CBCT-Based Morphometric and Volumetric Assessment of the Tongue, Soft Palate, and Palatal Height in Relation to Skeletal Class and Breathing Pattern

CBCT-Based Morphometric and Volumetric Assessment of the Tongue, Soft Palate, and Palatal Height in Relation to Skeletal Class and Breathing Pattern | 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 CBCT-Based Morphometric and Volumetric Assessment of the Tongue, Soft Palate, and Palatal Height in Relation to Skeletal Class and Breathing Pattern Busra Ozturk, Guldane Magat, Mucahid Yildirim, Alparslan Esen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9101919/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objectives This study aimed to evaluate the influence of skeletal class, breathing mode, age, and sex on the morphometric and volumetric features of the soft palate, tongue, and palatal height using cone-beam computed tomography(CBCT). Materials and Methods A total of 560 CBCT scans (295 females, 265 males; aged 8–73 years) were retrospectively analyzed. Soft palate length, width, angle, and volume; tongue height, width, area, and volume; and palatal height values were measured using Dolphin 3D software. Participants were categorized by skeletal class (I, II, III), breathing pattern (nasal/oral), and age group. Data were analyzed using robust three-way ANOVA and Bonferroni post hoc tests. Results In females, soft palate length (p < 0.001), width (p = 0.002), and volume (p < 0.001) showed significant age-related differences. Additional differences were found in soft palate width by breathing type (p = 0.041) and skeletal pattern (p = 0.004), as well as in tongue height (p = 0.024), tongue volume (p = 0.017), and tongue area (p = 0.033). In males, age significantly affected soft palate length (p < 0.001), tongue length (p = 0.036), tongue volume (p < 0.001), and tongue area (p = 0.004), with a notable breathing–skeletal interaction for soft palate length (p = 0.029). Palatal height was significantly influenced by breathing type in females (p = 0.04) and by both age (p < 0.001) and breathing type in males (p = 0.01). Conclusion Age, sex, breathing and skeletal patterns significantly influence soft palate, tongue, and palatal height morphology. Clinical Relevance: From a clinical standpoint; incorporating these parameters into orthodontic and surgical planning may help anticipate airway changes associated with growth, breathing habits, and skeletal discrepancies. Angle's Classification breathing cone beam tomography tongue soft palate anova Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The tongue and soft palate are two key anatomical structures that play a crucial role in maintaining upper airway patency and oral–maxillofacial function [ 1 , 2 ]. Their morphometric and volumetric characteristics are closely associated with craniofacial development, occlusal balance, and breathing function [ 1 ]. Even minor alterations in the dimensions of these structures may compromise airway stability and influence maxillomandibular relationships, underscoring their importance in orthodontic and maxillofacial assessment [ 2 ]. The tongue is involved in essential functions such as breathing, deglutition, mastication, and articulation. Alterations in its posture or size can markedly affect airway dimensions and skeletal relationships [ 1 , 2 ]. Likewise, the soft palate contributes to velopharyngeal closure and phonatory resonance, and its elongation or volumetric changes have been strongly linked to obstructive sleep apnea [ 3 ]. Beyond these two structures, palatal height has recently gained attention as a determinant of transverse maxillary development and airway morphology, with mouth breathers frequently exhibiting narrower and deeper palatal vaults[ 4 , 5 ]. Sexual dimorphism and skeletal discrepancies further modulate these relationships. CBCT-based studies have consistently demonstrated larger tongue and soft palate volumes in males [ 6 , 7 ], while skeletal Class II and III malocclusions have been associated with altered tongue posture and velar morphology [ 8 , 9 ]. Breathing mode is another critical determinant, as mouth breathing has been linked with increased palatal height, elongated soft palates, and compromised tongue posture [ 10 , 11 ]. However, most prior studies have evaluated these parameters in isolation or within limited populations, providing only a partial understanding of their combined effects. Cone-beam computed tomography (CBCT) has become the preferred imaging modality for such evaluations, as it enables three-dimensional analysis with relatively low radiation exposure and high diagnostic accuracy [ 12 , 13 ]. Despite these advantages, few studies have simultaneously examined the tongue, soft palate, and palatal height across age, sex, skeletal class, and breathing type within a single multifactorial framework. To our knowledge, no previous CBCT-based study has simultaneously assessed the tongue, soft palate, and palatal height using a multifactorial robust ANOVA approach. Based on this background, the present study aimed to comprehensively evaluate the morphometric and volumetric features of these structures using CBCT. A three-way robust ANOVA model was applied to analyze the main and interaction effects of age, sex, skeletal class, and breathing type. We hypothesized that these parameters would show significant differences according to skeletal class and age, display sex-specific patterns, and reveal multifactorial interactions not detectable through univariate analyses. The null hypothesis stated that skeletal class, breathing type, and age would not significantly affect the measured parameters. Methods Ethical Approval Ethics approval for this retrospective study was obtained from the Necmettin Erbakan University Faculty of Dentistry, Drug and Non-Medical Device Research Ethics Committee on 05.25.2023 (Protocol no: 2023/299), confirming its scientific and ethical appropriateness. Study Population and Power Calculation CBCT images obtained for diagnostic purposes from patients attending the Department of Oral and Maxillofacial Radiology, Necmettin Erbakan University, between February 2019 and October 2024, were retrospectively analyzed. A priori power analysis was performed using G*Power v3.1.9.7 with ANOVA parameters set at a 95% confidence level (1–α), 95% power (1–β), and an assumed medium effect size (Cohen’s f = 0.30) [14]. The minimum required sample size was 240. To further strengthen statistical power, a larger cohort of 560 scans was included. Inclusion Criteria: The study included patients aged ≥ 8 years with no congenital or acquired craniofacial anomalies, history of craniofacial trauma or surgery, cleft lip/palate, systemic syndromes, or missing teeth affecting occlusion, and with CBCT images of optimal diagnostic quality allowing clear identification of reference points. Exclusion Criteria: Patients were excluded if they had congenital or acquired craniofacial anomalies, a history of craniofacial trauma or surgery, cleft lip/palate, systemic syndromes, missing teeth affecting occlusion, suboptimal CBCT image quality, or unclear reference points. CBCT Acquisition Protocol In this retrospective study, CBCT images of 560 male and female patients aged 8-73 years with high diagnostic quality who met the inclusion criteria were analyzed. The CBCT images used in the study were obtained with Morita 3D Accuitomo 170 and NewTom GiANO 3D devices. The Morita 3D Accuitomo 170 (J Morita MFG Corp., Kyoto, Japan) was operated at 90 kVp and 5 mA, with an irradiation time of 17.5 seconds, 0.25 mm voxel size, 140 mm × 100 mm FOV, 360° data acquisition and no additional filtering. The NewTom GiANO 3D device (Verona, Italy) was operated at 90 kVp and 10 mA, with an irradiation time of 18 seconds, 0.15 mm voxel size, 140 mm × 100 mm FOV, 360° data acquisition and no additional filtering. Both devices were calibrated before each patient, and imaging was performed by the same technician following standardized protocols. As two different CBCT systems were used, potential variability in voxel size was minimized by calibration; however, this factor is acknowledged as a methodological limitation [15]. Measurement Procedure All scans were saved in DICOM format and analyzed with Dolphin 3D Imaging Software (Dolphin Imaging & Management Solutions®, Chatsworth, CA, USA). Measurements were performed on 3D reconstructions in sagittal, axial, and coronal views. A single examiner (B.O.-3 years’ experience) performed the measurements, blinded to skeletal class and respiratory type to minimize bias. Measurement reliability was assessed by repeating all measurements on 50 randomly selected scans after two weeks. Inter-observer reliability was tested by a second examiner (16 years’ experience). Intraclass correlation coefficients (ICC) >0.90 were considered excellent [16]. Three-Dimensional Cephalometric Measurements In the three-dimensional cephalometric analysis; the length, width, and angle values of the soft palate were measured. Accordingly, the soft palate length was measured as the distance between the posterior nasal spine (PNS) and the most distal point of the soft palate (P) (Figure 1a) [17]. The soft palate width was measured as the distance between the SP1 point, which defines the anterior border of the soft palate, and the SP2 point, which defines the posterior border of the soft palate ( Figure 1b )[18]. The soft palate angle was measured as the angle between the line drawn from the anterior nasal spine (ANS) to the PNS and the line drawn from the posterior nasal spine (PNS) to the most distal point of the soft palate (P) (Figure 1c) [17]. Figure 1. Sagittal CBCT images show the soft palate length (a), soft palate width (b), and soft palate angle (c). PNS: Posterior nasal spine, point determining the posterior border of the hard palate; P: The most extreme point of the soft palate; SP1: Point determining the anterior border of the soft palate; SP2: Point determining the posterior border of the soft palate; ANS: Anterior nasal spine; PNS: Posterior nasal spine; P: The most extreme point of the soft palate. The soft palate volume was calculated as the volume encompassed within the sagittal boundaries of the soft palate, extending from the PNS to the P (Figure 2b) [19]. The height, width, area, and volume values of the soft tissue of the tongue were measured. Tongue height was measured as the length of the vertical bisector from the dorsal surface of the tongue to the line between the base of the epiglottis and the tip of the tongue. Tongue width was measured as the length between the base of the epiglottis (the base of the epiglottis is the point where the epiglottis and the base of the tongue intersect) and the tip of the tongue (Figure 2a) [20]. Tongue area and volume were calculated as the cross-sectional area and volume defined by lines connecting the most superior and anterior point of the tongue dorsum and hyoid bone corpus (H), the base of the epiglottis (EB), the most distal point of the tongue (Tt), and the most posterior point of the mandibular symphysis (RGn) (Figure 2b) [19]. Figure 2. Sagittal CBCT images show tongue height and width (a), and the borders of the tongue (red) and soft palate (green). Tt: Point defining the tip of the tongue; RGn: Most posterior-inferior point of the mandibular symphysis; H: Center of the hyoid bone; Ep: Epiglottis. The palatal height value was measured as the distance from the mid-deepest point of the palate to the line connecting the distolingual tubercles of the upper first molars (Figure 3) [21]. Figure 3. Coronal CBCT section shows palatal height. Participant Grouping Criteria Sex-based categorization was applied in this study. A total of 560 CBCT scans were analyzed, comprising 295 female and 265 male patients. Participants ranged in age from 8 to 73 years and were stratified into five age groups for subgroup analysis: 8–18 years, 19–29 years, 30–40 years, 41–51 years, and over 52 years. Skeletal classification was determined by calculating the ANB angle on sagittal sections of the CBCT images using Dolphin 3D software (Dolphin Imaging & Management Solutions®, Chatsworth, CA, USA), based on the principles of Steiner analysis [22]. The ANB angle was obtained by subtracting the SNB (sella–nasion–point B) angle from the SNA (sella–nasion–point A) angle, which reflect the anteroposterior relationship of the maxilla and mandible to the cranial base. All measurements were performed on mid-sagittal slices aligned with standard cephalometric reference planes. Based on the measured ANB values, patients were categorized into three skeletal classes: Class I (ANB angle between 0° and 4°), Class II (ANB > 4°), and Class III (ANB < 0°). The breathing pattern of each participant was classified as either nasal or oral based on the “hyoid triangle” technique, applied to sagittal CBCT sections using Dolphin 3D software (Dolphin Imaging & Management Solutions®, Chatsworth, CA, USA). This method involves constructing a triangle using three anatomical landmarks: the anterior-inferior point of the third cervical vertebra (C3), the most anterior point of the hyoid bone, and the retrognathion (RGn). In this configuration, the RGn–C3 line serves as the base, and a triangle is formed by connecting these three points. When the hyoid bone is positioned above the RGn–C3 plane, the triangle has a superior vertex and is considered a “negative triangle,” indicating an oral breathing pattern ( Figure 4a, c ). Conversely, when the hyoid lies below the RGn–C3 line, the triangle takes on a “positive” configuration, which is indicative of nasal breathing ( Figure 4b, d ) [23]. Figure 4. Sagittal CBCT images illustrating the classification of breathing patterns using the hyoid triangle technique. (a, c) Oral breathing pattern: the hyoid bone is positioned above the RGn–C3 plane, forming a negative hyoid triangle. (b, d) Nasal breathing pattern: the hyoid bone is located below the RGn–C3 plane, forming a positive hyoid triangle. RGn: Most posterior-inferior point of the mandibular symphysis; Hyoid: Center of the hyoid bone; C3: Anterior-inferior point of the third cervical vertebra. To assess measurement reliability, 50 CBCT scans were randomly selected for both intra- and inter-observer evaluations. Intra-observer reliability was assessed by having the primary examiner (BO), with three years of experience in oral and maxillofacial radiology, repeat all measurements after a two-week interval. For inter-observer reliability analysis, a second examiner (GM), with sixteen years of experience in the same field, independently performed the same measurements on the selected scans. Both observers followed identical measurement protocols. Intraclass correlation coefficients (ICC) were calculated for both assessments, and values above 0.90 were considered indicative of excellent agreement [24]. Statistical Analysis Data analysis was performed with JAMOVI V2.3.22 (The Jamovi Project, Sydney, Australia). Compliance with normal distribution was evaluated by Shapiro-Wilk test. For the comparison of non-normally distributed data according to age, respiratory and skeletal pattern groups, three-way Robust ANOVA was applied using the Walrus package. Multiple comparisons were performed with the Bonferroni post-hoc test. Effect sizes (η²) were reported for significant results Analysis results are reported as pruned mean ± standard error of the mean for quantitative data. Statistical significance level was accepted as p<0.05. Results A total of 560 participants (295 females, 265 males) with a mean age of 33.74 ± 14.96 years were included. Of these, 28.6% (n = 160) were oral breathers and 71.4% (n = 400) were nasal breathers ( A1 ). Descriptive statistics for all morphometric and volumetric parameters are summarized in A2 . The mean soft palate length was 36.33 ± 5.10 mm, width 9.94 ± 2.10 mm, angle 127.10° ± 8.18°, and volume 3627.67 ± 2322.75 mm³. The mean tongue length was 74.31 ± 8.10 mm, height 34.46 ± 6.18 mm, area 12,642.85 ± 2307.14 mm², and volume 103,123.76 ± 22,266.33 mm³, while the mean palatal height measured 18.97 ± 4.84 mm. In females, soft palate length varied significantly across age groups (p < 0.001), showing an overall increase with age. Multiple comparisons revealed that the nasal-breathing Class I group aged 8–18 years had significantly shorter soft palates than the oral-breathing Class I group aged 30–40 years. No main effects of breathing type or skeletal class were detected (p = 0.43 and p = 0.35, respectively). However, the three-way interaction of age, breathing, and skeletal pattern was significant (p = 0.016) ( A3 ). In males, length was also affected by age (p < 0.001), and a breathing × skeletal pattern interaction (p = 0.029) indicated that nasal-breathing Class III males exhibited shorter soft palates than nasal-breathing Class I counterparts. Soft palate width in females differed significantly with age (p = 0.002), being greater in the 41–51-year group than in the 8–18 and 19–29-year groups. Significant effects of both breathing type (p = 0.041) and skeletal pattern (p = 0.004) were observed, with wider soft palates in oral breathers and Class II females. In males, no significant differences were found for any factor or interaction (p > 0.05) (Table 1). In both females and males, no significant differences were found in soft palate angle according to age, breathing type, or skeletal pattern, and no significant interaction effects were observed (all p > 0.05) (A4) . Soft palate volume exhibited a strong age effect in females (p < 0.001), increasing markedly from adolescence to middle age. The 8–18 and 19–29-year groups had significantly lower volumes than all older groups. Breathing type and skeletal class had no significant influence (p = 0.67 and p = 0.713, respectively). In males, neither age nor breathing nor skeletal pattern yielded statistically significant differences (A5) . In females, tongue length did not differ significantly among age groups, breathing types, or skeletal classes (p > 0.05). In males, tongue length varied significantly across age groups (p = 0.036), though post-hoc comparisons did not reveal specific pairwise differences, suggesting a general trend of increasing tongue length with age (A6) . Tongue height in females differed significantly across skeletal classes (p = 0.024), being greater in Class II than in Class I and III, but showed no effects of age or breathing type (p = 0.48 and p = 0.67). No significant differences were observed in males (p > 0.05) (Table 2) . Tongue volume exhibited the most consistent age-related variation in both sexes. In females, tongue volume increased significantly with age (p < 0.001), and significant differences were also detected among skeletal classes (p = 0.017), with Class II showing greater volumes than Class I. In males, age was again highly significant (p < 0.001), with markedly lower tongue volumes in the 8–18-year group compared to older age groups, while breathing and skeletal pattern effects remained nonsignificant (Table 3) . Tongue area followed a pattern similar to tongue volume. In females, it differed significantly across age groups (p < 0.001) and skeletal classes (p = 0.033), with larger areas in Class II females. In males, tongue area also differed with age (p = 0.004), being smaller in younger groups and larger in adults, while breathing type and skeletal class showed no significant differences (Table 4) . In females, palatal height did not differ significantly by age (p = 0.051), but oral breathers showed greater palatal height than nasal breathers (p = 0.04). Skeletal pattern had no significant effect (p = 0.555). In males, palatal height increased significantly with age (p < 0.001), especially between the 8–18 and 30–40/41–51 age groups, and was higher in oral breathers than nasal breathers (p = 0.01). Skeletal pattern effects were not significant in either sex (Table 5). Discussion This study provided a comprehensive evaluation of the morphology of the soft palate, tongue, and palatal height in relation to sex, age, breathing type, and skeletal pattern. By systematically comparing our findings with previous reports, both consistent and divergent results were identified, offering new insights into the complex and multifactorial determinants of craniofacial morphology. Soft palate morphology demonstrated clear sex-related differences, as males exhibited greater length, width, and volume compared with females. These findings corroborate earlier studies by Kollias and Krogstad (1999)[25], Awati et al. (2020)[26], and Lin et al. (2008)[27], which consistently reported sexual dimorphism in velar dimensions. Interestingly, no significant sex-based differences were detected in palatal angle, suggesting that angular parameters may be more sensitive to postural adaptations rather than intrinsic anatomical variance. Age-related analyses revealed a progressive increase in length in both sexes, with significant volumetric enlargement observed primarily in females. Similar trends were previously reported by Chalkoo et al. (2016)[28], Deepa and Ramnarayan (2013)[29], Verma et al. (2014)[30], and Jayaprakash et al. (2019)[31], who emphasized continuous morphometric alterations across adulthood. In contrast, other studies, such as Nagaraj et al. (2016)[32] and Crowley et al. (2021)[33], suggested stabilization of velar dimensions after early adulthood. These contrasting results highlight that velar growth may be influenced by population-specific, methodological, or functional factors. Skeletal pattern exerted limited influence on the soft palate, with significant differences observed only in females for width. Previous studies[34-36] reported distinct variations across malocclusion classes, suggesting that methodological differences, including three-dimensional imaging and sample heterogeneity, may explain the discrepancies. Breathing type demonstrated a more notable impact in females, as oral breathers exhibited greater soft palate width, supporting the findings of Matsuo et al. (2010)[37] and Bakor et al. (2011)[38], who linked oral breathing with transversal palatal alterations. Taken together, these findings underline that sex and breathing mode may exert synergistic effects on velar morphology, while skeletal classification alone may be less decisive. The tongue exhibited marked sexual dimorphism, as males presented significantly greater length, height, area, and volume compared with females. This observation is in accordance with CT- and CBCT-based studies by Abraham et al. (2023)[39], Ding et al. (2018)[7], Uysal et al. (2013)[2], and Iwasaki et al. (2019)[8]. Zhao et al. (2021)[10] additionally identified BMI as an independent determinant, further underscoring the multifactorial regulation of tongue size. The role of sex hormones, particularly the anabolic effect of testosterone, and sex-specific craniofacial growth trajectories, may explain the observed disparities. Age was another determinant, as tongue area and volume significantly increased with advancing age. While some investigations[40, 41] have described age-related muscle atrophy and volumetric decline, others such as Rana et al. (2020)[42] suggested more pronounced reductions in thickness. Skeletal pattern further influenced tongue morphology, with Class III subjects and hyperdivergent individuals presenting larger tongue volumes, in line with Iwasaki et al. (2019)[8] and Tseng et al. (2021)[9]. These results confirm that tongue morphology is closely integrated with skeletal structure and should be incorporated into orthodontic and airway evaluations. Surprisingly, no significant differences were observed between nasal and oral breathers in our sample, in contrast with Azevêdo et al. (2016)[43] and Engelke et al. (2010)[44], who highlighted changes in tongue posture associated with mouth breathing. This discrepancy may be attributable to temporal variations in breathing habits, environmental influences, or the sensitivity of imaging protocols. Palatal height analysis also revealed significant associations with sex and age. Consistent with Šidlauskienė et al. (2024)[45] and Araby et al. (2023)[46], males exhibited greater values, which have been attributed to genetic and hormonal influences, particularly post-pubertal testosterone effects. Age-related increases were significant in males but not in females, corroborating the reports of Eslami Amirabadi et al. (2018)[47] and Mei et al. (2023)[13]. Skeletal classification, however, did not reveal any significant effect, in agreement with Kairalla et al. (2022)[48], who reported no direct association, and Saadeh & Ghafari (2023)[49], who emphasized vertical rather than sagittal influences. Notably, breathing pattern demonstrated a consistent effect across sexes, as oral breathers exhibited significantly greater palatal height compared with nasal breathers. This finding supports earlier studies by Souki et al. (2009)[4], Lione et al. (2014)[50], and Harari et al. (2010)[11], which demonstrated that chronic oral breathing promotes a narrower and deeper palatal vault. These results underline the importance of recognizing oral breathing habits early in clinical practice to prevent maxillary constriction and related malocclusions. When the combined effects of age, sex, skeletal pattern, and breathing mode were considered, significant interactions were limited. Notably, soft palate length in females demonstrated a significant interaction among multiple variables, whereas tongue and palatal height parameters did not. This finding suggests that while individual factors exert strong influences, their combined or synergistic effects may not always reach statistical significance, likely due to adaptive compensations and the multifactorial nature of craniofacial development. The limited evidence in the literature addressing combined factor interactions highlights the originality of this study, as it provides a simultaneous assessment of these variables rather than focusing on isolated effects. From a clinical standpoint, the simultaneous evaluation of the soft palate, tongue, and palatal height provides a more integrative understanding of upper airway morphology. Incorporating these parameters into orthodontic and surgical planning may help anticipate airway changes associated with growth, breathing habits, and skeletal discrepancies, ultimately contributing to more functional and stable treatment outcomes. This study has several limitations that should be considered when interpreting the findings. First, its retrospective design inherently limits control over participant positioning, muscle activity, and breathing function during CBCT acquisition. Because all measurements were derived from static three-dimensional images, dynamic variables such as tongue motion, airway collapsibility, and real-time breathing patterns could not be assessed. Second, although calibration procedures were applied, two different CBCT devices with distinct voxel resolutions were used, which may have introduced minor variability in image scaling and segmentation accuracy. Third, breathing type classification was based on anatomical indicators and clinical history rather than objective airflow measurements, which could have led to misclassification in borderline cases. Fourth, skeletal classification relied solely on sagittal parameters (ANB angle), without integrating vertical or transverse skeletal components that might influence soft-tissue morphology. In addition, the sample was drawn from a single institution with a demographically homogeneous population, limiting the generalizability of the results across different ethnic and geographic groups. Finally, the cross-sectional nature of the study precludes causal inference; longitudinal or functional imaging studies would be required to confirm the observed associations and temporal changes. Future research should aim to overcome the current study’s limitations by incorporating dynamic and functional imaging modalities, such as cine-MRI or four-dimensional CBCT, to evaluate tongue and soft palate movements during actual breathing and swallowing. Objective airflow or polysomnographic measurements should also be integrated to validate breathing classification and its clinical implications. Moreover, longitudinal investigations following craniofacial growth trajectories could clarify the temporal sequence between skeletal development, soft-tissue adaptation, and airway morphology. Finally, multi-center studies with diverse populations and standardized voxel calibration protocols are recommended to enhance generalizability and establish normative reference data for different age and sex groups. Conclusion Taken together, this study demonstrated that age, sex, and breathing pattern significantly influence craniofacial soft-tissue morphology. Soft palate dimensions and tongue size increased progressively with age, showing more pronounced changes in males. Tongue morphometry exhibited distinct sex-related differences, with larger volumes and dimensions in males compared with females. Palatal height increased significantly with age in males but remained relatively stable in females, and was also affected by breathing type, with oral breathing associated with greater palatal height and reduced transverse expansion. Overall, by simultaneously evaluating the soft palate, tongue, and palatal height, this study provides a novel and comprehensive contribution to the literature, emphasizing the importance of age-, sex-, and breathing-related factors in craniofacial assessment. Abbreviations CBCT: Cone Beam Computed Tomography DICOM: Digital Imaging and Communications in Medicine ANS: Anterior Nasal Spine PNS: Posterior Nasal Spine EB: Epiglottis Base P: Most distal point of the soft palate Tt: Tip of the Tongue H: Hyoid bone corpus ICC: Intraclass Correlation Coefficient RGn: Retrognathion C3: Third Cervical Vertebra ANB: A–Nasion–B Angle SNA: Sella–Nasion–A Angle SNB: Sella–Nasion–B Angle Declarations Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to institutional data privacy policies but are available from the corresponding author on reasonable request. Conflict of Interest: The authors declare no competing interests. Ethics Approval and Consent to Participate: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments. The study was approved by the Ethics Committee of the Faculty of Dentistry, Necmettin Erbakan University (Approval No: 2023/299). Written informed consent was obtained from all participants. Consent for Publication: Not applicable. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Authors’ Contributions B.O. carried out the CBCT measurements, performed intra-observer reliability tests, conducted statistical analyses, and drafted the initial version of the manuscript. G.M. was responsible for the overall study conception and design, supervised the methodological framework, performed inter-observer measurements, and contributed substantially to the interpretation of the findings. M.Y. assisted in data collection, organization of patient records, and contributed to the literature review. A.E. provided methodological input, guided the structuring of the results and discussion sections, and critically revised the manuscript for intellectual content. All authors read, revised, and approved the final manuscript. Acknowledgements This study constitutes a part of the specialty thesis submitted by Busra Ozturk to the Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Necmettin Erbakan University. References Tseng, Y.-C., et al., Correlation between change of tongue area and skeletal stability after correction of mandibular prognathism. The Kaohsiung Journal of Medical Sciences, 2017. 33 (6): p. 302-307. Uysal, T., et al., Cone-beam computed tomography evaluation of relationship between tongue volume and lower incisor irregularity. The European Journal of Orthodontics, 2013. 35 (5): p. 555-562. Witt, M., Anatomy and development of the human taste system. Handbook of clinical neurology, 2019. 164 : p. 147-171. Souki, B.Q., et al., Prevalence of malocclusion among mouth breathing children: do expectations meet reality? International journal of pediatric otorhinolaryngology, 2009. 73 (5): p. 767-773. Lione, R., et al., Palatal surface and volume in mouth-breathing subjects evaluated with three-dimensional analysis of digital dental casts-a controlled study. Eur J Orthod, 2015. 37 (1): p. 101-4. Standring, S., Gray's Anatomy E-Book: Gray's Anatomy E-Book . 2021: Elsevier Health Sciences. Ding, X., et al., Evaluation of tongue volume and oral cavity capacity using cone-beam computed tomography. Odontology, 2018. 106 (3): p. 266-273. Iwasaki, T., et al., Oropharyngeal airway in children with Class III malocclusion evaluated by cone-beam computed tomography. American Journal of orthodontics Dentofacial orthopedics, 2009. 136 (3): p. 318. e1-318. e9. Tseng, Y.-C., et al., Evaluation of pharyngeal airway volume for different dentofacial skeletal patterns using cone-beam computed tomography. Journal of dental sciences, 2021. 16 (1): p. 51-57. Zhao, Z., et al., Effects of mouth breathing on facial skeletal development in children: a systematic review and meta-analysis. BMC oral health, 2021. 21 (1): p. 108. Harari, D., et al., The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. The Laryngoscope, 2010. 120 (10): p. 2089-2093. Celikoglu, M., et al., Comparison of pharyngeal airway volume among different vertical skeletal patterns: a cone-beam computed tomography study. The Angle Orthodontist, 2014. 84 (5): p. 782-787. Mei, Y.S., et al., Gender and age effects on dental and palatal arch dimensions among full siblings. Journal of Oral Science, 2023. 65 (4): p. 237-242. Faul, F., et al., G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods, 2007. 39 (2): p. 175-91. Scarfe, W.C. and A.G. Farman, What is cone-beam CT and how does it work? Dent Clin North Am, 2008. 52 (4): p. 707-30, v. Koo, T.K. and M.Y. Li, A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med, 2016. 15 (2): p. 155-63. Baka, Z.M. and M. Fidanboy, Pharyngeal airway, hyoid bone, and soft palate changes after Class II treatment with Twin-block and Forsus appliances during the postpeak growth period. American Journal of Orthodontics Dentofacial Orthopedics, 2021. 159 (2): p. 148-157. Çoban Büyükbayraktar, Z. and H. Camcı, Dentoalveolar, skeletal, pharyngeal airway, cervical posture, hyoid bone position, and soft palate changes with Myobrace and Twin-block: a retrospective study. BMC Oral Health, 2023. 23 (1): p. 53. Büyükçavuş, M.H., H. Orhan, and G.J.A.Ü.D.H.F.D. Kocakara, İskeletsel Sınıf I Maloklüzyona Sahip Hastaların Farengeal Havayolu Boyutları ve Hyoid Kemik Pozisyonunun Cinsiyete Göre İncelenmesi. Atatürk Üniversitesi Diş Hekimliği Fakültesi Dergisi, 2020. 30 (4): p. 599-606. Kim, S.-H. and S.-K. Choi, Changes in the hyoid bone, tongue, and oropharyngeal airway space after mandibular setback surgery evaluated by cone-beam computed tomography. Maxillofacial Plastic Reconstructive Surgery, 2020. 42 (1): p. 27. Nainan, O., et al., Dental arch morphology as a predictor of sleep disordered breathing. Sleep Hypn, 2017. 19 (2): p. 30-37. Steiner, C.C., Cephalometrics for you and me. American Journal of Orthodontics Dentofacial Orthopedics, 1953. 39 (10): p. 729-755. Da Costa, E.D., et al., Correlation between the position of hyoid bone and subregions of the pharyngeal airway space in lateral cephalometry and cone beam computed tomography. The Angle Orthodontist, 2017. 87 (5): p. 688-695. Babu, N. and P. Kohli, Commentary: Reliability in research. Indian Journal of Ophthalmology, 2023. 71 (2): p. 400-401. Kollias, I. and O. Krogstad, Adult craniofacial and pharyngeal changes-a longitudinal cephalometric study between 22 and 42 years of age. Part II: morphological uvulo-glossopharyngeal changes. The European Journal of Orthodontics, 1999. 21 (4): p. 345-355. Awati, A.S., et al., Gender determination using velar morphology. Indian J Oral Health Res, 2020. 6 : p. 8-11. Lin, C.M., T.M. Davidson, and S. Ancoli-Israel, Gender differences in obstructive sleep apnea and treatment implications. Sleep medicine reviews, 2008. 12 (6): p. 481-496. Chalkoo, A.H., et al., Morphological varieties of soft palate in normal subjects: a digital cephalometric study. Indian J. Dent. Adv, 2015. 7 (4): p. 241-245. Deepa, V. and B. Ramnarayan, Morphological varieties of soft palate in normal individuals, cleft palate patients and obstructive sleep apnea patients with reference to Indian population: a preliminary digital cephalometric study. World Journal of Dentistry, 2015. 4 (4): p. 241-249. Verma, P., et al., Correlation of morphological variants of the soft palate and Need's ratio in normal individuals: A digital cephalometric study. Imaging science in dentistry, 2014. 44 (3): p. 193-198. Jayaprakash, P.K., et al., Correlation of soft palate morphology to growth pattern: A retrospective cephalometric study. Journal of family medicine primary care, 2019. 8 (7): p. 2468-2472. Nagaraj, T., et al., A radiographic assessment of morphologies of soft palate: A retrospective study. Journal of Medicine, Radiology, Pathology Surgery, 2016. 3 (5): p. 1-4. Crowley, J.S., et al., Speech and audiology outcomes after single-stage versus early 2-stage cleft palate repair. Annals of plastic surgery, 2021. 86 (5S): p. S360-S366. Jena, A.K., S.P. Singh, and A.K. Utreja, Sagittal mandibular development effects on the dimensions of the awake pharyngeal airway passage. The Angle Orthodontist, 2010. 80 (6): p. 1061-1067. Paoloni, V., et al., Evaluation of the morphometric covariation between palatal and craniofacial skeletal morphology in class III malocclusion growing subjects. BMC Oral Health 2020. 20 (1): p. 152. Günaydın, Ç., Nazo-oro-farengeal hava yolu boyutlarının farklı maloklüzyonlarda gelişiminin longitudinal olarak incelenmesi . 2015, Ankara Universitesi (Turkey). Matsuo, K., et al., Effects of respiration on soft palate movement in feeding. Journal of dental research, 2010. 89 (12): p. 1401-1406. Bakor, S.F., et al., Craniofacial growth variations in nasal-breathing, oral-breathing, and tracheotomized children. American journal of orthodontics dentofacial orthopedics, 2011. 140 (4): p. 486-492. Abraham, J., et al., Evaluation of Tongue Volume and Airway Volume in Skeletal Class I and Class II Patients using Cone Beam Computed Tomography—A Cross Sectional Study. Dentistry, 2023. 3000 (1): p. a001. Nakao, Y., et al., Age-related composition changes in swallowing-related muscles: a Dixon MRI study. Aging Clinical Experimental Research, 2021. 33 (12): p. 3205-3213. Beghini, M., et al., Morphometric analysis of tongue in individuals of European and African ancestry. Journal of Forensic Investigation, 2017. 5 (1): p. 2330-0396.1000038. Rana, S., O. Kharbanda, and B. Agarwal, Influence of tongue volume, oral cavity volume and their ratio on upper airway: A cone beam computed tomography study. Journal of Oral Biology Craniofacial Research, 2020. 10 (2): p. 110-117. Azevêdo, M.S., et al., Evaluation of upper airways after bimaxillary orthognathic surgery in patients with skeletal Class III pattern using cone-beam computed tomography. Dental press journal of orthodontics, 2016. 21 (1): p. 34-41. Engelke, W., K. Jung, and M. Knösel, Intra-oral compartment pressures: a biofunctional model and experimental measurements under different conditions of posture. Clinical Oral Investigations, 2011. 15 (2): p. 165-176. Šidlauskienė, M., et al., Genetic and environmental impact on variation in the palatal dimensions in permanent dentition: a twin study. Scientific Reports, 2024. 14 (1): p. 19785. Araby, Y.A., et al., Morphometric analysis of the hard palate using cone beam computed tomography in a Saudi population. The Saudi Dental Journal, 2023. 35 (3): p. 270-274. Eslami Amirabadi, G., et al., Palatal dimensions at different stages of dentition in 5 to 18-year-old Iranian children and adolescent with normal occlusion. BMC Oral Health, 2018. 18 (1): p. 87. Kairalla, S.A., et al., Evaluation of palatal dimensions in different facial patterns by using digital dental casts. Dental Press Journal of Orthodontics, 2022. 27 (05): p. e222115. Saadeh, M.E. and J.G. Ghafari, Uniformity of palatal volume and surface area in various malocclusions. Orthodontics Craniofacial Research, 2023. 26 (1): p. 72-80. Lione, R., et al., Palatal surface and volume in mouth-breathing subjects evaluated with three-dimensional analysis of digital dental casts—a controlled study. European Journal of Orthodontics, 2015. 37 (1): p. 101-104. Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files AppendicesClin.OralInvestig.docx Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 12 May, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers invited by journal 19 Apr, 2026 Editor assigned by journal 19 Mar, 2026 Submission checks completed at journal 19 Mar, 2026 First submitted to journal 12 Mar, 2026 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9101919","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627939435,"identity":"75fb4b8b-2054-4d75-9fce-0e00f4d95801","order_by":0,"name":"Busra Ozturk","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYDCCAzwINmODgQ2IajyAV8sxmBY2kJaCNLBOUrR8OAyxGp8Ovvu9xyR/7rGTk5/fY/ZxhsF5u7Xth4G21NhE49IieYwvTZrnWbIxYxuP8cwNBreTt51JBGo5lpbbgEOLwTEeM2mGA8yJzWw8xowPgFrMDgC1MDYcxqtF8seB+sQ2iJZzyWbnHxLWIsFz4HBiD0jLBoMDdmY3CNgieSwv2ZrnwHFjCba0YsYZBskJZjeAtiTg8Qvf4bMHb/44UC0n33x4M2PPHzt7s/PpDx98qLHBqQUDJIJVJhCrHATsSVE8CkbBKBgFIwMAAMJVYRkZkmKfAAAAAElFTkSuQmCC","orcid":"","institution":"Necmettin Erbakan University","correspondingAuthor":true,"prefix":"","firstName":"Busra","middleName":"","lastName":"Ozturk","suffix":""},{"id":627939436,"identity":"aa29cf25-6402-409a-a2c8-730d4c843a27","order_by":1,"name":"Guldane Magat","email":"","orcid":"","institution":"Necmettin Erbakan University","correspondingAuthor":false,"prefix":"","firstName":"Guldane","middleName":"","lastName":"Magat","suffix":""},{"id":627939437,"identity":"08a2e964-588d-495a-b53f-4fbe8a8f70aa","order_by":2,"name":"Mucahid Yildirim","email":"","orcid":"","institution":"Necmettin Erbakan University","correspondingAuthor":false,"prefix":"","firstName":"Mucahid","middleName":"","lastName":"Yildirim","suffix":""},{"id":627939438,"identity":"ffb0efed-b98b-43c1-a41b-1c25b622c8d6","order_by":3,"name":"Alparslan Esen","email":"","orcid":"","institution":"Necmettin Erbakan University","correspondingAuthor":false,"prefix":"","firstName":"Alparslan","middleName":"","lastName":"Esen","suffix":""}],"badges":[],"createdAt":"2026-03-12 08:08:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9101919/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9101919/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108006537,"identity":"6dc33ec2-813a-46ae-8db2-2b7c6beb777e","added_by":"auto","created_at":"2026-04-28 12:55:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":196409,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal CBCT images show the soft palate length (a), soft palate width (b), and soft palate angle (c). PNS: Posterior nasal spine, point determining the posterior border of the hard palate; P: The most extreme point of the soft palate; SP1: Point determining the anterior border of the soft palate; SP2: Point determining the posterior border of the soft palate; ANS: Anterior nasal spine; PNS: Posterior nasal spine; P: The most extreme point of the soft palate.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9101919/v1/549dbb8f498d3df88631d222.png"},{"id":107918204,"identity":"40f40199-5663-402e-b3d6-67ce907e3364","added_by":"auto","created_at":"2026-04-27 14:27:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":176954,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal CBCT images show tongue height and width (a), and the borders of the tongue (red) and soft palate (green). Tt: Point defining the tip of the tongue; RGn: Most posterior-inferior point of the mandibular symphysis; H: Center of the hyoid bone; Ep: Epiglottis.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9101919/v1/8b20096126f5a385c43f5b34.png"},{"id":107918073,"identity":"e570a687-5f58-45d1-8695-72485f84df95","added_by":"auto","created_at":"2026-04-27 14:27:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":111294,"visible":true,"origin":"","legend":"\u003cp\u003eCoronal CBCT section shows palatal height.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9101919/v1/603661ba7270b074316715f1.png"},{"id":107918121,"identity":"4cff3b4a-492e-472d-88a8-85a2dccfa2be","added_by":"auto","created_at":"2026-04-27 14:27:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":465458,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal CBCT images illustrating the classification of breathing patterns using the hyoid triangle technique. (a, c) Oral breathing pattern: the hyoid bone is positioned above the RGn–C3 plane, forming a negative hyoid triangle. (b, d) Nasal breathing pattern: the hyoid bone is located below the RGn–C3 plane, forming a positive hyoid triangle. RGn: Most posterior-inferior point of the mandibular symphysis; Hyoid: Center of the hyoid bone; C3: Anterior-inferior point of the third cervical vertebra.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9101919/v1/00d398c4a77482fa7809b128.png"},{"id":108008682,"identity":"4b6000d7-2945-4080-a791-4878e262baea","added_by":"auto","created_at":"2026-04-28 13:07:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1328382,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9101919/v1/3f90936c-a5e5-4679-9bae-79e04fa90663.pdf"},{"id":107918212,"identity":"3c88c7e1-38a2-46e9-9db8-0cd8cd56684b","added_by":"auto","created_at":"2026-04-27 14:27:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":60296,"visible":true,"origin":"","legend":"","description":"","filename":"AppendicesClin.OralInvestig.docx","url":"https://assets-eu.researchsquare.com/files/rs-9101919/v1/8c096354dcca3f98424094bc.docx"},{"id":107918072,"identity":"cefd9557-8287-4fd7-8c61-0bb9a261cd69","added_by":"auto","created_at":"2026-04-27 14:27:19","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":65631,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-9101919/v1/cad1d45ed40f00f95c4b4e98.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"CBCT-Based Morphometric and Volumetric Assessment of the Tongue, Soft Palate, and Palatal Height in Relation to Skeletal Class and Breathing Pattern","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe tongue and soft palate are two key anatomical structures that play a crucial role in maintaining upper airway patency and oral\u0026ndash;maxillofacial function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Their morphometric and volumetric characteristics are closely associated with craniofacial development, occlusal balance, and breathing function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Even minor alterations in the dimensions of these structures may compromise airway stability and influence maxillomandibular relationships, underscoring their importance in orthodontic and maxillofacial assessment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe tongue is involved in essential functions such as breathing, deglutition, mastication, and articulation. Alterations in its posture or size can markedly affect airway dimensions and skeletal relationships [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Likewise, the soft palate contributes to velopharyngeal closure and phonatory resonance, and its elongation or volumetric changes have been strongly linked to obstructive sleep apnea [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Beyond these two structures, palatal height has recently gained attention as a determinant of transverse maxillary development and airway morphology, with mouth breathers frequently exhibiting narrower and deeper palatal vaults[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual dimorphism and skeletal discrepancies further modulate these relationships. CBCT-based studies have consistently demonstrated larger tongue and soft palate volumes in males [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], while skeletal Class II and III malocclusions have been associated with altered tongue posture and velar morphology [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Breathing mode is another critical determinant, as mouth breathing has been linked with increased palatal height, elongated soft palates, and compromised tongue posture [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, most prior studies have evaluated these parameters in isolation or within limited populations, providing only a partial understanding of their combined effects.\u003c/p\u003e \u003cp\u003eCone-beam computed tomography (CBCT) has become the preferred imaging modality for such evaluations, as it enables three-dimensional analysis with relatively low radiation exposure and high diagnostic accuracy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Despite these advantages, few studies have simultaneously examined the tongue, soft palate, and palatal height across age, sex, skeletal class, and breathing type within a single multifactorial framework.\u003c/p\u003e \u003cp\u003eTo our knowledge, no previous CBCT-based study has simultaneously assessed the tongue, soft palate, and palatal height using a multifactorial robust ANOVA approach. Based on this background, the present study aimed to comprehensively evaluate the morphometric and volumetric features of these structures using CBCT. A three-way robust ANOVA model was applied to analyze the main and interaction effects of age, sex, skeletal class, and breathing type. We hypothesized that these parameters would show significant differences according to skeletal class and age, display sex-specific patterns, and reveal multifactorial interactions not detectable through univariate analyses. The null hypothesis stated that skeletal class, breathing type, and age would not significantly affect the measured parameters.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical Approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval for this retrospective study was obtained from the Necmettin Erbakan University Faculty of Dentistry, Drug and Non-Medical Device Research Ethics Committee on 05.25.2023 (Protocol no: 2023/299), confirming its scientific and ethical appropriateness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Population and Power Calculation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCBCT images obtained for diagnostic purposes from patients attending the Department of Oral and Maxillofacial Radiology, Necmettin Erbakan University, between February 2019 and October 2024, were retrospectively analyzed.\u003c/p\u003e\n\u003cp\u003eA priori power analysis was performed using G*Power v3.1.9.7 with ANOVA parameters set at a 95% confidence level (1\u0026ndash;\u0026alpha;), 95% power (1\u0026ndash;\u0026beta;), and an assumed medium effect size (Cohen\u0026rsquo;s f = 0.30) [14]. The minimum required sample size was 240. To further strengthen statistical power, a larger cohort of 560 scans was included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInclusion Criteria:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included patients aged \u0026ge; 8 years with no congenital or acquired craniofacial anomalies, history of craniofacial trauma or surgery, cleft lip/palate, systemic syndromes, or missing teeth affecting occlusion, and with CBCT images of optimal diagnostic quality allowing clear identification of reference points.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExclusion Criteria:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were excluded if they had congenital or acquired craniofacial anomalies, a history of craniofacial trauma or surgery, cleft lip/palate, systemic syndromes, missing teeth affecting occlusion, suboptimal CBCT image quality, or unclear reference points.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCBCT Acquisition Protocol\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective study, CBCT images of 560 male and female patients aged 8-73 years with high diagnostic quality who met the inclusion criteria were analyzed. The CBCT images used in the study were obtained with Morita 3D Accuitomo 170 and NewTom GiANO 3D devices. The Morita 3D Accuitomo 170 (J Morita MFG Corp., Kyoto, Japan) was operated at 90 kVp and 5 mA, with an irradiation time of 17.5 seconds, 0.25 mm voxel size, 140 mm \u0026times; 100 mm FOV, 360\u0026deg; data acquisition and no additional filtering. The NewTom GiANO 3D device (Verona, Italy) was operated at 90 kVp and 10 mA, with an irradiation time of 18 seconds, 0.15 mm voxel size, 140 mm \u0026times; 100 mm FOV, 360\u0026deg; data acquisition and no additional filtering. Both devices were calibrated before each patient, and imaging was performed by the same technician following standardized protocols. As two different CBCT systems were used, potential variability in voxel size was minimized by calibration; however, this factor is acknowledged as a methodological limitation [15].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMeasurement Procedure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll scans were saved in DICOM format and analyzed with Dolphin 3D Imaging Software (Dolphin Imaging \u0026amp; Management Solutions\u0026reg;, Chatsworth, CA, USA). Measurements were performed on 3D reconstructions in sagittal, axial, and coronal views. A single examiner (B.O.-3 years\u0026rsquo; experience) performed the measurements, blinded to skeletal class and respiratory type to minimize bias. Measurement reliability was assessed by repeating all measurements on 50 randomly selected scans after two weeks. Inter-observer reliability was tested by a second examiner (16 years\u0026rsquo; experience). Intraclass correlation coefficients (ICC) \u0026gt;0.90 were considered excellent [16]. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThree-Dimensional Cephalometric Measurements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the three-dimensional cephalometric analysis; the length, width, and angle values of the soft palate were measured. Accordingly, the soft palate length was measured as the distance between the posterior nasal spine (PNS) and the most distal point of the soft palate (P) \u003cstrong\u003e(Figure 1a)\u003c/strong\u003e[17]. The soft palate width was measured as the distance between the SP1 point, which defines the anterior border of the soft palate, and the SP2 point, which defines the posterior border of the soft palate (\u003cstrong\u003eFigure 1b\u003c/strong\u003e)[18]. The soft palate angle was measured as the angle between the line drawn from the anterior nasal spine (ANS) to the PNS and the line drawn from the posterior nasal spine (PNS) to the most distal point of the soft palate (P)\u003cstrong\u003e(Figure 1c)\u003c/strong\u003e[17]. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFigure 1.\u003c/strong\u003e Sagittal CBCT images show the soft palate length (a), soft palate width (b), and soft palate angle (c). PNS: Posterior nasal spine, point determining the posterior border of the hard palate; P: The most extreme point of the soft palate; SP1: Point determining the anterior border of the soft palate; SP2: Point determining the posterior border of the soft palate; ANS: Anterior nasal spine; PNS: Posterior nasal spine; P: The most extreme point of the soft palate.\u003c/p\u003e\n\u003cp\u003eThe soft palate volume was calculated as the volume encompassed within the sagittal boundaries of the soft palate, extending from the PNS to the P \u003cstrong\u003e(Figure 2b)\u003c/strong\u003e[19]. The height, width, area, and volume values of the soft tissue of the tongue were measured. Tongue height was measured as the length of the vertical bisector from the dorsal surface of the tongue to the line between the base of the epiglottis and the tip of the tongue. Tongue width was measured as the length between the base of the epiglottis (the base of the epiglottis is the point where the epiglottis and the base of the tongue intersect) and the tip of the tongue \u003cstrong\u003e(Figure 2a) \u003c/strong\u003e[20]. Tongue area and volume were calculated as the cross-sectional area and volume defined by lines connecting the most superior and anterior point of the tongue dorsum and hyoid bone corpus (H), the base of the epiglottis (EB), the most distal point of the tongue (Tt), and the most posterior point of the mandibular symphysis (RGn) \u003cstrong\u003e(Figure 2b) \u003c/strong\u003e[19].\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFigure 2.\u003c/strong\u003e Sagittal CBCT images show tongue height and width (a), and the borders of the tongue (red) and soft palate (green). Tt: Point defining the tip of the tongue; RGn: Most posterior-inferior point of the mandibular symphysis; H: Center of the hyoid bone; Ep: Epiglottis.\u003c/p\u003e\n\u003cp\u003eThe palatal height value was measured as the distance from the mid-deepest point of the palate to the line connecting the distolingual tubercles of the upper first molars \u003cstrong\u003e(Figure 3) \u003c/strong\u003e[21].\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFigure 3.\u003c/strong\u003e Coronal CBCT section shows palatal height.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipant Grouping Criteria\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSex-based categorization was applied in this study. A total of 560 CBCT scans were analyzed, comprising 295 female and 265 male patients. Participants ranged in age from 8 to 73 years and were stratified into five age groups for subgroup analysis: 8\u0026ndash;18 years, 19\u0026ndash;29 years, 30\u0026ndash;40 years, 41\u0026ndash;51 years, and over 52 years.\u003c/p\u003e\n\u003cp\u003eSkeletal classification was determined by calculating the ANB angle on sagittal sections of the CBCT images using Dolphin 3D software (Dolphin Imaging \u0026amp; Management Solutions\u0026reg;, Chatsworth, CA, USA), based on the principles of Steiner analysis [22]. The ANB angle was obtained by subtracting the SNB (sella\u0026ndash;nasion\u0026ndash;point B) angle from the SNA (sella\u0026ndash;nasion\u0026ndash;point A) angle, which reflect the anteroposterior relationship of the maxilla and mandible to the cranial base. All measurements were performed on mid-sagittal slices aligned with standard cephalometric reference planes. Based on the measured ANB values, patients were categorized into three skeletal classes: Class I (ANB angle between 0\u0026deg; and 4\u0026deg;), Class II (ANB \u0026gt; 4\u0026deg;), and Class III (ANB \u0026lt; 0\u0026deg;).\u003c/p\u003e\n\u003cp\u003eThe breathing pattern of each participant was classified as either nasal or oral based on the \u0026ldquo;hyoid triangle\u0026rdquo; technique, applied to sagittal CBCT sections using Dolphin 3D software (Dolphin Imaging \u0026amp; Management Solutions\u0026reg;, Chatsworth, CA, USA). This method involves constructing a triangle using three anatomical landmarks: the anterior-inferior point of the third cervical vertebra (C3), the most anterior point of the hyoid bone, and the retrognathion (RGn). In this configuration, the RGn\u0026ndash;C3 line serves as the base, and a triangle is formed by connecting these three points. When the hyoid bone is positioned above the RGn\u0026ndash;C3 plane, the triangle has a superior vertex and is considered a \u0026ldquo;negative triangle,\u0026rdquo; indicating an oral breathing pattern (\u003cstrong\u003eFigure 4a, c\u003c/strong\u003e). Conversely, when the hyoid lies below the RGn\u0026ndash;C3 line, the triangle takes on a \u0026ldquo;positive\u0026rdquo; configuration, which is indicative of nasal breathing (\u003cstrong\u003eFigure 4b, d\u003c/strong\u003e) [23].\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFigure 4.\u003c/strong\u003e Sagittal CBCT images illustrating the classification of breathing patterns using the hyoid triangle technique. (a, c) Oral breathing pattern: the hyoid bone is positioned above the RGn\u0026ndash;C3 plane, forming a negative hyoid triangle. (b, d) Nasal breathing pattern: the hyoid bone is located below the RGn\u0026ndash;C3 plane, forming a positive hyoid triangle. RGn: Most posterior-inferior point of the mandibular symphysis; Hyoid: Center of the hyoid bone; C3: Anterior-inferior point of the third cervical vertebra.\u003c/p\u003e\n\u003cp\u003eTo assess measurement reliability, 50 CBCT scans were randomly selected for both intra- and inter-observer evaluations. Intra-observer reliability was assessed by having the primary examiner (BO), with three years of experience in oral and maxillofacial radiology, repeat all measurements after a two-week interval. For inter-observer reliability analysis, a second examiner (GM), with sixteen years of experience in the same field, independently performed the same measurements on the selected scans. Both observers followed identical measurement protocols. Intraclass correlation coefficients (ICC) were calculated for both assessments, and values above 0.90 were considered indicative of excellent agreement [24].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was performed with JAMOVI V2.3.22 (The Jamovi Project, Sydney, Australia). Compliance with normal distribution was evaluated by Shapiro-Wilk test. For the comparison of non-normally distributed data according to age, respiratory and skeletal pattern groups, three-way Robust ANOVA was applied using the Walrus package. Multiple comparisons were performed with the Bonferroni post-hoc test. Effect sizes (\u0026eta;\u0026sup2;) were reported for significant results Analysis results are reported as pruned mean \u0026plusmn; standard error of the mean for quantitative data. Statistical significance level was accepted as p\u0026lt;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 560 participants (295 females, 265 males) with a mean age of 33.74 \u0026plusmn; 14.96 years were included. Of these, 28.6% (n = 160) were oral breathers and 71.4% (n = 400) were nasal breathers (\u003cstrong\u003e\u003cem\u003eA1\u003c/em\u003e\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDescriptive statistics for all morphometric and volumetric parameters are summarized in \u003cstrong\u003e\u003cem\u003eA2\u003c/em\u003e\u003c/strong\u003e. The mean soft palate length was 36.33 \u0026plusmn; 5.10 mm, width 9.94 \u0026plusmn; 2.10 mm, angle 127.10\u0026deg; \u0026plusmn; 8.18\u0026deg;, and volume 3627.67 \u0026plusmn; 2322.75 mm\u0026sup3;. The mean tongue length was 74.31 \u0026plusmn; 8.10 mm, height 34.46 \u0026plusmn; 6.18 mm, area 12,642.85 \u0026plusmn; 2307.14 mm\u0026sup2;, and volume 103,123.76 \u0026plusmn; 22,266.33 mm\u0026sup3;, while the mean palatal height measured 18.97 \u0026plusmn; 4.84 mm.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn females, soft palate length varied significantly across age groups (p \u0026lt; 0.001), showing an overall increase with age. Multiple comparisons revealed that the nasal-breathing Class I group aged 8\u0026ndash;18 years had significantly shorter soft palates than the oral-breathing Class I group aged 30\u0026ndash;40 years. No main effects of breathing type or skeletal class were detected (p = 0.43 and p = 0.35, respectively). However, the three-way interaction of age, breathing, and skeletal pattern was significant (p = 0.016) (\u003cstrong\u003e\u003cem\u003eA3\u003c/em\u003e\u003c/strong\u003e). In males, length was also affected by age (p \u0026lt; 0.001), and a breathing \u0026times; skeletal pattern interaction (p = 0.029) indicated that nasal-breathing Class III males exhibited shorter soft palates than nasal-breathing Class I counterparts.\u003c/p\u003e\n\u003cp\u003eSoft palate width in females differed significantly with age (p = 0.002), being greater in the 41\u0026ndash;51-year group than in the 8\u0026ndash;18 and 19\u0026ndash;29-year groups. Significant effects of both breathing type (p = 0.041) and skeletal pattern (p = 0.004) were observed, with wider soft palates in oral breathers and Class II females. In males, no significant differences were found for any factor or interaction (p \u0026gt; 0.05) \u003cstrong\u003e\u003cem\u003e(Table 1).\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn both females and males, no significant differences were found in soft palate angle according to age, breathing type, or skeletal pattern, and no significant interaction effects were observed (all p \u0026gt; 0.05) \u003cstrong\u003e\u003cem\u003e(A4)\u003c/em\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eSoft palate volume exhibited a strong age effect in females (p \u0026lt; 0.001), increasing markedly from adolescence to middle age. The 8\u0026ndash;18 and 19\u0026ndash;29-year groups had significantly lower volumes than all older groups. Breathing type and skeletal class had no significant influence (p = 0.67 and p = 0.713, respectively). In males, neither age nor breathing nor skeletal pattern yielded statistically significant differences \u003cstrong\u003e\u003cem\u003e(A5)\u003c/em\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eIn females, tongue length did not differ significantly among age groups, breathing types, or skeletal classes (p \u0026gt; 0.05). In males, tongue length varied significantly across age groups (p = 0.036), though post-hoc comparisons did not reveal specific pairwise differences, suggesting a general trend of increasing tongue length with age \u003cstrong\u003e\u003cem\u003e(A6)\u003c/em\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eTongue height in females differed significantly across skeletal classes (p = 0.024), being greater in Class II than in Class I and III, but showed no effects of age or breathing type (p = 0.48 and p = 0.67). No significant differences were observed in males (p \u0026gt; 0.05) \u003cstrong\u003e\u003cem\u003e(Table 2)\u003c/em\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eTongue volume exhibited the most consistent age-related variation in both sexes. In females, tongue volume increased significantly with age (p \u0026lt; 0.001), and significant differences were also detected among skeletal classes (p = 0.017), with Class II showing greater volumes than Class I. In males, age was again highly significant (p \u0026lt; 0.001), with markedly lower tongue volumes in the 8\u0026ndash;18-year group compared to older age groups, while breathing and skeletal pattern effects remained nonsignificant \u003cstrong\u003e\u003cem\u003e(Table 3)\u003c/em\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eTongue area followed a pattern similar to tongue volume. In females, it differed significantly across age groups (p \u0026lt; 0.001) and skeletal classes (p = 0.033), with larger areas in Class II females. In males, tongue area also differed with age (p = 0.004), being smaller in younger groups and larger in adults, while breathing type and skeletal class showed no significant differences \u003cstrong\u003e\u003cem\u003e(Table 4)\u003c/em\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eIn females, palatal height did not differ significantly by age (p = 0.051), but oral breathers showed greater palatal height than nasal breathers (p = 0.04). Skeletal pattern had no significant effect (p = 0.555). In males, palatal height increased significantly with age (p \u0026lt; 0.001), especially between the 8\u0026ndash;18 and 30\u0026ndash;40/41\u0026ndash;51 age groups, and was higher in oral breathers than nasal breathers (p = 0.01). Skeletal pattern effects were not significant in either sex\u003cstrong\u003e\u003cem\u003e\u0026nbsp;(Table 5).\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provided a comprehensive evaluation of the morphology of the soft palate, tongue, and palatal height in relation to sex, age, breathing type, and skeletal pattern. By systematically comparing our findings with previous reports, both consistent and divergent results were identified, offering new insights into the complex and multifactorial determinants of craniofacial morphology.\u003c/p\u003e\n\u003cp\u003eSoft palate morphology demonstrated clear sex-related differences, as males exhibited greater length, width, and volume compared with females. These findings corroborate earlier studies by Kollias and Krogstad (1999)[25], Awati et al. (2020)[26], and Lin et al. (2008)[27], which consistently reported sexual dimorphism in velar dimensions. Interestingly, no significant sex-based differences were detected in palatal angle, suggesting that angular parameters may be more sensitive to postural adaptations rather than intrinsic anatomical variance. Age-related analyses revealed a progressive increase in length in both sexes, with significant volumetric enlargement observed primarily in females. Similar trends were previously reported by Chalkoo et al. (2016)[28], Deepa and Ramnarayan (2013)[29], Verma et al. (2014)[30], and Jayaprakash et al. (2019)[31], who emphasized continuous morphometric alterations across adulthood. In contrast, other studies, such as Nagaraj et al. (2016)[32] and Crowley et al. (2021)[33], suggested stabilization of velar dimensions after early adulthood. These contrasting results highlight that velar growth may be influenced by population-specific, methodological, or functional factors. Skeletal pattern exerted limited influence on the soft palate, with significant differences observed only in females for width. Previous studies[34-36] reported distinct variations across malocclusion classes, suggesting that methodological differences, including three-dimensional imaging and sample heterogeneity, may explain the discrepancies. Breathing type demonstrated a more notable impact in females, as oral breathers exhibited greater soft palate width, supporting the findings of Matsuo et al. (2010)[37] and Bakor et al. (2011)[38], who linked oral breathing with transversal palatal alterations. Taken together, these findings underline that sex and breathing mode may exert synergistic effects on velar morphology, while skeletal classification alone may be less decisive.\u003c/p\u003e\n\u003cp\u003eThe tongue exhibited marked sexual dimorphism, as males presented significantly greater length, height, area, and volume compared with females. This observation is in accordance with CT- and CBCT-based studies by Abraham et al. (2023)[39], Ding et al. (2018)[7], Uysal et al. (2013)[2], and Iwasaki et al. (2019)[8]. Zhao et al. (2021)[10] additionally identified BMI as an independent determinant, further underscoring the multifactorial regulation of tongue size. The role of sex hormones, particularly the anabolic effect of testosterone, and sex-specific craniofacial growth trajectories, may explain the observed disparities. Age was another determinant, as tongue area and volume significantly increased with advancing age. While some investigations[40, 41] have described age-related muscle atrophy and volumetric decline, others such as Rana et al. (2020)[42] suggested more pronounced reductions in thickness. Skeletal pattern further influenced tongue morphology, with Class III subjects and hyperdivergent individuals presenting larger tongue volumes, in line with Iwasaki et al. (2019)[8] and Tseng et al. (2021)[9]. These results confirm that tongue morphology is closely integrated with skeletal structure and should be incorporated into orthodontic and airway evaluations. Surprisingly, no significant differences were observed between nasal and oral breathers in our sample, in contrast with Azev\u0026ecirc;do et al. (2016)[43] and Engelke et al. (2010)[44], who highlighted changes in tongue posture associated with mouth breathing. This discrepancy may be attributable to temporal variations in breathing habits, environmental influences, or the sensitivity of imaging protocols.\u003c/p\u003e\n\u003cp\u003ePalatal height analysis also revealed significant associations with sex and age. Consistent with \u0026Scaron;idlauskienė et al. (2024)[45] and Araby et al. (2023)[46], males exhibited greater values, which have been attributed to genetic and hormonal influences, particularly post-pubertal testosterone effects. Age-related increases were significant in males but not in females, corroborating the reports of Eslami Amirabadi et al. (2018)[47] and Mei et al. (2023)[13]. Skeletal classification, however, did not reveal any significant effect, in agreement with Kairalla et al. (2022)[48], who reported no direct association, and Saadeh \u0026amp; Ghafari (2023)[49], who emphasized vertical rather than sagittal influences. Notably, breathing pattern demonstrated a consistent effect across sexes, as oral breathers exhibited significantly greater palatal height compared with nasal breathers. This finding supports earlier studies by Souki et al. (2009)[4], Lione et al. (2014)[50], and Harari et al. (2010)[11], which demonstrated that chronic oral breathing promotes a narrower and deeper palatal vault. These results underline the importance of recognizing oral breathing habits early in clinical practice to prevent maxillary constriction and related malocclusions.\u003c/p\u003e\n\u003cp\u003eWhen the combined effects of age, sex, skeletal pattern, and breathing mode were considered, significant interactions were limited. Notably, soft palate length in females demonstrated a significant interaction among multiple variables, whereas tongue and palatal height parameters did not. This finding suggests that while individual factors exert strong influences, their combined or synergistic effects may not always reach statistical significance, likely due to adaptive compensations and the multifactorial nature of craniofacial development. The limited evidence in the literature addressing combined factor interactions highlights the originality of this study, as it provides a simultaneous assessment of these variables rather than focusing on isolated effects. From a clinical standpoint, the simultaneous evaluation of the soft palate, tongue, and palatal height provides a more integrative understanding of upper airway morphology. Incorporating these parameters into orthodontic and surgical planning may help anticipate airway changes associated with growth, breathing habits, and skeletal discrepancies, ultimately contributing to more functional and stable treatment outcomes.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations that should be considered when interpreting the findings. First, its retrospective design inherently limits control over participant positioning, muscle activity, and breathing function during CBCT acquisition. Because all measurements were derived from static three-dimensional images, dynamic variables such as tongue motion, airway collapsibility, and real-time breathing patterns could not be assessed. Second, although calibration procedures were applied, two different CBCT devices with distinct voxel resolutions were used, which may have introduced minor variability in image scaling and segmentation accuracy. Third, breathing type classification was based on anatomical indicators and clinical history rather than objective airflow measurements, which could have led to misclassification in borderline cases. Fourth, skeletal classification relied solely on sagittal parameters (ANB angle), without integrating vertical or transverse skeletal components that might influence soft-tissue morphology. In addition, the sample was drawn from a single institution with a demographically homogeneous population, limiting the generalizability of the results across different ethnic and geographic groups. Finally, the cross-sectional nature of the study precludes causal inference; longitudinal or functional imaging studies would be required to confirm the observed associations and temporal changes.\u003c/p\u003e\n\u003cp\u003eFuture research should aim to overcome the current study\u0026rsquo;s limitations by incorporating dynamic and functional imaging modalities, such as cine-MRI or four-dimensional CBCT, to evaluate tongue and soft palate movements during actual breathing and swallowing. Objective airflow or polysomnographic measurements should also be integrated to validate breathing classification and its clinical implications. Moreover, longitudinal investigations following craniofacial growth trajectories could clarify the temporal sequence between skeletal development, soft-tissue adaptation, and airway morphology. Finally, multi-center studies with diverse populations and standardized voxel calibration protocols are recommended to enhance generalizability and establish normative reference data for different age and sex groups.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTaken together, this study demonstrated that age, sex, and breathing pattern significantly influence craniofacial soft-tissue morphology. Soft palate dimensions and tongue size increased progressively with age, showing more pronounced changes in males. Tongue morphometry exhibited distinct sex-related differences, with larger volumes and dimensions in males compared with females. Palatal height increased significantly with age in males but remained relatively stable in females, and was also affected by breathing type, with oral breathing associated with greater palatal height and reduced transverse expansion. Overall, by simultaneously evaluating the soft palate, tongue, and palatal height, this study provides a novel and comprehensive contribution to the literature, emphasizing the importance of age-, sex-, and breathing-related factors in craniofacial assessment.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eCBCT: Cone Beam Computed Tomography\u003c/p\u003e\n\u003cp\u003eDICOM: Digital Imaging and Communications in Medicine\u003c/p\u003e\n\u003cp\u003eANS: Anterior Nasal Spine\u003c/p\u003e\n\u003cp\u003ePNS: Posterior Nasal Spine\u003c/p\u003e\n\u003cp\u003eEB: Epiglottis Base\u003c/p\u003e\n\u003cp\u003eP: Most distal point of the soft palate\u003c/p\u003e\n\u003cp\u003eTt: Tip of the Tongue\u003c/p\u003e\n\u003cp\u003eH: Hyoid bone corpus\u003c/p\u003e\n\u003cp\u003eICC: Intraclass Correlation Coefficient\u003c/p\u003e\n\u003cp\u003eRGn: Retrognathion\u003c/p\u003e\n\u003cp\u003eC3: Third Cervical Vertebra\u003c/p\u003e\n\u003cp\u003eANB: A\u0026ndash;Nasion\u0026ndash;B Angle\u003c/p\u003e\n\u003cp\u003eSNA: Sella\u0026ndash;Nasion\u0026ndash;A Angle\u003c/p\u003e\n\u003cp\u003eSNB: Sella\u0026ndash;Nasion\u0026ndash;B Angle\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to institutional data privacy policies but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments. The study was approved by the Ethics Committee of the Faculty of Dentistry, Necmettin Erbakan University (Approval No: 2023/299). Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eB.O. carried out the CBCT measurements, performed intra-observer reliability tests, conducted statistical analyses, and drafted the initial version of the manuscript. G.M. was responsible for the overall study conception and design, supervised the methodological framework, performed inter-observer measurements, and contributed substantially to the interpretation of the findings. M.Y. assisted in data collection, organization of patient records, and contributed to the literature review. A.E. provided methodological input, guided the structuring of the results and discussion sections, and critically revised the manuscript for intellectual content. All authors read, revised, and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study constitutes a part of the specialty thesis submitted by Busra Ozturk to the Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Necmettin Erbakan University.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTseng, Y.-C., et al., \u003cem\u003eCorrelation between change of tongue area and skeletal stability after correction of mandibular prognathism.\u003c/em\u003e The Kaohsiung Journal of Medical Sciences, 2017. \u003cstrong\u003e33\u003c/strong\u003e(6): p. 302-307.\u003c/li\u003e\n\u003cli\u003eUysal, T., et al., \u003cem\u003eCone-beam computed tomography evaluation of relationship between tongue volume and lower incisor irregularity.\u003c/em\u003e The European Journal of Orthodontics, 2013. \u003cstrong\u003e35\u003c/strong\u003e(5): p. 555-562.\u003c/li\u003e\n\u003cli\u003eWitt, M., \u003cem\u003eAnatomy and development of the human taste system.\u003c/em\u003e Handbook of clinical neurology, 2019. \u003cstrong\u003e164\u003c/strong\u003e: p. 147-171.\u003c/li\u003e\n\u003cli\u003eSouki, B.Q., et al., \u003cem\u003ePrevalence of malocclusion among mouth breathing children: do expectations meet reality?\u003c/em\u003e International journal of pediatric otorhinolaryngology, 2009. \u003cstrong\u003e73\u003c/strong\u003e(5): p. 767-773.\u003c/li\u003e\n\u003cli\u003eLione, R., et al., \u003cem\u003ePalatal surface and volume in mouth-breathing subjects evaluated with three-dimensional analysis of digital dental casts-a controlled study.\u003c/em\u003e Eur J Orthod, 2015. \u003cstrong\u003e37\u003c/strong\u003e(1): p. 101-4.\u003c/li\u003e\n\u003cli\u003eStandring, S., \u003cem\u003eGray\u0026apos;s Anatomy E-Book: Gray\u0026apos;s Anatomy E-Book\u003c/em\u003e. 2021: Elsevier Health Sciences.\u003c/li\u003e\n\u003cli\u003eDing, X., et al., \u003cem\u003eEvaluation of tongue volume and oral cavity capacity using cone-beam computed tomography.\u003c/em\u003e Odontology, 2018. \u003cstrong\u003e106\u003c/strong\u003e(3): p. 266-273.\u003c/li\u003e\n\u003cli\u003eIwasaki, T., et al., \u003cem\u003eOropharyngeal airway in children with Class III malocclusion evaluated by cone-beam computed tomography.\u003c/em\u003e American Journal of orthodontics Dentofacial orthopedics, 2009. \u003cstrong\u003e136\u003c/strong\u003e(3): p. 318. e1-318. e9.\u003c/li\u003e\n\u003cli\u003eTseng, Y.-C., et al., \u003cem\u003eEvaluation of pharyngeal airway volume for different dentofacial skeletal patterns using cone-beam computed tomography.\u003c/em\u003e Journal of dental sciences, 2021. \u003cstrong\u003e16\u003c/strong\u003e(1): p. 51-57.\u003c/li\u003e\n\u003cli\u003eZhao, Z., et al., \u003cem\u003eEffects of mouth breathing on facial skeletal development in children: a systematic review and meta-analysis.\u003c/em\u003e BMC oral health, 2021. \u003cstrong\u003e21\u003c/strong\u003e(1): p. 108.\u003c/li\u003e\n\u003cli\u003eHarari, D., et al., \u003cem\u003eThe effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients.\u003c/em\u003e The Laryngoscope, 2010. \u003cstrong\u003e120\u003c/strong\u003e(10): p. 2089-2093.\u003c/li\u003e\n\u003cli\u003eCelikoglu, M., et al., \u003cem\u003eComparison of pharyngeal airway volume among different vertical skeletal patterns: a cone-beam computed tomography study.\u003c/em\u003e The Angle Orthodontist, 2014. \u003cstrong\u003e84\u003c/strong\u003e(5): p. 782-787.\u003c/li\u003e\n\u003cli\u003eMei, Y.S., et al., \u003cem\u003eGender and age effects on dental and palatal arch dimensions among full siblings.\u003c/em\u003e Journal of Oral Science, 2023. \u003cstrong\u003e65\u003c/strong\u003e(4): p. 237-242.\u003c/li\u003e\n\u003cli\u003eFaul, F., et al., \u003cem\u003eG*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences.\u003c/em\u003e Behav Res Methods, 2007. \u003cstrong\u003e39\u003c/strong\u003e(2): p. 175-91.\u003c/li\u003e\n\u003cli\u003eScarfe, W.C. and A.G. Farman, \u003cem\u003eWhat is cone-beam CT and how does it work?\u003c/em\u003e Dent Clin North Am, 2008. \u003cstrong\u003e52\u003c/strong\u003e(4): p. 707-30, v.\u003c/li\u003e\n\u003cli\u003eKoo, T.K. and M.Y. Li, \u003cem\u003eA Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research.\u003c/em\u003e J Chiropr Med, 2016. \u003cstrong\u003e15\u003c/strong\u003e(2): p. 155-63.\u003c/li\u003e\n\u003cli\u003eBaka, Z.M. and M. Fidanboy, \u003cem\u003ePharyngeal airway, hyoid bone, and soft palate changes after Class II treatment with Twin-block and Forsus appliances during the postpeak growth period.\u003c/em\u003e American Journal of Orthodontics Dentofacial Orthopedics, 2021. \u003cstrong\u003e159\u003c/strong\u003e(2): p. 148-157.\u003c/li\u003e\n\u003cli\u003e\u0026Ccedil;oban B\u0026uuml;y\u0026uuml;kbayraktar, Z. and H. Camcı, \u003cem\u003eDentoalveolar, skeletal, pharyngeal airway, cervical posture, hyoid bone position, and soft palate changes with Myobrace and Twin-block: a retrospective study.\u003c/em\u003e BMC Oral Health, 2023. \u003cstrong\u003e23\u003c/strong\u003e(1): p. 53.\u003c/li\u003e\n\u003cli\u003eB\u0026uuml;y\u0026uuml;k\u0026ccedil;avuş, M.H., H. Orhan, and G.J.A.\u0026Uuml;.D.H.F.D. Kocakara, \u003cem\u003eİskeletsel Sınıf I Malokl\u0026uuml;zyona Sahip Hastaların Farengeal Havayolu Boyutları ve Hyoid Kemik Pozisyonunun Cinsiyete G\u0026ouml;re İncelenmesi.\u003c/em\u003e Atat\u0026uuml;rk \u0026Uuml;niversitesi Diş Hekimliği Fak\u0026uuml;ltesi Dergisi, 2020. \u003cstrong\u003e30\u003c/strong\u003e(4): p. 599-606.\u003c/li\u003e\n\u003cli\u003eKim, S.-H. and S.-K. Choi, \u003cem\u003eChanges in the hyoid bone, tongue, and oropharyngeal airway space after mandibular setback surgery evaluated by cone-beam computed tomography.\u003c/em\u003e Maxillofacial Plastic Reconstructive Surgery, 2020. \u003cstrong\u003e42\u003c/strong\u003e(1): p. 27.\u003c/li\u003e\n\u003cli\u003eNainan, O., et al., \u003cem\u003eDental arch morphology as a predictor of sleep disordered breathing.\u003c/em\u003e Sleep Hypn, 2017. \u003cstrong\u003e19\u003c/strong\u003e(2): p. 30-37.\u003c/li\u003e\n\u003cli\u003eSteiner, C.C., \u003cem\u003eCephalometrics for you and me.\u003c/em\u003e American Journal of Orthodontics Dentofacial Orthopedics, 1953. \u003cstrong\u003e39\u003c/strong\u003e(10): p. 729-755.\u003c/li\u003e\n\u003cli\u003eDa Costa, E.D., et al., \u003cem\u003eCorrelation between the position of hyoid bone and subregions of the pharyngeal airway space in lateral cephalometry and cone beam computed tomography.\u003c/em\u003e The Angle Orthodontist, 2017. \u003cstrong\u003e87\u003c/strong\u003e(5): p. 688-695.\u003c/li\u003e\n\u003cli\u003eBabu, N. and P. Kohli, \u003cem\u003eCommentary: Reliability in research.\u003c/em\u003e Indian Journal of Ophthalmology, 2023. \u003cstrong\u003e71\u003c/strong\u003e(2): p. 400-401.\u003c/li\u003e\n\u003cli\u003eKollias, I. and O. Krogstad, \u003cem\u003eAdult craniofacial and pharyngeal changes-a longitudinal cephalometric study between 22 and 42 years of age. Part II: morphological uvulo-glossopharyngeal changes.\u003c/em\u003e The European Journal of Orthodontics, 1999. \u003cstrong\u003e21\u003c/strong\u003e(4): p. 345-355.\u003c/li\u003e\n\u003cli\u003eAwati, A.S., et al., \u003cem\u003eGender determination using velar morphology.\u003c/em\u003e Indian J Oral Health Res, 2020. \u003cstrong\u003e6\u003c/strong\u003e: p. 8-11.\u003c/li\u003e\n\u003cli\u003eLin, C.M., T.M. Davidson, and S. Ancoli-Israel, \u003cem\u003eGender differences in obstructive sleep apnea and treatment implications.\u003c/em\u003e Sleep medicine reviews, 2008. \u003cstrong\u003e12\u003c/strong\u003e(6): p. 481-496.\u003c/li\u003e\n\u003cli\u003eChalkoo, A.H., et al., \u003cem\u003eMorphological varieties of soft palate in normal subjects: a digital cephalometric study.\u003c/em\u003e Indian J. Dent. Adv, 2015. \u003cstrong\u003e7\u003c/strong\u003e(4): p. 241-245.\u003c/li\u003e\n\u003cli\u003eDeepa, V. and B. Ramnarayan, \u003cem\u003eMorphological varieties of soft palate in normal individuals, cleft palate patients and obstructive sleep apnea patients with reference to Indian population: a preliminary digital cephalometric study.\u003c/em\u003e World Journal of Dentistry, 2015. \u003cstrong\u003e4\u003c/strong\u003e(4): p. 241-249.\u003c/li\u003e\n\u003cli\u003eVerma, P., et al., \u003cem\u003eCorrelation of morphological variants of the soft palate and Need\u0026apos;s ratio in normal individuals: A digital cephalometric study.\u003c/em\u003e Imaging science in dentistry, 2014. \u003cstrong\u003e44\u003c/strong\u003e(3): p. 193-198.\u003c/li\u003e\n\u003cli\u003eJayaprakash, P.K., et al., \u003cem\u003eCorrelation of soft palate morphology to growth pattern: A retrospective cephalometric study.\u003c/em\u003e Journal of family medicine primary care, 2019. \u003cstrong\u003e8\u003c/strong\u003e(7): p. 2468-2472.\u003c/li\u003e\n\u003cli\u003eNagaraj, T., et al., \u003cem\u003eA radiographic assessment of morphologies of soft palate: A retrospective study.\u003c/em\u003e Journal of Medicine, Radiology, Pathology Surgery, 2016. \u003cstrong\u003e3\u003c/strong\u003e(5): p. 1-4.\u003c/li\u003e\n\u003cli\u003eCrowley, J.S., et al., \u003cem\u003eSpeech and audiology outcomes after single-stage versus early 2-stage cleft palate repair.\u003c/em\u003e Annals of plastic surgery, 2021. \u003cstrong\u003e86\u003c/strong\u003e(5S): p. S360-S366.\u003c/li\u003e\n\u003cli\u003eJena, A.K., S.P. Singh, and A.K. Utreja, \u003cem\u003eSagittal mandibular development effects on the dimensions of the awake pharyngeal airway passage.\u003c/em\u003e The Angle Orthodontist, 2010. \u003cstrong\u003e80\u003c/strong\u003e(6): p. 1061-1067.\u003c/li\u003e\n\u003cli\u003ePaoloni, V., et al., \u003cem\u003eEvaluation of the morphometric covariation between palatal and craniofacial skeletal morphology in class III malocclusion growing subjects.\u003c/em\u003e BMC Oral Health 2020. \u003cstrong\u003e20\u003c/strong\u003e(1): p. 152.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;naydın, \u0026Ccedil;., \u003cem\u003eNazo-oro-farengeal hava yolu boyutlarının farklı malokl\u0026uuml;zyonlarda gelişiminin longitudinal olarak incelenmesi\u003c/em\u003e. 2015, Ankara Universitesi (Turkey).\u003c/li\u003e\n\u003cli\u003eMatsuo, K., et al., \u003cem\u003eEffects of respiration on soft palate movement in feeding.\u003c/em\u003e Journal of dental research, 2010. \u003cstrong\u003e89\u003c/strong\u003e(12): p. 1401-1406.\u003c/li\u003e\n\u003cli\u003eBakor, S.F., et al., \u003cem\u003eCraniofacial growth variations in nasal-breathing, oral-breathing, and tracheotomized children.\u003c/em\u003e American journal of orthodontics dentofacial orthopedics, 2011. \u003cstrong\u003e140\u003c/strong\u003e(4): p. 486-492.\u003c/li\u003e\n\u003cli\u003eAbraham, J., et al., \u003cem\u003eEvaluation of Tongue Volume and Airway Volume in Skeletal Class I and Class II Patients using Cone Beam Computed Tomography\u0026mdash;A Cross Sectional Study.\u003c/em\u003e Dentistry, 2023. \u003cstrong\u003e3000\u003c/strong\u003e(1): p. a001.\u003c/li\u003e\n\u003cli\u003eNakao, Y., et al., \u003cem\u003eAge-related composition changes in swallowing-related muscles: a Dixon MRI study.\u003c/em\u003e Aging Clinical Experimental Research, 2021. \u003cstrong\u003e33\u003c/strong\u003e(12): p. 3205-3213.\u003c/li\u003e\n\u003cli\u003eBeghini, M., et al., \u003cem\u003eMorphometric analysis of tongue in individuals of European and African ancestry.\u003c/em\u003e Journal of Forensic Investigation, 2017. \u003cstrong\u003e5\u003c/strong\u003e(1): p. 2330-0396.1000038.\u003c/li\u003e\n\u003cli\u003eRana, S., O. Kharbanda, and B. Agarwal, \u003cem\u003eInfluence of tongue volume, oral cavity volume and their ratio on upper airway: A cone beam computed tomography study.\u003c/em\u003e Journal of Oral Biology Craniofacial Research, 2020. \u003cstrong\u003e10\u003c/strong\u003e(2): p. 110-117.\u003c/li\u003e\n\u003cli\u003eAzev\u0026ecirc;do, M.S., et al., \u003cem\u003eEvaluation of upper airways after bimaxillary orthognathic surgery in patients with skeletal Class III pattern using cone-beam computed tomography.\u003c/em\u003e Dental press journal of orthodontics, 2016. \u003cstrong\u003e21\u003c/strong\u003e(1): p. 34-41.\u003c/li\u003e\n\u003cli\u003eEngelke, W., K. Jung, and M. Kn\u0026ouml;sel, \u003cem\u003eIntra-oral compartment pressures: a biofunctional model and experimental measurements under different conditions of posture.\u003c/em\u003e Clinical Oral Investigations, 2011. \u003cstrong\u003e15\u003c/strong\u003e(2): p. 165-176.\u003c/li\u003e\n\u003cli\u003e\u0026Scaron;idlauskienė, M., et al., \u003cem\u003eGenetic and environmental impact on variation in the palatal dimensions in permanent dentition: a twin study.\u003c/em\u003e Scientific Reports, 2024. \u003cstrong\u003e14\u003c/strong\u003e(1): p. 19785.\u003c/li\u003e\n\u003cli\u003eAraby, Y.A., et al., \u003cem\u003eMorphometric analysis of the hard palate using cone beam computed tomography in a Saudi population.\u003c/em\u003e The Saudi Dental Journal, 2023. \u003cstrong\u003e35\u003c/strong\u003e(3): p. 270-274.\u003c/li\u003e\n\u003cli\u003eEslami Amirabadi, G., et al., \u003cem\u003ePalatal dimensions at different stages of dentition in 5 to 18-year-old Iranian children and adolescent with normal occlusion.\u003c/em\u003e BMC Oral Health, 2018. \u003cstrong\u003e18\u003c/strong\u003e(1): p. 87.\u003c/li\u003e\n\u003cli\u003eKairalla, S.A., et al., \u003cem\u003eEvaluation of palatal dimensions in different facial patterns by using digital dental casts.\u003c/em\u003e Dental Press Journal of Orthodontics, 2022. \u003cstrong\u003e27\u003c/strong\u003e(05): p. e222115.\u003c/li\u003e\n\u003cli\u003eSaadeh, M.E. and J.G. Ghafari, \u003cem\u003eUniformity of palatal volume and surface area in various malocclusions.\u003c/em\u003e Orthodontics Craniofacial Research, 2023. \u003cstrong\u003e26\u003c/strong\u003e(1): p. 72-80.\u003c/li\u003e\n\u003cli\u003eLione, R., et al., \u003cem\u003ePalatal surface and volume in mouth-breathing subjects evaluated with three-dimensional analysis of digital dental casts\u0026mdash;a controlled study.\u003c/em\u003e European Journal of Orthodontics, 2015. \u003cstrong\u003e37\u003c/strong\u003e(1): p. 101-104.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Angle's Classification, breathing, cone beam tomography, tongue, soft palate, anova","lastPublishedDoi":"10.21203/rs.3.rs-9101919/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9101919/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the influence of skeletal class, breathing mode, age, and sex on the morphometric and volumetric features of the soft palate, tongue, and palatal height using cone-beam computed tomography(CBCT).\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eA total of 560 CBCT scans (295 females, 265 males; aged 8\u0026ndash;73 years) were retrospectively analyzed. Soft palate length, width, angle, and volume; tongue height, width, area, and volume; and palatal height values were measured using Dolphin 3D software. Participants were categorized by skeletal class (I, II, III), breathing pattern (nasal/oral), and age group. Data were analyzed using robust three-way ANOVA and Bonferroni post hoc tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn females, soft palate length (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), width (p\u0026thinsp;=\u0026thinsp;0.002), and volume (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) showed significant age-related differences. Additional differences were found in soft palate width by breathing type (p\u0026thinsp;=\u0026thinsp;0.041) and skeletal pattern (p\u0026thinsp;=\u0026thinsp;0.004), as well as in tongue height (p\u0026thinsp;=\u0026thinsp;0.024), tongue volume (p\u0026thinsp;=\u0026thinsp;0.017), and tongue area (p\u0026thinsp;=\u0026thinsp;0.033). In males, age significantly affected soft palate length (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), tongue length (p\u0026thinsp;=\u0026thinsp;0.036), tongue volume (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and tongue area (p\u0026thinsp;=\u0026thinsp;0.004), with a notable breathing\u0026ndash;skeletal interaction for soft palate length (p\u0026thinsp;=\u0026thinsp;0.029). Palatal height was significantly influenced by breathing type in females (p\u0026thinsp;=\u0026thinsp;0.04) and by both age (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and breathing type in males (p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAge, sex, breathing and skeletal patterns significantly influence soft palate, tongue, and palatal height morphology.\u003c/p\u003e\u003ch2\u003eClinical Relevance:\u003c/h2\u003e \u003cp\u003eFrom a clinical standpoint; incorporating these parameters into orthodontic and surgical planning may help anticipate airway changes associated with growth, breathing habits, and skeletal discrepancies.\u003c/p\u003e","manuscriptTitle":"CBCT-Based Morphometric and Volumetric Assessment of the Tongue, Soft Palate, and Palatal Height in Relation to Skeletal Class and Breathing Pattern","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 14:26:24","doi":"10.21203/rs.3.rs-9101919/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-12T15:30:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108187832633925431554260753205797601493","date":"2026-04-22T13:22:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-19T21:03:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-19T06:15:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-19T06:15:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Clinical Oral Investigations","date":"2026-03-12T07:58:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bee61c8f-6194-4aa1-be54-7102d52dd309","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-12T15:30:22+00:00","index":31,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T14:26:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 14:26:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9101919","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9101919","identity":"rs-9101919","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}