{"paper_id":"29bb2456-2a07-41df-8e7f-313a75d85df8","body_text":"A multidisciplinary approach to the assessment of oral breathing, speech disorders, and dentofacial deformities in children – pilot study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A multidisciplinary approach to the assessment of oral breathing, speech disorders, and dentofacial deformities in children – pilot study Venelin Marinov, Tsvetomira Boycheva, Ekaterina Todorova, Greta Yordanova, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6957099/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Jan, 2026 Read the published version in Egyptian Pediatric Association Gazette → Version 1 posted 10 You are reading this latest preprint version Abstract This study presents a multidisciplinary evaluation of fourteen patients with adenoid hypertrophy, which causes pathological (oral) breathing and associated symptomatic manifestations, including snoring during sleep, halitosis, and an open mouth at rest. Oral breathing, especially during prolonged periods during the growth and development of the nasomaxillary complex, may lead to dentofacial deformities. The orthodontic analysis identifies dentofacial deformities of varying severities, including compression in the upper jaw, crossbite in the lateral and frontal segments, open bite, and class II occlusion. The speech-language status establishes a high frequency of disorders in articulating fricatives /s/, /z/, /sh/, /zh/, and affricatives /ts/ and /tsh/. Directional, interdental articulation of phonemes from early ontogenesis (plosives /t/ and /d/, nasal /n/), distinguished by an articulation position in the upper front part of the oral cavity. Disordered articulation of phonemes of later ontogenesis - approximants /l/. Manifestations of speech disorders are a direct consequence of established pathological speech, breathing, and dentofacial deformities. Results: The results categorically confirm the manifestation of pathological mouth breathing, dentofacial deformities, and articulation disorders. Conclusions: A multidisciplinary team and approach are necessary to assess and treat changes caused by adenoid hypertrophy, thereby preventing the development of craniofacial deformities and speech disorders. adenoid hypertrophy articulation disorders nasal breathing oral breathing dentofacial deformities Background Etiology of Mouth Breathing Mouth breathing has a multifactorial etiology. Some possible causes are related to genetic factors, poor oral habits, nasal obstruction, hypertrophy of the adenoids/palatine tonsils, nasal polyposis, severe deviation of the nasal septum, mucosal hypertrophy, or sinusitis (Abreu et al., 2008; Jiménez et al., 2017; Milanesi et al., 2018; Occasi et al., 2018; Pereira et al., 2019; Thomaz et al., 2012). Additionally, mouth breathing may be associated with allergies, climatic conditions, poor sleeping posture, and breastfeeding (Frasson et al., 2006). A study by Morais-Almeida, Wandalsen, and Solé (2019) reports that hypertrophy of the palatine and/or pharyngeal tonsils is the primary cause of mouth breathing in children. Adenoid hypertrophy (AH) and tonsillar hypertrophy are widespread, primarily affecting children aged 3 to 6. AH refers to the enlargement of the nasopharyngeal tonsil and is associated with mechanical obstruction and/or chronic inflammatory processes in the nasopharynx. Hypertrophy of the adenoids can lead to various local and systemic changes and consequences. Nasal airway obstruction can lead to malocclusion, facial deformity, and mouth breathing, with the scientific literature describing this physical condition as adenoid facies (Ahmad et al., 2023). Adenoid Facies Adenoid hypertrophy leads to airway narrowing, facilitating mouth breathing, and induces postural adaptations in multiple orofacial structures, including the oral cavity, tongue, and hyoid bone (Eom et al., 2014). Chronic nasal obstruction, a prevalent condition among young children, contributes to long-term compensatory mechanisms influencing craniofacial development. Linder-Aronson (1979) provides a comprehensive description of the craniofacial characteristics associated with adenoid facies, including an open-mouth posture, muscular hypotonia, a narrowed nasal base, proclined maxillary incisors, leading to reduced facial height, an increased mandibular angle, maxillary constriction, a high-arched palate, anterior tongue positioning, frequent mandibular retrognathia, and a vacant facial expression (Linder-Aronson, 1970; McNamara, 1981; Stellzig-Eisenhauer & Meyer-Marcotty, 2010). Individuals with adenoid facies further exhibit a hypotonic upper lip, posterior displacement of the hyoid bone, a constricted upper dental arch, reclined lower incisors, increased anterior facial height, a narrow or \"V\"-shaped maxillary arch, an enlarged mandibular angle, and backward mandibular rotation when compared to healthy controls (Koca, Erdem & Bayındır, 2016; Raffat & ul Hamid, 2009). Empirical evidence supports the hypothesis that nasal airway obstruction precipitates craniofacial alterations as the body compensates for the anatomic anomaly (Diouf et al., 2015). Meyer (1870) was the first to document that improvements in craniofacial morphology occur immediately following the resolution of the obstruction. Since then, multiple studies have substantiated the potential for craniofacial remodeling following the restoration of nasal breathing, with the most pronounced effects observed in younger patients (Linder-Aronson, Woodside & Daigle, 1975; Zettergren-Wijk et al., 2006). Dentofacial Deformities (DFD) and Manifestations of Speech Disorders The transition from nasal to oral breathing induces alterations in the positioning of the jaw, tongue, and head, thereby disrupting the equilibrium between the intrinsic muscular forces of the tongue and the extrinsic forces exerted by the facial and masticatory musculature. Two primary mechanisms elucidate the impact of mouth breathing on the development of dental and facial deformities (DFD) and articulation disorders. The first mechanism pertains to nasal obstruction caused by rhinitis, nasal polyps, or a deviated nasal septum. Under these circumstances, the mouth remains open to compensate for reduced nasal airflow, resulting in sustained isotonic contraction of the masticatory muscles and increased external muscular pressure. Consequently, the mandible assumes a posterior and open position, while the tongue is displaced inferiorly and posteriorly. Additionally, the head tilts backward. Depending on the duration and timing of the etiological factor, persistent external muscular pressure may lead to maxillary compression, the formation of a deep, gothic-arched palate, the development of distal occlusion, lateral crossbite, and anterior open bite due to overeruption of the posterior teeth. The second mechanism involves hypertrophy of the adenoid tissue along the posterior pharyngeal wall. This condition necessitates anterior tongue displacement to maintain an open airway, leading to excessive mandibular growth, classified as mandibular prognathism or Angle’s Class III malocclusion. Such alterations may further contribute to dental crossbite in both the posterior and anterior segments of the mouth. These anatomical and muscular modifications significantly influence speech production, primarily through alterations in tongue positioning and muscle tone. From a speech pathology perspective, individuals with oral breathing frequently exhibit articulation disorders, most notably interdental sigmatism. This disorder is especially prevalent among children with adenoid hypertrophy, obstructing more than 50% of the airway (Mohamed & Ibrahem, 2024). The underlying pathophysiology is attributed to altered tongue pressure dynamics caused by hypertrophic palatine and nasopharyngeal tonsils in children exhibiting oral breathing patterns (Pereir et al., 2019). Hitos, Arakaki, Solé, and Weckx (2013) emphasize that mouth breathing can harm speech development, socialization, academic performance, and overall physical health. A study by Eom et al. (2014) identified a higher prevalence of articulation disorders in children with adenoid hypertrophy, particularly the substitution of speech sounds, which was more frequently observed in this population than in children without adenoid hypertrophy. Moreover, these children often present with hyponasal speech due to nasal obstruction. The etiology of these speech impairments is multifaceted, encompassing adenoid facies, restricted tongue mobility, and reduced soft palate movement due to tonsillar hypertrophy. Collectively, these factors contribute to the exacerbation of speech disorders (Łapińska & Zawadzka-Glos, 2016). Early establishment of mouth breathing is critical to reduce its adverse effects on physiological and developmental outcomes. Multidisciplinary Approach to the Аssesment and Identification of Mouth Breathing Symptoms A multidisciplinary approach is crucial for confirming the diagnosis and identifying the symptoms of mouth breathing. Researchers emphasize the significance of this approach, as various fields of assessment, including otorhinolaryngology, orthodontics, and speech therapy, offer distinct yet interrelated factors contributing to diagnosing oral breathing (Milanesi et al., 2018). The preschool years represent a critical period for early diagnosis, as timely intervention can prevent the development of associated disorders (Alhazmi, 2022; Sano et al., 2018; Warnier et al., 2023). In clinical practice, the evaluation context for assessing a child's breathing pattern is often determined by the speech-language pathologist’s discretion (Warnier et al., 2023). Observing the child at rest, specifically the duration of mouth opening and closure, as well as the positioning of the tongue and lips, is the primary criterion for diagnosing mouth breathing. Additionally, experts suggest that assessing breathing patterns during mastication (whether the mouth remains open or closed) and immediately post-swallowing (whether the child takes a breath with an open or closed mouth) provides supplementary yet secondary diagnostic information (Warnier et al., 2023). Early identification of mouth breathing is crucial in minimizing its adverse effects on craniofacial and dental development, as well as mitigating related medical and social complications (Jefferson, 2010). Methods Aim, design, and setting of the study This study aims to evaluate patients with breathing disorders caused by adenoid hypertrophy. The difficulties will be described from the perspectives of three specialists: an ENT specialist, an orthodontist, and a speech-language pathologist. Each of them will independently provide an assessment. The collected data will serve as a foundation for developing an assessment approach carried out by a multidisciplinary team. Based on the diagnostic processes and the subsequent therapy, recommendations will be proposed for a comprehensive, interdisciplinary treatment approach. The objective of the present study was to identify the orthodontic DFD observed in a group of mouth-breathing patients diagnosed with adenoid hypertrophy and to determine the presence of concomitant speech pathology or exclude such manifestations. Patient Grouping Orthodontist: The patients will be divided into groups based on their skeletal growth, which will be evaluated using the cerebral vertebral maturation method, as determined by a cephalometric X-ray. There will be a group that is before the peak of growth, and the group with actively growing patients. For the speech-language analysis, the data will be grouped according to the age of the children participating in the study. ENT: The children will be grouped according to the grade of their adenoid hypertrophy. D escription of multidisciplinary methodology: Each child was consulted by a multidisciplinary team consisting of an otolaryngologist, an orthodontist, and a speech-language pathologist. Parents were provided with information about the purpose and method of assessment, and all parents received feedback from all specialists about their child's condition immediately after the study. Each team member examined the children individually, and information was provided in advance about what was required to remain calm and cooperative. ENT methodology: The diagnostic procedures included mesopharyngoscopy, anterior rhinoscopy using a nasal speculum, and otoscopy. An endoscopy of the epipharynx using a flexible endoscope was performed under local anesthesia. Adenoid hypertrophy was graded using a modified endoscopic assessment method, supplemented by lateral cervical radiography for obstruction measurement. The Brodsky scale was used to evaluate the size of the palatine tonsils and the extent to which the space between the palatoglossal pillars is occupied. Under general intubation anesthesia preoperatively, a second inspection was conducted, and adenoid tissue obstruction was classified as follows: Grade 0: No visible adenoid tissue Grade I: Adenoid tissue obstructing <25% of the epipharynx Grade II: Adenoid tissue obstructing 25%–50% of the epipharynx Grade III: Adenoid tissue obstructing 50%–75% of the upper airway space Grade IV: Adenoid tissue obstructing >75% of the epipharynx Classification based on the Brodsky grading scale: Grade 0: Tonsils are located entirely within the tonsillar fossa (the natural depressions where the tonsils sit) and are not visible or barely visible. Grade I: Tonsils are visible and extend slightly outside the fossa, taking up to 25% of the oropharyngeal width. Grade II: Tonsils occupy 26% to 50% of the oropharyngeal width. GradeIII: Tonsils occupy 51% to 75% of the oropharyngeal width. Grade IV: Tonsils are very large, occupying more than 75% of the oropharyngeal width and potentially touching each other or the uvula. Speech-language methodology: The \"Protocol for the Assessment of Articulation in Preschool and Early School-Aged Children\" (Todorova, 2018) was used to assess articulation disorders. A speech-language evaluation was conducted in a clinical setting, in the presence of a parent, who also provided anamnestic data necessary for establishing the child's speech profile. The assessment of the speech apparatus and articulation was engaging for the children, and they participated calmly and cooperatively. During the evaluation, the presence or absence of anatomical and physiological features of the articulatory apparatus, as well as the level of praxis ability, is established. The impairment of which consonant groups of sounds is investigated—the number of affected phoneme classes. A qualitative analysis of the types of errors and their specifics is performed. The research procedure encompasses the production of isolated phonemes, a series of oppositional phonemes, words with complex phonological contexts, and various positional distributions, at the level of repeated and spontaneous speech. The goal is to establish the stability and consistency of the type of incorrect articulation. To differentiate between articulatory and phonological disorders, tests assessing phonological and meta-phonological functioning are included. Orthodontist methodology: All patients underwent an orthodontic examination by a specialist, which documented any existing orthodontic deformities. The assessment included a detailed review of the patient's medical history in a clinical setting. As part of the comprehensive orthodontic evaluation, additional radiographic examinations—orthopantomography and cephalometric radiography—were performed to detect skeletal-level deformities. Changes were documented at dental and skeletal levels, and occlusion was assessed in three planes. Through extraoral examination, evaluate the presence of adenoid facies. Intraorally, assess the type of dentition (temporary, early mixed, late mixed, and permanent), separate dental arch problems, and occlusion in three planes: sagittal, transversal, and vertical, in both frontal and distal areas. The maturity of the skeletal system is evaluated through the CVM method in lateral cephalometry. Characteristics of participants The study group consisted of fourteen children, including 6 girls and 8 boys, with a mean age of 7.11 years (range: 4–11 years). An otorhinolaryngologist, an orthodontist, and a speech-language pathologist assessed each patient's medical history and conducted a comprehensive clinical examination, followed by diagnostic interventions. All three specialists have examined the patients included in the study and confirmed a diagnosis of nasal breathing difficulty. The etiology of the difficulty in nasal breathing is not of allergic origin, as confirmed by a specialist allergist. Refusal to visit even one of the three is an exclusion criteria. ENT exclusion criteria: age - children younger than 24 months and patients older than 21. Another exclusion criteria is the presence of a syndromic disease or other severe systemic disease. There are no patients with cleft palate included in the study. Another exclusion criteria is severe facial trauma Le Fort - I, II, III, and children with iatrogenic changes in the oro/hypopharyngeal, nasopharyngeal regions, and iatrogenic damage to the tongue. ENT inclusion criteria - children who sleep with open mouths for more than 6 months, snoring for more than 6 months, unaltered by medication. Severe and recurrent nasal and middle ear infections. Children with enlarged adenoids obstructing more than 40% of the epipharynx. Age- children older than 24 months. From a speech-language pathology perspective, the exclusion criteria that were taken into account are: no children in the present sample had developmental language disorder, intellectual disability, sensory impairment, neurological disorder, behavioral disorder, or were raised in a deprived environment. All children included in the studied sample demonstrate only a specific articulation disorder. Parental anamnesis confirmed that all children were monolingual, with Bulgarian as their native language. Results ENT Results and Diagnostic Analysis All fourteen children in the study were diagnosed with AH, and ten also exhibited signs of adenoid facies (AF), except for the four youngest children born in 2020. Six were presented with grade III AV, four with grade III-IV AH, and four with grade IV AH. Ten of the examined children had a history of ear pathology, ranging from acute purulent otitis to conductive hearing loss. Table 1. General Sample Data Gender Age (years) Adenoid Facies AH Gradе Palatine hypertrophy grade Female 4,11 No 3 2 Male 11,11 Yes 3 2 Female 8,1 Yes 3-4 3 Male 7,8 Yes 3-4 3 Male 6,6 Yes 4 4 Female 4,3 No 3 2 Male 8,1 Yes 4 3 Female 4,9 No 3 3 Male 11,8 Yes 3 2 Female 8,4 Yes 3-4 3 Male 7,6 Yes 3-4 4 Male 6,2 Yes 4 3 Female 4,1 No 3 2 Male 8,5 Yes 4 3 Table 1 describes the general data of the examined group. Twelve children exhibited oral breathing, while two of them (the youngest) demonstrated mixed breathing. According to parental reports, all children slept with their mouths open and experienced loud snoring during sleep. Following surgical intervention, 100% of the operated children showed improved sleep quality and normalized nasal breathing. Speech Therapy Results and Diagnostic Analysis In Table 2, the characteristics of the articulatory apparatus are described based on data collected by the speech-language pathologists and confirmed by the otolaryngologist who diagnosed the children. Six children were found to have a gothic palate, while two children had a short frenulum requiring surgical correction. The children exhibited atypical swallowing, attributed to improper tongue positioning and oral breathing. Examination of the speech apparatus revealed that the tongues of four children (see tab. 2) were in an interdental position at rest. Behind the lower incisors, the tongue rested low in the other ten children. The articulation disorders diagnosed during the speech therapy assessment are detailed in Table 3. Table 2. Characteristics of the Articulatory Apparatus Gender Age (years) Articulatory Apparatus Features Female 4,11 Short sublingual frenulum, interdental tongue position Male 11,11 Low tongue position Female 8,1 Gothic palate, Low tongue position Male 7,8 Gothic palate, Low tongue position Male 6,6 Interdental tongue position Female 4,3 Low tongue position Male 8,1 Gothic palate, Low tongue position Female 4,9 Short sublingual frenulum, interdental tongue position Male 11,8 Low tongue position Female 8,4 Gothic palate, Low tongue position Male 7,6 Gothic palate, Low tongue position Male 6,2 Interdental tongue position Female 4,1 Low tongue position Male 8,5 Gothic palate, Low tongue position Table 3. Type of Articulation Disorder Gender Age (years) Articulation Disorder Female 4,11 Intedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Substitute post-alveolar frivatives [sh, zh] and post-alveolar affricative [tsh] with alveolar fricatives [s, z] and alveolar affricative [ts] Male 11,11 Intedental sigmatism of fricative alveolar [s, z] and alveolar affricative [ts]; Interdental articulation of plosive alveolars [t, d] and nasal alveolar [n]; lambdacism of lateral approximant alveolar [l] Female 8,1 Interdental articulation of plosive alveolars [t, d] and nasal alveolar [n]; lambdacism of lateral approximant alveolar [l] Male 7,8 Interdental articulation of plosive alveolars [t, d] and nasal alveolar [n]; lambdacism of lateral approximant alveolar [l] Male 6,6 Intedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Interdental consonats [t,d,n]; lambdacism of lateral approximant alveolar [l] Female 4,3 Substitute post-alveolar fricatives [sh, zh] and post-alveolar affricative [tsh] with fricatives alveolar [s, z] and alveolar affricative [ts] Male 8,1 Intedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Interdental articulation of plosive alveolars [t, d] and nasal alveolar [n]; lambdacism of lateral approximant alveolar [l] Female 4,9 Intedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Substitute post-alveolar frivatives [sh, zh] and post-alveolar affricative [tsh] with alveolar fricatives [s, z] and alveolar affricative [ts] Male 11,8 Intedental sigmatism of fricative alveolar [s, z] and alveolar affricative [ts]; Interdental articulation of plosive alveolars [t d] and nasal alveolar [n]; lambdacism of lateral approximant alveolar [l] Female 8,4 Interdental articulation of plosive alveolars [t, d] and nasal alveolar [n]; lambdacism of lateral approximant alveolar [l] Male 7,6 Interdental articulation of plosive alveolars [t, d] and nasal alveolar [n]; lambdacism of lateral approximant alveolar [l] Male 6,2 Intedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Interdental consonats [t, d, n]; lambdacism of lateral approximant alveolar [l] Female 4,1 Substitute post-alveolar fricatives [sh, zh] and post-alveolar affricative [tsh] with fricatives alveolar [s, z] and alveolar affricative [ts] Male 8,5 Intedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Interdental articulation of plosive alveolars [t, d] and nasal alveolar [n]; lambdacism of lateral approximant alveolar [l] The data in Table 3 reveal the following articulatory characteristics in the children examined: none demonstrated correct articulation of speech sounds. The youngest children exhibited substitution of post-alveolar fricatives [sh, zh] and post-alveolar affricative [tsh] with alveolar fricatives [s, z] and alveolar affricative [ts] but did not demonstrate interdental tongue placement during articulation. The slightly older ones also demonstrate an articulation disorder of fricatives [sh, zh] and post-alveolar affricative [ch] as these consonants are replaced by [s, z, ts] but are pronounced interdentally already. The age of these children is approaching five years. In comparison, the younger children are at the age of four. So, a common articulation disorder involves the sibilant consonants [s, z, ts] and specifically their interdental pronunciation, known in speech therapy as interdental sigmatism. In the remaining children in the studied group, it was observed that six out of ten children exhibited an interdental pronunciation of the consonants [s, z, ts]. Notably, improper tongue positioning during the articulation of consonants [t, d] and [n] was also observed in children with adenoid hypertrophy. The results show that incorrect articulation of consonants [t, d] and [n] is more common in children from the study group. We can explain this articulation disorder by the tongue falling into a lower position during incorrect breathing and weakened muscles. Ten of fourteen children demonstrate a disorder in the pronunciation of [t, d] and [n], where the place of articulation of the sound is changed, and the position that the tongue occupies when pronouncing them occurs between the upper and lower incisors. These are all children who are over the age of 4. It is evident from the data in the table that children who are over 8 years and 4 months and where the AH factor has been active for the longest time, articulation disorders of several consonant classes of sounds are detected: Intedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts] Interdental articulation of plosive alveolars [t, d] and nasal alveolar [n] Lambdacism of lateral approximant alveolar [l] The same results are shown for children aged 6 years. They demonstrate articulation disorders typical of these children, which appear by the age of 8 years and 4 months. Four of the children, aged 7-8 years old, mispronounce only the sounds [t, d] and [n], as well as a consonant of late ontogenesis - [l]. Comparing the data from the orthodontic analysis, we can conclude that in patients with a Class II occlusion, characterized by distal and deep occlusion, incorrect articulation of [t, d] and [n] was a typical finding. In patients with Class III occlusion and grade IV AH, interdental sigmatism of sibilants and interdental articulation of [t, d] and [n] were observed. Additionally, all these children demonstrated bilabial pronunciation of lateral approximant alveolar [l] in syllables with vowels [ a, ɤ, ɔ, u ]. It is obvious that adenoid hypertrophy negatively affects the articulation of sounds that are produced from the tip of the tongue in the oral cavity, such as [s, z, ts, l, d, t, n]. In summary, the results of the assessment indicate that children with prolonged AH also exhibit orthodontic deformities and disordered articulation. Orthodontic Results and Diagnostic Analysis All patients undergo a specialized orthodontic examination. It begins with an extraoral examination - is there facial asymmetry between the two facial halves, are the three facial levels evenly developed. Another essential characteristic is the presence of blue circles under the eyes, skin turgor, and the development or underdevelopment of the nostrils. Additionally, the patient's posture, whether they stand with their mouth open, and their ability to concentrate efficiently are also essential factors. His ability to breathe through his nose for at least 1 minute is examined. The type of dentition is assessed - temporary, early mixed, late mixed, or permanent. The condition of the dentition is assessed as maintained or with caries. The soft tissues are assessed - are the frenums and the mucous membrane normal, is there inflammation of the gums. The plaque index of the front teeth is also assessed. In the individual dental arch, it is monitored whether there are diastemas and tremas or tooth crowding, there is tooth rotation or pronounced compression of the individual jaw. The depth and shape of the palate are monitored, including whether it is normal, deep, or Gothic, and whether it is symmetrical. The dentition is examined in three planes: vertical, transverse, and sagittal. Vertically, it is examined whether there is an open occlusion in the frontal or lateral segment. Transversely, it is observed whether there is a divergence of the midlines in the two jaws in the frontal segment or a cross occlusion in the lateral segment. Sagittally, it is monitored whether there is a cross-occlusion between one or several teeth in the frontal segment. In the lateral segment, the occlusion is assessed according to Angle's classification. According to Angle’s classification for sagittal relationships between jaws, the children were categorized as follows: Class I occlusion: seven patients an average age of 5.6 years; Class II: four with an average age of 9.9 years; Class III: three patients with an average age of 7.7 years. All patients underwent lateral cephalometry to assess the degree of bone maturation. The Cervical Vertebral Maturation (CVM) method is used to categorize the skeletal maturity of each patient. The procedure consists of six stages, based on changes in the cervical vertebrae. These stages are generally grouped into three categories: prepubertal (CS1 and CS2), pubertal (CS3 and CS4), and postpubertal (CS5 and CS6). Detailed data are presented in Table 4. Table 4. Type of Orthodontic Deformations Gender Age (years) CVM-stage maturation Orthodontic Deformation Female 4,11 I Class I skeletal occlusion, no orthodontic deformation Male 11,11 III Deep distal (Class II) occlusion, maxillary compression Female 8,10 III Deep distal (Class II) occlusion, maxillary compression Male 7,8 II Class I skeletal occlusion, maxillary compression Male 6,6 I Class III skeletal occlusion, edge-to-edge bite Female 4,3 I Class I skeletal occlusion, no orthodontic deformation Male 8,10 II Class III occlusion, maxillary compression Female 4,9 I Class I skeletal occlusion, no orthodontic deformation Male 11,8 III Deep distal (Class II) occlusion, maxillary compression Female 8,4 III Deep distal (Class II) occlusion, maxillary compression Male 7,6 II Class I skeletal occlusion, maxillary compression Male 6,2 I Class I skeletal occlusion, no orthodontic deformation Female 4,1 I Class I skeletal occlusion, no orthodontic deformation Male 8,5 II Class III occlusion, maxillary compression Patients with a Class I occlusion and no orthodontic deformation are in CVM stage I, before the spur of skeletal growth. There are 4-year-old females. No orthodontic deformities were found, and they are the only ones in the group without adenoid facies or compression of the maxillofacial region. Two females and two males with Class II occlusion, with an average age of 9.85, were included. All of them are in the CVM III stage. In the vertical dimension, a deep bite and distal occlusion were established in all patients. Patients with Class III occlusion are three males aged 6,6 and 8,1 and 8,5 years. The 6,6 -year-old male shows edge-to-edge occlusion in the vertical dimension and a tendency toward Class III malocclusion. The male, aged 8,1 and 8,5, presents compression in the UJ, which is a deformation in the transversal dimension of the jaw. The youngest patients, 4-year-old females, have no established orthodontic deformities or adenoid facies. They are the only ones without compression in the maxillofacial region. In contrast, all other patients exhibit varying degrees of orthodontic deformities. These are related to improper breathing patterns, such as mouth breathing, which results in compression in the maxillofacial region and the development of Class II and III malocclusions, depending on the deformation mechanism. In the group with an average age of 8 years, after a detailed anamnestic history, it was determined that the etiological factor—mouth breathing—had been present for a more extended period, which coincided with the development of the bones in the nasomaxillary complex. This group exhibited a distal occlusion. The patient showed edge-to-edge occlusion and a tendency toward a medial occlusion, indicating the formation of another expected group. In this group, the etiological factor - difficult nasal breathing—leads to a long-term change in the shape of the UJ, but through a different mechanism. While in the previous group, where patients had a distal occlusion, only mouth opening and a posterior position of the lower jaw were observed, in this group, the tongue shifts to the anterior sections to free up additional space for air passage, thereby developing the anterior segment of the lower jaw. Transversal expansion is a widely used method in clinical practice; however, it should be performed strictly in accordance with clinical indications. For it to be a purely orthodontic method and not a surgical-orthodontic one, expansion in the transversal direction is most suitable before the complete ossification of the palatal suture. Ossification (maturation) of the suture is most accurately determined radiographically or, more specifically, by Cone beam computed tomography (CBCT). This is supported by the study of Angelieri et al. (2013), which serves as fundamental research in this field. Clinically, this process manifests as a diastema, which appears during active expansion and self-closes after the process is complete. A more detailed study involves measuring the volumes of the maxillofacial region before and after treatment to observe changes in the volume and assess whether there is a correlation between transversal expansion and the increase in the volume of the maxillofacial region. Discussion In today's life, the problem of mouth breathing is increasingly widespread and shouldn’t be underestimated. The condition may be a consequence of a long illness and a habit of breathing through the mouth, for no other reason. The increasingly common allergic conditions affecting patients at a younger age pose another challenge to modern society. The reason for this is the widespread use of chemicals and fragrances in detergents and products that have permeated all levels of our daily lives. Differentiating the exact cause of mouth breathing is crucial for a correct treatment approach. Suppose there are no other reasons for mouth breathing, and it has become a habit, and is discovered in time. In that case, it can be easily overcome with a system of exercises and a myofunctional device for a short period. However, if there is an allergy or another reason, it is unacceptable to use a myofunctional device, which can further disrupt and complicate the child's breathing. If the exact cause of the allergy is identified, it can be controlled with medication, and treatment can then be initiated if mouth breathing has become a habit. An accurate diagnosis by an ENT specialist is necessary to differentiate between a large part of the other possible causes of mouth breathing, such as a deviated nasal septum, nasal mucosa hypertrophy, and adenoid hypertrophy. AH was reported to be the reason for mouth breathing in 44% of all cases, allergic rhinitis in 11.3%, and both in 34.6%. (Atar Bese et al., 2024 ) In another literature review, Ma et al. ( 2024 ) report the range of adenoid hypertrophy from 42–70%. Making an accurate diagnosis also allows for accurate and precise treatment. Disruption of a basic vital function, such as breathing, inevitably leads to disruption of all other systems. For an extended period, a compensation process occurs within the body, but when the possibilities for compensation are exhausted, morphological changes take place. The change in the position and function of the tongue is a direct reflection of changes in breathing and occlusion patterns. A factor acting for a long time, especially during the period of active growth of the bone system, and leading to different contractions and functions of all muscles—masticatory and mimic — leads to changes in the development of the facial bones and to severe maxillofacial deformities. It is essential for parents to be aware of the problem and to be promptly informed and convinced of the need for treatment of their children, as well as the consequences that would arise if they do not receive appropriate treatment. A systematic review has evidenced dentofacial changes in numerous studies (Lin et al., 2022 ). The most common changes include a retrognathic mandible, an increased angle of the mandibular plane, and downward and backward rotation of the mandible. It is necessary to establish a transparent and systematized approach to work and collaboration among individual specialists to ensure a precise, individualized, and professional attitude and consideration of each clinical case. The pilot study aimed to conduct a more in-depth investigation of the issue and monitor the duration for which the etiological factor has been acting. The primary focus of this pilot study is to establish a strong correlation between patients with adenoid and/or palatine hypertrophy and their relationship to orthodontic and speech abnormalities. The study revealed that orthodontic deformities were not observed when the etiological factor was absent for a sufficiently long time and the period of its action occurred before the primary growth and development of the structures in the craniofacial area (CFA). This was evident in the youngest participants in the study, in whom speech sound disorders were associated with tongue malpositioning. The continued presence of the etiological factor contributes to the manifestation of irregular speech production and the development of various orthodontic symptoms. Patients who participated in the study had orthodontic abnormalities consistent with the etiologic factor and expected based on it. Articulation disorders are commonly seen in adenoid hypertrophy and persist until the cause is corrected, resulting in mouth breathing and malpositioning of the tongue. Orthodontic treatment would be compromised without speech therapy intervention to properly position the tongue in the oral cavity. AH is a condition that can alter speech and potentially lead to a speech sound disorder. Airway obstruction can lead to constricted oral breathing. That, in turn, can lead to postural alterations in several oral-facial structures. Evaluating all the patient's problems systematically and working towards removing the cause of improper breathing and all related conditions can dramatically improve the child's physical growth, articulation ability, and reduce facial and dental problems associated with the condition. The study was conducted among professionals working in the field of early childhood development and is considered innovative for our country, which is reflected in the lack of data from studies on the same topic. However, the pilot study also has its limitations. Data collection is labour-intensive, as each patient must undergo three separate consultations: first with an ENT specialist, then with an orthodontist, and finally with a speech therapist. And it often happens that the recommendations given by the ENT for further consultations with the other two specialists are not followed. This is the reason why the data presented is limited to this number. As a result, data collection is a time-consuming process. It should be emphasized that the small number of subjects also represents a limitation for presenting the results by statistical analysis. Conclusion Early diagnosis of adenoid hypertrophy serves as a preventive measure and protection against related complications. With early diagnosis and resolution of the issue through conservative or surgical treatment, permanent facial and jaw changes, as well as speech sound disorders, could be prevented. Children with conductive hearing loss and frequent perforative, purulent otitis media require specific examination for the presence of adenoid hypertrophy. Children diagnosed with adenoid hypertrophy by an ENT specialist should be referred for consultation with a speech-language pathologist and an orthodontist. To achieve optimal results, post-operative follow-up with patients is necessary, focusing on acquiring voluntary nasal breathing and intentional changes in tongue position, which will lead to the reinforcement and automatization of these processes. In cases where surgical intervention has been performed, but post-operative speech therapy and orthodontic treatment are lacking, the results for the patients are poorer. A multidisciplinary team and approach are required to assess and treat changes caused by adenoid hypertrophy before permanent changes occur. Early screening, assessment, and timely multidisciplinary therapy are crucial in preventing the development of craniofacial deformities and speech sound disorders. Recommendations This study provides a reasonable basis and a request for its continuation. Including more children will clarify the expected consequences of adenoid hypertrophy. Including data from the therapy being carried out by the multidisciplinary team will also be interesting from a research perspective. Declarations Ethics Approval and Consent to Participate This study was not deceptive, and there was no risk or harm to participants (Code of Ethics and Conduct, 2018). The experimental procedure complied with the ethical standards of the Declaration of Helsinki. It was approved by the Ethics Committee of the Department of Health Care and Social Work at New Bulgarian University, with protocol No. 137, dated April 15, 2025. The parents of the participants provided written informed consent before the study. Funding This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution VM, TSB, and GG contributed by designing the study, collecting and interpreting the data, providing the assessment, and drafting and revising the manuscript. ET and GY contributed by writing and revising the manuscript. All authors contributed to data analysis and interpretation. Data Availability The authors confirm that the data supporting the findings of this study are available within the article and/or its supplementary materials. References Abreu RR, Rocha RL, Lamounier JA, Guerra AF (2008) Etiology, clinical manifestations and concurrent findings in mouth-breathing children. Jornal de pediatria 84(6):529–535. https://doi.org/10.2223/JPED.1844. Angelieri , Cevidanes LH, Franchi L, Gonçalves JR, Benavides E, McNamara, JA (2013) Midpalatal suture maturation: classification method for individual assessment before rapid maxillary expansion. American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 144(5):759–769. https://doi.org/10.1016/j.ajodo.2013.04.022. Ahmad Z, Krüger, K, Lautermann J, Lippert B, Tenenbaum T, Tigges M, Tisch M (2023) Adenoid hypertrophy-diagnosis and treatment: the new S2k guideline. Adenoide Vegetationen – Diagnostik und Therapie – die neue S2k-Leitlinie. HNO, 71(Suppl 1):67–72. https://doi.org/10.1007/s00106-023-01299-6. Alhazmi WA (2022) Mouth Breathing and Speech Disorders: A Multidisciplinary Evaluation Based on The Etiology. Journal of pharmacy & bioallied sciences, 14 (Suppl 1) S911–S916. https://doi.org/10.4103/jpbs.jpbs_235_22. Atar Bese S, Ozdemir O, Tuncerler G, Erge D, Uysal P. Do not ignore mouth breathing syndrome: respiratory functions are affected in early childhood. Rhinology. 2024 Dec 1;62(6):659-668. doi: 10.4193/Rhin24.133. PMID: 39254513. Diouf JS, Ngom PI, Sonko O, Diop-Bâ K, Badiane A, Diagne F (2015) Influence of tonsillar grade on the dental arch measurements. American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics, 147(2):214–220. https://doi.org/10.1016/j.ajodo.2014.10.028. Eom TH, Jang ES, Kim YH, Chung SY, Lee IG (2014) Articulation error of children with adenoid hypertrophy. Korean journal of pediatrics 57(7):323–328. https://doi.org/10.3345/kjp.2014.57.7.323. Frasson JM, Magnani MB, Nouer DF, de Siqueira VC, Lunardi N (2006) Comparative cephalometric study between nasal and predominantly mouth breathers. Brazilian journal of otorhinolaryngology 72(1):72–81. https://doi.org/10.1016/s1808-8694(15)30037-9. Jefferson Y (2010) Mouth breathing: adverse effects on facial growth, health, academics, and behavior. General dentistry 58(1):18–80. https://assets.cdn.thewebconsole.com/S3WEB8659/images/Mouth-breathing---adverse-effects-on-facial-growth-health-academics-and-behaviour.pdf. Jiménez EL, Barrios R, Calvo JC, de la Rosa, MT, Campillo JS, Bayona JC, Bravo M (2017) Association of oral breathing with dental malocclusions and general health in children. Minerva pediatrica 69(3):188–193 https://doi.org/10.23736/S0026-4946.16.04288-2. Koca CF, Erdem T, Bayındır T (2016) The effect of adenoid hypertrophy on maxillofacial development: an objective photographic analysis. Journal of otolaryngology - head & neck surgery. Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale 45(1): 48. https://doi.org/10.1186/s40463-016-0161-3. Lapinska I, Zawadzka-Glos L (2016) Adenoid and tonsils hypertrophy - Symptoms and treatment. New Medicine 20:103-106 10.5604/14270994.1228134. Linder-Aronson S (1970) Adenoids. Their effect on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the denition. A biometric, rhino-manometric, and cephalometric-radiographic study on children with and without adenoids. Acta oto-laryngologica. Supplementum 265:1–132. Linder-Aronson S (1979) Respiratory function in relation to facial morphology and the dentition. British journal of orthodontics 6(2):59–71. https://doi.org/10.1179/bjo.6.2.59. Lin L, Zhao T, Qin D, Hua F, He H. The impact of mouth breathing on dentofacial development: A concise review. Front Public Health. 2022 Sep 8;10:929165. doi: 10.3389/fpubh.2022.929165. PMID: 36159237; PMCID: PMC9498581. Ma Y, Xie L, Wu W. The effects of adenoid hypertrophy and oral breathing on maxillofacial development: a review of the literature. J Clin Pediatr Dent. 2024 Jan;48(1):1-6. doi: 10.22514/jocpd.2024.001. Epub 2024 Jan 3. PMID: 38239150. McNamara JA (1981) Influence of respiratory pattern on craniofacial growth. The Angle orthodontist 51(4):269–300. https://doi.org/10.1043/0003-3219(1981)051<0269:IORPOC>2.0.CO;2.Meyer W (1870) On Adenoid Vegetations in the Naso-pharyngeal Cavity: their Pathology, Diagnosis, and Treatment. Medico-chirurgical transactions 53:191–216.1. https://doi.org/10.1177/095952877005300110. Milanesi JM, Berwig LC, Marquezan M, Schuch LH, Moraes AB, Silva AMTD, Corrêa ECR (2018) Variables associated with mouth breathing diagnosis in children based on a multidisciplinary assessment. CoDAS 30(4):e20170071. https://doi.org/10.1590/2317-1782/20182017071. Mohamed HA, Ibrahem RA (2024) Speech Sound Disorders in Arabic School aged Children with Adenoid Hypertrophy. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India, 76(6):5195–5200. https://doi.org/10.1007/s12070-024-04942-y. Occasi F, Perri L, Saccucci M, Di Carlo G, Ierardo G, Luzzi V, De Castro G, Brindisi G, Loffredo L, Duse M, Polimeni A, Zicari AM (2018) Malocclusion and rhinitis in children: an easy-going relationship or a yet to be resolved paradox? A systematic literature revision. Italian journal of pediatrics 44(1):100. https://doi.org/10.1186/s13052-018-0537-2. Pereira TC, Furlan RMMM, Motta AR (2019) Relationship between mouth breathing etiology and maximum tongue pressure. Relação entre a etiologia da respiração oral e a pressão máxima da língua. CoDAS 31(2), e20180099. https://doi.org/10.1590/2317-1782/20182018099. Raffat A, ul Hamid W (2009) Cephalometric assessment of patients with adenoidal faces. JPMA. The Journal of the Pakistan Medical Association 59(11): 747–752. Sano M, Sano S, Kato H, Arakawa K, Arai M (2018) Proposal for a screening questionnaire for detecting habitual mouth breathing, based on a mouth-breathing habit score. BMC oral health 18(1): 216. https://doi.org/10.1186/s12903-018-0672-6. Stellzig-Eisenhauer A, Meyer-Marcotty P (2010) Interaction between otorhinolaryngology and orthodontics: correlation between the nasopharyngeal airway and the craniofacial complex. GMS current topics in otorhinolaryngology, head and neck surgery, 9 https://doi.org/10.3205/cto000068. Todorova E (2018) Articulation disorders - therapy guide. New Bulgarian University, Sofia. Thomaz E B, Cangussu MC, Assis AM (2012) Maternal breastfeeding, parafunctional oral habits and malocclusion in adolescents: a multivariate analysis. International journal of pediatric otorhinolaryngology, 76(4): 500–506. https://doi.org/10.1016/j.ijporl.2012.01.005. Warnier M, Piron L, Morsomme D, Maillart C (2023) Assessment of mouth breathing by Speech-Language Pathologists: an international Delphi consensus. CoDAS 35(3) e20220065. https://doi.org/10.1590/2317-1782/20232022065 Download .nbib . Zettergren-Wijk L, Forsberg CM, Linder-Aronson S (2006) Changes in dentofacial morphology after adeno-/tonsillectomy in children with obstructive sleep apnoea--there (4): 319–326. https://doi.org/10.1093/ejo/cji119. Chenxing Lv, Liu Yang, Ngan Peter, Xiao Wenjie, Zhao Tingting, Tang, Bojun, Chen Xiong, He Hong (2023) Role of the tonsil–oropharynx ratio on lateral cephalograms in assessing tonsillar hypertrophy in children seeking orthodontic treatment. BMC Oral Health. 23. 10.1186/s12903-023-03573-z. Huang L, Zheng L, Chen X, Bai Y. Age-group-specific associations between adenoid/tonsillar hypertrophy and craniofacial features. BMC Oral Health . 2024;24(1):1212. Published 2024 Oct 14. doi:10.1186/s12903-024-04932-0 Huang X, Gong X, Gao X (2023) Age-related hypertrophy of adenoid and tonsil with its relationship with craniofacial morphology. BMC Pediatr . 23(1):163. 6. doi:10.1186/s12887-023-03979-2 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Jan, 2026 Read the published version in Egyptian Pediatric Association Gazette → Version 1 posted Editorial decision: Revision requested 12 Sep, 2025 Reviews received at journal 12 Sep, 2025 Reviewers agreed at journal 30 Aug, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers agreed at journal 12 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers invited by journal 10 Jul, 2025 Submission checks completed at journal 09 Jul, 2025 First submitted to journal 08 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6957099\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":484665611,\"identity\":\"28a78fc0-54b8-4fcc-a25f-3058eec8d8e3\",\"order_by\":0,\"name\":\"Venelin Marinov\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Department of Otorhinolaryngology, University Hospital “Queen-Joanna-ISUL\\\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Venelin\",\"middleName\":\"\",\"lastName\":\"Marinov\",\"suffix\":\"\"},{\"id\":484665612,\"identity\":\"edb32bb8-a6cf-491b-aeac-79d4d3b7885c\",\"order_by\":1,\"name\":\"Tsvetomira Boycheva\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYFACHhBxAIiZDzADyQQiNMC1sCWQrIXHgDgt9vxnDz7mqbkjZ3D8zLfHhW0MefIOhGyRyEs25jn2zNjgTO5245ltDMWGBwhq4TGT5m04nDizIXebNG8bQ+LGBkJa+M+AtdTP7H/zjEgtDDlgLQn8EjlsYC3zCehg4LmRl2w459hhw36JZ2bSM85JFBsQ0sLef/bggzc1h+XZ+JOfSReU2eTJE3IYCDDxINgSDAYHiNDC+AOZR5Qto2AUjIJRMKIAAEpmPiNixaX+AAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"New Bulgarian University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Tsvetomira\",\"middleName\":\"\",\"lastName\":\"Boycheva\",\"suffix\":\"\"},{\"id\":484665613,\"identity\":\"8b416519-ae96-4298-a2bd-a481bf6135bc\",\"order_by\":2,\"name\":\"Ekaterina Todorova\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"New Bulgarian University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ekaterina\",\"middleName\":\"\",\"lastName\":\"Todorova\",\"suffix\":\"\"},{\"id\":484665614,\"identity\":\"9f418268-9cd8-4c13-bf03-a391fac0f859\",\"order_by\":3,\"name\":\"Greta Yordanova\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Medical University of Sofia\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Greta\",\"middleName\":\"\",\"lastName\":\"Yordanova\",\"suffix\":\"\"},{\"id\":484665615,\"identity\":\"73f60be0-2519-442b-93d3-7d8fc1912706\",\"order_by\":4,\"name\":\"Gergana Gurgurova\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Private practice “GreOrtho”\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Gergana\",\"middleName\":\"\",\"lastName\":\"Gurgurova\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-06-23 13:08:16\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6957099/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6957099/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s43054-025-00472-6\",\"type\":\"published\",\"date\":\"2026-01-15T16:30:57+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":100614958,\"identity\":\"ef23ef14-d2d2-4b6b-888f-469bfe22227b\",\"added_by\":\"auto\",\"created_at\":\"2026-01-19 17:28:57\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":807154,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6957099/v1/0d3eef0e-c3d5-4d65-86de-f51848c11193.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"A multidisciplinary approach to the assessment of oral breathing, speech disorders, and dentofacial deformities in children – pilot study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003e\\n \\u003ch3\\u003e\\u003cstrong\\u003eEtiology of Mouth Breathing\\u003c/strong\\u003e\\u003c/h3\\u003e\\n \\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003eMouth breathing has a multifactorial etiology. Some possible causes are related to genetic factors, poor oral habits, nasal obstruction, hypertrophy of the adenoids/palatine tonsils, nasal polyposis, severe deviation of the nasal septum, mucosal hypertrophy, or sinusitis (Abreu et al., 2008; Jim\\u0026eacute;nez et al., 2017; Milanesi et al., 2018; Occasi et al., 2018; Pereira et al., 2019; Thomaz et al., 2012). Additionally, mouth breathing may be associated with allergies, climatic conditions, poor sleeping posture, and breastfeeding (Frasson et al., 2006). A study by Morais-Almeida, Wandalsen, and Sol\\u0026eacute; (2019) reports that hypertrophy of the palatine and/or pharyngeal tonsils is the primary cause of mouth breathing in children. Adenoid hypertrophy (AH)\\u0026nbsp;and tonsillar hypertrophy are widespread, primarily affecting children aged 3 to 6. AH\\u0026nbsp;refers to the enlargement of the nasopharyngeal tonsil and is associated with mechanical obstruction and/or chronic inflammatory processes in the nasopharynx. Hypertrophy of the adenoids can lead to various local and systemic changes and consequences. Nasal airway obstruction can\\u0026nbsp;lead to malocclusion, facial deformity, and mouth breathing, with the scientific literature describing this physical condition as adenoid facies (Ahmad et al., 2023).\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003col start=\\\"2\\\"\\u003e\\n \\u003cli\\u003e\\n \\u003ch3\\u003e\\u003cstrong\\u003eAdenoid Facies\\u003c/strong\\u003e\\u003c/h3\\u003e\\n \\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003eAdenoid\\u0026nbsp;hypertrophy leads to\\u0026nbsp;airway narrowing,\\u0026nbsp;facilitating\\u0026nbsp;mouth breathing,\\u0026nbsp;and induces postural adaptations in multiple orofacial structures, including the oral cavity, tongue, and hyoid bone (Eom et al., 2014). Chronic nasal obstruction, a prevalent condition among young children, contributes to long-term compensatory mechanisms influencing craniofacial development. Linder-Aronson (1979) provides a comprehensive description of the craniofacial characteristics associated with adenoid facies, including an open-mouth posture, muscular hypotonia, a narrowed nasal base, proclined maxillary incisors,\\u0026nbsp;leading to reduced facial height, an increased mandibular angle, maxillary constriction, a high-arched palate, anterior tongue positioning, frequent mandibular retrognathia, and a vacant facial expression (Linder-Aronson, 1970; McNamara, 1981; Stellzig-Eisenhauer \\u0026amp; Meyer-Marcotty, 2010).\\u003c/p\\u003e\\n\\u003cp\\u003eIndividuals with adenoid facies further exhibit a hypotonic upper lip, posterior displacement of the hyoid bone, a constricted upper dental arch, reclined lower incisors, increased anterior facial height, a narrow or \\u0026quot;V\\u0026quot;-shaped maxillary arch, an enlarged mandibular angle, and backward mandibular rotation when compared to healthy controls (Koca, Erdem \\u0026amp; Bayındır, 2016; Raffat \\u0026amp; ul Hamid, 2009). Empirical evidence supports the hypothesis that nasal airway obstruction precipitates craniofacial alterations as the body compensates for the anatomic anomaly (Diouf et al., 2015). Meyer (1870) was the first to document that improvements in craniofacial morphology occur immediately following the resolution of the obstruction. Since then, multiple studies have substantiated the potential for craniofacial remodeling following the restoration of nasal breathing, with the most pronounced effects observed in younger patients (Linder-Aronson, Woodside \\u0026amp; Daigle, 1975; Zettergren-Wijk et al., 2006).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003col start=\\\"3\\\"\\u003e\\n \\u003cli\\u003e\\n \\u003ch3\\u003e\\u003cstrong\\u003eDentofacial Deformities (DFD) and Manifestations of Speech Disorders\\u003c/strong\\u003e\\u003c/h3\\u003e\\n \\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003eThe transition from nasal to oral breathing induces alterations in the positioning of the jaw, tongue, and head, thereby disrupting the equilibrium between the intrinsic muscular forces of the tongue and the extrinsic forces exerted by the facial and masticatory musculature. Two\\u0026nbsp;primary mechanisms elucidate the impact of mouth breathing on the development of\\u0026nbsp;dental and facial deformities (DFD)\\u0026nbsp;and articulation disorders.\\u003c/p\\u003e\\n\\u003cp\\u003eThe first mechanism pertains to nasal obstruction caused by rhinitis, nasal polyps, or\\u0026nbsp;a deviated nasal septum. Under these circumstances, the mouth remains open to compensate for reduced nasal airflow, resulting in sustained isotonic contraction of the masticatory muscles and increased external muscular pressure. Consequently, the mandible assumes a posterior and open position, while the tongue is displaced inferiorly and posteriorly. Additionally, the head tilts backward. Depending on the duration and timing of the etiological factor, persistent external muscular pressure may lead to maxillary compression, the formation of a deep, gothic-arched palate, the development of distal occlusion, lateral crossbite, and anterior open bite due to overeruption of the posterior teeth.\\u003c/p\\u003e\\n\\u003cp\\u003eThe second mechanism involves hypertrophy of the adenoid tissue along the posterior pharyngeal wall. This condition necessitates anterior tongue displacement to maintain an open airway, leading to excessive mandibular growth, classified as mandibular prognathism or Angle\\u0026rsquo;s Class III malocclusion. Such alterations may further contribute to dental crossbite in both the\\u0026nbsp;posterior\\u0026nbsp;and anterior segments of the mouth.\\u003c/p\\u003e\\n\\u003cp\\u003eThese anatomical and muscular modifications significantly influence speech production, primarily through alterations in tongue positioning and muscle tone. From a speech pathology perspective, individuals with oral breathing frequently exhibit articulation disorders, most notably interdental sigmatism. This disorder is especially prevalent among children with adenoid hypertrophy, obstructing more than 50% of the airway (Mohamed \\u0026amp; Ibrahem, 2024). The underlying pathophysiology is attributed to altered tongue pressure dynamics caused by hypertrophic palatine and nasopharyngeal tonsils in children exhibiting oral breathing patterns (Pereir et al., 2019).\\u003c/p\\u003e\\n\\u003cp\\u003eHitos, Arakaki, Sol\\u0026eacute;, and Weckx (2013) emphasize that mouth breathing can harm speech development, socialization, academic performance, and overall physical health. A study by Eom et al. (2014) identified a higher prevalence of articulation disorders in children with adenoid hypertrophy, particularly the substitution of speech sounds, which was more frequently observed in this population than in children without adenoid hypertrophy. Moreover, these children often present with hyponasal speech due to nasal obstruction. The etiology of these speech impairments is multifaceted, encompassing adenoid facies, restricted tongue mobility, and reduced soft palate movement due to tonsillar hypertrophy. Collectively, these factors contribute to the exacerbation of speech disorders (Łapińska \\u0026amp; Zawadzka-Glos, 2016).\\u003c/p\\u003e\\n\\u003cp\\u003eEarly establishment of mouth breathing is critical to reduce its adverse effects on physiological and developmental outcomes.\\u003c/p\\u003e\\n\\u003col start=\\\"4\\\"\\u003e\\n \\u003cli\\u003e\\n \\u003ch3\\u003e\\u003cstrong\\u003eMultidisciplinary Approach to the Аssesment and Identification of Mouth Breathing Symptoms\\u003c/strong\\u003e\\u003c/h3\\u003e\\n \\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003eA multidisciplinary approach is crucial for confirming the diagnosis and identifying the symptoms of mouth breathing.\\u0026nbsp;Researchers emphasize the significance of this approach, as various fields of assessment, including otorhinolaryngology, orthodontics, and speech therapy,\\u0026nbsp;offer distinct yet interrelated factors contributing to diagnosing oral breathing (Milanesi et al., 2018). The preschool years represent a critical period for early diagnosis, as timely intervention can prevent the development of associated disorders (Alhazmi, 2022; Sano et al., 2018; Warnier et al., 2023).\\u003c/p\\u003e\\n\\u003cp\\u003eIn clinical practice, the evaluation context for assessing a child\\u0026apos;s breathing pattern is often determined by the speech-language pathologist\\u0026rsquo;s discretion (Warnier et al., 2023). Observing the child at rest, specifically the duration of mouth opening and closure, as well as the positioning of the tongue and lips, is the primary criterion for diagnosing mouth breathing. Additionally, experts suggest that assessing breathing patterns during mastication (whether the mouth remains open or closed) and immediately post-swallowing (whether the child takes a breath with an open or closed mouth) provides supplementary yet secondary diagnostic information (Warnier et al., 2023). Early identification of mouth breathing is crucial in minimizing its adverse effects on craniofacial and dental development, as well as mitigating related medical and social complications (Jefferson, 2010).\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAim, design, and setting of the study\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study aims to evaluate patients with breathing disorders caused by adenoid hypertrophy. The difficulties will be described from the perspectives of three specialists: an ENT specialist, an orthodontist, and a speech-language pathologist. Each of them will independently provide an assessment. The collected data will serve as a foundation for developing an assessment approach carried out by a multidisciplinary team. Based on the diagnostic processes and the subsequent therapy, recommendations will be proposed for a comprehensive, interdisciplinary treatment approach.\\u003c/p\\u003e\\n\\u003cp\\u003eThe objective of the present study was to identify the orthodontic DFD observed in a group of mouth-breathing patients diagnosed with adenoid hypertrophy and to determine the presence of concomitant speech pathology or exclude such manifestations.\\u003cstrong\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePatient Grouping\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eOrthodontist:\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003eThe patients will be divided into groups based on their skeletal growth, which will be evaluated using the cerebral vertebral maturation method, as determined by a cephalometric X-ray. There will be a group that is before the peak of growth, and the group with actively growing patients.\\u003c/p\\u003e\\n\\u003cp\\u003eFor the speech-language analysis, the data will be grouped according to the age of the children participating in the study.\\u003c/p\\u003e\\n\\u003cp\\u003eENT: The children will be grouped according to the grade of their adenoid hypertrophy.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003e\\u003cstrong\\u003eD\\u003c/strong\\u003e\\u003cstrong\\u003eescription of\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003emultidisciplinary\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003emethodology:\\u003c/strong\\u003e\\u003c/h3\\u003e\\n\\u003cp\\u003eEach child was consulted by a multidisciplinary team consisting of an otolaryngologist, an orthodontist, and a speech-language pathologist. Parents were provided with information about the purpose and method of assessment, and all parents received feedback from all specialists about their child\\u0026apos;s condition immediately after the study. Each team member examined the children individually, and information was provided in advance about what was required to remain calm and cooperative.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eENT methodology:\\u003c/em\\u003e The diagnostic procedures included mesopharyngoscopy, anterior rhinoscopy using a nasal speculum, and otoscopy. An endoscopy of the epipharynx using a flexible endoscope was performed under local anesthesia. Adenoid hypertrophy was graded using a modified endoscopic assessment method, supplemented by lateral cervical radiography for obstruction measurement. The Brodsky scale was used to evaluate the size of the palatine tonsils and the extent to which the space between the palatoglossal pillars is occupied. Under general intubation anesthesia preoperatively, a second inspection was conducted, and adenoid tissue obstruction was classified as follows:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eGrade 0: No visible adenoid tissue\\u003c/li\\u003e\\n \\u003cli\\u003eGrade I: Adenoid tissue obstructing \\u0026lt;25% of the epipharynx\\u003c/li\\u003e\\n \\u003cli\\u003eGrade II: Adenoid tissue obstructing 25%\\u0026ndash;50% of the epipharynx\\u003c/li\\u003e\\n \\u003cli\\u003eGrade III: Adenoid tissue obstructing 50%\\u0026ndash;75% of the upper airway space\\u003c/li\\u003e\\n \\u003cli\\u003eGrade IV: Adenoid tissue obstructing \\u0026gt;75% of the epipharynx\\u0026nbsp;\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eClassification based on the Brodsky grading scale: Grade 0: Tonsils are located entirely within the tonsillar fossa (the natural depressions where the tonsils sit) and are not visible or barely visible.\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003e\\u0026nbsp;Grade I: Tonsils are visible and extend slightly outside the fossa, taking up to \\u0026nbsp;25% of the oropharyngeal width.\\u003c/li\\u003e\\n \\u003cli\\u003e\\u0026nbsp;Grade II: Tonsils occupy 26% to 50% of the oropharyngeal width.\\u003c/li\\u003e\\n \\u003cli\\u003e\\u0026nbsp;GradeIII: Tonsils occupy 51% to 75% of the oropharyngeal width.\\u003c/li\\u003e\\n \\u003cli\\u003e\\u0026nbsp;Grade IV: Tonsils are very large, occupying more than 75% of the oropharyngeal width and potentially touching each other or the uvula.\\u0026nbsp;\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eSpeech-language methodology:\\u003c/em\\u003e The \\u0026quot;Protocol for the Assessment of Articulation in Preschool and Early School-Aged Children\\u0026quot; (Todorova, 2018) was used to assess articulation disorders. A speech-language evaluation was conducted in a clinical setting, in the presence of a parent, who also provided anamnestic data necessary for establishing the child\\u0026apos;s speech profile. The assessment of the speech apparatus and articulation was engaging for the children, and they participated calmly and cooperatively. During the evaluation, the presence or absence of anatomical and physiological features of the articulatory apparatus, as well as the level of praxis ability, is established. The impairment of which consonant groups of sounds is investigated\\u0026mdash;the number of affected phoneme classes. A qualitative analysis of the types of errors and their specifics is performed. The research procedure encompasses the production of isolated phonemes, a series of oppositional phonemes, words with complex phonological contexts, and various positional distributions, at the level of repeated and spontaneous speech. The goal is to establish the stability and consistency of the type of incorrect articulation. To differentiate between articulatory and phonological disorders, tests assessing phonological and meta-phonological functioning are included.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eOrthodontist methodology:\\u003c/em\\u003e All patients underwent an orthodontic examination by a specialist, which documented any existing orthodontic deformities. The assessment included a detailed review of the patient\\u0026apos;s medical history in a clinical setting. As part of the comprehensive orthodontic evaluation, additional radiographic examinations\\u0026mdash;orthopantomography and cephalometric radiography\\u0026mdash;were performed to detect skeletal-level deformities. Changes were documented at dental and skeletal levels, and occlusion was assessed in three planes. Through extraoral examination, evaluate the presence of adenoid facies. Intraorally, assess the type of dentition (temporary, early mixed, late mixed, and permanent), separate dental arch problems, and occlusion in three planes: sagittal, transversal, and vertical, in both frontal and distal areas. The maturity of the skeletal system is evaluated through the CVM method in lateral cephalometry.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCharacteristics of participants\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study group consisted of fourteen children, including 6 girls and 8 boys, with a mean age of 7.11 years (range: 4\\u0026ndash;11 years). An otorhinolaryngologist, an orthodontist, and a speech-language pathologist assessed each patient\\u0026apos;s medical history and conducted a comprehensive clinical examination, followed by diagnostic interventions.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAll three specialists have examined the patients included in the study and confirmed a diagnosis of nasal breathing difficulty. The etiology of the difficulty in nasal breathing is not of allergic origin, as confirmed by a specialist allergist. Refusal to visit even one of the three is an exclusion criteria.\\u003c/p\\u003e\\n\\u003cp\\u003eENT exclusion criteria:\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003eage - children younger than 24 months and patients older than 21.\\u0026nbsp;Another exclusion criteria is the presence of a syndromic disease or other severe systemic disease. There are no patients with cleft palate included in the study. Another exclusion criteria is severe facial trauma Le Fort - I, II, III, and children with iatrogenic changes in the oro/hypopharyngeal, nasopharyngeal regions, and iatrogenic damage to the tongue. ENT inclusion criteria - children who sleep with open mouths for more than 6 months, snoring for more than 6 months, unaltered by medication. Severe and recurrent nasal and middle ear infections. Children with enlarged adenoids obstructing more than 40% of the epipharynx. Age- children older than 24 months.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;From a speech-language pathology perspective, the exclusion criteria that were taken into account are: no children in the present sample had developmental language disorder, intellectual disability, sensory impairment, neurological disorder, behavioral disorder, or were raised in a deprived environment. All children included in the studied sample demonstrate only a specific articulation disorder. Parental anamnesis confirmed that all children were monolingual, with Bulgarian as their native language.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eENT Results and Diagnostic Analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll\\u0026nbsp;fourteen\\u0026nbsp;children in the study were diagnosed with AH, and\\u0026nbsp;ten\\u0026nbsp;also exhibited signs of adenoid facies (AF), except for the\\u0026nbsp;four\\u0026nbsp;youngest children born in 2020. Six were presented with grade III AV,\\u0026nbsp;four\\u0026nbsp;with grade III-IV AH, and four with grade IV AH.\\u0026nbsp;Ten\\u0026nbsp;of the examined children had a history of ear pathology, ranging from acute purulent otitis to conductive hearing loss.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1.\\u0026nbsp;\\u003c/strong\\u003eGeneral Sample Data\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"639\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eGender\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eAge (years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eAdenoid Facies\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eAH Gradе\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003ePalatine hypertrophy grade\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"41\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"23\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e4,11\\u003c/p\\u003e\\n 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style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e6,6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e4,3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e8,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e4,9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e11,8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e8,4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e3-4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e7,6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e3-4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e6,2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e4,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e8,5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 119px;\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 236px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"24\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eTable 1 describes the general data of the examined group.\\u0026nbsp;Twelve\\u0026nbsp;children exhibited oral breathing, while\\u0026nbsp;two of them\\u0026nbsp;(the\\u0026nbsp;youngest) demonstrated mixed breathing. According to parental reports, all children slept with their mouths open and experienced loud snoring during sleep. Following surgical intervention, 100% of the operated children showed improved sleep quality and normalized nasal breathing.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSpeech Therapy Results and Diagnostic Analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn Table 2, the characteristics of the articulatory apparatus are described based on data collected by the speech-language pathologists and confirmed by the otolaryngologist who diagnosed the children. Six children were found to have a gothic palate, while two children had a short frenulum requiring surgical correction. The children exhibited atypical swallowing, attributed to improper tongue positioning and oral breathing. Examination of the speech apparatus revealed that the tongues of four children (see tab. 2) were in an interdental position at rest. Behind the lower incisors, the tongue rested low in the other ten children. The articulation disorders diagnosed during the speech therapy assessment are detailed in Table 3.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2.\\u0026nbsp;\\u003c/strong\\u003eCharacteristics of the Articulatory Apparatus\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"634\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eGender\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003eAge (years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eArticulatory Apparatus Features\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e4,11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eShort sublingual frenulum, interdental tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e11,11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eLow tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e8,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eGothic palate, Low tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e7,8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eGothic palate, Low tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e6,6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eInterdental tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e4,3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eLow tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e8,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eGothic palate, Low tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e4,9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eShort sublingual frenulum, interdental tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e11,8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eLow tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e8,4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eGothic palate, Low tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e7,6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eGothic palate, Low tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e6,2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eInterdental tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e4,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eLow tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 87px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 101px;\\\"\\u003e\\n \\u003cp\\u003e8,5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 446px;\\\"\\u003e\\n \\u003cp\\u003eGothic palate, Low tongue position\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 3.\\u0026nbsp;\\u003c/strong\\u003eType of Articulation Disorder\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"649\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eGender\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eAge (years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eArticulation Disorder\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"21\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"21\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e4,11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eIntedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Substitute post-alveolar frivatives [sh, zh] and post-alveolar affricative [tsh] with alveolar fricatives [s, z] and alveolar affricative [ts]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"71\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e11,11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eIntedental sigmatism of fricative alveolar [s, z] and alveolar affricative [ts]; Interdental articulation of plosive alveolars [t, d] and \\u0026nbsp; \\u0026nbsp; nasal alveolar [n]; lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"65\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e8,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eInterdental articulation of plosive alveolars [t, d] and \\u0026nbsp;nasal alveolar [n]; lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"37\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e7,8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eInterdental articulation of plosive alveolars [t, d] and \\u0026nbsp;nasal alveolar [n]; \\u0026nbsp;lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"33\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e6,6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eIntedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Interdental consonats [t,d,n]; lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"53\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e4,3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eSubstitute post-alveolar fricatives [sh, zh] and post-alveolar affricative [tsh] with fricatives alveolar [s, z] and alveolar affricative [ts]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"51\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e8,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eIntedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Interdental articulation of plosive alveolars [t, d] and \\u0026nbsp; \\u0026nbsp; nasal alveolar [n]; \\u0026nbsp;lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"63\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e4,9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eIntedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Substitute post-alveolar frivatives [sh, zh] and post-alveolar affricative [tsh] with alveolar fricatives [s, z] and alveolar affricative [ts]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"62\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e11,8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eIntedental sigmatism of fricative alveolar [s, z] and alveolar affricative [ts]; Interdental articulation of plosive alveolars [t d] and \\u0026nbsp; \\u0026nbsp; nasal alveolar [n]; lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"41\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e8,4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eInterdental articulation of plosive alveolars [t, d] and \\u0026nbsp;nasal alveolar [n]; lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"34\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e7,6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eInterdental articulation of plosive alveolars [t, d] and \\u0026nbsp;nasal alveolar [n]; \\u0026nbsp;lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"40\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e6,2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eIntedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Interdental consonats [t, d, n]; lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"56\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e4,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eSubstitute post-alveolar fricatives [sh, zh] and post-alveolar affricative [tsh] with fricatives alveolar [s, z] and alveolar affricative [ts]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"57\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e8,5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 462px;\\\"\\u003e\\n \\u003cp\\u003eIntedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]; Interdental articulation of plosive alveolars [t, d] and \\u0026nbsp;nasal alveolar [n]; \\u0026nbsp;lambdacism of lateral approximant alveolar [l]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 16px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd height=\\\"51\\\" style=\\\"width: 0px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eThe data in Table 3 reveal the following articulatory characteristics in the children examined: none demonstrated correct articulation of speech sounds. The youngest children exhibited substitution of post-alveolar fricatives [sh, zh] and post-alveolar affricative [tsh] with alveolar fricatives [s, z] and alveolar affricative [ts] but did not demonstrate interdental tongue placement during articulation. The slightly older ones also demonstrate an articulation disorder of fricatives [sh, zh] and post-alveolar affricative [ch] as these consonants are replaced by \\u0026nbsp;[s, z, ts] but are pronounced interdentally already. The age of these children is approaching five years. In comparison, the younger children are at the age of four. So, a common articulation disorder involves the sibilant consonants [s, z, ts] and specifically their interdental pronunciation, known in speech therapy as interdental sigmatism. In the remaining children in the studied group, it was observed that six out of ten children exhibited an interdental pronunciation of the consonants [s, z, ts]. Notably, improper tongue positioning during the articulation of consonants [t, d] and [n] was also observed in children with adenoid hypertrophy. The results show that incorrect articulation of consonants [t, d] and [n] is more common in children from the study group. We can explain this articulation disorder by the tongue falling into a lower position during incorrect breathing and weakened muscles. Ten of fourteen children demonstrate a disorder in the pronunciation of [t, d] and [n], where the place of articulation of the sound is changed, and the position that the tongue occupies when pronouncing them occurs between the upper and lower incisors. These are all children who are over the age of 4.\\u003c/p\\u003e\\n\\u003cp\\u003eIt is evident from the data in the table that children who are over 8 years and 4 months and where the AH factor has been active for the longest time, articulation disorders of several consonant classes of sounds are detected:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eIntedental sigmatism of fricatives alveolar [s, z] and alveolar affricative [ts]\\u003c/li\\u003e\\n \\u003cli\\u003eInterdental articulation of plosive alveolars [t, d] and \\u0026nbsp;nasal alveolar [n]\\u003c/li\\u003e\\n \\u003cli\\u003eLambdacism of lateral approximant alveolar [l]\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eThe same results are shown for children aged 6 years. They demonstrate articulation disorders typical of these children, which appear by the age of 8 years and 4 months. Four of the children, aged 7-8 years old, mispronounce only the sounds [t, d] and [n], as well as a consonant of late ontogenesis - [l].\\u003c/p\\u003e\\n\\u003cp\\u003eComparing the data from the orthodontic analysis, we can conclude that in patients with a Class II occlusion, characterized by distal and deep occlusion, incorrect articulation of [t, d] and [n] was a typical finding. In patients with Class III occlusion and grade IV AH, interdental sigmatism of sibilants and interdental articulation of [t, d] and [n] were observed. Additionally, all these children demonstrated bilabial pronunciation of lateral approximant alveolar [l] in syllables with vowels [\\u003cem\\u003ea, ɤ, ɔ, u\\u003c/em\\u003e].\\u003c/p\\u003e\\n\\u003cp\\u003eIt is obvious that adenoid hypertrophy negatively affects the articulation of sounds that are produced from the tip of the tongue in the oral cavity, such as [s, z, ts, l, d, t, n]. In summary, the results of the assessment indicate that children with prolonged AH also exhibit orthodontic deformities and disordered articulation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eOrthodontic Results and Diagnostic Analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll patients undergo a specialized orthodontic examination. It begins with an extraoral examination - is there facial asymmetry between the two facial halves, are the three facial levels evenly developed. Another essential characteristic is the presence of blue circles under the eyes, skin turgor, and the development or underdevelopment of the nostrils. Additionally, the patient\\u0026apos;s posture, whether they stand with their mouth open, and their ability to concentrate efficiently are also essential factors. His ability to breathe through his nose for at least 1 minute is examined.\\u003c/p\\u003e\\n\\u003cp\\u003eThe type of dentition is assessed - temporary, early mixed, late mixed, or permanent. The condition of the dentition is assessed as maintained or with caries.\\u003c/p\\u003e\\n\\u003cp\\u003eThe soft tissues are assessed - are the frenums and the mucous membrane normal, is there inflammation of the gums. The plaque index of the front teeth is also assessed.\\u003c/p\\u003e\\n\\u003cp\\u003eIn the individual dental arch, it is monitored whether there are diastemas and tremas or tooth crowding, there is tooth rotation or pronounced compression of the individual jaw. The depth and shape of the palate are monitored, including whether it is normal, deep, or Gothic, and whether it is symmetrical.\\u003c/p\\u003e\\n\\u003cp\\u003eThe dentition is examined in three planes: vertical, transverse, and sagittal.\\u003c/p\\u003e\\n\\u003cp\\u003eVertically, it is examined whether there is an open occlusion in the frontal or lateral segment.\\u003c/p\\u003e\\n\\u003cp\\u003eTransversely, it is observed whether there is a divergence of the midlines in the two jaws in the frontal segment or a cross occlusion in the lateral segment.\\u003c/p\\u003e\\n\\u003cp\\u003eSagittally, it is monitored whether there is a cross-occlusion between one or several teeth in the frontal segment. In the lateral segment, the occlusion is assessed according to Angle\\u0026apos;s classification.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;According to Angle\\u0026rsquo;s classification for sagittal relationships between jaws, the children were categorized as follows:\\u003c/p\\u003e\\n\\u003cul class=\\\"decimal_type\\\"\\u003e\\n \\u003cli\\u003eClass I occlusion: seven patients an average age of 5.6 years;\\u003c/li\\u003e\\n \\u003cli\\u003eClass II: four with an average age of 9.9 years;\\u003c/li\\u003e\\n \\u003cli\\u003eClass III: three patients with an average age of 7.7 years.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eAll patients underwent lateral cephalometry to assess the degree of bone maturation.\\u003c/p\\u003e\\n\\u003cp\\u003eThe Cervical Vertebral Maturation (CVM) method is used to categorize the skeletal maturity of each patient. The procedure consists of six stages, based on changes in the cervical vertebrae. These stages are generally grouped into three categories: prepubertal (CS1 and CS2), pubertal (CS3 and CS4), and postpubertal (CS5 and CS6).\\u003c/p\\u003e\\n\\u003cp\\u003eDetailed data are presented in Table 4.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 4.\\u0026nbsp;\\u003c/strong\\u003eType of Orthodontic Deformations\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"624\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eGender\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eAge (years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eCVM-stage\\u003c/p\\u003e\\n \\u003cp\\u003ematuration\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eOrthodontic Deformation\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e4,11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass I skeletal occlusion, no orthodontic deformation\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;11,11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eIII\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eDeep distal (Class II) occlusion, maxillary compression\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e8,10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eIII\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eDeep distal (Class II) occlusion, maxillary compression\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e7,8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eII\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass I skeletal occlusion, maxillary compression\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e6,6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass III skeletal occlusion, edge-to-edge bite\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e4,3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass I skeletal occlusion, no orthodontic deformation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e8,10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eII\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass III occlusion, maxillary compression\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e4,9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass I skeletal occlusion, no orthodontic deformation\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e11,8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eIII\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eDeep distal (Class II) occlusion, maxillary compression\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e8,4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eIII\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eDeep distal (Class II) occlusion, maxillary compression\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e7,6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eII\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass I skeletal occlusion, maxillary compression\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e6,2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass I skeletal occlusion, no orthodontic deformation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e4,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass I skeletal occlusion, no orthodontic deformation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003e8,5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 96px;\\\"\\u003e\\n \\u003cp\\u003eII\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 366px;\\\"\\u003e\\n \\u003cp\\u003eClass III occlusion, maxillary compression\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003ePatients with a Class I occlusion and no orthodontic deformation are in CVM stage I, before the spur of skeletal growth. There are 4-year-old females. No orthodontic deformities were found, and they are the only ones in the group without adenoid facies or compression of the maxillofacial region.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTwo females and two males with Class II occlusion, with an average age of 9.85, were included. All of them are in the CVM III stage. In the vertical dimension, a deep bite and distal occlusion were established in all patients.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003ePatients with Class III\\u0026nbsp;occlusion\\u0026nbsp;are\\u0026nbsp;three\\u0026nbsp;males\\u0026nbsp;aged\\u0026nbsp;6,6 and 8,1 and 8,5 years. The\\u0026nbsp;6,6 -year-old\\u0026nbsp;male\\u0026nbsp;shows edge-to-edge occlusion in\\u0026nbsp;the vertical\\u0026nbsp;dimension\\u0026nbsp;and a tendency toward Class III malocclusion. The\\u0026nbsp;male, aged\\u0026nbsp;8,1 and 8,5,\\u0026nbsp;presents compression in the UJ, which is a deformation in the transversal dimension of the jaw.\\u003c/p\\u003e\\n\\u003cp\\u003eThe\\u0026nbsp;youngest patients, 4-year-old females, have\\u0026nbsp;no established orthodontic deformities or adenoid facies. They are the only ones without compression in the maxillofacial region. In contrast, all other patients exhibit\\u0026nbsp;varying degrees of orthodontic deformities. These are related to improper breathing patterns, such as mouth breathing, which results in compression in the maxillofacial region and the development of Class II and III malocclusions, depending on the deformation mechanism.\\u003c/p\\u003e\\n\\u003cp\\u003eIn the group with an average age of 8 years, after a detailed anamnestic history, it was determined that the etiological factor\\u0026mdash;mouth breathing\\u0026mdash;had been present for a more extended period, which coincided with the development of the bones in the nasomaxillary complex. This group exhibited a distal occlusion. The patient showed edge-to-edge occlusion and a tendency toward a medial occlusion, indicating the formation of another expected group. In this group, the etiological factor - difficult nasal breathing\\u0026mdash;leads to a long-term change in the shape of the UJ, but through a different mechanism. While in the previous group, where patients had a distal\\u0026nbsp;occlusion, only mouth opening and a posterior position of the lower jaw were observed, in this group, the tongue shifts to the anterior sections to free up additional space for air passage, thereby developing the anterior segment of the lower jaw.\\u003c/p\\u003e\\n\\u003cp\\u003eTransversal expansion is a widely used method in clinical practice; however, it should be performed strictly in accordance with clinical indications. For it to be a purely orthodontic method and not a surgical-orthodontic one, expansion in the transversal direction is most suitable before the complete ossification of the palatal suture. Ossification (maturation) of the suture is most accurately determined radiographically or, more specifically, by Cone beam computed tomography (CBCT). This is supported by the study of Angelieri et al. (2013), which serves as fundamental research in this field. Clinically, this process manifests as a diastema, which appears during active expansion and self-closes after the process is complete. A more detailed study involves measuring the volumes of the maxillofacial region before and after treatment to observe changes in the volume and assess whether there is a correlation between transversal expansion and the increase in the volume of the maxillofacial region.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eIn today's life, the problem of mouth breathing is increasingly widespread and shouldn\\u0026rsquo;t be underestimated. The condition may be a consequence of a long illness and a habit of breathing through the mouth, for no other reason. The increasingly common allergic conditions affecting patients at a younger age pose another challenge to modern society. The reason for this is the widespread use of chemicals and fragrances in detergents and products that have permeated all levels of our daily lives. Differentiating the exact cause of mouth breathing is crucial for a correct treatment approach.\\u003c/p\\u003e\\u003cp\\u003eSuppose there are no other reasons for mouth breathing, and it has become a habit, and is discovered in time. In that case, it can be easily overcome with a system of exercises and a myofunctional device for a short period. However, if there is an allergy or another reason, it is unacceptable to use a myofunctional device, which can further disrupt and complicate the child's breathing.\\u003c/p\\u003e\\u003cp\\u003eIf the exact cause of the allergy is identified, it can be controlled with medication, and treatment can then be initiated if mouth breathing has become a habit.\\u003c/p\\u003e\\u003cp\\u003eAn accurate diagnosis by an ENT specialist is necessary to differentiate between a large part of the other possible causes of mouth breathing, such as a deviated nasal septum, nasal mucosa hypertrophy, and adenoid hypertrophy. AH was reported to be the reason for mouth breathing in 44% of all cases, allergic rhinitis in 11.3%, and both in 34.6%. (Atar Bese et al., \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e) In another literature review, Ma et al. (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e) report the range of adenoid hypertrophy from 42\\u0026ndash;70%.\\u003c/p\\u003e\\u003cp\\u003eMaking an accurate diagnosis also allows for accurate and precise treatment.\\u003c/p\\u003e\\u003cp\\u003eDisruption of a basic vital function, such as breathing, inevitably leads to disruption of all other systems. For an extended period, a compensation process occurs within the body, but when the possibilities for compensation are exhausted, morphological changes take place.\\u003c/p\\u003e\\u003cp\\u003eThe change in the position and function of the tongue is a direct reflection of changes in breathing and occlusion patterns.\\u003c/p\\u003e\\u003cp\\u003eA factor acting for a long time, especially during the period of active growth of the bone system, and leading to different contractions and functions of all muscles\\u0026mdash;masticatory and mimic \\u0026mdash; leads to changes in the development of the facial bones and to severe maxillofacial deformities.\\u003c/p\\u003e\\u003cp\\u003e It is essential for parents to be aware of the problem and to be promptly informed and convinced of the need for treatment of their children, as well as the consequences that would arise if they do not receive appropriate treatment. A systematic review has evidenced dentofacial changes in numerous studies (Lin et al., \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e). The most common changes include a retrognathic mandible, an increased angle of the mandibular plane, and downward and backward rotation of the mandible. It is necessary to establish a transparent and systematized approach to work and collaboration among individual specialists to ensure a precise, individualized, and professional attitude and consideration of each clinical case.\\u003c/p\\u003e\\u003cp\\u003eThe pilot study aimed to conduct a more in-depth investigation of the issue and monitor the duration for which the etiological factor has been acting. The primary focus of this pilot study is to establish a strong correlation between patients with adenoid and/or palatine hypertrophy and their relationship to orthodontic and speech abnormalities. The study revealed that orthodontic deformities were not observed when the etiological factor was absent for a sufficiently long time and the period of its action occurred before the primary growth and development of the structures in the craniofacial area (CFA). This was evident in the youngest participants in the study, in whom speech sound disorders were associated with tongue malpositioning. The continued presence of the etiological factor contributes to the manifestation of irregular speech production and the development of various orthodontic symptoms.\\u003c/p\\u003e\\u003cp\\u003ePatients who participated in the study had orthodontic abnormalities consistent with the etiologic factor and expected based on it. Articulation disorders are commonly seen in adenoid hypertrophy and persist until the cause is corrected, resulting in mouth breathing and malpositioning of the tongue. Orthodontic treatment would be compromised without speech therapy intervention to properly position the tongue in the oral cavity. AH is a condition that can alter speech and potentially lead to a speech sound disorder. Airway obstruction can lead to constricted oral breathing. That, in turn, can lead to postural alterations in several oral-facial structures. Evaluating all the patient's problems systematically and working towards removing the cause of improper breathing and all related conditions can dramatically improve the child's physical growth, articulation ability, and reduce facial and dental problems associated with the condition.\\u003c/p\\u003e\\u003cp\\u003eThe study was conducted among professionals working in the field of early childhood development and is considered innovative for our country, which is reflected in the lack of data from studies on the same topic. However, the pilot study also has its limitations. Data collection is labour-intensive, as each patient must undergo three separate consultations: first with an ENT specialist, then with an orthodontist, and finally with a speech therapist. And it often happens that the recommendations given by the ENT for further consultations with the other two specialists are not followed. This is the reason why the data presented is limited to this number. As a result, data collection is a time-consuming process. It should be emphasized that the small number of subjects also represents a limitation for presenting the results by statistical analysis.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eEarly diagnosis of adenoid hypertrophy serves as a preventive measure and protection against related complications. With early diagnosis and resolution of the issue through conservative or surgical treatment, permanent facial and jaw changes, as well as speech sound disorders, could be prevented. Children with conductive hearing loss and frequent perforative, purulent otitis media require specific examination for the presence of adenoid hypertrophy. Children diagnosed with adenoid hypertrophy by an ENT specialist should be referred for consultation with a speech-language pathologist and an orthodontist. To achieve optimal results, post-operative follow-up with patients is necessary, focusing on acquiring voluntary nasal breathing and intentional changes in tongue position, which will lead to the reinforcement and automatization of these processes. In cases where surgical intervention has been performed, but post-operative speech therapy and orthodontic treatment are lacking, the results for the patients are poorer. A multidisciplinary team and approach are required to assess and treat changes caused by adenoid hypertrophy before permanent changes occur. Early screening, assessment, and timely multidisciplinary therapy are crucial in preventing the development of craniofacial deformities and speech sound disorders.\\u003c/p\\u003e\"},{\"header\":\"Recommendations\",\"content\":\"\\u003cp\\u003eThis study provides a reasonable basis and a request for its continuation. Including more children will clarify the expected consequences of adenoid hypertrophy. Including data from the therapy being carried out by the multidisciplinary team will also be interesting from a research perspective.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003c/p\\u003e\\u003ch2\\u003eEthics Approval and Consent to Participate\\u003c/h2\\u003e\\u003cp\\u003eThis study was not deceptive, and there was no risk or harm to participants (Code of Ethics and Conduct, 2018). The experimental procedure complied with the ethical standards of the Declaration of Helsinki. It was approved by the Ethics Committee of the Department of Health Care and Social Work at New Bulgarian University, with protocol No. 137, dated April 15, 2025. The parents of the participants provided written informed consent before the study.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003ch2\\u003eFunding\\u003c/h2\\u003e\\u003cp\\u003eThis research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eVM, TSB, and GG contributed by designing the study, collecting and interpreting the data, providing the assessment, and drafting and revising the manuscript. ET and GY contributed by writing and revising the manuscript. All authors contributed to data analysis and interpretation.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eThe authors confirm that the data supporting the findings of this study are available within the article and/or its supplementary materials.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eAbreu RR, Rocha RL, Lamounier JA, Guerra AF (2008) Etiology, clinical manifestations and concurrent findings in mouth-breathing children. Jornal de pediatria 84(6):529\\u0026ndash;535. https://doi.org/10.2223/JPED.1844.\\u003c/li\\u003e\\n\\u003cli\\u003eAngelieri , Cevidanes LH, Franchi L, Gon\\u0026ccedil;alves JR, Benavides E, McNamara, JA (2013) Midpalatal suture maturation: classification method for individual assessment before rapid maxillary expansion. American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 144(5):759\\u0026ndash;769. https://doi.org/10.1016/j.ajodo.2013.04.022.\\u003c/li\\u003e\\n\\u003cli\\u003eAhmad Z, Kr\\u0026uuml;ger, K, Lautermann J, Lippert B, Tenenbaum T, Tigges M, Tisch M (2023) Adenoid hypertrophy-diagnosis and treatment: the new S2k guideline. Adenoide Vegetationen \\u0026ndash; Diagnostik und Therapie \\u0026ndash; die neue S2k-Leitlinie. HNO, 71(Suppl 1):67\\u0026ndash;72. https://doi.org/10.1007/s00106-023-01299-6.\\u003c/li\\u003e\\n\\u003cli\\u003eAlhazmi WA (2022) Mouth Breathing and Speech Disorders: A Multidisciplinary Evaluation Based on The Etiology. Journal of pharmacy \\u0026amp; bioallied sciences, 14 (Suppl 1) S911\\u0026ndash;S916. https://doi.org/10.4103/jpbs.jpbs_235_22.\\u003c/li\\u003e\\n\\u003cli\\u003eAtar Bese S, Ozdemir O, Tuncerler G, Erge D, Uysal P. Do not ignore mouth breathing syndrome: respiratory functions are affected in early childhood. Rhinology. 2024 Dec 1;62(6):659-668. doi: 10.4193/Rhin24.133. PMID: 39254513.\\u003c/li\\u003e\\n\\u003cli\\u003eDiouf JS, Ngom PI, Sonko O, Diop-B\\u0026acirc; K, Badiane A, Diagne F (2015) Influence of tonsillar grade on the dental arch measurements. American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics, 147(2):214\\u0026ndash;220. https://doi.org/10.1016/j.ajodo.2014.10.028.\\u003c/li\\u003e\\n\\u003cli\\u003eEom TH, Jang ES, Kim YH, Chung SY, Lee IG (2014) Articulation error of children with adenoid hypertrophy. Korean journal of pediatrics 57(7):323\\u0026ndash;328. https://doi.org/10.3345/kjp.2014.57.7.323.\\u003c/li\\u003e\\n\\u003cli\\u003eFrasson JM, Magnani MB, Nouer DF, de Siqueira VC, Lunardi N (2006) Comparative cephalometric study between nasal and predominantly mouth breathers. Brazilian journal of otorhinolaryngology 72(1):72\\u0026ndash;81. https://doi.org/10.1016/s1808-8694(15)30037-9.\\u003c/li\\u003e\\n\\u003cli\\u003eJefferson Y (2010) Mouth breathing: adverse effects on facial growth, health, academics, and behavior. General dentistry 58(1):18\\u0026ndash;80. https://assets.cdn.thewebconsole.com/S3WEB8659/images/Mouth-breathing---adverse-effects-on-facial-growth-health-academics-and-behaviour.pdf.\\u003c/li\\u003e\\n\\u003cli\\u003eJim\\u0026eacute;nez EL, Barrios R, Calvo JC, de la Rosa, MT, Campillo JS, Bayona JC, Bravo M (2017) Association of oral breathing with dental malocclusions and general health in children. Minerva pediatrica 69(3):188\\u0026ndash;193 https://doi.org/10.23736/S0026-4946.16.04288-2.\\u003c/li\\u003e\\n\\u003cli\\u003eKoca CF, Erdem T, Bayındır T (2016) The effect of adenoid hypertrophy on maxillofacial development: an objective photographic analysis. Journal of otolaryngology - head \\u0026amp; neck surgery. Le Journal d\\u0026apos;oto-rhino-laryngologie et de chirurgie cervico-faciale 45(1): 48. https://doi.org/10.1186/s40463-016-0161-3.\\u003c/li\\u003e\\n\\u003cli\\u003eLapinska I, Zawadzka-Glos L (2016) Adenoid and tonsils hypertrophy - Symptoms and treatment. New Medicine 20:103-106 10.5604/14270994.1228134.\\u003c/li\\u003e\\n\\u003cli\\u003eLinder-Aronson S (1970) Adenoids. Their effect on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the denition. A biometric, rhino-manometric, and cephalometric-radiographic study on children with and without adenoids. Acta oto-laryngologica. Supplementum 265:1\\u0026ndash;132.\\u003c/li\\u003e\\n\\u003cli\\u003eLinder-Aronson S (1979) Respiratory function in relation to facial morphology and the dentition. British journal of orthodontics 6(2):59\\u0026ndash;71. https://doi.org/10.1179/bjo.6.2.59.\\u003c/li\\u003e\\n\\u003cli\\u003eLin L, Zhao T, Qin D, Hua F, He H. The impact of mouth breathing on dentofacial development: A concise review. Front Public Health. 2022 Sep 8;10:929165. doi: 10.3389/fpubh.2022.929165. PMID: 36159237; PMCID: PMC9498581.\\u003c/li\\u003e\\n\\u003cli\\u003eMa Y, Xie L, Wu W. The effects of adenoid hypertrophy and oral breathing on maxillofacial development: a review of the literature. J Clin Pediatr Dent. 2024 Jan;48(1):1-6. doi: 10.22514/jocpd.2024.001. Epub 2024 Jan 3. PMID: 38239150.\\u003c/li\\u003e\\n\\u003cli\\u003eMcNamara JA (1981) Influence of respiratory pattern on craniofacial growth. The Angle orthodontist 51(4):269\\u0026ndash;300. https://doi.org/10.1043/0003-3219(1981)051\\u0026lt;0269:IORPOC\\u0026gt;2.0.CO;2.Meyer W (1870) On Adenoid Vegetations in the Naso-pharyngeal Cavity: their Pathology, Diagnosis, and Treatment. Medico-chirurgical transactions 53:191\\u0026ndash;216.1. https://doi.org/10.1177/095952877005300110.\\u003c/li\\u003e\\n\\u003cli\\u003eMilanesi JM, Berwig LC, Marquezan M, Schuch LH, Moraes AB, Silva AMTD, Corr\\u0026ecirc;a ECR (2018) Variables associated with mouth breathing diagnosis in children based on a multidisciplinary assessment. CoDAS 30(4):e20170071. https://doi.org/10.1590/2317-1782/20182017071.\\u003c/li\\u003e\\n\\u003cli\\u003eMohamed HA, Ibrahem RA (2024) Speech Sound Disorders in Arabic School aged Children with Adenoid Hypertrophy. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India, 76(6):5195\\u0026ndash;5200. https://doi.org/10.1007/s12070-024-04942-y.\\u003c/li\\u003e\\n\\u003cli\\u003eOccasi F, Perri L, Saccucci M, Di Carlo G, Ierardo G, Luzzi V, De Castro G, Brindisi G, Loffredo L, Duse M, Polimeni A, Zicari AM (2018) Malocclusion and rhinitis in children: an easy-going relationship or a yet to be resolved paradox? A systematic literature revision. Italian journal of pediatrics 44(1):100. https://doi.org/10.1186/s13052-018-0537-2.\\u003c/li\\u003e\\n\\u003cli\\u003ePereira TC, Furlan RMMM, Motta AR (2019) Relationship between mouth breathing etiology and maximum tongue pressure. Rela\\u0026ccedil;\\u0026atilde;o entre a etiologia da respira\\u0026ccedil;\\u0026atilde;o oral e a press\\u0026atilde;o m\\u0026aacute;xima da l\\u0026iacute;ngua. CoDAS 31(2), e20180099. https://doi.org/10.1590/2317-1782/20182018099.\\u003c/li\\u003e\\n\\u003cli\\u003eRaffat A, ul Hamid W (2009) Cephalometric assessment of patients with adenoidal faces. JPMA. The Journal of the Pakistan Medical Association 59(11): 747\\u0026ndash;752.\\u003c/li\\u003e\\n\\u003cli\\u003eSano M, Sano S, Kato H, Arakawa K, Arai M (2018) Proposal for a screening questionnaire for detecting habitual mouth breathing, based on a mouth-breathing habit score. BMC oral health 18(1): 216. https://doi.org/10.1186/s12903-018-0672-6.\\u003c/li\\u003e\\n\\u003cli\\u003eStellzig-Eisenhauer A, Meyer-Marcotty P (2010) Interaction between otorhinolaryngology and orthodontics: correlation between the nasopharyngeal airway and the craniofacial complex. GMS current topics in otorhinolaryngology, head and neck surgery, 9 https://doi.org/10.3205/cto000068.\\u003c/li\\u003e\\n\\u003cli\\u003eTodorova E (2018) Articulation disorders - therapy guide. New Bulgarian University, Sofia.\\u003c/li\\u003e\\n\\u003cli\\u003eThomaz E B, Cangussu MC, Assis AM (2012) Maternal breastfeeding, parafunctional oral habits and malocclusion in adolescents: a multivariate analysis. International journal of pediatric otorhinolaryngology, 76(4): 500\\u0026ndash;506. https://doi.org/10.1016/j.ijporl.2012.01.005.\\u003c/li\\u003e\\n\\u003cli\\u003eWarnier M, Piron L, Morsomme D, Maillart C (2023) Assessment of mouth breathing by Speech-Language Pathologists: an international Delphi consensus. CoDAS 35(3) e20220065. https://doi.org/10.1590/2317-1782/20232022065 Download .nbib\\u003cu\\u003e.\\u003c/u\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003eZettergren-Wijk L, Forsberg CM, Linder-Aronson S (2006) Changes in dentofacial morphology after adeno-/tonsillectomy in children with obstructive sleep apnoea--there (4): 319\\u0026ndash;326. https://doi.org/10.1093/ejo/cji119.\\u003c/li\\u003e\\n\\u003cli\\u003eChenxing Lv, Liu Yang, Ngan Peter, Xiao Wenjie, Zhao Tingting, Tang, Bojun, Chen Xiong, He Hong (2023) Role of the tonsil\\u0026ndash;oropharynx ratio on lateral cephalograms in assessing tonsillar hypertrophy in children seeking orthodontic treatment. BMC Oral Health. 23. 10.1186/s12903-023-03573-z. \\u003c/li\\u003e\\n\\u003cli\\u003eHuang L, Zheng L, Chen X, Bai Y. Age-group-specific associations between adenoid/tonsillar hypertrophy and craniofacial features. \\u003cem\\u003eBMC Oral Health\\u003c/em\\u003e. 2024;24(1):1212. Published 2024 Oct 14. doi:10.1186/s12903-024-04932-0\\u003c/li\\u003e\\n\\u003cli\\u003eHuang X, Gong X, Gao X (2023) Age-related hypertrophy of adenoid and tonsil with its relationship with craniofacial morphology. \\u003cem\\u003eBMC Pediatr\\u003c/em\\u003e. 23(1):163. 6. doi:10.1186/s12887-023-03979-2\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"egyptian-pediatric-association-gazette\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"epag\",\"sideBox\":\"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)\",\"snPcode\":\"43054\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/43054/3?\",\"title\":\"Egyptian Pediatric Association Gazette\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"adenoid hypertrophy, articulation disorders, nasal breathing, oral breathing, dentofacial deformities\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6957099/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6957099/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eThis study presents a multidisciplinary evaluation of fourteen patients with adenoid hypertrophy, which causes pathological (oral) breathing and associated symptomatic manifestations, including snoring during sleep, halitosis, and an open mouth at rest.\\u003c/p\\u003e\\u003cp\\u003eOral breathing, especially during prolonged periods during the growth and development of the nasomaxillary complex, may lead to dentofacial deformities. The orthodontic analysis identifies dentofacial deformities of varying severities, including compression in the upper jaw, crossbite in the lateral and frontal segments, open bite, and class II occlusion. The speech-language status establishes a high frequency of disorders in articulating fricatives /s/, /z/, /sh/, /zh/, and affricatives /ts/ and /tsh/. Directional, interdental articulation of phonemes from early ontogenesis (plosives /t/ and /d/, nasal /n/), distinguished by an articulation position in the upper front part of the oral cavity. Disordered articulation of phonemes of later ontogenesis - approximants /l/. Manifestations of speech disorders are a direct consequence of established pathological speech, breathing, and dentofacial deformities.\\u003c/p\\u003e\\u003cp\\u003eResults: The results categorically confirm the manifestation of pathological mouth breathing, dentofacial deformities, and articulation disorders.\\u003c/p\\u003e\\u003cp\\u003eConclusions: A multidisciplinary team and approach are necessary to assess and treat changes caused by adenoid hypertrophy, thereby preventing the development of craniofacial deformities and speech disorders.\\u003c/p\\u003e\",\"manuscriptTitle\":\"A multidisciplinary approach to the assessment of oral breathing, speech disorders, and dentofacial deformities in children – pilot study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-07-15 15:53:58\",\"doi\":\"10.21203/rs.3.rs-6957099/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-09-12T18:33:57+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-09-12T13:38:13+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"73254791219606169203248084023243925071\",\"date\":\"2025-08-30T16:17:09+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"139118571965976188649603426863786810628\",\"date\":\"2025-07-15T09:53:12+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"150350968400121303713771719623787132442\",\"date\":\"2025-07-13T12:58:39+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"239022736387549350746536888584509049183\",\"date\":\"2025-07-12T05:03:09+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"302568582644872144404601034767429057045\",\"date\":\"2025-07-10T05:27:11+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-07-10T04:59:23+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-07-10T03:17:17+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Egyptian Pediatric Association Gazette\",\"date\":\"2025-07-08T15:42:18+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"egyptian-pediatric-association-gazette\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"epag\",\"sideBox\":\"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)\",\"snPcode\":\"43054\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/43054/3?\",\"title\":\"Egyptian Pediatric Association Gazette\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"96f5efae-9fb0-4eef-a387-26066eefbdd9\",\"owner\":[],\"postedDate\":\"July 15th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-01-19T16:51:13+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-6957099\",\"link\":\"https://doi.org/10.1186/s43054-025-00472-6\",\"journal\":{\"identity\":\"egyptian-pediatric-association-gazette\",\"isVorOnly\":false,\"title\":\"Egyptian Pediatric Association Gazette\"},\"publishedOn\":\"2026-01-15 16:30:57\",\"publishedOnDateReadable\":\"January 15th, 2026\"},\"versionCreatedAt\":\"2025-07-15 15:53:58\",\"video\":\"\",\"vorDoi\":\"10.1186/s43054-025-00472-6\",\"vorDoiUrl\":\"https://doi.org/10.1186/s43054-025-00472-6\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6957099\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6957099\",\"identity\":\"rs-6957099\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}