The Influence of Different Tonsillar Hypertrophy Types on Dentofacial and Craniofacial Development in Children with Mixed Dentition

The Influence of Different Tonsillar Hypertrophy Types on Dentofacial and Craniofacial Development in Children with Mixed Dentition | 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 The Influence of Different Tonsillar Hypertrophy Types on Dentofacial and Craniofacial Development in Children with Mixed Dentition Ciao-syuan Cai, Huimin Li, Yanmei Huang, Baozhen Luo, Xuepeng Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7357398/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Nov, 2025 Read the published version in BMC Oral Health → Version 1 posted 10 You are reading this latest preprint version Abstract Objectives : To evaluate the effects of different subtypes of tonsillar hypertrophy on dentofacial and craniofacial development in children during the mixed dentition stage, and to preliminarily explore associated craniofacial growth trends. Methods : A total of 275 children in the mixed dentition stage were retrospectively recruited from two hospitals between August 2023 and July 2024. Tonsillar hypertrophy was assessed using the Brodsky and Baroni methods, and patients were categorized by airway obstruction type: mild (Group A), transverse (Group B), anteroposterior (Group C), or combined (Group D). Anterior occlusion, sagittal skeletal classification, and lateral cephalometric parameters (Jarabak analysis) were recorded and compared across groups. Results : Groups C and D exhibited significantly higher rates of anterior crossbite and skeletal Class III patterns compared to Groups A and B ( p < 0.05). Subgroup D2 (severe combined obstruction) demonstrated the most pronounced skeletal Class III features, including increased SNB, decreased ANB, and evident mandibular prognathism. Both dental and skeletal compensatory changes were most prominent in the combined obstruction group, indicating aggravated craniofacial imbalance. Conclusions : Anteroposterior tonsillar hypertrophy is strongly associated with anterior crossbite and skeletal Class III development, primarily through mandibular advancement and rotational growth adaptations. Transverse obstruction has minimal skeletal impact, whereas combined obstruction of multiple directions exacerbates dentoskeletal compensation. These findings highlight the directional influence of upper airway obstruction on craniofacial morphology in growing children and underscore the importance of early interdisciplinary evaluation. Tonsillar Hypertrophy Malocclusion Anterior Crossbite Cephalometric Analysis Child Craniofacial Growth and Development Figures Figure 1 Figure 2 Figure 3 Figure 4 1 Introduction The palatine tonsils, commonly known as the tonsils, are situated in the tonsillar fossa between the anterior and posterior palatal arches and represent a key component of the pharyngeal lymphatic ring. They are essential to the immune function of children. Tonsillar hypertrophy is a common condition in children, with a prevalence reported to be approximately 11–15% among school-aged individuals [ 1 ]. Chronic and pronounced tonsillar hypertrophy is associated with oropharyngeal airway narrowing, which may result in difficulties related to respiration, sleep, speech, feeding, and swallowing. Chronic airway obstruction is strongly linked to sleep-disordered breathing (SDB) [ 2 ] [ 3 ] [ 4 ], and it has been reported that the prevalence of tonsillar hypertrophy in children with SDB is approximately 3.7 times higher than in healthy peers [ 5 ]. Common clinical manifestations include mouth breathing, snoring, and obstructive sleep apnea (OSA). Without timely intervention, prolonged SDB can lead to maladaptive behaviors, neurocognitive impairments, and disruptions in brain development [ 6 ]. Moreover, sustained abnormal breathing patterns may negatively influence craniofacial and jaw development [ 7 ] [ 8 ]. In recent decades, multiple hypotheses have been proposed regarding the relationship between upper airway obstruction and craniofacial development in children. Early studies by Trotman et al. indicated that adenoidal and tonsillar hypertrophy have been associated with distinct craniofacial skeletal patterns: adenoidal hypertrophy has been linked to mandibular retrusion and increased lower anterior facial height, leading to skeletal Class II malocclusion [ 9 ], whereas tonsillar hypertrophy is more commonly associated with mandibular protrusion and skeletal Class III malocclusion [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ]. Iwasaki et al. reported a significant association between tonsil size and anterior displacement of the tongue and mandibular incisors in Class III patients [ 15 ]. These findings support a biomechanical mechanism in which tonsillar hypertrophy results in anterior displacement of the tongue, which in turn promotes mandibular advancement and subsequent skeletal remodeling. Consequently, comprehensive assessment of upper airway status—particularly tonsillar hypertrophy—is considered essential for tailored orthodontic planning. Tonsillar hypertrophy has been implicated in upper airway narrowing and may act as an etiological factor for the development of craniofacial abnormalities in children with mixed dentition [ 11 ] [ 16 ] [ 17 ]. However, most existing studies have failed to adequately control for the confounding effects of adenoidal hypertrophy, thereby complicating the interpretation of how obstructions at different levels of the upper airway are associated with anterior occlusal relationships and craniofacial development [ 18 ] [ 19 ]. In addition, the potential impact of tonsillar hypertrophy across various anatomical dimensions has been insufficiently investigated [ 16 ] [ 20 ] [ 21 ]. For instance, the widely adopted Brodsky grading system primarily assesses the transverse dimension of the tonsils, while anteroposterior hypertrophy is frequently neglected. Based on clinical observations, some children not identified as having tonsillar hypertrophy under the Brodsky criteria still present with occlusal features commonly associated with this condition, including anterior crossbite and skeletal Class III malocclusion. These findings suggest that current clinical otorhinolaryngological assessment criteria for tonsillar hypertrophy may lack dimensional comprehensiveness. In summary, tonsillar hypertrophy not only impairs respiratory function in children but may also influence craniofacial growth patterns [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] [ 15 ]. Therefore, elucidating the relationship and underlying mechanisms linking tonsillar hypertrophy to anterior occlusal relationships and craniofacial development is clinically important for early airway intervention, multidisciplinary management, and the prevention of malocclusion in children with mixed dentition. In contrast to prior studies focusing primarily on transverse tonsillar hypertrophy, the present study investigates the association between anteroposterior tonsillar hypertrophy, anterior occlusal relationships, and craniofacial development. Specifically, the prevalence of anterior occlusal patterns and malocclusion types is compared across different anatomical presentations of tonsillar hypertrophy to clarify this association. A clearer understanding of these relationships may inform early airway management strategies and contribute to the prevention of craniofacial abnormalities in children with mixed dentition. 2 Materials and methods This study was designed as a retrospective analysis, and all data were obtained from routine clinical records. Ethical approval was granted by the Institutional Ethics Committee of Zhejiang University School of Medicine Stomatology Hospital (Approval No. 2024 − 141(R)) and Shulan (Hangzhou) Hospital (Approval No. KY2025024). Informed consent was waived due to the retrospective nature of the study and the absence of identifiable patient information. 2.1 Participants Patients who underwent lateral cephalometric radiography during visits to the Department of Orthodontics at the Stomatology Hospital, Zhejiang University School of Medicine, and the Department of Otolaryngology–Head and Neck Surgery at Shulan Hospital between August 2023 and July 2024 were enrolled in this study. Eligible participants were aged 6–12 years and in the stage of mixed dentition. The exclusion criteria included an adenoid A/N ratio ≥ 0.6 [ 22 ], a history of recurrent rhinitis, poor-quality cephalograms, craniofacial syndromes (e.g., cleft lip and palate), incomplete medical history, acute upper respiratory tract infections, maxillofacial trauma, temporomandibular joint osteoarthritis, or prior orthodontic treatment. 2.2 Sample size calculation This study was designed as a multicenter retrospective cohort study. The sample size was calculated based on the primary outcome: the prevalence of anterior crossbite. According to previous studies and our preliminary data, the expected prevalence of anterior crossbite was 6.9% in the control group and 45.8% in children with tonsillar hypertrophy, consistent with earlier reports [ 6 , 23 ]. Assuming a two-sided significance level of 0.05, a statistical power of 90%, and equal sample sizes between groups (k = 1), the minimum required sample size per group was calculated using the following formula: $$\:n=\frac{{（{Z}_{\frac{\alpha\:}{2}}+{Z}_{\beta\:}）}^{2}\bullet\:\left[{p}_{1}\right(1-{p}_{1})+{p}_{2}(1-{p}_{2}\left)\right]}{{({p}_{1}-{p}_{2})}^{2}}$$ The expected prevalence of anterior crossbite in the control and tonsillar hypertrophy groups was estimated at 6.9% and 45.8%, respectively. Assuming a two-sided significance level of α = 0.05 and a power of 90% (β = 0.1), the corresponding critical values were \(\:{Z}_{\frac{\alpha\:}{2}}\) (α = 0.05)=1.96, \(\:{Z}_{\beta\:}\) ༈β = 0.1༉=1.282. The sample size was calculated using a standard formula for comparing two proportions. Substituting these values into the equation yielded a minimum required sample size of 22 participants per group (total n = 88), which was sufficient to detect statistically significant differences between the groups. 2.3 Experimental equipment (1) Cephalometric radiographic systems, including the Orhopantomograph OP200 D (Instrumentarium Imaging Corporation, Tuusula, Finland), Planmeca Promax Ethernet Interface (Planmeca Group, Helsinki, Finland), and Digital Diagnost (Philips Medical Systems, Eindhoven, Netherlands); (2) Dolphin Imaging software version 11.95 (Dolphin Imaging and Management Solutions, Chatsworth, CA, USA) for cephalometric landmark identification and measurement; (3) SPSS software version 27.0 (IBM Corporation, Armonk, NY, USA) for statistical analysis; (4) GraphPad Prism version 8.3 (GraphPad Software, San Diego, CA, USA) for data visualization. 2.4 Measurement and analysis 2.4.1 Tonsil size measurement Oral examination using a tongue depressor or nasopharyngolaryngoscopy was performed to diagnose tonsillar hypertrophy in the transverse dimension. The Brodsky grading system was employed to assess tonsil size, classifying it on a scale from 0 to 4 based on the proportion of the oropharyngeal width occupied by the bilateral tonsils [ 16 ]. Intraoral examination of the dentition was also conducted to record the dentition stage and anterior occlusal relationship. The sagittal anterior occlusion was determined by the presence of overbite and overjet, defined as the vertical and horizontal overlap of the maxillary incisors over the mandibular incisors, respectively. In cases with localized occlusal discrepancies, the predominant incisor relationship was used as the representative pattern. As shown in Fig. 1 , lateral cephalograms were used to assess tonsillar hypertrophy in the anteroposterior dimension using the method described by Baroni et al. Specifically, the maximal anteroposterior diameter of the tonsil, referred to as Tonsil Size (TS), and the Total Oropharyngeal Airway Space (TOAS) were measured. A tangent was drawn along the posterior pharyngeal wall, and from the most prominent point of the tonsil (Tonsil Point, TO), a perpendicular line was extended to intersect the tangent at the Oropharynx Posterior point (OP). The anterior extension of this line intersected the tongue base at the Oropharynx Anterior point (Oa). The distance from Oa to TO was defined as TS, and the distance from Oa to OP as TOAS. The ratio TS/TOAS was calculated to evaluate the degree of anteroposterior tonsillar hypertrophy. A ratio < 50% was classified as non-obstructive anteroposterior tonsillar hypertrophy, while a ratio ≥ 50% was considered obstructive anteroposterior tonsillar hypertrophy[ 24 ]. 2.4.2 Cephalometric Measurements All lateral cephalometric radiographs were analyzed using Dolphin Imaging software (version 11.95; Dolphin Imaging & Management Solutions, Chatsworth, CA, USA). Anatomical landmarks were manually identified by a single calibrated examiner after importing the images into the software. All measurements were performed during a standardized time window to ensure measurement consistency. Each subject’s cephalogram was assessed twice, with a two-week interval between measurements. The mean of the two measurements was used for the final analysis. 2.4.3 Quality control All measurements were performed by the same examiner. Each anatomical landmark was independently identified and measured twice at a two-week interval. Intra-operator measurement reliability was assessed using intraclass correlation coefficients (ICC). An ICC value greater than 0.75 was interpreted as indicating good reliability, while values ≥ 0.90 were considered to reflect excellent reliability. 2.5 Categorize All lateral cephalograms were acquired under standardized conditions by the lead radiologic technologist using the following devices: Orthopantomograph OP200 D (Instrumentarium Imaging Corporation, Tuusula, Finland), Planmeca Promax Ethernet Interface (Planmeca Group, Helsinki, Finland), and Digital Diagnost (Philips Medical Systems, Eindhoven, Netherlands). The imaging parameters were a tube voltage of 73.0 kV, tube current of 10.0 mA, and exposure time of 1.1 seconds. All cephalograms were obtained with patients positioned in the natural head position and the intercuspal position (ICP). Based on intraoral examination and lateral cephalometric assessment, subjects were classified using the Brodsky grading system and the Baroni method as follows: Group A (non-hypertrophic or mildly hypertrophic): Brodsky grade 0–1 on intraoral examination and non-obstructive tonsils in the anteroposterior dimension on lateral cephalometry. Group B (transverse hypertrophy): Brodsky grade 2–4 and non-obstructive tonsils in the anteroposterior dimension. Group C (anteroposterior hypertrophy): Brodsky grade 0–1 and obstructive tonsils in the anteroposterior dimension. Group D (combined transverse and anteroposterior hypertrophy): Brodsky grade 2–4 and obstructive tonsils in the anteroposterior dimension. Further subgrouping was performed within Group D according to the degree of transverse hypertrophy: patients with Brodsky grade 2 were categorized into subgroup D1, and those with grades 3–4 into subgroup D2. According to the ANB angle, patients were classified into sagittal skeletal patterns as follows: skeletal Class I (ANB: 0°–4°), skeletal Class II (ANB > 4°), and skeletal Class III (ANB < 0°) [ 25 , 26 ]. 2.6 Statistical methods Statistical analyses were performed using SPSS software (version 27.0; IBM Corp., Armonk, NY, USA). Continuous variables were presented as mean ± standard deviation (SD) for normally distributed data or as median with interquartile range (IQR) for non-normally distributed data. Normality was assessed using the Shapiro–Wilk test, and homogeneity of variances was evaluated using Levene’s test. For normally distributed data with equal variances, one-way ANOVA with Tukey’s post hoc test was applied. When variances were unequal, Welch’s ANOVA with the Games–Howell post hoc test was used. For non-normally distributed data, the Kruskal–Wallis H test was employed, and pairwise comparisons were conducted using the Mann–Whitney U test with Bonferroni correction when significant differences were observed. Categorical variables were analyzed using the chi-square test or Fisher’s exact test, with post hoc correction as appropriate. A p -value < 0.05 was considered statistically significant. 3 Results A total of 275 participants were included in this study, with a mean age of 8.85 ± 2.06 years. Among them, 36 children were classified into Group A, 50 into Group B, 42 into Group C, and 147 into Group D. Further subgroup analysis identified 70 children in subgroup D1 and 77 in subgroup D2. All groups met the minimum required sample size (≥ 22 participants). Intraclass correlation coefficient (ICC) analysis demonstrated values ranging from 0.83 to 0.92, indicating good measurement reliability. The baseline characteristics of each group were compared, and the results are summarized in Table 1 . Table 1 Baseline characteristics of the participants Characteristics Group A B C D D1 D2 Age (Mean ± SD) 9.25 ± 1.52 8.54 ± 1.97 9.38 ± 2.01 8.63 ± 1.99 * 8.46 ± 1.85 8.78 ± 2.11 * Gender, Number of cases (%) Male 18 (50.00) 23 (46.94) 20 (47.62) 86 (58.50) 41 (58.57) 45 (58.44) Female 18 (50.00) 26 (53.06) 22 (52.38) 61 (41.50) 29 (41.43) 32 (41.56) Group A = non-hypertrophic or mildly hypertrophic; Group B = transverse hypertrophy; Group C = anteroposterior hypertrophy; Group D = combined transverse and anteroposterior hypertrophy; D1 = Brodsky grade 2; D2 = Brodsky grade 3–4. 3.1 Comparison of anterior occlusal relationships among groups Significant differences were observed among groups in anterior occlusal relationships (Table 2 ). The prevalence rates of both anterior crossbite and edge-to-edge bite were significantly higher in Group C and D compared to Group A and B ( p < 0.001), with Group D exhibiting a higher prevalence than Group C. Significant differences were also observed between Groups A and D, and between Groups B and C ( p < 0.01). Additionally, the prevalence of deep overbite and overjet differed significantly between Group A and both Groups C and D ( p < 0.01 or p < 0.05). Overall, Groups C and D exhibited a markedly higher frequency of anterior crossbite and edge-to-edge bite, and a significantly lower frequency of deep overbite and overjet compared to Group A. Several malocclusion features were also more common in Groups C and D than in Group B. Subgroup analysis within Group D revealed that Group D2 had slightly higher rates of anterior crossbite and edge-to-edge bite, and slightly lower rates of deep overbite and deep overjet compared to Group D1; however, these differences were not statistically significant. Table 2 Analysis of anterior occlusal relationship characteristics among groups Anterior occlusal relationship, Number of cases (%) Group A B C D D1 D2 Normal overbite and overjet 19 (52.78) 34 (68.00) 21 (50.00) 61(41.50) 32 (45.71) 29 (37.67) Anterior crossbite 0 (0.00) 0 (0.00) 7 (16.67) 32 (21.77) 11 (15.71) 21 (27.27) Edge-to-edge bite 1 (2.78) 5 (10.00) 9 (21.42) 35 (23.81) 15 (21.43) 20 (25.97) Deep overbite 6 (16.67) 3 (6.00) 1 (2.38) 4 (2.72) 3 (4.29) 1 (1.30) Deep overjet 6 (16.67) 6 (12.00) 4 (9.52) 12 (8.16) 8 (11.42) 4 (5.19) Deep overbite and overjet 4 (11.11) 2 (4.00) 0 (0.00) 3 (2.04) 1 (1.43) 2 (2.60) Group A = non-hypertrophic or mildly hypertrophic; Group B = transverse hypertrophy; Group C = anteroposterior hypertrophy; Group D = combined transverse and anteroposterior hypertrophy; D1 = Brodsky grade 2; D2 = Brodsky grade 3–4. 3.2 Comparison of sagittal skeletal patterns among groups Statistical analysis of sagittal skeletal patterns revealed significant intergroup differences (Table 3 ). Multiple significant differences in the distribution of skeletal Class II and III patterns were observed between Groups A and C/D, and between Groups B and C/D ( p < 0.01 or p < 0.05), while no significant differences were found between Groups A and B or between Groups C and D. Additionally, the proportion of skeletal Class I malocclusion was comparable across all groups, with a slightly lower value observed in Group D; however, this difference was not statistically significant. ( p > 0.05). Specifically, the prevalence of skeletal Class III malocclusion was significantly higher in Group D than in Groups A and B ( p < 0.001), and also higher in Group C than in Groups A and B ( p < 0.05). Conversely, skeletal Class II malocclusion was significantly lower in prevalence in Groups C and D compared to Groups A and B ( p < 0.05). Subgroup analysis within Group D showed a slightly higher proportion of skeletal Class III and a lower proportion of skeletal Class I in Group D2 compared to Group D1; however, these differences were not statistically significant. Additionally, the proportion of skeletal Class II was comparable between the two subgroups. Table 3 Sagittal Skeletal Pattern Distribution Across Groups Characteristics Group A B C D D1 D2 Sagittal Skeletal Patter, Number of cases (%) Skeletal Class I 18 (50.00) 24 (48.00) 20 (47.61) 66 (44.90) 35 (50.00) 31 (40.26) Skeletal Class II 17 (47.22) 23 (46.00) 9 (21.43) 31 (21.09) 15 (21.43) 16 (20.78) Skeletal Class III 1 (2.78) 3 (6.00) 13 (30.95) 50 (34.01) 20 (28.57) 30 (38.96) Group A = non-hypertrophic or mildly hypertrophic; Group B = transverse hypertrophy; Group C = anteroposterior hypertrophy; Group D = combined transverse and anteroposterior hypertrophy; D1 = Brodsky grade 2; D2 = Brodsky grade 3-4. 3.3 Comparison of craniofacial skeletal characteristics among groups Significant differences in craniofacial skeletal parameters were observed among the groups. Compared with Group A, Group B demonstrated trends toward skeletal compensation, including reduced SN-Ar angle, increased Na-Go-Me and SN-MP angles, and decreased ANB and NA-Apo angles; however, these differences were not statistically significant ( p > 0.05). Group C showed a significantly smaller SN-Ar angle than Group A ( p < 0.01), indicating anterior positioning of the condyle. The Ar-Go-Me and Na-Go-Me angles were significantly larger ( p < 0.001 and p < 0.05, respectively), consistent with a vertical mandibular growth pattern. Additionally, increased SNB and decreased ANB and NA-Apo angles (all p < 0.01) indicated mandibular prognathism and maxillary retrusion. The NP-FH angle was also significantly increased ( p < 0.01), indicating a skeletal Class III tendency. Group D exhibited significant differences in SN-Ar, Ar-Go-Me, Ar-Go-Na, SNB, and NA-Apo angles compared with Group A ( p < 0.05 to p < 0.001), reflecting multidimensional skeletal compensation and mandibular protrusion. The SGn and NP-FH angles were significantly increased, while the posterior-to-anterior facial height ratio (P/A) was significantly reduced ( p < 0.05), indicating chin projection and a high-angle growth pattern. A decreased SGn-SN angle further indicated prognition of the chin. Compared with Group B, Group D showed more significant alterations in mandibular morphology (Ar-Go-Me, Go-Gn, Ar-Go), jaw relationships (increased SNB, decreased ANB and NA-Apo), and facial growth pattern (increased NP-FH, decreased P/A) ( p < 0.05 to p < 0.0001), indicating more pronounced mandibular prognathism, maxillary retrusion, and vertical growth. Compared with Group C, Group D showed a significantly greater total craniofacial triangle angle ( p < 0.001). Although other measurements (Go-Gn, Ar-Go, SGn, Na-Me) were higher in Group D, these differences were not statistically significant, which may reflect overall skeletal integration with limited regional variation, potentially attributable to individual differences. Within Group D, subgroup D2 exhibited a significantly lower ANB angle ( p < 0.05) and P/A ratio ( p < 0.05) than subgroup D1, indicating features consistent with stronger mandibular protrusion and increased anterior facial height—characteristics of skeletal Class III and vertical growth compensation. No other parameters showed significant differences (Table 4 , Fig. 2 ). Table 4 Mean and Standard Deviation of Skeletal Measurements Across Groups Measurement items Group A B C D D1 D2 SN-Ar ( 。 ) 123.06 ± 6.33 120.37 ± 5.44 118.20 ± 8.02 119.13 ± 5.74 119.13 ± 5.21 119.12 ± 6.22 SN (mm) 62.33 ± 5.59 62.46 ± 6.18 63.35 ± 9.98 64.33 ± 7.54 65.37 ± 5.55 63.38 ± 8.92 S-Ar (mm) 31.62 ± 3.61 32.06 ± 4.52 31.10 ± 5.46 30.90 ± 4.57 31.67 ± 3.91 30.21 ± 5.01 Ar-Go-Me ( 。 ) 122.34 ± 4.31 122.94 ± 6.63 128.19 ± 6.05 128.07 ± 6.25 127.44 ± 5.50 128.64 ± 6.85 Go-Gn (mm) 69.39 ± 6.80 68.24 ± 8.59 71.76 ± 10.03 73.32 ± 9.19 74.10 ± 7.78 72.60 ± 10.31 Ar-Go-Na ( 。 ) 46.70 ± 3.06 46.61 ± 4.78 49.23 ± 4.96 49.04 ± 4.15 48.69 ± 3.77 49.35 ± 4.48 Na-Go-Me ( 。 ) 75.64 ± 4.07 76.32 ± 4.31 78.95 ± 4.64 77.98 ± 5.15 78.75 ± 4.83 77.29 ± 5.35 Ar-Go (mm) 36.50 ± 4.12 36.79 ± 5.71 38.80 ± 7.59 40.76 ± 6.09 41.9 ± 5.29 39.72 ± 6.60 SNA ( 。 ) 79.58 ± 3.25 78.40 ± 3.64 79.04 ± 4.71 79.01 ± 3.62 79.35 ± 3.24 78.72 ± 3.93 SNB ( 。 ) 75.88 ± 3.30 74.87 ± 3.57 78.40 ± 6.48 78.37 ± 3.85 77.94 ± 3.76 78.75 ± 3.92 ANB ( 。 ) 3.69 ± 2.14 3.54 ± 2.75 0.65 ± 3.85 0.65 ± 3.39 1.40 ± 2.93 -0.03 ± 3.65 NA-Apo ( 。 ) 8.56 ± 5.81 7.60 ± 6.86 3.11 ± 5.82 3.86 ± 6.70 5.05 ± 4.83 2.78 ± 7.92 S-Ar-Go ( 。 ) 151.87 ± 7.62 152.09 ± 7.73 148.417.57 148.9 ± 7.41 148.84 ± 6.87 148.94 ± 7.92 the Three Angle ( 。 ) 397.27 ± 4.49 395.40 ± 5.35 394.80 ± 7.01 399.04 ± 5.99 399.41 ± 5.84 398.7 ± 6.14 Jarabak Anterior Ratio (*100) 90.12 ± 6.30 92.05 ± 7.08 88.45 ± 6.70 88.10 ± 6.78 88.61 ± 6.57 87.65 ± 6.97 SN-MP ( 。 ) 36.27 ± 4.47 38.4 ± 5.35 38.81 ± 7.00 38.57 ± 5.98 38.41 ± 5.84 38.71 ± 6.15 N-Go (mm) 104.01 ± 8.89 102.48 ± 11.03 101.14 ± 15.71 101.63 ± 11.73 101.28 ± 7.97 101.94 ± 14.37 SGn (mm) 112.80 ± 8.22 111.54 ± 12.47 118.25 ± 18.10 120.31 ± 13.16 120.00 ± 11.14 120.51 ± 14.83 NP-FH ( 。 ) 81.67 ± 3.42 80.86 ± 3.79 84.72 ± 6.49 84.74 ± 3.87 84.07 ± 3.64 85.35 ± 3.99 S-Go (mm) 69.50 ± 5.82 67.05 ± 8.34 66.75 ± 11.61 66.26 ± 8.45 66.27 ± 6.68 66.25 ± 9.83 Na-Me (mm) 107.2 ± 8.22 106.21 ± 11.43 108.43 ± 16.83 110.49 ± 12.75 107.68 ± 14.26 113.06 ± 10.67 P/A (%) 64.86 ± 3.07 63.15 ± 4.26 61.64 ± 5.40 60.53 ± 8.88 62.34 ± 8.67 58.89 ± 8.80 SGn-SN ( 。 ) 72.00 ± 3.61 72.40 ± 3.77 69.71 ± 6.22 69.80 ± 3.97 70.00 ± 3.77 69.62 ± 4.16 Group A = non-hypertrophic or mildly hypertrophic; Group B = transverse hypertrophy; Group C = anteroposterior hypertrophy; Group D = combined transverse and anteroposterior hypertrophy; D1 = Brodsky grade 2; D2 = Brodsky grade 3–4. 3.4 Comparison of dental characteristics among groups Compared with Group A, Group B showed slightly reduced FMIA and U1-SN angles, suggesting minor dental differences; however, these differences were not statistically significant ( p > 0.05). Group C showed a significantly lower IMPA angle ( p < 0.05), reduced U1-NP ( p < 0.001), and increased MP-OP angle ( p < 0.05), indicating compensatory lingual inclination of the mandibular incisors. In Group D, the IMPA angle was significantly decreased ( p < 0.01), the U1-NP angle was significantly reduced ( p < 0.0001), and the MP-OP angle was significantly increased ( p < 0.0001) compared with Group A, reflecting more pronounced mandibular incisor retroclination and a steeper occlusal plane. Compared with Group B, Group D also showed a significantly higher FMIA ( p < 0.01), lower IMPA and U1-NP angles, and a greater MP-OP angle (all p < 0.01), indicating stronger dental compensation. No statistically significant differences in dental parameters were observed between Group D and Group C, or between subgroups D2 and D1. However, minor trends toward increased dental compensation were observed, which may reflect consistent individual variation in incisor inclination (Table 5 , Fig. 3 ). Table 5 Mean and standard deviation of dental measurement items among groups Measure-ment items Group A B C D D1 D2 IMPA ( 。 ) 93.63 ± 7.11 93.66 ± 6.94 88.44 ± 8.03 88.14 ± 8.04 88.64 ± 8.30 87.69 ± 7.83 FMIA ( 。 ) 59.36 ± 6.38 58.03 ± 7.29 61.57 ± 8.50 62.23 ± 8.16 61.44 ± 8.53 62.94 ± 7.8 L1-NP (mm) 6.09 ± 2.84 5.69 ± 2.76 6.21 ± 3.34 6.01 ± 2.96 6.08 ± 3.25 5.95 ± 2.69 U1-NP (mm) 11.27 ± 3.54 10.26 ± 3.19 7.30 ± 5.51 7.60 ± 4.55 7.50 ± 4.40 7.70 ± 4.71 U1-SN ( 。 ) 105.53 ± 6.94 103.89 ± 9.65 103.16 ± 11.87 103.39 ± 9.32 103.25 ± 8.75 103.52 ± 9.87 MP-OP ( 。 ) 15.58 ± 3.28 15.88 ± 4.53 18.47 ± 4.61 19.37 ± 4.36 18.73 ± 3.91 19.95 ± 4.68 U1-L1 ( 。 ) 123.58 ± 9.56 124.04 ± 10.88 125.59 ± 9.56 128.46 ± 12.75 126.69 ± 13.01 130.07 ± 12.36 Group A = non-hypertrophic or mildly hypertrophic; Group B = transverse hypertrophy; Group C = anteroposterior hypertrophy; Group D = combined transverse and anteroposterior hypertrophy; D1 = Brodsky grade 2; D2 = Brodsky grade 3–4. 3.5 Comparison of soft tissue measurements among groups No statistically significant differences were observed among groups in the distances from the upper and lower lips to the E-line ( p > 0.05). However, a trend was observed in which the upper lip in Group D2 (1.49 ± 2.51 mm) was slightly more retrusive than in Groups A (2.31 ± 2.42 mm), B (2.51 ± 1.97 mm), C (2.38 ± 3.23 mm), and D1 (2.44 ± 2.19 mm). Additionally, Groups C (0.70 ± 2.33 mm) and D (0.98 ± 2.68 mm) demonstrated a trend toward increased lower lip protrusion relative to Groups A (− 0.04 ± 2.76 mm) and B (0.05 ± 2.74 mm), with Group D2 (1.45 ± 2.64 mm) showing greater protrusion than Group D1 (0.46 ± 2.64 mm) (Table 6 , Fig. 4 ). Table 6 Mean and standard deviation of soft tissue measurement items among groups Measurement items Group A B C D D1 D2 LL-E -0.04 ± 2.76 0.05 ± 2.74 0.70 ± 2.33 0.98 ± 2.68 0.46 ± 2.64 1.45 ± 2.64 UL-E 2.31 ± 2.42 2.51 ± 1.97 2.38 ± 3.23 1.94 ± 2.4 2.44 ± 2.19 1.49 ± 2.51 Group A = non-hypertrophic or mildly hypertrophic; Group B = transverse hypertrophy; Group C = anteroposterior hypertrophy; Group D = combined transverse and anteroposterior hypertrophy; D1 = Brodsky grade 2; D2 = Brodsky grade 3–4. 4 Discussion This study utilized the Baroni method on lateral cephalograms to assess anteroposterior tonsillar hypertrophy, aiming to address the limitations of the traditional Brodsky grading system, which primarily evaluates transverse hypertrophy. The findings revealed a significant association between anteroposterior tonsillar hypertrophy and an increased risk of anterior crossbite and edge-to-edge bite, primarily due to sagittal airway obstruction leading to mandibular advancement as a compensatory mechanism and contributing to the development of skeletal Class III patterns. In contrast, transverse airway obstruction exerted minimal influence on jaw morphology. 4.1 Anterior occlusal characteristics in children with different types of tonsillar hypertrophy Significant differences in anterior occlusal relationships were observed among the groups (χ² = 56.10, p < 0.001). Group A (normal/mild hypertrophy) showed the highest proportion of normal overbite (52.78%) and no observed cases of anterior crossbite. In contrast, the prevalence of anterior crossbite was 16.67% and 21.77% in Groups C and D, respectively (C vs. A: p = 0.013; D vs. A: p = 0.002), suggesting that tonsillar hypertrophy may influence the anterior occlusion. This potential effect may be attributed to the alterations in tongue position and mandibular posture caused by tonsillar hypertrophy, which subsequently modify the biomechanical environment of the anterior dentition and thereby increase the risk of anterior crossbite and edge-to-edge bite. Group B (transverse obstruction) did not differ significantly from Group A ( p > 0.05), whereas Group C (anteroposterior obstruction) demonstrated significantly higher rates of anterior crossbite and edge-to-edge bite ( p = 0.013 and p = 0.017, respectively), indicating a more pronounced impact of sagittal airway obstruction on occlusion, which was consist with previous studies[ 27 , 28 ]. Within Group D, although D2 (severe transverse obstruction) had slightly higher malocclusion rates than D1, the differences were not statistically significant ( p > 0.05), further reinforcing anteroposterior obstruction as the primary risk factor. Additionally, deep overbite was most prevalent in Group A (16.67%) and least common in Groups C and D (2.38–2.72%), possibly reflecting compensatory head and neck postural adaptations associated with airway restriction. Altered tongue posture resulting from airway obstruction—including low tongue positioning and tongue thrust—may further contribute to anterior occlusal disturbances [ 29 ]. 4.2 Sagittal skeletal patterns in children with different types of tonsillar hypertrophy A significant association was observed between the type of tonsillar hypertrophy and sagittal skeletal pattern (χ² = 33.45, p < 0.001). Groups C and D, both characterized by anteroposterior obstruction, showed a significantly higher prevalence of skeletal Class III malocclusion (33.33% and 34.01%, respectively), compared to only 2.78% in Group A. This finding suggests that anteroposterior airway narrowing may contribute to mandibular protrusion through compensatory mechanisms such as forward mandibular posturing[ 30 ]. In contrast, Group B (transverse obstruction only) had a low proportion of Class III cases (6%), comparable to Group A ( p > 0.05) and significantly lower than Groups C and D ( p < 0.01), indicating that anteroposterior obstruction may exert a greater influence on sagittal skeletal development[ 10 , 15 ]. Moreover, the proportion of skeletal Class II malocclusion decreased notably in Groups C and D (19.04% and 21.09%), possibly resulting from compensatory head and neck postures that modify maxillomandibular growth toward a Class III pattern[ 31 ]. Within Group D, the prevalence of skeletal Class III was slightly higher in D2 (38.96%) than in D1 (28.57%), though this difference was not statistically significant ( p > 0.05), suggesting that transverse obstruction may play a secondary role unless accompanied by severe anteroposterior narrowing. Future studies integrating three-dimensional airway imaging and biomechanical modeling are needed to elucidate the proposed “obstruction vector–compensatory pathway–skeletal response” mechanism and to facilitate personalized craniofacial growth prediction. 4.3 Cephalometric skeletal analysis in children with different types of tonsillar hypertrophy This study identified a significant association between the directional dimension of airway obstruction caused by tonsillar hypertrophy and patterns of craniofacial skeletal compensation. Specifically, anteroposterior obstruction (Groups C and D) was linked to increased SNB and Ar-Go-Me angles and decreased NA-Apo angles, indicating mandibular advancement, maxillary retrusion, and a vertical growth tendency[ 12 ]. Group D demonstrated the most pronounced reduction in ANB angle, with some values turning negative, suggesting that combined (anteroposterior and transverse) obstruction may surpass the compensatory threshold, potentially resulting in skeletal Class III malocclusion. In contrast, transverse obstruction alone (Group B) showed limited impact on skeletal parameters. From a biomechanical perspective, the skeletal compensatory mechanism associated with sagittal airway obstruction may arise from respiration-driven adaptive regulation across the airway, soft tissue, and skeletal systems. Anteroposterior hypertrophy of the tonsils directly obstructs nasal airflow at the oropharyngeal level, exerting posterior pressure on the tongue root and displacing the tongue anteriorly[ 12 ]. Sustained tension in the genioglossus muscle stimulates the mandibular symphysis, promoting a forward and downward growth trajectory of the mandible. To preserve adequate oropharyngeal airway volume, children may adopt a habitual mandibular protrusion posture. If airway obstruction remains unresolved, prolonged mechanical traction—coupled with complex neuromuscular and skeletal regulatory networks—may ultimately result in irreversible skeletal Class III malocclusion[ 32 ]. In contrast, transverse tonsillar hypertrophy causing coronal airway obstruction appears to exert a more limited influence on maxillomandibular relationships. Although a slight increase in the mandibular plane angle (SN-MP) was noted, the symmetrical tension distribution of the bilateral masticatory muscles may mitigate significant skeletal displacement. 4.4 Dentoskeletal compensation in children with different types of tonsillar hypertrophy This study suggests that tonsillar hypertrophy in different anatomical directions may elicit distinct dentofacial compensatory mechanisms through variable patterns of airway obstruction. In Group B (transverse obstruction), no significant dental changes were observed, possibly due to compensatory adaptations such as soft tissue repositioning or postural adjustments. In contrast, Group C (anteroposterior obstruction) demonstrated marked dental compensation, including retroclination of the mandibular incisors (significantly reduced IMPA), reduced proclination of the maxillary incisors (sharp decrease in U1-NP), and a steeper occlusal plane angle (MP-OP), consistent with a compensatory pattern involving posterior and inferior mandibular rotation. Group D (mixed obstruction) showed more pronounced dentoalveolar and skeletal compensation, with significantly greater changes in IMPA and MP-OP, indicating that the masticatory system may be nearing its limit of dentoskeletal adaptation. Although no significant differences were found between subgroups D1 and D2, a slight increase in occlusal plane steepness with worsening obstruction suggests a potential threshold of compensatory breakdown, warranting interdisciplinary assessment and early intervention involving otolaryngologists. From a biomechanical perspective, Group C exhibited a pattern of mandibular protrusion accompanied by retroclined lower incisors, while Group D presented a high-angle, open-growth pattern with downward mandibular rotation—illustrating a biomechanical sequence of mandibular advancement, incisor retroclination, and occlusal plane steepening. In summary, transverse obstruction may have limited impact; anteroposterior obstruction may trigger adaptive responses of the occlusal system; and mixed obstruction may result in more complex malocclusions and craniofacial dysmorphology. 4.5 Soft tissue characteristics in children with different types of tonsillar hypertrophy This study suggests that different types of tonsillar hypertrophy may contribute to distinct patterns of perioral soft tissue adaptation as a result of multidirectional airway obstruction. Although no statistically significant differences were found in upper and lower lip positions relative to the E-line, Group C (anteroposterior obstruction) demonstrated a trend toward increased lower lip protrusion (+ 0.74 mm vs. Group A), possibly reflecting underlying skeletal compensation and the influence of suprahyoid and orbicularis oris muscle adaptation. Group D (mixed obstruction) exhibited a more complex pattern of soft tissue adaptation, with greater lower lip protrusion and upper lip retrusion in subgroup D2 compared to D1. This may suggest a dual adaptive mechanism under severe three-dimensional obstruction: downward mandibular rotation associated with lower lip advancement, and chronic mouth breathing associated with reduced lip muscle tone[ 33 ]. Despite a significant increase in chin projection (SGn) in Group D, corresponding changes in the lower lip were less prominent, indicating a dampening effect of soft tissue recoil on skeletal compensation. Notably, despite the most pronounced skeletal compensation in Group D2, E-line parameters did not differ significantly, suggesting involvement of non-skeletal mechanisms such as altered tongue posture or head–neck positional adjustments. Given the inherent limitations in static soft tissue measurements, future studies should incorporate dynamic modalities (e.g., four-dimensional facial analysis) to better elucidate the neuromuscular mechanisms underlying soft tissue adaptation[ 33 ]. 4.6 Limitations This study has several limitations. First, its retrospective cross-sectional design precludes causal inference and prevents evaluation of dynamic changes in mandibular growth. Second, selection bias may be present, as participants were recruited from clinical settings, potentially leading to overrepresentation of malocclusion in specific subgroups. Third, the use of two-dimensional cephalometric analysis restricted assessment of three-dimensional skeletal and dental morphology. Future studies should adopt prospective designs, incorporate three-dimensional imaging techniques, and apply multivariate analytical models to more precisely delineate the independent effects of tonsillar hypertrophy on craniofacial development and to inform personalized early intervention strategies. 5 Conclusions Anteroposterior tonsillar hypertrophy is significantly associated with a higher prevalence of anterior crossbite and edge-to-edge bite in children during the mixed dentition stage. Compared to transverse hypertrophy, it shows a stronger correlation with occlusal disturbances. Anteroposterior tonsillar hypertrophy is also significantly associated with an increased prevalence of skeletal Class III patterns, while transverse obstruction appears to have minimal effect. These findings support a dimension-specific, hierarchical influence of airway obstruction vectors on craniofacial development. In children at the mixed dentition stage, anteroposterior hypertrophy induces mandibular protrusion, clockwise rotation, open-bite growth tendencies, and retroclination of the incisors—resulting in skeletal remodeling that prioritizes airway patency. These skeletal adaptations are accompanied by perioral soft tissue compensation. Mixed-pattern obstruction further amplifies these changes through sagittal-coronal mechanical synergy, whereas transverse hypertrophy alone exerts minimal influence on jaw morphology. Declarations Clinical trial number Not applicable. Ethics approval and consent to participate This retrospective study was approved by the Institutional Ethics Committee of Zhejiang University School of Medicine Stomatology Hospital (Approval Number: No. 2024-141（R）) and Shulan (Hangzhou) Hospital (Approval Number: No. KY2025024). The requirement for informed consent was waived due to the retrospective nature of the study and the use of anonymized data. No identifiable personal information of individual patients was collected or disclosed. Consent to participate Not applicable. Informed consent was waived due to retrospective design of the study and the absence of identifiable patient information. Consent for publication Not applicable. This manuscript does not contain any individual person’s data in any form (including images, videos, or other identifying information), thus consent for publication was not required. Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Key Program of Zhejiang Provincial Natural Science Foundation (LZ25H140001); the Fundamental Research Funds for the Central Universities (2023QZJH60); the Research and Development Project of Stomatology Hospital Zhejiang University School of Medicine (RD2022DLYB03). Author Xuepeng Chen is sponsored by the Zhejiang Provincial Program for the Cultivation of High-level Innovative Health Talents. Authors' contributions CC: Methodology, Investigation, Visualization, Writing – original draft. HL: Data collection, Formal analysis, Writing – review & editing. YH: Writing – review & editing. BL: Supervision, Writing – review & editing. XC: Conceptualization, Resources, Writing – review & editing. All authors have read and approved the final manuscript. CC and HL contributed equally to this work and share first authorship. Acknowledgements The authors would like to thank Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine and Department of Otolaryngology-Head and Neck Surgery, Shulan (Hangzhou) Hospital for providing support for this study. References Kara CO, Ergin H, Koçak G, Kiliç I, Yurdakul M: Prevalence of tonsillar hypertrophy and associated oropharyngeal symptoms in primary school children in Denizli, Turkey . 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Šidlauskienė M, Smailienė D, Lopatienė K, Čekanauskas E, Pribuišienė R, Šidlauskas M: Relationships between Malocclusion, Body Posture, and Nasopharyngeal Pathology in Pre-Orthodontic Children . Med Sci Monit 2015, 21 :1765-1773. Pawłowska-Seredyńska K, Umławska W, Resler K, Morawska-Kochman M, Pazdro-Zastawny K, Kręcicki T: Craniofacial proportions in children with adenoid or adenotonsillar hypertrophy are related to disease duration and nasopharyngeal obstruction . Int J Pediatr Otorhinolaryngol 2020, 132 :109911. Cai M, Brown EC, Hatt A, Cheng S, Bilston LE: Effect of head and jaw position on respiratory-related motion of the genioglossus . J Appl Physiol (1985) 2016, 120 (7):758-765. Jia P, Fu M, Zeng X: Changes of upper airway morphology induced by mandibular advancement inpatients with obstructive sleep apnea syndrome . Journal of Peking University(Health Sciences) 2003(06):663-667. Ciscar MA, Juan G, Martínez V, Ramón M, Lloret T, Mínguez J, Armengot M, Marín J, Basterra J: Magnetic resonance imaging of the pharynx in OSA patients and healthy subjects . Eur Respir J 2001, 17 (1):79-86. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Published Journal Publication published 28 Nov, 2025 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 26 Sep, 2025 Reviews received at journal 09 Sep, 2025 Reviews received at journal 08 Sep, 2025 Reviewers agreed at journal 07 Sep, 2025 Reviewers agreed at journal 07 Sep, 2025 Reviewers invited by journal 07 Sep, 2025 Editor invited by journal 02 Sep, 2025 Editor assigned by journal 29 Aug, 2025 Submission checks completed at journal 29 Aug, 2025 First submitted to journal 12 Aug, 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-7357398","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512320167,"identity":"425c3250-7faa-4f20-b05e-f09f1f1e099e","order_by":0,"name":"Ciao-syuan Cai","email":"","orcid":"","institution":"Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ciao-syuan","middleName":"","lastName":"Cai","suffix":""},{"id":512320168,"identity":"07a669ad-70c6-4807-b225-c3d4d70629cc","order_by":1,"name":"Huimin Li","email":"","orcid":"","institution":"Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Huimin","middleName":"","lastName":"Li","suffix":""},{"id":512320175,"identity":"220d80ca-ac48-4923-adf8-ade1e60e9440","order_by":2,"name":"Yanmei Huang","email":"","orcid":"","institution":"Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yanmei","middleName":"","lastName":"Huang","suffix":""},{"id":512320177,"identity":"2e683a85-01a8-434a-9914-4fb42089c406","order_by":3,"name":"Baozhen Luo","email":"","orcid":"","institution":"Department of Otolaryngology-Head and Neck Surgery, Shulan (Hangzhou) Hospital, Shulan International Medical College, Zhejiang Shuren University","correspondingAuthor":false,"prefix":"","firstName":"Baozhen","middleName":"","lastName":"Luo","suffix":""},{"id":512320178,"identity":"192fcf36-d6df-47f1-8c92-8920764e672f","order_by":4,"name":"Xuepeng Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYJCCAx//2cgBKSCTjTgdjAdnsKUZk6SF+TAP2+HEBjCbGC38M3IPHObhOZw+v/GMAcOHssMM/LMb8GuROHMu4eAcifTcxoYzBowzzh1mkLhzAL8WA/YegwNvDKxzmxnOGDDzth1mMJBIIKCFmcfgAE8CczobSMtforQAbTnIc8A5gQekhZEYLWC/zGxIM5zBcKzgYM+5dB6JGwS0AEPs8IePDTby8jMOb3zwo8xajn8GAS0MDDww+w6AI5MHj1J0LfwNRCgeBaNgFIyCEQkARpdGhEZ0WPYAAAAASUVORK5CYII=","orcid":"","institution":"Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Xuepeng","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2025-08-12 15:38:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7357398/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7357398/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-025-07350-y","type":"published","date":"2025-11-28T15:57:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91198230,"identity":"b1823d70-3182-423c-a7c8-e01b44382b5f","added_by":"auto","created_at":"2025-09-12 15:14:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":85978,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic representation of tonsil and oropharyngeal airway measurements on a lateral cephalogram. TgO line marks a tangent was drawn along the posterior pharyngeal wall; TO (Tonsil Point) represents most protruding point of the tonsil; OP(Oropharynx Posterior point) is the foot of the perpendicular line from TO to TgO line, where the perpendicular intersects the TgO line; Oa(Oropharynx Anterior point) is the intersection of the perpendicular line from point TO to TgO line with the anterior wall of the oropharyngeal space; The distance from Oa to TO was measured as TS, and the distance from Oa to OP as TOAS. The ratio TS/TOAS was calculated to assess the degree of anteroposterior tonsillar hypertrophy. A ratio \u0026lt;50% was classified as non-obstructive, whereas a ratio ≥50% was considered obstructive.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7357398/v1/4df23572400adbb950f9c9a1.jpg"},{"id":91200635,"identity":"7cddbece-b88a-42fe-8da6-b28a81875223","added_by":"auto","created_at":"2025-09-12 15:30:06","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":194667,"visible":true,"origin":"","legend":"\u003cp\u003ePairwise comparisons of skeletal measurement items among groups. \u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05, **\u003cem\u003e p\u003c/em\u003e \u0026lt; 0.01, ***\u003cem\u003e p\u003c/em\u003e \u0026lt; 0.001, ****\u003cem\u003e p\u003c/em\u003e \u0026lt; 0.001, ns = no significant difference (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.05).\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7357398/v1/aaa4d519eb1da200a4c0908c.jpg"},{"id":91198232,"identity":"653fdaa1-db55-413e-916f-4f5e84b74591","added_by":"auto","created_at":"2025-09-12 15:14:06","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":100546,"visible":true,"origin":"","legend":"\u003cp\u003ePairwise comparisons of dental measurement items among groups. \u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep \u003c/em\u003e\u0026lt; 0.05, \u003csup\u003e**\u003c/sup\u003e\u003cem\u003ep \u003c/em\u003e\u0026lt; 0.01, \u003csup\u003e***\u003c/sup\u003e\u003cem\u003ep \u003c/em\u003e\u0026lt; 0.001, \u003csup\u003e****\u003c/sup\u003e\u003cem\u003ep \u003c/em\u003e\u0026lt; 0.001, ns = no significant difference (\u003cem\u003ep \u003c/em\u003e\u0026gt; 0.05).\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7357398/v1/7efad08707bececef98061cd.jpg"},{"id":91198236,"identity":"f0855fb3-0b82-4691-8a4f-2bbe663b7737","added_by":"auto","created_at":"2025-09-12 15:14:07","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":67834,"visible":true,"origin":"","legend":"\u003cp\u003ePairwise comparisons of soft tissue measurement items among groups. ns = no significant difference (\u003cem\u003ep \u003c/em\u003e\u0026gt; 0.05).\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7357398/v1/ee1e747a2ef9dd21c3cdbe0e.jpg"},{"id":97178702,"identity":"33b15469-adde-41f0-a3b7-ea5f3438b48b","added_by":"auto","created_at":"2025-12-01 16:12:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3034143,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7357398/v1/26059b96-cdb8-4b6c-95c2-6876bb97964a.pdf"},{"id":91198235,"identity":"aab7a9aa-abb5-408b-b739-cffaf311acb2","added_by":"auto","created_at":"2025-09-12 15:14:06","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27856,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7357398/v1/efd2ce709ed3a62984244735.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Influence of Different Tonsillar Hypertrophy Types on Dentofacial and Craniofacial Development in Children with Mixed Dentition","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eThe palatine tonsils, commonly known as the tonsils, are situated in the tonsillar fossa between the anterior and posterior palatal arches and represent a key component of the pharyngeal lymphatic ring. They are essential to the immune function of children. Tonsillar hypertrophy is a common condition in children, with a prevalence reported to be approximately 11\u0026ndash;15% among school-aged individuals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Chronic and pronounced tonsillar hypertrophy is associated with oropharyngeal airway narrowing, which may result in difficulties related to respiration, sleep, speech, feeding, and swallowing. Chronic airway obstruction is strongly linked to sleep-disordered breathing (SDB) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and it has been reported that the prevalence of tonsillar hypertrophy in children with SDB is approximately 3.7 times higher than in healthy peers [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Common clinical manifestations include mouth breathing, snoring, and obstructive sleep apnea (OSA). Without timely intervention, prolonged SDB can lead to maladaptive behaviors, neurocognitive impairments, and disruptions in brain development [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Moreover, sustained abnormal breathing patterns may negatively influence craniofacial and jaw development [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn recent decades, multiple hypotheses have been proposed regarding the relationship between upper airway obstruction and craniofacial development in children. Early studies by Trotman et al. indicated that adenoidal and tonsillar hypertrophy have been associated with distinct craniofacial skeletal patterns: adenoidal hypertrophy has been linked to mandibular retrusion and increased lower anterior facial height, leading to skeletal Class II malocclusion [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], whereas tonsillar hypertrophy is more commonly associated with mandibular protrusion and skeletal Class III malocclusion [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Iwasaki et al. reported a significant association between tonsil size and anterior displacement of the tongue and mandibular incisors in Class III patients [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These findings support a biomechanical mechanism in which tonsillar hypertrophy results in anterior displacement of the tongue, which in turn promotes mandibular advancement and subsequent skeletal remodeling. Consequently, comprehensive assessment of upper airway status\u0026mdash;particularly tonsillar hypertrophy\u0026mdash;is considered essential for tailored orthodontic planning.\u003c/p\u003e\u003cp\u003eTonsillar hypertrophy has been implicated in upper airway narrowing and may act as an etiological factor for the development of craniofacial abnormalities in children with mixed dentition [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, most existing studies have failed to adequately control for the confounding effects of adenoidal hypertrophy, thereby complicating the interpretation of how obstructions at different levels of the upper airway are associated with anterior occlusal relationships and craniofacial development [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In addition, the potential impact of tonsillar hypertrophy across various anatomical dimensions has been insufficiently investigated [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. For instance, the widely adopted Brodsky grading system primarily assesses the transverse dimension of the tonsils, while anteroposterior hypertrophy is frequently neglected. Based on clinical observations, some children not identified as having tonsillar hypertrophy under the Brodsky criteria still present with occlusal features commonly associated with this condition, including anterior crossbite and skeletal Class III malocclusion. These findings suggest that current clinical otorhinolaryngological assessment criteria for tonsillar hypertrophy may lack dimensional comprehensiveness.\u003c/p\u003e\u003cp\u003eIn summary, tonsillar hypertrophy not only impairs respiratory function in children but may also influence craniofacial growth patterns [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, elucidating the relationship and underlying mechanisms linking tonsillar hypertrophy to anterior occlusal relationships and craniofacial development is clinically important for early airway intervention, multidisciplinary management, and the prevention of malocclusion in children with mixed dentition. In contrast to prior studies focusing primarily on transverse tonsillar hypertrophy, the present study investigates the association between anteroposterior tonsillar hypertrophy, anterior occlusal relationships, and craniofacial development. Specifically, the prevalence of anterior occlusal patterns and malocclusion types is compared across different anatomical presentations of tonsillar hypertrophy to clarify this association. A clearer understanding of these relationships may inform early airway management strategies and contribute to the prevention of craniofacial abnormalities in children with mixed dentition.\u003c/p\u003e"},{"header":"2 Materials and methods","content":"\u003cp\u003eThis study was designed as a retrospective analysis, and all data were obtained from routine clinical records. Ethical approval was granted by the Institutional Ethics Committee of Zhejiang University School of Medicine Stomatology Hospital (Approval No. 2024\u0026thinsp;\u0026minus;\u0026thinsp;141(R)) and Shulan (Hangzhou) Hospital (Approval No. KY2025024). Informed consent was waived due to the retrospective nature of the study and the absence of identifiable patient information.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Participants\u003c/h2\u003e\u003cp\u003ePatients who underwent lateral cephalometric radiography during visits to the Department of Orthodontics at the Stomatology Hospital, Zhejiang University School of Medicine, and the Department of Otolaryngology\u0026ndash;Head and Neck Surgery at Shulan Hospital between August 2023 and July 2024 were enrolled in this study. Eligible participants were aged 6\u0026ndash;12 years and in the stage of mixed dentition. The exclusion criteria included an adenoid A/N ratio\u0026thinsp;\u0026ge;\u0026thinsp;0.6 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], a history of recurrent rhinitis, poor-quality cephalograms, craniofacial syndromes (e.g., cleft lip and palate), incomplete medical history, acute upper respiratory tract infections, maxillofacial trauma, temporomandibular joint osteoarthritis, or prior orthodontic treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Sample size calculation\u003c/h2\u003e\u003cp\u003eThis study was designed as a multicenter retrospective cohort study. The sample size was calculated based on the primary outcome: the prevalence of anterior crossbite. According to previous studies and our preliminary data, the expected prevalence of anterior crossbite was 6.9% in the control group and 45.8% in children with tonsillar hypertrophy, consistent with earlier reports [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Assuming a two-sided significance level of 0.05, a statistical power of 90%, and equal sample sizes between groups (k\u0026thinsp;=\u0026thinsp;1), the minimum required sample size per group was calculated using the following formula:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:n=\\frac{{（{Z}_{\\frac{\\alpha\\:}{2}}+{Z}_{\\beta\\:}）}^{2}\\bullet\\:\\left[{p}_{1}\\right(1-{p}_{1})+{p}_{2}(1-{p}_{2}\\left)\\right]}{{({p}_{1}-{p}_{2})}^{2}}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe expected prevalence of anterior crossbite in the control and tonsillar hypertrophy groups was estimated at 6.9% and 45.8%, respectively. Assuming a two-sided significance level of α\u0026thinsp;=\u0026thinsp;0.05 and a power of 90% (β\u0026thinsp;=\u0026thinsp;0.1), the corresponding critical values were \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Z}_{\\frac{\\alpha\\:}{2}}\\)\u003c/span\u003e\u003c/span\u003e(α\u0026thinsp;=\u0026thinsp;0.05)=1.96, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Z}_{\\beta\\:}\\)\u003c/span\u003e\u003c/span\u003e༈β\u0026thinsp;=\u0026thinsp;0.1༉=1.282. The sample size was calculated using a standard formula for comparing two proportions. Substituting these values into the equation yielded a minimum required sample size of 22 participants per group (total n\u0026thinsp;=\u0026thinsp;88), which was sufficient to detect statistically significant differences between the groups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Experimental equipment\u003c/h2\u003e\u003cp\u003e(1) Cephalometric radiographic systems, including the Orhopantomograph OP200 D (Instrumentarium Imaging Corporation, Tuusula, Finland), Planmeca Promax Ethernet Interface (Planmeca Group, Helsinki, Finland), and Digital Diagnost (Philips Medical Systems, Eindhoven, Netherlands);\u003c/p\u003e\u003cp\u003e(2) Dolphin Imaging software version 11.95 (Dolphin Imaging and Management Solutions, Chatsworth, CA, USA) for cephalometric landmark identification and measurement;\u003c/p\u003e\u003cp\u003e(3) SPSS software version 27.0 (IBM Corporation, Armonk, NY, USA) for statistical analysis;\u003c/p\u003e\u003cp\u003e(4) GraphPad Prism version 8.3 (GraphPad Software, San Diego, CA, USA) for data visualization.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Measurement and analysis\u003c/h2\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.4.1 Tonsil size measurement\u003c/h2\u003e\u003cp\u003e Oral examination using a tongue depressor or nasopharyngolaryngoscopy was performed to diagnose tonsillar hypertrophy in the transverse dimension. The Brodsky grading system was employed to assess tonsil size, classifying it on a scale from 0 to 4 based on the proportion of the oropharyngeal width occupied by the bilateral tonsils [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Intraoral examination of the dentition was also conducted to record the dentition stage and anterior occlusal relationship. The sagittal anterior occlusion was determined by the presence of overbite and overjet, defined as the vertical and horizontal overlap of the maxillary incisors over the mandibular incisors, respectively. In cases with localized occlusal discrepancies, the predominant incisor relationship was used as the representative pattern.\u003c/p\u003e\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, lateral cephalograms were used to assess tonsillar hypertrophy in the anteroposterior dimension using the method described by Baroni et al. Specifically, the maximal anteroposterior diameter of the tonsil, referred to as Tonsil Size (TS), and the Total Oropharyngeal Airway Space (TOAS) were measured. A tangent was drawn along the posterior pharyngeal wall, and from the most prominent point of the tonsil (Tonsil Point, TO), a perpendicular line was extended to intersect the tangent at the Oropharynx Posterior point (OP). The anterior extension of this line intersected the tongue base at the Oropharynx Anterior point (Oa). The distance from Oa to TO was defined as TS, and the distance from Oa to OP as TOAS. The ratio TS/TOAS was calculated to evaluate the degree of anteroposterior tonsillar hypertrophy. A ratio\u0026thinsp;\u0026lt;\u0026thinsp;50% was classified as non-obstructive anteroposterior tonsillar hypertrophy, while a ratio\u0026thinsp;\u0026ge;\u0026thinsp;50% was considered obstructive anteroposterior tonsillar hypertrophy[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.4.2 Cephalometric Measurements\u003c/h2\u003e\u003cp\u003eAll lateral cephalometric radiographs were analyzed using Dolphin Imaging software (version 11.95; Dolphin Imaging \u0026amp; Management Solutions, Chatsworth, CA, USA). Anatomical landmarks were manually identified by a single calibrated examiner after importing the images into the software. All measurements were performed during a standardized time window to ensure measurement consistency. Each subject\u0026rsquo;s cephalogram was assessed twice, with a two-week interval between measurements. The mean of the two measurements was used for the final analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.4.3 Quality control\u003c/h2\u003e\u003cp\u003eAll measurements were performed by the same examiner. Each anatomical landmark was independently identified and measured twice at a two-week interval. Intra-operator measurement reliability was assessed using intraclass correlation coefficients (ICC). An ICC value greater than 0.75 was interpreted as indicating good reliability, while values\u0026thinsp;\u0026ge;\u0026thinsp;0.90 were considered to reflect excellent reliability.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Categorize\u003c/h2\u003e\u003cp\u003eAll lateral cephalograms were acquired under standardized conditions by the lead radiologic technologist using the following devices: Orthopantomograph OP200 D (Instrumentarium Imaging Corporation, Tuusula, Finland), Planmeca Promax Ethernet Interface (Planmeca Group, Helsinki, Finland), and Digital Diagnost (Philips Medical Systems, Eindhoven, Netherlands). The imaging parameters were a tube voltage of 73.0 kV, tube current of 10.0 mA, and exposure time of 1.1 seconds. All cephalograms were obtained with patients positioned in the natural head position and the intercuspal position (ICP).\u003c/p\u003e\u003cp\u003eBased on intraoral examination and lateral cephalometric assessment, subjects were classified using the Brodsky grading system and the Baroni method as follows:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eGroup A (non-hypertrophic or mildly hypertrophic): Brodsky grade 0\u0026ndash;1 on intraoral examination and non-obstructive tonsils in the anteroposterior dimension on lateral cephalometry.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eGroup B (transverse hypertrophy): Brodsky grade 2\u0026ndash;4 and non-obstructive tonsils in the anteroposterior dimension.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eGroup C (anteroposterior hypertrophy): Brodsky grade 0\u0026ndash;1 and obstructive tonsils in the anteroposterior dimension.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eGroup D (combined transverse and anteroposterior hypertrophy): Brodsky grade 2\u0026ndash;4 and obstructive tonsils in the anteroposterior dimension.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eFurther subgrouping was performed within Group D according to the degree of transverse hypertrophy: patients with Brodsky grade 2 were categorized into subgroup D1, and those with grades 3\u0026ndash;4 into subgroup D2.\u003c/p\u003e\u003cp\u003eAccording to the ANB angle, patients were classified into sagittal skeletal patterns as follows: skeletal Class I (ANB: 0\u0026deg;\u0026ndash;4\u0026deg;), skeletal Class II (ANB\u0026thinsp;\u0026gt;\u0026thinsp;4\u0026deg;), and skeletal Class III (ANB\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026deg;) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Statistical methods\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using SPSS software (version 27.0; IBM Corp., Armonk, NY, USA). Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) for normally distributed data or as median with interquartile range (IQR) for non-normally distributed data. Normality was assessed using the Shapiro\u0026ndash;Wilk test, and homogeneity of variances was evaluated using Levene\u0026rsquo;s test.\u003c/p\u003e\u003cp\u003eFor normally distributed data with equal variances, one-way ANOVA with Tukey\u0026rsquo;s post hoc test was applied. When variances were unequal, Welch\u0026rsquo;s ANOVA with the Games\u0026ndash;Howell post hoc test was used. For non-normally distributed data, the Kruskal\u0026ndash;Wallis H test was employed, and pairwise comparisons were conducted using the Mann\u0026ndash;Whitney U test with Bonferroni correction when significant differences were observed.\u003c/p\u003e\u003cp\u003eCategorical variables were analyzed using the chi-square test or Fisher\u0026rsquo;s exact test, with post hoc correction as appropriate. A \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eA total of 275 participants were included in this study, with a mean age of 8.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06 years. Among them, 36 children were classified into Group A, 50 into Group B, 42 into Group C, and 147 into Group D. Further subgroup analysis identified 70 children in subgroup D1 and 77 in subgroup D2. All groups met the minimum required sample size (\u0026ge;\u0026thinsp;22 participants). Intraclass correlation coefficient (ICC) analysis demonstrated values ranging from 0.83 to 0.92, indicating good measurement reliability. The baseline characteristics of each group were compared, and the results are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eBaseline characteristics of the participants\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eD1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eD2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e9.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e8.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e9.38\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e8.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.11 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eGender, Number of cases (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e18 (50.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e23 (46.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e20 (47.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e86 (58.50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e41 (58.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e45 (58.44)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e18 (50.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e26 (53.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e22 (52.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e61 (41.50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29 (41.43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e32 (41.56)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eGroup A\u0026thinsp;=\u0026thinsp;non-hypertrophic or mildly hypertrophic; Group B\u0026thinsp;=\u0026thinsp;transverse hypertrophy; Group C\u0026thinsp;=\u0026thinsp;anteroposterior hypertrophy; Group D\u0026thinsp;=\u0026thinsp;combined transverse and anteroposterior hypertrophy; D1\u0026thinsp;=\u0026thinsp;Brodsky grade 2; D2\u0026thinsp;=\u0026thinsp;Brodsky grade 3\u0026ndash;4.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Comparison of anterior occlusal relationships among groups\u003c/h2\u003e\u003cp\u003eSignificant differences were observed among groups in anterior occlusal relationships (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The prevalence rates of both anterior crossbite and edge-to-edge bite were significantly higher in Group C and D compared to Group A and B (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with Group D exhibiting a higher prevalence than Group C. Significant differences were also observed between Groups A and D, and between Groups B and C (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Additionally, the prevalence of deep overbite and overjet differed significantly between Group A and both Groups C and D (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01 or \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eOverall, Groups C and D exhibited a markedly higher frequency of anterior crossbite and edge-to-edge bite, and a significantly lower frequency of deep overbite and overjet compared to Group A. Several malocclusion features were also more common in Groups C and D than in Group B.\u003c/p\u003e\u003cp\u003eSubgroup analysis within Group D revealed that Group D2 had slightly higher rates of anterior crossbite and edge-to-edge bite, and slightly lower rates of deep overbite and deep overjet compared to Group D1; however, these differences were not statistically significant.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eAnalysis of anterior occlusal relationship characteristics among groups\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAnterior occlusal relationship,\u003c/p\u003e\u003cp\u003eNumber of cases (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eD1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eD2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNormal overbite and overjet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e19 (52.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e34 (68.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e21 (50.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e61(41.50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32 (45.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29 (37.67)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAnterior crossbite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e7 (16.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e32 (21.77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11 (15.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21 (27.27)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEdge-to-edge bite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1 (2.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e5 (10.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e9 (21.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e35 (23.81)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15 (21.43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20 (25.97)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDeep overbite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e6 (16.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e3 (6.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1 (2.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4 (2.72)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (4.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 (1.30)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDeep overjet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e6 (16.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e6 (12.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e4 (9.52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e12 (8.16)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 (11.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4 (5.19)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDeep overbite and overjet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e4 (11.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2 (4.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e3 (2.04)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (1.43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (2.60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eGroup A\u0026thinsp;=\u0026thinsp;non-hypertrophic or mildly hypertrophic; Group B\u0026thinsp;=\u0026thinsp;transverse hypertrophy; Group C\u0026thinsp;=\u0026thinsp;anteroposterior hypertrophy; Group D\u0026thinsp;=\u0026thinsp;combined transverse and anteroposterior hypertrophy; D1\u0026thinsp;=\u0026thinsp;Brodsky grade 2; D2\u0026thinsp;=\u0026thinsp;Brodsky grade 3\u0026ndash;4.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Comparison of sagittal skeletal patterns among groups\u003c/h2\u003e\u003cp\u003eStatistical analysis of sagittal skeletal patterns revealed significant intergroup differences (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Multiple significant differences in the distribution of skeletal Class II and III patterns were observed between Groups A and C/D, and between Groups B and C/D (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01 or \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while no significant differences were found between Groups A and B or between Groups C and D. Additionally, the proportion of skeletal Class I malocclusion was comparable across all groups, with a slightly lower value observed in Group D; however, this difference was not statistically significant. (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Specifically, the prevalence of skeletal Class III malocclusion was significantly higher in Group D than in Groups A and B (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and also higher in Group C than in Groups A and B (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Conversely, skeletal Class II malocclusion was significantly lower in prevalence in Groups C and D compared to Groups A and B (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eSubgroup analysis within Group D showed a slightly higher proportion of skeletal Class III and a lower proportion of skeletal Class I in Group D2 compared to Group D1; however, these differences were not statistically significant. Additionally, the proportion of skeletal Class II was comparable between the two subgroups.\u003c/p\u003e\u003cp\u003eTable 3 \u003cem\u003eSagittal Skeletal Pattern Distribution Across Groups\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"580\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 474px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eD1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eD2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 580px;\"\u003e\n \u003cp\u003eSagittal Skeletal Patter, Number of cases\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 106px;\"\u003e\n \u003cp\u003eSkeletal Class I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e18 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e24 (48.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e20 (47.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e66 (44.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e35 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e31 (40.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 106px;\"\u003e\n \u003cp\u003eSkeletal Class II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e17 (47.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e23 (46.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e9 (21.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e31 (21.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e15 (21.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e16 (20.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 106px;\"\u003e\n \u003cp\u003eSkeletal Class III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (2.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3 (6.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e13 (30.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e50 (34.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e20 (28.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e30 (38.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGroup A = non-hypertrophic or mildly hypertrophic; Group B = transverse hypertrophy; Group C = anteroposterior hypertrophy; Group D = combined transverse and anteroposterior hypertrophy; D1 = Brodsky grade 2; D2 = Brodsky grade 3-4.\u003c/p\u003e\n\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Comparison of craniofacial skeletal characteristics among groups\u003c/h2\u003e\u003cp\u003eSignificant differences in craniofacial skeletal parameters were observed among the groups. Compared with Group A, Group B demonstrated trends toward skeletal compensation, including reduced SN-Ar angle, increased Na-Go-Me and SN-MP angles, and decreased ANB and NA-Apo angles; however, these differences were not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eGroup C showed a significantly smaller SN-Ar angle than Group A (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating anterior positioning of the condyle. The Ar-Go-Me and Na-Go-Me angles were significantly larger (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, respectively), consistent with a vertical mandibular growth pattern. Additionally, increased SNB and decreased ANB and NA-Apo angles (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) indicated mandibular prognathism and maxillary retrusion. The NP-FH angle was also significantly increased (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating a skeletal Class III tendency.\u003c/p\u003e\u003cp\u003eGroup D exhibited significant differences in SN-Ar, Ar-Go-Me, Ar-Go-Na, SNB, and NA-Apo angles compared with Group A (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 to \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), reflecting multidimensional skeletal compensation and mandibular protrusion. The SGn and NP-FH angles were significantly increased, while the posterior-to-anterior facial height ratio (P/A) was significantly reduced (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating chin projection and a high-angle growth pattern. A decreased SGn-SN angle further indicated prognition of the chin.\u003c/p\u003e\u003cp\u003eCompared with Group B, Group D showed more significant alterations in mandibular morphology (Ar-Go-Me, Go-Gn, Ar-Go), jaw relationships (increased SNB, decreased ANB and NA-Apo), and facial growth pattern (increased NP-FH, decreased P/A) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 to \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), indicating more pronounced mandibular prognathism, maxillary retrusion, and vertical growth.\u003c/p\u003e\u003cp\u003eCompared with Group C, Group D showed a significantly greater total craniofacial triangle angle (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although other measurements (Go-Gn, Ar-Go, SGn, Na-Me) were higher in Group D, these differences were not statistically significant, which may reflect overall skeletal integration with limited regional variation, potentially attributable to individual differences.\u003c/p\u003e\u003cp\u003eWithin Group D, subgroup D2 exhibited a significantly lower ANB angle ( \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and P/A ratio (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) than subgroup D1, indicating features consistent with stronger mandibular protrusion and increased anterior facial height\u0026mdash;characteristics of skeletal Class III and vertical growth compensation. No other parameters showed significant differences (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eMean and Standard Deviation of Skeletal Measurements Across Groups\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eMeasurement items\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eD1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eD2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSN-Ar (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e123.06\u0026thinsp;\u0026plusmn;\u0026thinsp;6.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e120.37\u0026thinsp;\u0026plusmn;\u0026thinsp;5.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e118.20\u0026thinsp;\u0026plusmn;\u0026thinsp;8.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e119.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e119.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e119.12\u0026thinsp;\u0026plusmn;\u0026thinsp;6.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSN (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e62.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e62.46\u0026thinsp;\u0026plusmn;\u0026thinsp;6.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e63.35\u0026thinsp;\u0026plusmn;\u0026thinsp;9.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e64.33\u0026thinsp;\u0026plusmn;\u0026thinsp;7.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65.37\u0026thinsp;\u0026plusmn;\u0026thinsp;5.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e63.38\u0026thinsp;\u0026plusmn;\u0026thinsp;8.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eS-Ar (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e31.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e32.06\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e31.10\u0026thinsp;\u0026plusmn;\u0026thinsp;5.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e30.90\u0026thinsp;\u0026plusmn;\u0026thinsp;4.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30.21\u0026thinsp;\u0026plusmn;\u0026thinsp;5.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAr-Go-Me (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e122.34\u0026thinsp;\u0026plusmn;\u0026thinsp;4.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e122.94\u0026thinsp;\u0026plusmn;\u0026thinsp;6.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e128.19\u0026thinsp;\u0026plusmn;\u0026thinsp;6.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e128.07\u0026thinsp;\u0026plusmn;\u0026thinsp;6.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e127.44\u0026thinsp;\u0026plusmn;\u0026thinsp;5.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e128.64\u0026thinsp;\u0026plusmn;\u0026thinsp;6.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGo-Gn (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e69.39\u0026thinsp;\u0026plusmn;\u0026thinsp;6.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e68.24\u0026thinsp;\u0026plusmn;\u0026thinsp;8.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e71.76\u0026thinsp;\u0026plusmn;\u0026thinsp;10.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e73.32\u0026thinsp;\u0026plusmn;\u0026thinsp;9.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e74.10\u0026thinsp;\u0026plusmn;\u0026thinsp;7.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e72.60\u0026thinsp;\u0026plusmn;\u0026thinsp;10.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAr-Go-Na (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e46.70\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e46.61\u0026thinsp;\u0026plusmn;\u0026thinsp;4.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e49.23\u0026thinsp;\u0026plusmn;\u0026thinsp;4.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e49.04\u0026thinsp;\u0026plusmn;\u0026thinsp;4.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e48.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNa-Go-Me (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e75.64\u0026thinsp;\u0026plusmn;\u0026thinsp;4.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e76.32\u0026thinsp;\u0026plusmn;\u0026thinsp;4.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e78.95\u0026thinsp;\u0026plusmn;\u0026thinsp;4.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e77.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e78.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e77.29\u0026thinsp;\u0026plusmn;\u0026thinsp;5.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAr-Go (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e36.50\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e36.79\u0026thinsp;\u0026plusmn;\u0026thinsp;5.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e38.80\u0026thinsp;\u0026plusmn;\u0026thinsp;7.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e40.76\u0026thinsp;\u0026plusmn;\u0026thinsp;6.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e41.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e39.72\u0026thinsp;\u0026plusmn;\u0026thinsp;6.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSNA (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e79.58\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e78.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e79.04\u0026thinsp;\u0026plusmn;\u0026thinsp;4.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e79.01\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e79.35\u0026thinsp;\u0026plusmn;\u0026thinsp;3.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e78.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSNB (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e75.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e74.87\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e78.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e78.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e77.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e78.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eANB (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e3.69\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e3.54\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.65\u0026thinsp;\u0026plusmn;\u0026thinsp;3.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.65\u0026thinsp;\u0026plusmn;\u0026thinsp;3.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.40\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNA-Apo (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e8.56\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e7.60\u0026thinsp;\u0026plusmn;\u0026thinsp;6.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e3.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e3.86\u0026thinsp;\u0026plusmn;\u0026thinsp;6.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.05\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.78\u0026thinsp;\u0026plusmn;\u0026thinsp;7.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eS-Ar-Go (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e151.87\u0026thinsp;\u0026plusmn;\u0026thinsp;7.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e152.09\u0026thinsp;\u0026plusmn;\u0026thinsp;7.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e148.417.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e148.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e148.84\u0026thinsp;\u0026plusmn;\u0026thinsp;6.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e148.94\u0026thinsp;\u0026plusmn;\u0026thinsp;7.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ethe Three Angle (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e397.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e395.40\u0026thinsp;\u0026plusmn;\u0026thinsp;5.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e394.80\u0026thinsp;\u0026plusmn;\u0026thinsp;7.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e399.04\u0026thinsp;\u0026plusmn;\u0026thinsp;5.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e399.41\u0026thinsp;\u0026plusmn;\u0026thinsp;5.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e398.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eJarabak Anterior Ratio (*100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e90.12\u0026thinsp;\u0026plusmn;\u0026thinsp;6.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e92.05\u0026thinsp;\u0026plusmn;\u0026thinsp;7.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e88.45\u0026thinsp;\u0026plusmn;\u0026thinsp;6.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e88.10\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e88.61\u0026thinsp;\u0026plusmn;\u0026thinsp;6.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e87.65\u0026thinsp;\u0026plusmn;\u0026thinsp;6.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSN-MP (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e36.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e38.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e38.81\u0026thinsp;\u0026plusmn;\u0026thinsp;7.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e38.57\u0026thinsp;\u0026plusmn;\u0026thinsp;5.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38.41\u0026thinsp;\u0026plusmn;\u0026thinsp;5.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e38.71\u0026thinsp;\u0026plusmn;\u0026thinsp;6.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eN-Go (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e104.01\u0026thinsp;\u0026plusmn;\u0026thinsp;8.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e102.48\u0026thinsp;\u0026plusmn;\u0026thinsp;11.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e101.14\u0026thinsp;\u0026plusmn;\u0026thinsp;15.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e101.63\u0026thinsp;\u0026plusmn;\u0026thinsp;11.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e101.28\u0026thinsp;\u0026plusmn;\u0026thinsp;7.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e101.94\u0026thinsp;\u0026plusmn;\u0026thinsp;14.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eSGn (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e112.80\u0026thinsp;\u0026plusmn;\u0026thinsp;8.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e111.54\u0026thinsp;\u0026plusmn;\u0026thinsp;12.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e118.25\u0026thinsp;\u0026plusmn;\u0026thinsp;18.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e120.31\u0026thinsp;\u0026plusmn;\u0026thinsp;13.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e120.00\u0026thinsp;\u0026plusmn;\u0026thinsp;11.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e120.51\u0026thinsp;\u0026plusmn;\u0026thinsp;14.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eNP-FH (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e81.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e80.86\u0026thinsp;\u0026plusmn;\u0026thinsp;3.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e84.72\u0026thinsp;\u0026plusmn;\u0026thinsp;6.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e84.74\u0026thinsp;\u0026plusmn;\u0026thinsp;3.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e84.07\u0026thinsp;\u0026plusmn;\u0026thinsp;3.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e85.35\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eS-Go (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e69.50\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e67.05\u0026thinsp;\u0026plusmn;\u0026thinsp;8.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e66.75\u0026thinsp;\u0026plusmn;\u0026thinsp;11.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e66.26\u0026thinsp;\u0026plusmn;\u0026thinsp;8.45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e66.27\u0026thinsp;\u0026plusmn;\u0026thinsp;6.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e66.25\u0026thinsp;\u0026plusmn;\u0026thinsp;9.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eNa-Me (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e107.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e106.21\u0026thinsp;\u0026plusmn;\u0026thinsp;11.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e108.43\u0026thinsp;\u0026plusmn;\u0026thinsp;16.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e110.49\u0026thinsp;\u0026plusmn;\u0026thinsp;12.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e107.68\u0026thinsp;\u0026plusmn;\u0026thinsp;14.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e113.06\u0026thinsp;\u0026plusmn;\u0026thinsp;10.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eP/A (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e64.86\u0026thinsp;\u0026plusmn;\u0026thinsp;3.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e63.15\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e61.64\u0026thinsp;\u0026plusmn;\u0026thinsp;5.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e60.53\u0026thinsp;\u0026plusmn;\u0026thinsp;8.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e62.34\u0026thinsp;\u0026plusmn;\u0026thinsp;8.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e58.89\u0026thinsp;\u0026plusmn;\u0026thinsp;8.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eSGn-SN (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e72.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e72.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e69.71\u0026thinsp;\u0026plusmn;\u0026thinsp;6.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e69.80\u0026thinsp;\u0026plusmn;\u0026thinsp;3.97\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e70.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e69.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eGroup A\u0026thinsp;=\u0026thinsp;non-hypertrophic or mildly hypertrophic; Group B\u0026thinsp;=\u0026thinsp;transverse hypertrophy; Group C\u0026thinsp;=\u0026thinsp;anteroposterior hypertrophy; Group D\u0026thinsp;=\u0026thinsp;combined transverse and anteroposterior hypertrophy; D1\u0026thinsp;=\u0026thinsp;Brodsky grade 2; D2\u0026thinsp;=\u0026thinsp;Brodsky grade 3\u0026ndash;4.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Comparison of dental characteristics among groups\u003c/h2\u003e\u003cp\u003eCompared with Group A, Group B showed slightly reduced FMIA and U1-SN angles, suggesting minor dental differences; however, these differences were not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eGroup C showed a significantly lower IMPA angle (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), reduced U1-NP (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and increased MP-OP angle (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating compensatory lingual inclination of the mandibular incisors.\u003c/p\u003e\u003cp\u003eIn Group D, the IMPA angle was significantly decreased (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), the U1-NP angle was significantly reduced (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and the MP-OP angle was significantly increased (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) compared with Group A, reflecting more pronounced mandibular incisor retroclination and a steeper occlusal plane. Compared with Group B, Group D also showed a significantly higher FMIA (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), lower IMPA and U1-NP angles, and a greater MP-OP angle (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating stronger dental compensation.\u003c/p\u003e\u003cp\u003eNo statistically significant differences in dental parameters were observed between Group D and Group C, or between subgroups D2 and D1. However, minor trends toward increased dental compensation were observed, which may reflect consistent individual variation in incisor inclination (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eMean and standard deviation of dental measurement items among groups\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eMeasure-ment items\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eD1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eD2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eIMPA (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e93.63\u0026thinsp;\u0026plusmn;\u0026thinsp;7.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e93.66\u0026thinsp;\u0026plusmn;\u0026thinsp;6.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e88.44\u0026thinsp;\u0026plusmn;\u0026thinsp;8.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e88.14\u0026thinsp;\u0026plusmn;\u0026thinsp;8.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e88.64\u0026thinsp;\u0026plusmn;\u0026thinsp;8.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e87.69\u0026thinsp;\u0026plusmn;\u0026thinsp;7.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFMIA (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e59.36\u0026thinsp;\u0026plusmn;\u0026thinsp;6.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e58.03\u0026thinsp;\u0026plusmn;\u0026thinsp;7.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e61.57\u0026thinsp;\u0026plusmn;\u0026thinsp;8.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e62.23\u0026thinsp;\u0026plusmn;\u0026thinsp;8.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61.44\u0026thinsp;\u0026plusmn;\u0026thinsp;8.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e62.94\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eL1-NP (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e6.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e5.69\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e6.21\u0026thinsp;\u0026plusmn;\u0026thinsp;3.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e6.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eU1-NP (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e11.27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e10.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e7.30\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e7.60\u0026thinsp;\u0026plusmn;\u0026thinsp;4.55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.50\u0026thinsp;\u0026plusmn;\u0026thinsp;4.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.70\u0026thinsp;\u0026plusmn;\u0026thinsp;4.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eU1-SN (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e105.53\u0026thinsp;\u0026plusmn;\u0026thinsp;6.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e103.89\u0026thinsp;\u0026plusmn;\u0026thinsp;9.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e103.16\u0026thinsp;\u0026plusmn;\u0026thinsp;11.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e103.39\u0026thinsp;\u0026plusmn;\u0026thinsp;9.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e103.25\u0026thinsp;\u0026plusmn;\u0026thinsp;8.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e103.52\u0026thinsp;\u0026plusmn;\u0026thinsp;9.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMP-OP (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e15.58\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e15.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e18.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e19.37\u0026thinsp;\u0026plusmn;\u0026thinsp;4.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.73\u0026thinsp;\u0026plusmn;\u0026thinsp;3.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19.95\u0026thinsp;\u0026plusmn;\u0026thinsp;4.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eU1-L1 (\u003csup\u003e。\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e123.58\u0026thinsp;\u0026plusmn;\u0026thinsp;9.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e124.04\u0026thinsp;\u0026plusmn;\u0026thinsp;10.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e125.59\u0026thinsp;\u0026plusmn;\u0026thinsp;9.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e128.46\u0026thinsp;\u0026plusmn;\u0026thinsp;12.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e126.69\u0026thinsp;\u0026plusmn;\u0026thinsp;13.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e130.07\u0026thinsp;\u0026plusmn;\u0026thinsp;12.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eGroup A\u0026thinsp;=\u0026thinsp;non-hypertrophic or mildly hypertrophic; Group B\u0026thinsp;=\u0026thinsp;transverse hypertrophy; Group C\u0026thinsp;=\u0026thinsp;anteroposterior hypertrophy; Group D\u0026thinsp;=\u0026thinsp;combined transverse and anteroposterior hypertrophy; D1\u0026thinsp;=\u0026thinsp;Brodsky grade 2; D2\u0026thinsp;=\u0026thinsp;Brodsky grade 3\u0026ndash;4.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Comparison of soft tissue measurements among groups\u003c/h2\u003e\u003cp\u003eNo statistically significant differences were observed among groups in the distances from the upper and lower lips to the E-line (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, a trend was observed in which the upper lip in Group D2 (1.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51 mm) was slightly more retrusive than in Groups A (2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42 mm), B (2.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97 mm), C (2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23 mm), and D1 (2.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.19 mm). Additionally, Groups C (0.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.33 mm) and D (0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68 mm) demonstrated a trend toward increased lower lip protrusion relative to Groups A (\u0026minus;\u0026thinsp;0.04\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76 mm) and B (0.05\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74 mm), with Group D2 (1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64 mm) showing greater protrusion than Group D1 (0.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64 mm) (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eMean and standard deviation of soft tissue measurement items among groups\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eMeasurement items\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eD1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eD2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eLL-E\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-0.04\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.05\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUL-E\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e1.94\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eGroup A\u0026thinsp;=\u0026thinsp;non-hypertrophic or mildly hypertrophic; Group B\u0026thinsp;=\u0026thinsp;transverse hypertrophy; Group C\u0026thinsp;=\u0026thinsp;anteroposterior hypertrophy; Group D\u0026thinsp;=\u0026thinsp;combined transverse and anteroposterior hypertrophy; D1\u0026thinsp;=\u0026thinsp;Brodsky grade 2; D2\u0026thinsp;=\u0026thinsp;Brodsky grade 3\u0026ndash;4.\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study utilized the Baroni method on lateral cephalograms to assess anteroposterior tonsillar hypertrophy, aiming to address the limitations of the traditional Brodsky grading system, which primarily evaluates transverse hypertrophy. The findings revealed a significant association between anteroposterior tonsillar hypertrophy and an increased risk of anterior crossbite and edge-to-edge bite, primarily due to sagittal airway obstruction leading to mandibular advancement as a compensatory mechanism and contributing to the development of skeletal Class III patterns. In contrast, transverse airway obstruction exerted minimal influence on jaw morphology.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Anterior occlusal characteristics in children with different types of tonsillar hypertrophy\u003c/h2\u003e\u003cp\u003eSignificant differences in anterior occlusal relationships were observed among the groups (χ\u0026sup2; = 56.10, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Group A (normal/mild hypertrophy) showed the highest proportion of normal overbite (52.78%) and no observed cases of anterior crossbite. In contrast, the prevalence of anterior crossbite was 16.67% and 21.77% in Groups C and D, respectively (C vs. A: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013; D vs. A: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), suggesting that tonsillar hypertrophy may influence the anterior occlusion. This potential effect may be attributed to the alterations in tongue position and mandibular posture caused by tonsillar hypertrophy, which subsequently modify the biomechanical environment of the anterior dentition and thereby increase the risk of anterior crossbite and edge-to-edge bite. Group B (transverse obstruction) did not differ significantly from Group A (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), whereas Group C (anteroposterior obstruction) demonstrated significantly higher rates of anterior crossbite and edge-to-edge bite (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013 and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017, respectively), indicating a more pronounced impact of sagittal airway obstruction on occlusion, which was consist with previous studies[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWithin Group D, although D2 (severe transverse obstruction) had slightly higher malocclusion rates than D1, the differences were not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), further reinforcing anteroposterior obstruction as the primary risk factor. Additionally, deep overbite was most prevalent in Group A (16.67%) and least common in Groups C and D (2.38\u0026ndash;2.72%), possibly reflecting compensatory head and neck postural adaptations associated with airway restriction. Altered tongue posture resulting from airway obstruction\u0026mdash;including low tongue positioning and tongue thrust\u0026mdash;may further contribute to anterior occlusal disturbances [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Sagittal skeletal patterns in children with different types of tonsillar hypertrophy\u003c/h2\u003e\u003cp\u003eA significant association was observed between the type of tonsillar hypertrophy and sagittal skeletal pattern (χ\u0026sup2; = 33.45, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Groups C and D, both characterized by anteroposterior obstruction, showed a significantly higher prevalence of skeletal Class III malocclusion (33.33% and 34.01%, respectively), compared to only 2.78% in Group A. This finding suggests that anteroposterior airway narrowing may contribute to mandibular protrusion through compensatory mechanisms such as forward mandibular posturing[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In contrast, Group B (transverse obstruction only) had a low proportion of Class III cases (6%), comparable to Group A (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) and significantly lower than Groups C and D (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating that anteroposterior obstruction may exert a greater influence on sagittal skeletal development[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMoreover, the proportion of skeletal Class II malocclusion decreased notably in Groups C and D (19.04% and 21.09%), possibly resulting from compensatory head and neck postures that modify maxillomandibular growth toward a Class III pattern[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Within Group D, the prevalence of skeletal Class III was slightly higher in D2 (38.96%) than in D1 (28.57%), though this difference was not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), suggesting that transverse obstruction may play a secondary role unless accompanied by severe anteroposterior narrowing. Future studies integrating three-dimensional airway imaging and biomechanical modeling are needed to elucidate the proposed \u0026ldquo;obstruction vector\u0026ndash;compensatory pathway\u0026ndash;skeletal response\u0026rdquo; mechanism and to facilitate personalized craniofacial growth prediction.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Cephalometric skeletal analysis in children with different types of tonsillar hypertrophy\u003c/h2\u003e\u003cp\u003eThis study identified a significant association between the directional dimension of airway obstruction caused by tonsillar hypertrophy and patterns of craniofacial skeletal compensation. Specifically, anteroposterior obstruction (Groups C and D) was linked to increased SNB and Ar-Go-Me angles and decreased NA-Apo angles, indicating mandibular advancement, maxillary retrusion, and a vertical growth tendency[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Group D demonstrated the most pronounced reduction in ANB angle, with some values turning negative, suggesting that combined (anteroposterior and transverse) obstruction may surpass the compensatory threshold, potentially resulting in skeletal Class III malocclusion. In contrast, transverse obstruction alone (Group B) showed limited impact on skeletal parameters.\u003c/p\u003e\u003cp\u003eFrom a biomechanical perspective, the skeletal compensatory mechanism associated with sagittal airway obstruction may arise from respiration-driven adaptive regulation across the airway, soft tissue, and skeletal systems. Anteroposterior hypertrophy of the tonsils directly obstructs nasal airflow at the oropharyngeal level, exerting posterior pressure on the tongue root and displacing the tongue anteriorly[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Sustained tension in the genioglossus muscle stimulates the mandibular symphysis, promoting a forward and downward growth trajectory of the mandible. To preserve adequate oropharyngeal airway volume, children may adopt a habitual mandibular protrusion posture. If airway obstruction remains unresolved, prolonged mechanical traction\u0026mdash;coupled with complex neuromuscular and skeletal regulatory networks\u0026mdash;may ultimately result in irreversible skeletal Class III malocclusion[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn contrast, transverse tonsillar hypertrophy causing coronal airway obstruction appears to exert a more limited influence on maxillomandibular relationships. Although a slight increase in the mandibular plane angle (SN-MP) was noted, the symmetrical tension distribution of the bilateral masticatory muscles may mitigate significant skeletal displacement.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Dentoskeletal compensation in children with different types of tonsillar hypertrophy\u003c/h2\u003e\u003cp\u003eThis study suggests that tonsillar hypertrophy in different anatomical directions may elicit distinct dentofacial compensatory mechanisms through variable patterns of airway obstruction. In Group B (transverse obstruction), no significant dental changes were observed, possibly due to compensatory adaptations such as soft tissue repositioning or postural adjustments. In contrast, Group C (anteroposterior obstruction) demonstrated marked dental compensation, including retroclination of the mandibular incisors (significantly reduced IMPA), reduced proclination of the maxillary incisors (sharp decrease in U1-NP), and a steeper occlusal plane angle (MP-OP), consistent with a compensatory pattern involving posterior and inferior mandibular rotation.\u003c/p\u003e\u003cp\u003eGroup D (mixed obstruction) showed more pronounced dentoalveolar and skeletal compensation, with significantly greater changes in IMPA and MP-OP, indicating that the masticatory system may be nearing its limit of dentoskeletal adaptation. Although no significant differences were found between subgroups D1 and D2, a slight increase in occlusal plane steepness with worsening obstruction suggests a potential threshold of compensatory breakdown, warranting interdisciplinary assessment and early intervention involving otolaryngologists.\u003c/p\u003e\u003cp\u003eFrom a biomechanical perspective, Group C exhibited a pattern of mandibular protrusion accompanied by retroclined lower incisors, while Group D presented a high-angle, open-growth pattern with downward mandibular rotation\u0026mdash;illustrating a biomechanical sequence of mandibular advancement, incisor retroclination, and occlusal plane steepening. In summary, transverse obstruction may have limited impact; anteroposterior obstruction may trigger adaptive responses of the occlusal system; and mixed obstruction may result in more complex malocclusions and craniofacial dysmorphology.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Soft tissue characteristics in children with different types of tonsillar hypertrophy\u003c/h2\u003e\u003cp\u003eThis study suggests that different types of tonsillar hypertrophy may contribute to distinct patterns of perioral soft tissue adaptation as a result of multidirectional airway obstruction. Although no statistically significant differences were found in upper and lower lip positions relative to the E-line, Group C (anteroposterior obstruction) demonstrated a trend toward increased lower lip protrusion (+\u0026thinsp;0.74 mm vs. Group A), possibly reflecting underlying skeletal compensation and the influence of suprahyoid and orbicularis oris muscle adaptation.\u003c/p\u003e\u003cp\u003eGroup D (mixed obstruction) exhibited a more complex pattern of soft tissue adaptation, with greater lower lip protrusion and upper lip retrusion in subgroup D2 compared to D1. This may suggest a dual adaptive mechanism under severe three-dimensional obstruction: downward mandibular rotation associated with lower lip advancement, and chronic mouth breathing associated with reduced lip muscle tone[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Despite a significant increase in chin projection (SGn) in Group D, corresponding changes in the lower lip were less prominent, indicating a dampening effect of soft tissue recoil on skeletal compensation.\u003c/p\u003e\u003cp\u003eNotably, despite the most pronounced skeletal compensation in Group D2, E-line parameters did not differ significantly, suggesting involvement of non-skeletal mechanisms such as altered tongue posture or head\u0026ndash;neck positional adjustments. Given the inherent limitations in static soft tissue measurements, future studies should incorporate dynamic modalities (e.g., four-dimensional facial analysis) to better elucidate the neuromuscular mechanisms underlying soft tissue adaptation[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Limitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations. First, its retrospective cross-sectional design precludes causal inference and prevents evaluation of dynamic changes in mandibular growth. Second, selection bias may be present, as participants were recruited from clinical settings, potentially leading to overrepresentation of malocclusion in specific subgroups. Third, the use of two-dimensional cephalometric analysis restricted assessment of three-dimensional skeletal and dental morphology.\u003c/p\u003e\u003cp\u003eFuture studies should adopt prospective designs, incorporate three-dimensional imaging techniques, and apply multivariate analytical models to more precisely delineate the independent effects of tonsillar hypertrophy on craniofacial development and to inform personalized early intervention strategies.\u003c/p\u003e\u003c/div\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAnteroposterior tonsillar hypertrophy is significantly associated with a higher prevalence of anterior crossbite and edge-to-edge bite in children during the mixed dentition stage. Compared to transverse hypertrophy, it shows a stronger correlation with occlusal disturbances.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAnteroposterior tonsillar hypertrophy is also significantly associated with an increased prevalence of skeletal Class III patterns, while transverse obstruction appears to have minimal effect. These findings support a dimension-specific, hierarchical influence of airway obstruction vectors on craniofacial development.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIn children at the mixed dentition stage, anteroposterior hypertrophy induces mandibular protrusion, clockwise rotation, open-bite growth tendencies, and retroclination of the incisors\u0026mdash;resulting in skeletal remodeling that prioritizes airway patency. These skeletal adaptations are accompanied by perioral soft tissue compensation. Mixed-pattern obstruction further amplifies these changes through sagittal-coronal mechanical synergy, whereas transverse hypertrophy alone exerts minimal influence on jaw morphology.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eClinical trial number\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by\u0026nbsp;the Institutional Ethics Committee of Zhejiang University School of Medicine Stomatology Hospital (Approval Number: No.\u0026nbsp;2024-141（R）)\u0026nbsp;and\u0026nbsp;Shulan (Hangzhou) Hospital\u0026nbsp;(Approval Number:\u0026nbsp;No.\u0026nbsp;KY2025024).\u0026nbsp;The requirement for informed consent was waived due to the retrospective nature of the study and the use of anonymized data. No identifiable personal information of individual patients was collected or disclosed.\u003c/p\u003e\n\u003cp\u003eConsent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;Informed consent was waived due to retrospective design of the study and the absence of identifiable patient information.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026rsquo;s data in any form (including images, videos, or other identifying information), thus consent for publication was not required.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Key Program of Zhejiang Provincial Natural Science Foundation (LZ25H140001); the Fundamental Research Funds for the Central Universities (2023QZJH60); the Research and Development Project of Stomatology Hospital Zhejiang University School of Medicine (RD2022DLYB03). Author Xuepeng Chen is sponsored by the Zhejiang Provincial Program for the Cultivation of High-level Innovative Health Talents.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eCC: Methodology, Investigation, Visualization, Writing \u0026ndash; original draft.\u003c/p\u003e\n\u003cp\u003eHL: Data collection, Formal analysis, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eYH: Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eBL: Supervision, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eXC: Conceptualization, Resources, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript. CC and HL contributed equally to this work and share first authorship.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine and Department of Otolaryngology-Head and Neck Surgery, Shulan (Hangzhou) Hospital for providing support for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKara CO, Ergin H, Ko\u0026ccedil;ak G, Kili\u0026ccedil; I, Yurdakul M: \u003cstrong\u003ePrevalence of tonsillar hypertrophy and associated oropharyngeal symptoms in primary school children in Denizli, Turkey\u003c/strong\u003e. \u003cem\u003eInt J Pediatr Otorhinolaryngol \u003c/em\u003e2002, \u003cstrong\u003e66\u003c/strong\u003e(2):175-179.\u003c/li\u003e\n\u003cli\u003eAllen AJH, Jen R, Mazzotti DR, Keenan BT, Goodfellow SD, Taylor CM, Daniele P, Peres B, Liu Y, Mehrtash M\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eSymptom subtypes and risk of incident cardiovascular and cerebrovascular disease in a clinic-based obstructive sleep apnea cohort\u003c/strong\u003e. \u003cem\u003eJ Clin Sleep Med \u003c/em\u003e2022, \u003cstrong\u003e18\u003c/strong\u003e(9):2093-2102.\u003c/li\u003e\n\u003cli\u003eAubertin G, Schr\u0026ouml;der C, Sevin F, Clouteau F, Lamblin MD, Vecchierini MF: \u003cstrong\u003e[Obstructive sleep apnea-hypopnea syndrome in children: Clinical diagnosis]\u003c/strong\u003e. \u003cem\u003eArch Pediatr \u003c/em\u003e2017, \u003cstrong\u003e24 Suppl 1\u003c/strong\u003e:S7-s15.\u003c/li\u003e\n\u003cli\u003eHuang X, Gong X, Gao X: \u003cstrong\u003eAge-related hypertrophy of adenoid and tonsil with its relationship with craniofacial morphology\u003c/strong\u003e. \u003cem\u003eBMC Pediatr \u003c/em\u003e2023, \u003cstrong\u003e23\u003c/strong\u003e(1):163.\u003c/li\u003e\n\u003cli\u003eBaik UB, Suzuki M, Ikeda K, Sugawara J, Mitani H: \u003cstrong\u003eRelationship between cephalometric characteristics and obstructive sites in obstructive sleep apnea syndrome\u003c/strong\u003e. \u003cem\u003eAngle Orthod \u003c/em\u003e2002, \u003cstrong\u003e72\u003c/strong\u003e(2):124-134.\u003c/li\u003e\n\u003cli\u003eTong X, Li Y, Yang G, Zhang H, Jiang Y, Yu J, Da D, Zeng X, Liu Y: \u003cstrong\u003eThe Association of Tonsil Hypertrophy with Pediatric Dentofacial Development: Evidence from a Cross-Sectional Study of Young Children in Shanghai, China\u003c/strong\u003e. \u003cem\u003eNat Sci Sleep \u003c/em\u003e2022, \u003cstrong\u003e14\u003c/strong\u003e:1867-1875.\u003c/li\u003e\n\u003cli\u003eMarkkanen S, Rautiainen M, Niemi P, Helminen M, Peltom\u0026auml;ki T: \u003cstrong\u003eIs securing normal dentofacial development an indication for tonsil surgery in children? 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\u003cstrong\u003e132\u003c/strong\u003e:109911.\u003c/li\u003e\n\u003cli\u003eCai M, Brown EC, Hatt A, Cheng S, Bilston LE: \u003cstrong\u003eEffect of head and jaw position on respiratory-related motion of the genioglossus\u003c/strong\u003e. \u003cem\u003eJ Appl Physiol (1985) \u003c/em\u003e2016, \u003cstrong\u003e120\u003c/strong\u003e(7):758-765.\u003c/li\u003e\n\u003cli\u003eJia P, Fu M, Zeng X: \u003cstrong\u003eChanges of upper airway morphology induced by mandibular advancement inpatients with obstructive sleep apnea syndrome\u003c/strong\u003e. \u003cem\u003eJournal of Peking University(Health Sciences) \u003c/em\u003e2003(06):663-667.\u003c/li\u003e\n\u003cli\u003eCiscar MA, Juan G, Mart\u0026iacute;nez V, Ram\u0026oacute;n M, Lloret T, M\u0026iacute;nguez J, Armengot M, Mar\u0026iacute;n J, Basterra J: \u003cstrong\u003eMagnetic resonance imaging of the pharynx in OSA patients and healthy subjects\u003c/strong\u003e. \u003cem\u003eEur Respir J \u003c/em\u003e2001, \u003cstrong\u003e17\u003c/strong\u003e(1):79-86.\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":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tonsillar Hypertrophy, Malocclusion, Anterior Crossbite, Cephalometric Analysis, Child Craniofacial Growth and Development","lastPublishedDoi":"10.21203/rs.3.rs-7357398/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7357398/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e: \u0026nbsp;To evaluate the effects of different subtypes of tonsillar hypertrophy on dentofacial and craniofacial development in children during the mixed dentition stage, and to preliminarily explore associated craniofacial growth trends.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: \u0026nbsp;A total of 275 children in the mixed dentition stage were retrospectively recruited from two hospitals between August 2023 and July 2024. Tonsillar hypertrophy was assessed using the Brodsky and Baroni methods, and patients were categorized by airway obstruction type: mild (Group A), transverse (Group B), anteroposterior (Group C), or combined (Group D). Anterior occlusion, sagittal skeletal classification, and lateral cephalometric parameters (Jarabak analysis) were recorded and compared across groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Groups C and D exhibited significantly higher rates of anterior crossbite and skeletal Class III patterns compared to Groups A and B (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). Subgroup D2 (severe combined obstruction) demonstrated the most pronounced skeletal Class III features, including increased SNB, decreased ANB, and evident mandibular prognathism. Both dental and skeletal compensatory changes were most prominent in the combined obstruction group, indicating aggravated craniofacial imbalance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Anteroposterior tonsillar hypertrophy is strongly associated with anterior crossbite and skeletal Class III development, primarily through mandibular advancement and rotational growth adaptations. Transverse obstruction has minimal skeletal impact, whereas combined obstruction of multiple directions exacerbates dentoskeletal compensation. These findings highlight the directional influence of upper airway obstruction on craniofacial morphology in growing children and underscore the importance of early interdisciplinary evaluation.\u003c/p\u003e","manuscriptTitle":"The Influence of Different Tonsillar Hypertrophy Types on Dentofacial and Craniofacial Development in Children with Mixed Dentition","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-12 15:14:02","doi":"10.21203/rs.3.rs-7357398/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-26T16:59:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-09T07:18:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-08T09:06:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264086364871910506166548113208218919066","date":"2025-09-07T17:35:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263505478303217881901403180826701372039","date":"2025-09-07T09:47:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-07T09:43:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-02T11:10:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-29T10:18:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-29T10:17:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-08-12T15:22:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2efb4291-6520-4e6d-9240-ce1aaeda5def","owner":[],"postedDate":"September 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:06:24+00:00","versionOfRecord":{"articleIdentity":"rs-7357398","link":"https://doi.org/10.1186/s12903-025-07350-y","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2025-11-28 15:57:12","publishedOnDateReadable":"November 28th, 2025"},"versionCreatedAt":"2025-09-12 15:14:02","video":"","vorDoi":"10.1186/s12903-025-07350-y","vorDoiUrl":"https://doi.org/10.1186/s12903-025-07350-y","workflowStages":[]},"version":"v1","identity":"rs-7357398","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7357398","identity":"rs-7357398","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}