Review Article 1, Issue 13.3
Craniofacial Cephalometric Analysis Parameters Predictive of Obstructive Sleep Apnea in Children and Adolescents: A Systematic Review
http://dx.doi.org/10.15331/jdsm.7456Nazila Ameli, DDS, MSc, PhD1; Nathalia Fernandes Fagundes, DDS, PhD1; Manuel Lagravere, DDS, MSc, PhD1; Susana Falardo, DMD, MSc, PhD2
1Mike Petryk School of Dentistry, University of Alberta, Edmonton, AB, Canada; 2Catholic Medical School. Universidade Católica Portuguesa. Centre for Interdisciplinary Research in Health - Catholic Med, Universidade Católica Portugal. Scientific Co-worker PhD at VUB-Vrij Universiteit Brussel, Belgium
ABSTRACT
Objectives:
Obstructive sleep apnea (OSA) is increasingly prevalent. Beyond adeno tonsillar hypertrophy and obesity, craniofacial morphology may influence airway patency. This systematic review examined cephalometric parameters predicting presence and severity of pediatric OSA.Methods:
This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Observational studies assessing cephalometric parameters in participants 18 years or younger with OSA confirmed by polysomnography or validated polygraphy were eligible. Studies were selected through database and gray literature searches. Data were extracted, and the risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklists.
Results:
Of 4,199 records screened, 5 studies met the inclusion criteria. OSA was consistently associated with vertical craniofacial growth patterns (increased mandibular plane angle, anterior facial height), mandibular retrusion, inferior hyoid positioning, and reduced airway dimensions. The adenoid-to-nasopharynx ratio also correlated with OSA severity in children. Risk of bias assessment indicated two studies were low risk, whereas three were flagged “include with caution” due to limited reporting of confounders, calibration, and assessor blinding.
Conclusions:
Cephalometric features, including vertical growth, mandibular retrusion, inferior hyoid, and narrowed airway, may help dentists screen and triage children and adolescents at high risk for OSA, supporting early referral and interdisciplinary care.
Keywords:
Obstructive sleep apnea, Children, Cephalometric analysis, Adolescents
Citation:
Ameli, N, Fernandes Fagundes N, Lagravere M, Falardo S. Craniofacial Cephalometric Analysis Parameters Predictive of Obstructive Sleep Apnea in Children and Adolescents: A Systematic Review. J Dent Sleep Med. 2026;13(3).
INTRODUCTION
Pediatric obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by recurrent partial or complete upper airway obstruction during sleep, leading to intermittent hypoxemia, sleep fragmentation, and daytime sequelae affecting behavior, neurocognition, and cardiometabolic health.1, 2 The prevalence of OSA was reported between 0.7% to 5% in the general pediatric population.3, 4 Based on a recent systematic review, among preschoolers, there is a trend suggesting a possible increase in the prevalence of OSA over the past decade, underscoring the clinical importance of timely identification and management.3
The pathophysiology of pediatric OSA is multifactorial. Adeno tonsillar hypertrophy and obesity are well-recognized contributors, but craniofacial morphology and upper airway soft-tissue relationships also play a substantial role.5-7 In children and adolescents, prior syntheses have highlighted associations between OSA and features such as vertical growth tendency, mandibular retrognathia, inferior hyoid position, increased soft palate length, and reduced posterior airway dimensions, although reported effect sizes and specific landmarks vary across studies.8
Polysomnography (PSG) is the gold standard for diagnosing sleep-related breathing disorders, which include OSA, but it does not indicate the exact site of airflow obstruction.9 PSG records variables such as electroencephalogram, electrooculogram, and electromyography of the suprahyoid and masseter muscles, electrocardiogram, airflow, oxygen saturation and heart rate.10
Lateral cephalometry is widely available in dental and orthodontic practice and offers standardized, reproducible measurements of craniofacial and upper airway anatomy. Pediatric studies have reported relationships between OSA severity and measures including the mandibular plane angle (SN-MP), hyoid position (MP-H, C3-H, Sella-hyoid), soft palate length (PNS-P), and airway caliber (posterior airway space/minimal pharyngeal airway).11-13 These markers, alone or in combination, may help triage symptomatic children and adolescents for a full diagnostic assessment for OSA, including a nocturnal PSG examination.
Despite multiple reviews, the pediatric literature remains heterogeneous in age ranges, dentofacial growth stages, reference standards for OSA, and cephalometric panels reported. A 2022 systematic review and meta-analysis broadly synthesized craniofacial features in pediatric OSA,8 whereas a 2024 meta-analysis focused specifically on cephalometry as a diagnostic aid, both reinforcing the potential value of cephalometric assessment while also emphasizing variability in methods and outcomes.14 This heterogeneity limits direct clinical translation and motivates focused appraisal of which specific cephalometric parameters show the most consistent associations with pediatric OSA presence or severity.
Therefore, this systematic review aims to identify and synthesize cephalometric parameters that are predictive of OSA in children and adolescents, to clarify which skeletal and soft-tissue measurements demonstrate the most consistent, clinically meaningful associations, and to inform targeted referral for sleep testing and multidisciplinary management.
METHODS
Protocol and Registration
This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.15 The study protocol was developed and registered in Prospero with the ID number of CRD42023493280.
Eligibility Criteria
This review addressed the question: Which craniofacial cephalometric parameters, if any, are predictive of OSA in children and adolescents? The review followed the PECOs framework: Participants (P) included children and adolescents (18 years or younger) who underwent cephalometric radiography as part of a diagnostic evaluation, including skeletal, dental, and airway-related parameters (mandibular plane angle, SNA, SNB, ANB, hyoid bone position, posterior airway space, soft palate length, adenoid–nasopharynx ratio). Exposure (E) involved children or adolescents with OSA, presenting a positive diagnosis according to the American Academy of Sleep Disorders (AASM) guidelines. Comparison (C) used for comparing children and adolescents without OSA or with different severities of OSA. Outcome (O) involved the presence and/or alterations in OSA severity (assessed by apnea–hypopnea index [AHI]) and reported associations or correlations between cephalometric variables and OSA. Study types (s) included observational studies such as cross-sectional, case-control, and cohort studies that investigated the relationship between cephalometric parameters and pediatric/adolescent OSA.
The exclusion criteria were the following: (1) studies involving only adult populations (older than 18 years); (2) studies not including cephalometric analysis; (3) studies that did not confirm OSA with PSG or a validated sleep diagnostic test; (4) interventional clinical trials (for example, adenotonsillectomy outcomes without baseline cephalometry); (5) case reports, reviews, editorials, commentaries, conference abstracts, theses, or opinion pieces; (6) animal or non-human studies; (7) studies not published in English; and (8) studies for which full text was unavailable.
Information Sources and Search Strategy
An experienced health sciences librarian designed and conducted comprehensive searches in Ovid MEDLINE, Ovid Embase, Scopus, and Web of Science Core Collection on May 20, 2025. Grey literature was explored via Google Scholar by screening the top 200 results (filtered by relevance). No restrictions were applied regarding publication year. The complete search strategy is included in the supplementary Appendix A.
In addition to the electronic search, consultations with experts and hand searches of the reference lists of the selected articles were conducted. All references were imported into Covidence (Covidence systematic review software, Veritas Health Innovation, available at www.covidence.org) for deduplication and blinded screening.
Study Selection and Data Collection Process
Two reviewers (N.A. and N.F.) independently screened titles and abstracts, followed by full-text reviews for eligibility. Disagreements between the two reviewers were initially resolved by a third reviewer (M.L.). The final selections were always based on the full text of the publication.
Data extraction was conducted using a standardized spreadsheet with the following information: author, year, country, population/sample characteristics (sample size, age range, sex, body mass index [BMI], OSA severity and its diagnostic method); and cephalometric analysis (methods, landmarks, and measurements) as well as outcomes (main results and conclusion).
Risk-of-Bias Assessment
The methodologic quality of the included studies was evaluated using the Joanna Briggs Institute (JBI) critical appraisal tool for observational studies.16 Two reviewers (N.A. and N.F.) independently assessed each study against the JBI checklist items, rating each as Yes (Y), No (N), Unclear (U), or not applicable (NA). An overall appraisal was then assigned using the following categories: (1) “Include” (low risk of bias [Rob]) when most domains were rated as Y and no critical concerns were identified; (2) “Seek further information” (include with caution) when some domains were rated as N or U, raising concerns about methodological rigor or reporting; and (3) “Exclude” (high RoB) when several key domains were rated N and the study was judged unreliable. A third reviewer (M.L.) was consulted to resolve any disagreements and to ensure consensus on final judgments.
RESULTS
Study Selection
A flow diagram detailing the process of identification, inclusion, and exclusion of the studies is shown in Figure 1. The database search retrieved a total of 4,199 citations. Two thousand one hundred fifty-nine duplicates were removed, and the titles and abstracts of the remaining 2,040 studies were screened in the first phase of the review. After reading the titles and abstracts, 1,805 studies were excluded. In the second phase of the review, the full texts of 235 studies were checked and 230 were excluded due to the following reasons: studies that did not use lateral cephalograms (8 studies), no full-text available (4 studies), non-English papers (11 studies), wrong patient population (195 studies), wrong comparator (5 studies), and wrong study design (7 studies). Finally, five studies were included in the review.
Study Characteristics
The included studies were published between 2012 and 2023 and represented diverse countries (Brazil,17 Taiwan,11 Italy,12 China,18 and Armenia19). The designs comprised two case–control studies12, 19 and three cross-sectional studies.11, 17, 19
Sample sizes ranged from 41 to 317 participants.18,19 Ages covered a broad range, from preschool children (as young as 3 years) to adolescents up to 17 years. Both boys and girls were included, though only one study17 reported sex-stratified analyses.
OSA diagnosis was confirmed by overnight PSG in three studies,11, 17, 18 by validated respiratory polygraphy in the study by Manrikyan et al.,19 and by PSG plus clinical criteria in the last study.12 The AHI served as the primary diagnostic outcome, with severity thresholds varying slightly across studies.
Cephalometric assessment was performed with lateral cephalograms in all studies, and the number of parameters examined ranged from fewer than 1017 to more than 27.12 The variables assessed included: (1) skeletal angular measures (SNA, SNB, ANB, mandibular plane angle, facial depth, facial axis); (2) vertical and horizontal dimensions (anterior facial height, lower anterior facial height, posterior facial height, mandibular/maxillary unit lengths); (3) airway-related parameters (posterior airway space [PAS], minimal pharyngeal airway, Hor–PNS, R–PNS); (4) hyoid bone position indices (mandibular plane–hyoid [MP–H], AH–C3H, Sella–hyoid distance, MP-H/Go–Gn ratio); (5) soft-tissue measures (soft-palate length, tongue length); and (6) composite indices and ratios (vertical growth coefficient)17 adenoid-to-nasopharynx ratio.11
All studies applied standard cephalometric tracing methods. However, only two studies12, 18 explicitly reported examiner calibration or reliability testing of landmark identification, whereas others did not specify. In addition, only one study17 specified the use of a defined cephalometric analysis method (Ricketts analysis), whereas the remaining studies did not clearly report which cephalometric analysis framework was applied. The detailed summary of the study characteristics, population evaluated, cephalometric analysis used, and outcomes is provided in Table 1.
RoB and Applicability
The findings showed that the two case–control studies were generally well conducted. The study by Perillo et al.12 was rated “Include” (low RoB), with clear case and control definitions, standardized cephalometric measures, and appropriate statistical analysis (Figure 2). Another study conducted by Feng et al.18 was rated “Seek further information” because of concerns about matching of groups, incomplete handling of confounders such as adeno tonsillar hypertrophy and BMI, and unclear blinding of outcome assessment.
Among the cross-sectional studies, the study by Di Francesco et al.17 was judged “Include” (low RoB), reflecting well-defined participants, use of PSG, and consistent cephalometric methods. Studies by Manrikyan et al.19 and Chiang et al.11 were rated “Seek further information” because they provided insufficient detail on recruitment procedures, confounding factors, and assessor blinding, although their outcome measures and analyses were sound.
No study was excluded. Overall, two studies were deemed low risk of bias and three were included with caution. Applicability was judged to be moderate to high, because all studies involved pediatric or adolescent populations with OSA diagnosed by PSG or validated polygraphy, and all used cephalometry as the index assessment. Variation in age ranges, ethnicities, and cephalometric protocols limits direct comparability but does not undermine the clinical relevance of findings.
Figure 1.
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Table 1.
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Figure 2.
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Results of Individual Studies
Case–Control Studies
In the large case–control study by Feng et al. in China,18 children with OSA were compared with mouth breathing children and healthy control patients. The OSA group demonstrated skeletal discrepancies including decreased SNB, increased ANB, and a steeper mandibular plane angle (SN-MP). Airway measurements such as Hor-PNS and R-PNS were significantly smaller in children with OSA, reflecting a constricted nasopharyngeal space. Dentoalveolar parameters such as U1-NA inclination also differed, with children with OSA showing intermediate values between mouth-breathing and control groups. These findings suggest that pediatric OSA is associated with both skeletal disharmony and reduced nasopharyngeal dimensions, and that dentoalveolar adaptations may also contribute.
In the second case-control study conducted by Perillo et al.,12 27 linear and angular measurements were assessed. Children with OSA showed increased anterior and lower facial heights, a steeper mandibular plane inclination, and inferior hyoid displacement (greater hyoid-mandibular/Sella distances) compared with control patients. Both the maxilla and mandible were retro positioned relative to the cranial base, and nasopharyngeal depth was significantly reduced. These findings suggest a vertical craniofacial pattern, posterior positioning of the jaws, inferior hyoid bone, and narrowed nasopharyngeal airway as distinctive features of pediatric OSA.
Cross-Sectional Studies
The study by Di Francesco et al.17 investigated associations between craniofacial morphology and OSA severity measured by PSG. In boys, significant correlations were observed between facial depth, mandibular plane angle, and the vertical growth coefficient and AHI; however, no such associations were found in girls. The results suggested that a dolichocephalic growth pattern, steep mandibular plane, and reduced facial depth are predictive of OSA in boys, highlighting possible sex-related differences in craniofacial risk markers.
Using partial correlation analyses, Chiang et al.11 identified four cephalometric parameters among 21 studied parameters significantly associated with AHI (P< 0.05): Gn-Go-H angle, mandibular plane to hyoid distance (MP-H), MP-H/Go-Gn ratio, and the adenoid-to-nasopharynx ratio. These results demonstrated that both skeletal morphology (mandibular plane inclination, gonial angle) and soft tissue/airway variables (hyoid position, adenoidal hypertrophy) contributed to OSA severity in children.
In the adolescent cohort study conducted by Manrikyan et al.,19 OSA was associated with retrognathic mandibles (low SNB, high ANB), increased maxillomandibular plane angle, and inferior hyoid bone position (AH-C3H, MP-H). Airway dimensions, including PAS1-PAS3 and PAS min, were reduced in patients with OSA compared with reference values, suggesting pharyngeal airway compromise. Dentoalveolar findings also showed increased overjet and overbite, and adeno tonsillar hypertrophy was frequently observed. These findings emphasized that in adolescents, skeletal retrusion, vertical growth patterns, and airway narrowing play a central role in OSA pathophysiology.
DISCUSSION
This systematic review synthesized evidence from five observational studies published between 2012 and 2023 that investigated the relationship between craniofacial cephalometric parameters and pediatric OSA. Despite heterogeneity in study design, populations, and cephalometric variables examined, several consistent patterns emerged. Across both case–control and cross-sectional studies, pediatric and adolescent OSA was most associated with a vertical craniofacial growth pattern, retrognathic skeletal features, inferior hyoid bone positioning, and reduced upper airway dimensions, with additional contributions from adenoidal hypertrophy and soft palate elongation.11, 12, 17-19
The findings of this review demonstrate that specific cephalometric markers are recurrently linked with the presence and/or severity of pediatric OSA. Increased mandibular plane angle (SN-MP) and greater anterior and lower facial height were reported in multiple studies, consistent with a vertical skeletal pattern.12, 17 Retro positioned mandible and class II maxillomandibular relationship, reflected by decreased SNB and increased ANB, were observed in both case–control studies and in adolescents with OSA.18, 19 Measures of hyoid bone position, such as MP-H, AH-C3H, and related ratios, were consistently associated with OSA severity,11, 12, 19 underscoring the role of tongue and suprahyoid musculature in airway stability during sleep. Reduced posterior airway space and constricted nasopharyngeal dimensions, such as Hor–PNS, R–PNS, and PAS min, were also significant in several studies,18, 19 whereas the adenoid-to-nasopharynx ratio emerged as an additional marker of severity.17 These findings are consistent with earlier observations by Guilleminault et al.,20 who linked mandibular morphology and growth patterns to pediatric airway obstruction, and Jo et al.,21 who demonstrated that hyoid bone descent correlates with OSA severity. These findings highlight that both skeletal morphology and soft-tissue factors contribute to airway patency and OSA risk in growing individuals.
An important consideration in interpreting the findings of this review is the methodologic quality of the included studies. Using the JBI critical appraisal tools, two studies12, 17 were rated as having a low risk of bias, whereas the remaining three11, 18, 19 were judged to include with caution. The main concerns were limited reporting of participant recruitment methods, lack of clarity on blinding of cephalometric assessors, inconsistent control of confounders such as BMI and adenotonsillar hypertrophy, and absence of explicit examiner calibration in most studies. Only one study specified the cephalometric analysis framework used (Ricketts analysis),17 further limiting comparability across reports. These factors underscore the need for more rigorous study designs, standardized reporting, and quality assurance measures in future research to strengthen confidence in the associations observed.
Interestingly, one study reported sex-specific differences, with correlations between craniofacial features and OSA severity significant in boys but not in girls.17 Although this observation was based on a relatively small sample, it suggests that craniofacial risk markers may interact with sex-related growth patterns or airway physiology in childhood, an area that warrants further investigation. This aligns with findings from Schwarz et al.22 and Bonsignore et al.,23 who reported sex differences and noted differences in airway collapsibility thresholds between boys and girls.
The results of this review are consistent with recent systematic reviews and meta-analyses that have identified vertical maxillomandibular relationships, mandibular retrusion, inferior hyoid positioning, and reduced airway dimensions as characteristic of pediatric OSA.8, 14 Narrative reviews have further emphasized the complex interplay between skeletal morphology, adeno-tonsillar hypertrophy, obesity, and soft-tissue growth, which may explain the variability observed across studies. Additional work by Galeotti et al.24 and Xu et al.25 also reinforces that soft palate elongation and upper airway narrowing might represent parameters suggestive of high risk of OSA in children and adolescents.
From a clinical standpoint, PSG remains the gold standard for diagnosis of OSA in children, but it does not identify the anatomic site of obstruction. Lateral cephalometry, although limited to two-dimensional assessment, is widely available in orthodontic and pediatric dental practice. The parameters consistently associated with OSA in this review, vertical growth pattern, retrognathia, inferior hyoid bone, and narrowed upper airway dimensions, may therefore serve as useful adjunctive indicators for identifying children and adolescents at a high risk for OSA.
For orthodontists and pediatric dentists, awareness of these cephalometric features could enhance timely recognition of children at high risk of OSA and improve interdisciplinary collaboration with sleep medicine and otolaryngology specialists. However, cephalometry should not be considered a diagnostic test for OSA; rather, it is best used as a screening or risk stratification tool that complements clinical history, adeno-tonsillar evaluation, and BMI assessment. This review has significant methodologic strengths, including adherence to PRISMA guidelines, and the development of a wide search strategy, including studies from diverse geographic regions, enhancing generalizability. Nonetheless, limitations must be acknowledged. Only five studies met the eligibility criteria, restricting the evidence base and precluding meta-analysis. There was notable heterogeneity in cephalometric variables measured, methods of analysis, and OSA severity thresholds. Only two studies explicitly reported examiner calibration for cephalometric landmark tracing, and only one specified the use of a defined analysis method, raising concerns about measurement reliability. Potential confounders such as BMI, pubertal stage, and adeno-tonsillar hypertrophy were inconsistently addressed, and most studies were hospital based, which may limit applicability to community populations. Furthermore, Liu et al.26 demonstrated that three-dimensional imaging after adenotonsillectomy reveals volumetric changes in the airway not captured by lateral cephalometry, highlighting the limitations of two-dimensional methods.
Future research should aim for large-scale, prospective cohort studies, which are needed to clarify causal relationships between craniofacial morphology and OSA development across growth stages. Additionally, the standardization of cephalometric protocols in pediatric OSA studies, ideally including a core set of skeletal, airway, and soft-tissue parameters would be beneficial to facilitate the development of a craniofacial-based assessment among children and adolescents. Reliability testing of landmark identification should be routinely reported.
CONCLUSION
This systematic review identified consistent craniofacial cephalometric features associated with pediatric OSA, including vertical skeletal growth patterns, mandibular retrusion, inferior hyoid bone positioning, and reduced airway dimensions. These markers, although not diagnostic in isolation, may serve as valuable adjunctive indicators for early identification and referral of at-risk children and adolescents for PSG and multidisciplinary evaluation. The evidence highlights the potential role of cephalometry in screening and risk stratification within dental and orthodontic practice, but methodologic heterogeneity, small study numbers, and limited standardization restrict direct clinical translation.
REFERENCES
Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012 Sep;130(3):576-84. doi: 10.1542/peds.2012-1671.
Esposito S, Ricci G, Gobbi R, et al. Diagnostic and Therapeutic approach to children and adolescents with obstructive sleep apnea syndrome (OSA): recommendations in Emilia-Romagna Region, Italy. Life (Basel). 2022 May 16;12(5):739. doi: 10.3390/life12050739.
Magnusdottir S, Hill EA. Prevalence of obstructive sleep apnea (OSA) among preschool aged children in the general population: a systematic review. Sleep Med Rev. 2024 Feb; 73:101871. doi: 10.1016/j.smrv.2023.101871.
Bixler EO, Vgontzas AN, Lin HM, et al. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009 Jun;32(6):731-6. doi: 10.1093/sleep/32.6.731. PMID: 19544748; PMCID: PMC2690559.
Huynh N, Zhang J, Pliska B, et al. Prevalence of Altered craniofacial Morphology in Children With OSA. J Sleep Res. 2025 Apr 17:e70060. doi: 10.1111/jsr.70060.
Kang KT, Chou CH, Weng WC, Lee PL, Hsu WC. Associations between adenotonsillar hypertrophy, age, and obesity in children with obstructive sleep apnea. PLoS One. 2013 Oct 25;8(10):e78666. doi: 10.1371/journal.pone.0078666.
Hakim F, Kheirandish-Gozal L, Gozal D. Obesity and Altered Sleep: A Pathway to Metabolic Derangements in Children? Semin Pediatr Neurol. 2015 Jun;22(2):77-85. doi: 10.1016/j.spen.2015.04.006.
Fagundes NCF, Gianoni-Capenakas S, Heo G, Flores-Mir C. Craniofacial features in children with obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med. 2022;18(7):1865–1875.
Rundo JV, Downey R 3rd. Polysomnography. Handb Clin Neurol. 2019;160:381-392. doi: 10.1016/B978-0-444-64032-1.00025-4.
Rundell OH, Jones RK. Polysomnography methods and interpretations. Otolaryngol Clin North Am. 1990;23(4):583–92.
Ping-Ying Chiang R, Lin CM, Powell N, Chiang YC, Tsai YJ. Systematic analysis of cephalometry in obstructive sleep apnea in Asian children. Laryngoscope. 2012 Aug;122(8):1867-72. doi: 10.1002/lary.23297.
Perillo L, Cappabianca S, Montemarano M, et al. Morfologia craniofacciale e sindrome delle apnee-ipopnee ostruttive nel sonno: un'analisi craniometrica comparativa [Craniofacial morphology and obstructive sleep apnoea-hypopnoea syndrome: a craniometric comparative analysis]. Radiol Med. 2013 Jun;118(4):648-59. Italian. doi: 10.1007/s11547-012-0904-9.
Xu L, Keenan BT, Wiemken AS, Staley B, Benediktsdottir B, Juliusson S, Pack AI, Gislason T, Schwab RJ. et al. The Relationship between and in with. Ann Am Thorac Soc. 2025 Jun 16. doi: 10.1513/AnnalsATS.202410-1027OC.
S S, Shetty V, Priya K, Saha S, Jaswanth J, Sethi S. Cephalometry as an aid in the diagnosis of pediatric obstructive sleep apnoea: A systematic review and meta-analysis. J Oral Biol Craniofac Res. 2024 Sep-Oct;14(5):512-521. doi: 10.1016/j.jobcr.2024.06.007.
Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. doi: 10.1136/bmj.n71.
Moola S, Munn Z, Tufanaru C, et al. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. JBI; 2020. Available from: https://synthesismanual.jbi.global
Di Francesco R, Monteiro R, Paulo ML, Buranello F, Imamura R. Craniofacial morphology and sleep apnea in children with obstructed upper airways: differences between genders. Sleep Med. 2012 Jun;13(6):616-20. doi: 10.1016/j.sleep.2011.12.011.
Feng G, Gong X, Yu M, Huang X, Gao X. Differences of craniofacial characteristics in oral breathing and pediatric obstructive sleep apnea. J Craniofac Surg. 2021 Mar-Apr 01;32(2):564-568. doi: 10.1097/SCS.0000000000006957.
Manrikyan GE, Vardanyan IF, Markaryan MM, et al. Association between the obstructive sleep apnea and cephalometric parameters in teenagers. J Clin Med. 2023 Oct 30;12(21):6851. doi: 10.3390/jcm12216851.
Guilleminault C, Eldridge FL, Tilkian A, Simmons FB, Dement WC. Sleep apnea syndrome due to upper airway obstruction: a review of 25 cases. Arch Intern Med. 1977 Mar;137(3):296-300. PMID: 557314
Jo JH, Park JW, Jang JH, Chung JW. Hyoid bone position as an indicator of severe obstructive sleep apnea. BMC Pulm Med. 2022 Sep 16;22(1):349. doi: 10.1186/s12890-022-02146-0.
Schwarz EI, Schiza S. Sex differences in sleep and sleep-disordered breathing. Curr Opin Pulm Med. 2024 Nov 1;30(6):593-599. doi: 10.1097/MCP.0000000000001116.
Bonsignore MR, Saaresranta T, Riha RL. Sex differences in obstructive sleep apnoea. Eur Respir Rev. 2019 Nov 6;28(154):190030. doi: 10.1183/16000617.0030-2019.
Galeotti A, Festa P, Viarani V, et al. Correlation between cephalometric variables and obstructive sleep apnoea severity in children. Eur J Paediatr Dent. 2019 Mar;20(1):43-47. doi: 10.23804/ejpd.2019.20.01.09.
Xu Q, Wang X, Li N, Wang Y, Xu X, Guo J. Craniofacial and upper airway morphological characteristics associated with the presence and severity of obstructive sleep apnea in Chinese children. Front Pediatr. 2023 Mar 31;11:1124610. doi: 10.3389/fped.2023.1124610. Erratum in: Front Pediatr. 2023 Jun 09;11:1208674. doi: 10.3389/fped.2023.1208674.
Liu CN, Kang KT, Yao CJ, et al. Changes in cone-beam computed tomography pediatric airway measurements after adenotonsillectomy in patients with OSA. JAMA Otolaryngol Head Neck Surg. 2022 Jul 1;148(7):621-629. doi: 10.1001/jamaoto.2022.0925.
SUBMISSION & CORRESPONDENCE INFORMATION
Submitted September 25, 2025
Submitted in final revised form March 1, 2026
Accepted for publication April 7, 2026
DISCLOSURE STATEMENT
Financial Support: No external financial support was received for the preparation of this manuscript.
Off-label or Investigational Use: No off-label or investigational use of products is reported in this work.
Conflict of Interest: All authors declare no conflicts of interest. None of the authors have any financial interests, commercial affiliations, personal relationships, or academic competition that could be perceived as influencing the content, conclusions, or interpretations of this manuscript.