive sleep apnea by Terence M. Davidson. Sleep Med. 2003;4(3):171–3.

    Article  Google Scholar 

  18. 18.

    Li HY, Chen NH, Wang CR, Shu YH, Wang PC. Use of 3-dimensional computed tomography scan to evaluate upper airway patency for patients undergoing sleep-disordered breathing surgery. Otolaryngol Head Neck Surg. 2003;129(4):336–42.

    Article  Google Scholar 

  19. 19.

    Avrahami E, Englender M. Relation between CT axial cross-sectional area of the oropharynx and obstructive sleep apnea syndrome in adults. AJNR Am J Neuroradiol. 1995;16(1):135–40.

    PubMed  Google Scholar 

  20. 20.

    Ogawa T, Enciso R, Shintaku WH, Clark GT. Evaluation of cross-section airway configuration of obstructive sleep apnea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103(1):102–8.

    Article  Google Scholar 

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Correspondence to Ahmed I. Masoud.

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Masoud, A.I., Alwadei, F.H., Alwadei, A.H. et al. Developing pediatric three-dimensional upper airway normative values using fixed and interactive thresholds. Oral Radiol 36, 89–99 (2020).

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  • Airway
  • CBCT
  • OSA
  • Sleep apnea
  • Adenoids