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How palatine tonsil grades shape the architecture of dental arches: a cross-sectional study

BMC Oral Health volume 25, Article number: 624 (2025) Cite this article

Abstract

Background

This study aims to investigate the influence of palatine tonsil size on dental arch parameters and identify potential orthodontic anomalies.

Methods

82 participants between ages of 6–12 who applied to the Otorhinolaryngology Clinic of the Department of Medicine at Istanbul University were divided into 5 subgroups based on their tonsil size using the Brodsky’s tonsil grading scale. After measuring the casts using an electronic caliper, dental arch measurements were made. Quantitative variables was assessed by the Spearman’s rank correlation coefficient. The SPSS v.22.0 software was used. The significance threshold was set at p < 0.05.

Results

82 patients as 43 boys (52.4%) and 39 girls (47.6%) aged between 6 and 12 years old with a mean age of 8.0 ± 1.8 years were included in this study. The maxillary intercanine (r=-0.530), inter-first premolar (r =-0.559), and inter-first molar widths (r =-0.579) were significantly and negatively correlated to the grade (p < 0.001). There was significant relationship between the tonsil grade and the age (r = 0.272, p = 0.013).

Conclusions

Early assessment of palatine tonsil size may help prevent orthodontic abnormalities arising from upper airway obstruction. It is necessary for dentists to conduct a thorough evaluation in children exhibiting respiratory alterations, thereby reduce the risk of potential orthodontic abnormalities.

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Background

The process of postnatal face growth is complicated and affected by several variables [1]. While genetics strongly determine fundamental facial characteristics, children’s facial structure and soft tissue features show how much they resemble their parents. “Environmental” influences also play a crucial role. These influences include intercellular interactions and biomechanical forces, such as physical pressures exerted on bones [2]. Wolff’s law (1870) states that “Changes in a bone’s function are accompanied by alterations in its structure.” This highlights that the dynamic nature of bone allows it to change shape in reaction to external pressures [3].

The palatine tonsils are situated on either side at the back of the throat and are part of Waldeyer’s ring, which includes the adenoid, paired tubal tonsils, paired palatine tonsils, and lingual tonsils [4]. Enlarged tonsils and adenoids are a significant factor in pediatric illnesses and are among the leading causes of airway obstruction in children [5, 6]. Normal breathing patterns play a crucial role in shaping craniofacial structures, promoting balanced growth through coordinated actions with chewing and swallowing. Respiratory obstructions, especially in the nasal and pharyngeal regions, can lead to breathing challenges, often causing the individual to resort to mouth breathing [7]. This can result in malocclusions, such as posterior crossbite, open bite, or Class II malocclusion [8,9,10].

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by recurrent episodes of partial or complete upper airway obstruction, which disrupt the normal sleep cycle. Adenotonsillar hypertrophy is widely recognized as the most common cause of pediatric OSA [11]. Numerous studies have demonstrated that untreated pediatric OSA can result in a range of adverse effects on children’s overall health [11, 12]. These include impaired growth, cardiovascular dysfunction, neurocognitive impairments, poor academic performance, behavioral problems, and abnormalities in craniofacial morphology [12]. Evidence has suggested that children with OSA may have signs of malocclusion, such as increased palatal depth, a narrowed upper dental arch, a greater overjet, and a higher occurrence of anterior open bite and posterior crossbite [8, 13]. In 2019, the American Association of Orthodontists, through its White Paper on OSA, strongly advocated for orthodontists to be well-versed in the signs and symptoms of pediatric OSA. It emphasized the importance of orthodontists conducting clinical risk assessments for OSA in children and referring at-risk patients to the appropriate medical professionals for a definitive diagnosis [14].

The role of tonsil size in the etiopathogenesis of malocclusions remains a topic of ongoing debate. Despite this controversy, when enlarged tonsils are observed in conjunction with malocclusion, their presence carries significant implications for prognosis. Therefore, this study’s primary goal was to investigate the influence of palatine tonsil size on dental arch parameters and identify potential orthodontic anomalies associated with this variation. Furthermore, after an extensive search, we found no studies examining the effect of tonsil size on the dental arches of Turkish children. Our study is the first of its kind in this regard. The study hypotheses were that (1) tonsil size would influence the dimensions of the dental arches, and (2) there was a correlation between malocclusions and tonsil grading.

Methods

This observational, cross-sectional study was performed jointly with the Department of Otolaryngology of the Faculty of Medicine and the Department of Pedodontics of the Faculty of Dentistry at Istanbul University. This study is reported in accordance with STROBE guidelines [15].

This cross-sectional study was conducted in accordance with the rules of the Helsinki Declaration with the approval of the Clinical Research Ethical Board of the Faculty of Dentistry of Istanbul University, Istanbul, Turkey (no: 2022/5) from July 2022 to July 2023. Participants in this study were enrolled after their parents and/or guardians signed an informed consent form following a thorough explanation of the study.

The minimum sample size for the study was determined as 82 participants, with a margin of error of 5% and 80% power. This calculation was based on the 0.30 biserial correlation coefficient reported in the study by Diouf et al., entitled “Influence of Tonsillar Grade on the Dental Arch Measurements” [8].

Eighty-two children, aged 6 to 12 years, who presented to the Department of Otorhinolaryngology at Istanbul University’s Faculty of Medicine, were divided into five subgroups based on their tonsil size. Participants included in the study met these inclusion criteria: no history of adenoidectomy, orthodontic treatment, or non-nutritive sucking habits (such as finger, pacifier, lip, or tongue); absence of chronic allergic rhinitis, nostril collapse, deviated septum, nasal polyps, or adenoidal hypertrophy; and the lack of a cleft lip and palate or craniofacial syndromes. Additionally, no clinical findings or medical history suggestive of central apnea were detected. The patients included in the study were referred to the Istanbul University’s Faculty of Dentistry, Department of Pedodontics, for dental and oral rehabilitation. Participants who met the inclusion criteria were enrolled consecutively until the required sample size was achieved.

The tonsillar grade for each patient who was chosen was assessed by a single observer (LA). The patient was instructed to lie in a supine position, open their mouth wide, and repeatedly articulate the phoneme /r/. Simultaneously, the observer placed a tongue depressor at the posterior part of the dorsum of the tongue. The pharynx was examined without triggering the gag reflex, allowing the tonsils to rotate and artificially move closer to the median line. In this study, the size classification of the tonsils was conducted according to the standardized Brodsky and Koch scale [16], which is based on the area covered by the tonsils between the palatoglossal arches (see Table 1; Fig. 1). To assess the reliability of the measurements, 25% of the patients (n = 20) were randomly selected for reevaluation. The analysis showed a high degree of agreement between the initial and repeated measurements taken by the observer assessing the tonsil size.

Table 1 Palatine tonsil hypertrophy classification according to the criteria of Brodsky and Koch
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Fig. 1
figure 1

Clinical grading of tonsil size. (Available from: https://www.pristyncare.com/blog/tonsil-grading-pc0135/)

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To evaluate the upper and lower jaw arches, study models were prepared by taking alginate impressions from both jaws of each participant. All arch measurements were taken with a digital caliper (Mitutoyo Corp., Tokyo, Japan) that has an accuracy of 0.02 mm, a resolution and reproducibility of 0.01 mm, with the measurements displayed directly in millimeters on the caliper’s mini screen. The measurements were taken from the study models by one observer (EA). To assess intra-observer reproducibility, a random sample of a specific number of study models was chosen for reevaluation after a three-week period to calculate the concordance correlation coefficient. After calculating the investigator’s test–retest reliability, the correlation coefficient was revealed to be 0.85.

We measured various interarch and intra-arch parameters to assess dental and skeletal relationships. For the interarch parameters, the transverse dimension included the evaluation of normal transverse occlusion and the existence of posterior crossbite. Vertically, we assessed overbite—defined as the distance between the free edges of the maxillary and mandibular central incisors—and recorded the presence of deep overbite, anterior open bite, and normal overbite. In the sagittal dimension, the Angle molar relationship and the quantity of overjet were determined.

Regarding the intra-arch parameters, the transverse measurements included the maxillary and mandibular intercanine widths, which is the distance between the canine cusp tips. We also measured the maxillary and mandibular inter-first molar widths—defined as the distance between the first permanent molars’ mesio-vestibular cusp tips. Additionally, the distance between the tips of the mesio-vestibular cusps of the first premolars or the first deciduous molars was used to determine the maxillary and mandibular inter-first premolar widths (also known as the inter-first deciduous molar widths) (see Fig. 2). The ratios of mandibular to maxillary inter-first molar widths and inter-first premolar widths (or inter-first deciduous molar widths) were also calculated.

Fig. 2
figure 2

Reference points and distances used for measurements on dental casts

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For the vertical dimension, the total depth of the palatal vault was measured from the line connecting the mesio-vestibular cusps of the maxillary first permanent molars to a point along the median raphe positioned vertically. Additionally, we calculated the ratio between the palatal vault depth and the maxillary inter-first molar width.

In the sagittal dimension, the total lengths of the maxillary and mandibular arches were measured from a tangent line at the buccal surfaces of the central incisors to a tangent at the distal surfaces of the second deciduous molars or second permanent premolars.

Statistical analysis

Categorical data are presented with counts and percentages, and numerical data are presented with means and standard deviations. Spearman’s rank correlation was used to evaluate the relationship between continuous variables. Correlation coefficients with absolute values of 0.10–0.29 were considered weak, 0.30–0.49 were considered moderate, and 0.50 and above were considered strong correlations [17]. The Phi (φ) test was used to evaluate the relationship between categorical and ordinal variables. Ordinal logistic regression analysis was applied to evaluate factors associated with the tonsil grade as the dependent variable. To identify the most influential variables in the model, the backward elimination method was used. As a result of the analysis, beta coefficients were reported, and the cutoff values for grade distinctions were calculated. Statistical analysis was conducted using IBM SPSS Statistics version 22 software. A p-value of < 0.05 was considered statistically significant.

Results

A total of 82 patients were included in this study, consisting of 43 boys (52.4%) and 39 girls (47.6%), with ages ranging from 6 to 12 (mean age, 8 ± 1.8) years. The flowchart for participant enrollment is shown in Fig. 3.

Fig. 3
figure 3

Flow chart of the patient enrollment

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The patients were classified into five groups by tonsil grade: 12 patients presented grade 0, 23 grade 1, 22 grade 2, 17 grade 3, and 8 patients presented grade 4.

Transversely, the maxillary intercanine width was significantly and negatively correlated to tonsillar grade (r= -0.530; p < 0.001). Similarly, the maxillary inter-first premolar width (r= -0.559; p < 0.001) and the maxillary inter-first molar width (r= -0.579; p < 0.001) were significantly and negatively correlated to grade. The ratio of the maxillary inter-first molar width to the mandibular inter-first molar width was also significantly correlated to grade, but the correlation was negative (r= -0.572; p < 0.001). Similar results were found for the ratio of inter-first premolar widths and grade (r= -0.507; p < 0.001). No statistically significant correlation was observed between the grade and either the mandibular intercanine width (r= -0.092; p = 0.409) or the mandibular inter-first molar width (r= -0.163; p = 0.143). However, the mandibular inter-first premolar width was significantly and negatively correlated to grade (r= -0.403; p < 0.001) (see Table 2).

Table 2 Correlation coefficient between quantitative dental arch parameters and tonsillar grade (n=82)
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The combination of vertical and transverse dimensions showed that the ratio of the total depth of the palatal vault to the maxillary inter-first molar width was significantly and positively correlated to grade (r = 0.614; p < 0.001).

In the sagittal dimension, a significant correlation was observed between the total lengths of the maxillary (p = 0.004) and mandibular arches (p = 0.007) and the tonsillar grade. We observed no correlation between tonsil grade and the total depth of the palatal vault (p = 0.217) (see Table 2).

Following the reanalysis with age-adjusted data, significant relationships were observed between tonsil size and dental arch parameters. Specifically, a significant correlation was found between tonsil grade and palatal vault depth (p = 0.019) as well as between tonsil grade and mandibular intercanine distance (p = 0.025). In contrast to the initial analysis, where no significant relationship was found between tonsil size and these dental arch parameters, the age-adjusted analysis revealed meaningful associations. These findings highlight the importance of controlling for age-related changes in dental arch morphology when studying the relationship between tonsil size and dental arch dimensions (see Table 2).

For the assessment of qualitative dental arch parameters, comparisons according to grade showed significant differences from Angle’s molar relationship (p < 0.001), the presence of open bite (p < 0.001), the presence of overjet (p < 0.001), and the presence of overbite (p = 0.020). The strength of the association between grade and these qualitative parameters was assessed using the Phi coefficient (φ) equal to 0.936, 0.793, 0.856, and 0.378, respectively (see Table 3).

Table 3 Association between qualitative dental arch parameters and tonsillar grade
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A significant negative correlation was found between tonsil grade and age (r= -0.272, p = 0.013). However, there was no correlation between tonsil grade and sex (p = 0.418).

Upon reviewing the results of the ordinal logistic regression analysis, it was determined that the most prominent effects on tonsil size were produced by the variables open bite (B = 4.67, p < 0.001) and overbite (B = 1.60, p = 0.035). Although the ratio of the depth of the palatal vault/maxillary inter-first molar width (B = 3.88, p = 0.095) was not statistically significant, it was included in the model. When examining the threshold values for the grade groups, the cutoff values for Tonsil Grade 1, Grade 2, and Grade 3 were calculated as 2.37, 5.01, and 7.49, respectively, and were found to be statistically significant (p = 0.012, p < 0.001, and p < 0.001, respectively). When evaluating the overall fit of the model, the AIC value was calculated as 196.7, and the final model (shown in Table 4) explains 60.5% of the variance.

Table 4 Ordinal logistic regression analysis for tonsil grade thresholds and associated factors
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Discussion

The most common otorhinolaryngological issues in children include the enlargement of the adenoids and palatine tonsils. These enlargements are primary contributors to upper respiratory tract obstruction, leading to conditions such as obstructive sleep apnea and snoring. Affected children often experience recurrent upper respiratory infections, resulting in the overuse of nontargeted antibiotics [18]. Also, upper airway obstruction that leads to mouth breathing alters craniofacial growth patterns, resulting in malocclusion. There are several publications in the literature on how breathing affects the shape of the craniofacial region. While some authors argue that both genetic and environmental variables can affect changes in the typical pattern of dento-skeletal growth, the majority believe that upper airway obstruction leading to mouth breathing significantly modifies craniofacial growth patterns, resulting in characteristic facial features and dentition. These features include a long face, a narrowed upper dental arch, a high-arched palate, a gummy smile, and dental malocclusions classified as Class II and Class III [19,20,21]. In individuals who mouth breathe, compared with the general population, there is a higher prevalence of posterior crossbite, anterior open bite, and Class II malocclusion [22].

There are at least three methods documented in the literature for clinically measuring tonsil dimensions: the Brodsky scale [16], the Friedman scale [23], and the Mallampati classification [6, 24]. Among these, the most widely recognized and accepted grading scale is the Brodsky scale [16]. According to Kumar et al., the Brodsky grading scale offers higher inter-observer and intra-observer reliability than the Friedman scale [25]. Moreover, Kwan et al. found that the Brodsky scale demonstrated acceptable intra-observer and inter-observer reproducibility [26]. Consequently, in this study, tonsil-size classification was carried out using the standardized Brodsky and Koch scale.

In the literature, it has been mentioned that palatine tonsil volume typically declines with age; atrophy of the tonsils begins at age 10 and is maintained until adulthood [3]. In the present research, we observed a significant negative correlation between the patients’ ages and grades (p = 0.013; r = 0.272). Similarly, Diouf et al.’s study [8] found a significant negative correlation between patient age and grade (p = 0.009; r=-0.29). However, Pérez et al. [5] found no significant correlation between age and tonsil grade.

In the present study, there was no significant correlation between tonsil grade and the total depth of the palatal vault (p = 0.217). Similarly, Tawfik et al. [27] found no significant correlation between the total depth of the palatal vault and tonsillar grade. Our findings indicate that as the degree of tonsillar hypertrophy increased, there was an observed increase in palatal vault depth. However, this result was not statistically significant. In contrast to our study, Diouf et al. [8] and Behlfelt et al. [28] found that the total depth of the palatal vault was significantly and positively correlated to tonsillar grade: the higher the grade, the deeper the maxillary arch. According to other research, bigger tonsils that cause oral respiration may also hinder the maxilla’s transverse expansion and raise the incidence of posterior crossbite [29, 30]. We believe that this discrepancy may be attributed to variations in study design, patient populations, or methodologies between the different studies.

Furthermore, we found that the maxillary intercanine (r= -0.530; p < 0.001), inter-first premolar (r= -0.559; p < 0.001), and inter-first molar widths (r= -0.579; p < 0.001) were significantly and negatively correlated to grade: the higher the tonsillar grade, the lower the transversal dimension of the maxillary arch. According to Becking et al. [31], this association was caused by the tonsils’ larger distance between the oropharynx’s anterior pillars. The forces that the tongue exerts when swallowing and at rest affect the maxilla’s natural growth and expansion. It seems that the tongue’s lateral forces are necessary for the best possible jaw extension. This agrees with the findings of Behlfelt et al. [28], Diouf et al. [8], and Pérez et al. [5], who also related the presence of a narrower maxillary arch with higher tonsil grade.

The reanalysis of our data, which accounted for age-related changes in dental arch dimensions, revealed significant correlations between tonsil size and specific dental arch parameters, such as palatal vault depth and mandibular intercanine distance. These findings contrast with the initial analysis, where no significant relationships were observed between tonsil size and these parameters. The age-adjusted analysis underscores the importance of considering age as a confounding factor when examining the effects of tonsil size on dental arch shape, particularly in growing children. Our results suggest that, while tonsil size may influence dental arch morphology, this effect is modulated by age-related changes in dental development. Future studies should consider using age-matched controls or additional statistical adjustments to further isolate the relationship between tonsil hypertrophy and dental arch parameters, particularly in younger populations.

The combination of vertical and transverse dimensions shows a ratio of the total depth of the palatal vault to the maxillary inter-first molar width, which was significantly and positively correlated to grade (r = 0.614; p < 0.001). Similarly, Behlfelt et al. [28] showed that the size of the tonsils and the narrowness of the maxillary arch or the depth of the palatine vault were positively and significantly correlated.

When evaluating the sagittal dimension’s qualitative dental arch parameters, significant differences were observed in Angle’s molar relationship according to grade. In the present study, patients with grade 4 tonsils had Class II malocclusion. Similarly, according to Diouf et al. [8], an enlarged tonsil was strongly related to a Class II molar relationship and posterior crossbite with functional lateral deviation of the mandible. However, some publications have reached different conclusions. Iwasaki et al. [32] indicated that hypertrophic tonsils with an anterior tongue posture might induce mandibular protrusion. Tonsillar hypertrophy often results in obstruction and can present as a Class III skeletal pattern, characterized by maxillary sagittal dysplasia and mandibular protrusion [33]. In the current study, we attribute Class II malocclusion in patients with Grade 3 and Grade 4 tonsils to the following reasons: the muscles responsible for depressing the jaw to open the mouth exert backward pressure, displacing the mandible distally and impeding its growth. Additionally, the buccinator muscles become tense when the mouth is open, exerting lingual pressure on the maxillary bicuspids and molars. These teeth do not receive adequate support from the tongue, leading to a narrowing of the palate and the upper dental arch. This combination of factors causes the mandible to rotate posteriorly and inferiorly, resulting in a Class II malocclusion and a skeletal Class II profile with increased overjet.

In vertical observations, patients classified as grades 3 and 4 were notably more likely to develop an anterior open bite compared with those with grades 0, 1, and 2. Pathologic hypertrophy of the tonsils can obstruct the lower section of the upper airway, leading a child to position their mandibula forward to widen the oropharyngeal airway. This frequently results in open bite [34]. Our results are in line with those of Behlfelt et al. [28] and Diouf et al. [8].

Tonsillar hypertrophy is a leading cause of airway obstruction and obstructive sleep apnea syndrome. Early identification and management of abnormal dental parameters, particularly when lymphoid tissue is enlarged, can support optimal dentofacial growth. In these cases, tonsillectomy is commonly suggested. However, recent trends show a more conservative approach to adenoidectomy and tonsillectomy, as the tonsils and adenoids are now recognized as essential elements of the primary immune defense system. This shift has prompted a reevaluation of the risk–benefit ratio of these surgeries due to potential surgical and post-surgical complications. More robust evidence is needed to confirm that adenoidectomy and tonsillectomy provide benefits for children with airway obstruction, mouth breathing, and dental deformities. Therefore, dentists must conduct comprehensive assessments in children with respiratory changes to help prevent orthodontic issues in the early stages [12, 35].

This study has several strengths. The findings connect two fields—dentistry and otolaryngology—providing insights into how airway obstruction or enlarged tonsils may affect craniofacial development. The study emphasizes the importance of recognizing airway-related factors early in life to prevent or address craniofacial developmental issues. The results may encourage clinicians to consider tonsillar size as part of a comprehensive assessment, leading to more tailored orthodontic and medical interventions. Furthermore, it may serve as a guide for future studies and the development of clinical guidelines in orthodontics and otorhinolaryngology.

This study had some limitations. Although the most accurate method involves using digitized casts with three-dimensional computerized electromagnetic instrumentation, we used a digital caliper to determine the arch dimensions. A significant limitation of this study is the lack of analysis regarding adenoidal hypertrophy in these children, which is important because palatine tonsil hypertrophy is often accompanied by adenoid hypertrophy. Therefore, although the patients’ history of adenoid hypertrophy is unknown, those without clinically significant adenoid hypertrophy based on current examination findings were specifically included in the study. Furthermore, in the sample, an imbalance in the number of patients across groups has occurred due to differences in the natural prevalence of tonsillar grades in the population. In addition, since the tonsil size assessment was performed by a single observer, interrater reliability could not be evaluated. In future studies, conducting comparative measurements with multiple evaluators will help mitigate this limitation. This study was open only to participants who visited the Faculty of Dentistry at Istanbul University; thus, the findings are not generalizable.

Conclusions

This study has yielded the following conclusions:

  • The maxillary intercanine, inter-first premolar, and inter-first molar width were significantly and negatively correlated to tonsillar grade.

  • There was a significant correlation between the total lengths of the maxillary (p = 0.004) and mandibular arches (p = 0.007) and the tonsillar grade.

  • Grade-based comparisons revealed notable deviations from Angle’s molar relationship, the presence of open bite, overjet, and overbite.

  • There was no correlation between tonsil grade and the total depth of the palatal vault.

  • The mandibular inter-first premolar width was significantly and negatively correlated to grade.

  • Further research is needed to explore the applicability of these results to the wider pediatric population.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to privacy concerns but are available from the corresponding author on reasonable request.

References

  1. Rengasamy Venugopalan S, Allareddy V. Craniofacial growth and development. In: Miloro M, Ghali GE, Larsen PE, Waite P, editors. Peterson’s principles of oral and maxillofacial surgery. Cham: Springer International Publishing; 2022. pp. 1729–65.

    Chapter  Google Scholar 

  2. Manlove AE, Romeo G, Venugopalan SR. Craniofacial growth: current theories and influence on management. Oral Maxillofac Surg Clin N Am. 2020;32(2):167–75.

    Article  Google Scholar 

  3. Kozak FK, Ospina JC, Cardenas F. Characteristics of normal and abnormal postnatal craniofacial growth and development. Cumming pediatric otolaryngology Philadelphia, PA; 2014;55–80.

  4. Arambula A, Brown JR, Neff L. Anatomy and physiology of the palatine tonsils, adenoids, and lingual tonsils. World J Otorhinolaryngology-Head Neck Surg. 2021;7(03):155–60.

    Article  Google Scholar 

  5. Pérez I, Alves N, Lizana C, Deana NF. Influence of the palatine tonsil grade on the morphology of the maxillary and mandibular dental arches. Int J Morphology. 2020;38(5).

  6. Hellsing E, McWilliam J, Reigo T, Spangfort E. The relationship between craniofacial morphology, head posture and spinal curvature in 8, 11 and 15-year-old children. Eur J Orthod. 1987;9(1):254–64.

    Article  CAS  PubMed  Google Scholar 

  7. Diouf JS, Ouédraogo Y, Souaré N, Badiane A, Diop-Bâ K, Ngom PI, et al. Comparison of dental arch measurements according to the grade and the obstructive character of adenoids. Int Orthod. 2019;17(2):333–41.

    Article  PubMed  Google Scholar 

  8. Diouf JS, Ngom PI, Sonko O, Diop-Bâ K, Badiane A, Diagne F. Influence of tonsillar grade on the dental arch measurements. Am J Orthod Dentofac Orthop. 2015;147(2):214–20.

    Article  Google Scholar 

  9. Aronson S, Sheikholeslam A. Changes in postural EMG activity in the neck and masticatory muscles following obstruction of the nasal airways. Eur J Orthod. 1986;8(4):247–53.

    Article  Google Scholar 

  10. McNamara JA Jr. Influence of respiratory pattern on craniofacial growth. Angle Orthod. 1981;51(4):269–300.

    CAS  PubMed  Google Scholar 

  11. Liu Y, Zhao T, Ngan P, Qin D, Hua F, He H. The dental and craniofacial characteristics among children with obstructive sleep apnoea: a systematic review and meta-analysis. Eur J Orthod. 2023;45(3):346–55.

    Article  PubMed  Google Scholar 

  12. Marcus CL, Brooks LJ, Draper KA, Sally DW, David G, Ann CH, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):576–84.

    Article  PubMed  Google Scholar 

  13. Oulis CJ, Vadiakas GP, Ekonomides J, Dratsa J. The effect of hypertrophic adenoids and tonsils on the development of posterior crossbite and oral habits. J Clin Pediatr Dent. 1994;18(3):197–201.

    CAS  PubMed  Google Scholar 

  14. Behrents RG, Shelgikar AV, Conley RS, Flores-Mir C, Hans M, Levine M, et al. Obstructive sleep apnea and orthodontics: an American association of orthodontists white paper. Am J Orthod Dentofac Orthop. 2019;156(1):13–28.

    Article  Google Scholar 

  15. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–57.

    Article  Google Scholar 

  16. Brodsky SJ, Lepage GP. Perturbative quantum chromodynamics. 1989;93–240.

  17. Cohen J. Statistical power analysis for the behavioral science. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.

    Google Scholar 

  18. Carneiro LEP, Neto GCR, Camera MG. Adenotonsillectomy effect on the life quality of children with adenotonsillar hyperplasia. Internationzl Archives Otorhinolaryngol. 2009;13(3):270–6.

    Google Scholar 

  19. Warren DW. Effect of airway obstruction upon facial growth. Otolaryngol Clin North Am. 1990;23(4):699–712.

    Article  CAS  PubMed  Google Scholar 

  20. Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am J Orthod. 1981;79(4):359–72.

    Article  CAS  PubMed  Google Scholar 

  21. Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. Laryngoscope. 2010;120(10):2089–93.

    Article  PubMed  Google Scholar 

  22. Souki BQ, Pimenta GB, Souki MQ, Franco LP, Becker HM, Pinto JA. Prevalence of malocclusion among mouth breathing children: do expectations Meet reality? Int J Pediatr Otorhinolaryngol. 2009;73(5):767–73.

    Article  PubMed  Google Scholar 

  23. Friedman HH, Amoo T. Rating the rating scales. J Mark Manage Winter. 1999. pp. 114–23.

  24. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can J Anesth. 1985;32(4):429–34.

    Article  CAS  Google Scholar 

  25. Kumar DS, Valenzuela D, Kozak FK, Ludeman JP, Moxham JP, Lea J, et al. The reliability of clinical tonsil size grading in children. JAMA Otolaryngol – Head Neck Surg. 2014;140(11):1034–7.

    Article  PubMed  Google Scholar 

  26. Ng SK, Lee DL, Li AM, Wing YK, Tong MC. Reproducibility of clinical grading of tonsillar size. Archieve Otolaryngol Head Neck Surg. 2010;136(2):159–62.

    Article  Google Scholar 

  27. Tawfiq HF, Chawshli OF. The effect of palatine tonsil size on occlusion among 10–12 years students in Erbil City. Erbil Dent J (EDJ). 2022;5(2):155–63.

    Google Scholar 

  28. Behlfelt K, Linder-Aronson S, McWilliam J, Neander P, Laage-Hellman J. Dentition in children with enlarged tonsils compared to control children. Eur J Orthod. 1989;11(4):416–29.

    Article  CAS  PubMed  Google Scholar 

  29. Tang H, Liu Q, Lin JH, Zeng H. Three-dimensional morphological analysis of the palate of mouth-breathing children in mixed dentition. West China J Stomatology. 2019;37(4):389–93.

    Google Scholar 

  30. Galeotti A, Festa P, Viarani V, D’Antò V, Sitzia E, Piga S, et al. Prevalence of malocclusion in children with obstructive sleep Apnoea. Orthod Craniofac Res. 2018;21(4):242–7.

    Article  PubMed  Google Scholar 

  31. Becking BE, Verweij JP, Kalf-Scholte SM, Valkenburg C, Bakker EW, van Merkesteyn JR. Impact of adenotonsillectomy on the dentofacial development of obstructed children: a systematic review and meta-analysis. Eur J Orthod. 2017;39(5):509–18.

    Article  PubMed  Google Scholar 

  32. Iwasaki T, Sugiyama T, Yanagisawa-Minami A, Oku Y, Yokura A, Yamasaki Y. Effect of adenoids and tonsil tissue on pediatric obstructive sleep apnea severity determined by computational fluid dynamics. J Clin Sleep Med. 2020;16(12):2021–28.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Zhao TT, Wang M, Yang Z, Zhang J, Hua F, He H. Percentage of tonsil hypertrophy in orthodontic patients with different sagittal skeletal relationship. Chin J Stomatology. 2022;57(3):266–71.

    CAS  Google Scholar 

  34. Grippaudo C, Paolantonio EG, Antonini G, Saulle R, La Torre G, Deli R. Association between oral habits, mouth breathing and malocclusion. Acta Otorhinolaryngol Ital. 2016;36(5):386.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Zucconi M, Fermi Strambi L, Pestalozza G, Tessitore E, Smirne S. Habitual snoring and obstructive sleep Apnoea syndrome in children: effects of early surgery. Int J Pediatr Otorhinolaryngol. 1993;26(3):235–43.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

Partial funding for open access was provided by the Istanbul University Services Library’s Open Access Fund.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

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Authors and Affiliations

  1. Department of Pedodontics, Faculty of Dentistry, Istanbul University, Istanbul, Türkiye

    Erenay Alpayçetin & Elif Bahar Tuna İnce

  2. Department of Public Health, Faculty of Medicine, Ege University, Bornova, Türkiye

    Caner Baysan

  3. Ear Nose Throat Diseases Department, Faculty of Medicine, Istanbul University, Istanbul, Türkiye

    Levent Aydemir

Authors
  1. Erenay Alpayçetin
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  2. Caner Baysan
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  3. Levent Aydemir
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  4. Elif Bahar Tuna İnce
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Contributions

E. A., contributed to conceptualization, data curation, investigation, methodology, project administration, resources, supervision, validation, visualization, writing – original draft, writing – review & editing. C.B., contributed to data curation, formal analysis, methodology, software, validation. L.A., contributed to investigation, methodology, resources, validation, visualization. E.B.T., contributed to conceptualization, data curation, investigation, methodology, project administration, resources, supervision, validation, visualization, writing – original draft, writing – review & editing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Erenay Alpayçetin.

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Ethics approval and consent to participate

This study was performed in accordance with the principles of the Declaration of Helsinki. Ethical approval for the study was obtained from the Istanbul University Faculty of Dentistry Clinical Research Ethics Committee (Approval number: 2022/5). Informed consent was obtained from the all participants and all the participants gave written informed assent. Clinical trial number: not applicable.

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No/Not applicable.

Competing interests

The authors declare no competing interests.

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Alpayçetin, E., Baysan, C., Aydemir, L. et al. How palatine tonsil grades shape the architecture of dental arches: a cross-sectional study. BMC Oral Health 25, 624 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12903-025-06032-z

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12903-025-06032-z

Keywords

BMC Oral Health

ISSN: 1472-6831

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