Evalua&on of Tongue Volume and Airway Volume in Skeletal Class I and Class II Pa&ents using Cone Beam Tomography- A Cross 
Sec&onal Study 

  
 

Vol 11 No 1 (2023)    DOI 10.5195/d3000.2023.245 

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Evaluation of Tongue Volume and Airway Volume in Skeletal 
Class I and Class II Patients using Cone Beam Computed 
Tomography- A Cross Sectional Study 
 
Jim Thomas Abraham1, Roshan M Sagarkar2, Sharanya Sabrish2, Prashantha Govinakovi Shivamurthy3, Silju Ma<hew2, 
Nagaraju Rakesh4 

 

1Faculty of Dental Sciences, M S Ramaiah University of Applied Sciences, MSRIT Post, M S R Nagar, Bengaluru, Karnataka, India. Pin 560054 
2Department of Orthodontics, Faculty of Dental Sciences, M S Ramaiah University of Applied Sciences, MSRIT Post, M S R Nagar, Bengaluru, 
Karnataka, India. Pin 560054 
3Head of Department of Orthodontics, Faculty of Dental Sciences, M S Ramaiah University of Applied Sciences, MSRIT Post, M S R Nagar, Bengaluru, 
Karnataka, India. Pin 560054 
4Department of Oral Medicine and Radiology, Faculty of Dental Sciences, M S Ramaiah University of Applied Sciences, MSRIT Post, M S R Nagar, 
Bengaluru, Karnataka, India. Pin 560054

Abstract 

BACKGROUND: The volumetric rela&onship between the tongue and the oral cavity is an 
important factor in tooth alignment and occlusion. The aim of this study was to evaluate 
the difference in tongue and airway volume in skeletal Class I and Class II malocclusion. 
MATERIALS AND METHODS: The CBCT data which comprised of 30 skeletal Class I and 30 
skeletal Class II was stored in DICOM format. Tongue volume and airway volume was 
analyzed with the help of 3D dolphin soKware. Values obtained were subjected to 
sta&s&cal analysis with help of SPSS. 
RESULTS: Skeletal Class I paMern had more tongue volume with a mean of 45.32 mm3 than 
skeletal Class II paMern with mean value of 40.27 mm3 with P value of <0.001. Skeletal Class 
I paMern has more airway volume with a mean of 15058.6 mm3 than pa&ents with skeletal 
Class II paMern with mean value of 12458.8 mm3 with a P value of 0.003. A P value of 0.001 
indicated that there is a strong correla&on between the tongue volume and airway volume 
in both skeletal Class I and skeletal Class II subjects. 

 

CONCLUSION: The volume of tongue and 
airway was greater in skeletal Class I 
malocclusion compared to skeletal Class 
II malocclusion. There exists a posi&ve 
correla&on between the tongue volume 
and airway volume in both the skeletal 
paMerns. 
KEYWORDS: airway volume; Class I 
skeletal malocclusion; Class II skeletal 
malocclusion; Dolphin soKware; tongue 
volume   

Cita9on: Thomas Abraham, J et al. (2023) Evalua9on of 
Tongue Volume and Airway Volume in Skeletal Class I 
and Class II Pa9ents using Cone Beam Computed 
Tomography- A Cross Sec9onal Study 
Den9stry 3000. 1:a001 doi:10.5195/d3000.2023.245 
Received: October 5, 2021  
Accepted: April 4, 2023 
Published: October 13, 2023 
Copyright: ©2023 Thomas Abraham, J et al. This is an 
open access ar9cle licensed under a Crea9ve Commons 
AVribu9on Work 4.0 United States License. 
Email: drsharanyaortho@gmail.com

 

 

Introduction 

According to the equilibrium theory, 
teeth alignment is influenced by the 
tongue and the lip [1]. The tongue is 

a powerful muscular organ which is 
centrally located within the oral 
cavity and has the ability to affect the 
position of the teeth and the 

surrounding structures [2]. 

Abnormality of either function or 
position of tongue can lead to change 
in the surrounding dentoalveolar 

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Evalua&on of Tongue Volume and Airway Volume in Skeletal Class I and Class II Pa&ents using Cone Beam Tomography- A Cross Sec&onal Study 
  
 

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structures and skeleton. In cases of 
mandibular prognathism, the tongue 
occupies the floor of the mouth, and 
can be bulky, hypotensive, and 
projected [3]. On the other hand, 
when mandibular retrognathism 
occurs, with reduction in the 
anteroposterior space, the usual 
tongue position shows a lowered 
apex with dorsum more elevated, 
which can be located between the 
dental arches in case there is a 
concomitant maxillary retrusion [4]. 

Respiratory function and the upper 
airway are very important for 
orthodontic diagnosis and treatment 
planning as varied breathing function 
could influence facial growth and 
morphology [3,5]. Oropharyngeal and 
nasopharyngeal structures play a role 
in the development of the dentofacial 
complex [5]. According to the 
functional-matrix hypothesis 
proposed by Melvin Moss, soft-tissue 
units guide the hard tissues to an 
extent. It has also been suggested 
that an increase in the volume of soft 
tissues induces osteogenic reaction at 
the growth site of the bone [5]. 

Patient exhibiting Class II skeletal 
base tend to have smaller airway 
volume, but the tongue volume 
remains a topic of debate. There are 
2 schools of thought regarding this 
issue. The first is that the tongue 
adapts to the retrognathic mandible, 
which leads to the posterior 
positioning of tongue as well as the 
inferior and posterior displacement of 
the hyoid bone. But studies have 
shown that although the hyoid bone 

adapts to the tongue position, there 
is always a tendency for the hyoid 
bone to relapse to a superior position 
which eventually can cause narrowing 
of airway leading to obstructive sleep 
apnea in Class II skeletal base. The 
other concept regarding the same is 
that the mandible adapts to the high-
volume tongue which eventually 
leads to increase in the inter molar 
distance in Class II skeletal base [6]. 
This debate has been longstanding. 
Hence determining the size of the 
tongue in different facial 
morphological variants can be useful 
[3]. 

Dentistry has witnessed tremendous 
advances and with these advances, 
the need for use of precise diagnostic 
tools, especially imaging methods, 
has become mandatory. Cone beam 
CT technology (CBCT) has emerged as 
a potential alternative to Magnetic 
Resonance Imaging (MRI) and CT 
scanning to obtain complete, fast, 
and detailed images at a relatively 
modest cost. The advantages of CBCT 
include lower radiation dose which 
causes less radiation hazards to the 
patients [7]. Hence the present study 
was done to evaluate the tongue 
volume in skeletal Class I and Class II 
subjects and its association with the 
airway volume using CBCT. 

Material and Methods 

This cross-sectional study conducted 
using Cone Beam Computed 
Tomography scans of 60 patients. The 
scans were obtained from the patient 
archives from ORAL D SCAN center 

and from the Department of Oral 
Medicine and Radiology FDS, RUAS.  
The study protocol was approved by 
the Ethics review committee of 
Ramaiah University of Applied 
Sciences. The research project 
protocol number was EC-
2020/UG/075 and approval date was 
01/09/2020.  

The sample size was estimated using 
the G Power software v. 3.1.9.2. 
Considering the effect size to be 80%, 
power of the study at 85% and the 
margin of the error at 5%, the sample 
size needed was calculated to be 60. 

The scans which were selected for the 
study were of those patients whose 
CBCTs were made placing the patient 
in natural head position during the 
image acquiring procedure with the 
lips and tongue relaxed so that the 
borders delineating the tongue shape 
could be obtained. The patients 
whose scans were used from the 
institute archives had all given 
informed consent for their scans to 
be used for research purposes. Care 
was taken to avoid any involuntary 
movements like swallowing, which 
would have caused kinetic defects in 
CBCT slices. All the scans in the 
archives were made using the same 
machine and using Carestream 
software (Carestream 9300) with 
parameters of 6.3 mA, 90 kvp, and 
300 microns resolution with full field 
of view (FOV) of 17x13.5 cms. The age 
of the patients ranged from 14- 20 
years, and this included 39 females 
and 21 males. 

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Inclusion criteria applied for the study 
were: CBCT of male or female 
patients in the age group ranging 
between 14- 20 years, no history of 
orthodontic treatment or facial 
surgery, CBCT was taken with patient 
biting in centric occlusion and no 
enlarged tonsil or adenoids present. 
The exclusion criteria applied were: 
CBCT with bite block placed, 
Congenital anomalies like cleft lip and 
palate.  

Patients were categorized into 
skeletal Class I and Class II based on 
following cephalometric 
parameters[8, 9]: ANB value: ANB 
angle ranging from 20-40 were 
classified as Class I skeletal pattern 
and ANB value greater than 40 were 
classified as Class II skeletal pattern 
[8]. Witt’s appraisal: AO ahead of BO 
greater than 2mm was classified as 
Class II skeletal pattern [9]; Angle’s 
molar relation; Overjet: overjet of 2-
4mm was considered as skeletal Class 
I pattern and greater than 4 mm was 
considered as skeletal Class II pattern.  
60 CBCTs (30 Class I, 30 Class II) which 
fulfilled all the inclusion and exclusion 
criteria, were selected for the study. 

The CBCT data which comprised of 30 
skeletal Class I and 30 skeletal Class II 
was transferred to a computer which 
stored the data in the Digital Imaging 
and Communications in Medicine 
(DICOM) format. A 3D data and 3D 
coordinate system were constructed 
using Dolphin 3D software. (Dolphin 
software, version-11.96, Dolphin 

Imaging & Management solutions, 
Chatsworth, CA) 

The tongue volume determination 
was carried out as follows. Landmarks 
were considered both in lateral and 
transverse plane to delineate the 
borders of the tongue from the 
adjacent structures. Once the image 
in the lateral view was cropped it was 
then assessed in the transverse view 
to obtain the final 3D image. The 
obtained cropped 3D image of the 
tongue was subjected to volumetric 
analysis using 3D Dolphin software 
(version 11.96) in the computer. The 
volume of the tongue was hence 
displayed in cubic millimeters by the 
software. The boundaries considered 
in the lateral view aspect were 
(Figure 1) anterior point: Incisal point 
of maxillary incisor, Superiorly: ANS –
PNS plane, Postero-superiorly: PNS 
point, Postero-inferiorly: At the 
junction of C 2 and C 3, Inferiorly: CEJ 
level of second molar to first 
premolar.  The boundaries considered 
in the transverse plane are: (Figure 2) 
Laterally: Borders delineating the 
alveolar bone and the soft tissue, 
Posteriorly: borders delineating the 
soft tissue and the airway pathway 
(Figure 3).  

 

 

 

The airway volume determination 
was carried out as follows. To obtain 
airway volume using Dolphin 3D, it 
was required to define the outline of 
the airway. Seed points were placed 
in the target airway. Seed points 
denote densities which represents 
the airway. The volume of the airway 
was displayed in cubic millimeters. 
The boundaries of the airway: 
Superior- Superior tip of 
nasopharyngeal airway, Anterior 
border-Vertical plane through 
Posterior Nasal Spine, perpendicular 
to the sagittal plane, Posterior 
border-Posterior wall of the pharynx, 
Inferior border- Plane tangent to the 
most medial projection which is in 
the caudal aspect of the third cervical 
vertebrae at right angles to the 
sagittal plane. 

Figure 1. Boundaries marked for cropping to 
obtain the borders of the tongue from lateral 
view aspect (A); image obtained after 
cropping (B). 

Figure 2. Boundaries delineating alveolar & bone 
airway from the tongue (A); cropped 3D image (B). 

Figure 3. Boundaries delineating the airway from 
the adjacent structures. 

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Evalua&on of Tongue Volume and Airway Volume in Skeletal Class I and Class II Pa&ents using Cone Beam Tomography- A Cross Sec&onal Study 
  
 

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SPSS (SPSS Inc., Chicago v 18.5) 
software packages were used for data 
entry and analysis respectively. The 
results were averaged (mean + 
standard deviation) for continuous 
data and number and percentage was 
used for dichotomous data. The 
student ‘t’ test was used to 
determine if there was a statistical 
difference. Pearson correlation 
coefficients were calculated to 
determine if there was any 
correlation between the Tongue 
Volume and the airway volume. 

Results 

The current study consisted of 60 
CBCT samples of skeletal Class I and 
Class II subjects. Among the 60 
samples, the percentage distribution 
was 68.3% females and 31.7% males 
as shown in figure 4.  

Table 1 depicts the distribution of 
males and females in skeletal Class I 
and Class II and there was no 
statistically significant difference 
seen. Table 2 shows that the mean 
age of males and females in skeletal 
Class I case was 17.4 years and 16.9 
years respectively. P value was 0.448 

which indicates statistically 
insignificant difference. The mean age 
of males and females in skeletal Class 
II cases were 17.7 years and 18.3 
years respectively. P value was 0.420 
which indicated statistically 
insignificant difference.  

Table 3 depicts the comparison of 
mean values of Tongue Volume in 
skeletal Class I and Class II pattern. 
Patients with skeletal Class I pattern 
had a significant more tongue 
volume with a mean of 45.32 mm3 
compared to patients with skeletal 

Class II pattern who had mean value 
of 40.27mm3 respectively with p value 
of <0.001. Table 4 shows the 
comparison of mean values of Airway 
volume between skeletal Class I and 
Class II pattern. Patients with skeletal 
Class I pattern have large airway 
volume (with a mean of 15058.6 

mm3) compared to patients with 
skeletal Class II pattern (with mean 
value of 12458.8mm3) respectively 
with p value of 0.003. 

Table 5 shows the correlation 
between Tongue Volume and airway 

volume in skeletal Class I and Class II 
pattern. The P value of 0.001 
indicates that there is a strong 
correlation between the tongue 
volume and airway volume in skeletal 
Class I and skeletal Class II subjects. 
Also, R value of 0.4596 depicted 
strong positive correlation between 
tongue volume and airway volume in 
skeletal Class I subjects. The R value 
of 0.3211 depicted strong positive 
correlation between tongue volume 
and airway volume in skeletal Class II 
subjects. 

Skeletal 
Pattern 

Gender N Mean 
Age 

SD Min. Max. t 
value 

P 
value 

Class 1 Male 9 17.4 2.404 15 21 0.592 0.448 
Female 21 16.9 1.682 15 20 
Total 30 17.0 1.903 15 21 

Class 2 Male 10 17.7 2.312 14 21 0.670 0.420 
Female 20 18.3 1.658 14 21 
Total 30 18.1 1.882 14 21 

Skeletal pattern Gender Total c2 value P value 
Male Female 

Class 1 9 21 30 0.077 0.781 
30.0% 70.0% 100.0% 

Class 2 10 20 30 

33.3% 66.7% 100.0% 
Total 19 41 60 

31.7% 68.3% 100.0% 

Figure 4. Pie diagram representing gender 
distribution among the study samples. 

Table 1: Gender distribution amongst the individual skeletal pattern and its significance. 

Table 2: Table showing age distribution in skeletal Class I and Class II subjects. 

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Evalua&on of Tongue Volume and Airway Volume in Skeletal Class I and Class II Pa&ents using Cone Beam Tomography- A Cross Sec&onal Study 
  
 

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Skeletal 
pattern N Me

an SD Median Min. Max. Mean 
Diff SE ‘t’ 

value 
P 
value 

Class 1 30 45.
32 

2.5
17 

45.40 39.83 49.46 

5.052 0.545 9.270 <0.00
1 Class 2 30 40.

27 
1.6
04 

40.25 37.54 42.92 

Skeletal 
pattern N Mean SD Median Min. Max. Mean 

Diff SE ‘t’ 
value 

P 
value 

Class 1 30 15058.
6 

3960.46
7 14,241.0 9569 23367 

2599.7 836.623 3.107 0.003 
Class 2 30 12458.

8 
2304.96
1 12,716.0 8150 16834 

Skeletal pattern   Airway volume 

Class 1 
 
Tongue Volume 
 

Correlation 0.678 
P value <0.001 

Class 2 
 
Tongue Volume 
 

Correlation 0.567 
P value 
 0.001 

Discussion 

The present study was done to 
evaluate the tongue volume and 
airway volume in skeletal Class I and 
Class II malocclusion and also to find 
if there is a correlation between the 
tongue volume and airway volume in 
the respective skeletal pattern. With 
the advent of imaging techniques like 
CBCT, diagnosis and treatment 
planning is greatly supplemented, 
thus making 3D analysis of 
maxillofacial skeleton and soft tissues 
possible [10]. The usual method of 
evaluating the tongue volume was 

Magnetic Resonance Imaging (MRI), 
since MRI is the gold standard for 
measuring soft tissues. 3D Dolphin 
Software is considered as the gold 
standard method for evaluating the 
airway volume [11].. Currently 
numerous imaging software’s are 
available for evaluating the tongue 
volume and the airway volume. 
Mimics (Materialize Interactive 
Medical Image Control System) is an 
image processing software for 3D 
design and modeling. It is used to 
create 3D surface models from stacks 
of 2D image data. Weissheimer et al 
compared 6 imaging software’s and 

concluded that Mimics, Dolphin3D, 
Osiri X and ITKsnap were similar and 
more accurate than In vivo Dental 
and On Demand for upper airway 
assessment [12]. 

In the present study, the ANB angle 
was used to identify the skeletal 
pattern of the samples. Using ANB 
alone for identification of skeletal 
pattern is unreliable as it is subjective 
to many variables like nasion area 
morphology, vertical dimension of 
the face, anterior cranial base 
inclination, and inclination of the 
jaws. Using only ANB would have 

Table 3: Comparison of Mean values of Tongue Volume in skeletal Class I and Class II pattern. 

Table 4: Comparison of Mean values of Airway volume between skeletal Class I and Class II pattern. 

Table 5: Correlation between Tongue Volume and airway volume in skeletal Class I and Class II pattern. 

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confounded the study, as the location 
of point A and point B will have an 
impact on the angle. Thus, in addition 
to ANB values, Witt’s appraisal and 
molar relationship were also taken 
into consideration for identifying the 
skeletal pattern [13].  

The age group of the sample 
consisted of both adolescents and 
adults, despite the fact that airway 
volume varies with age. Kollias et al 
had performed a long term follow up 
study and had concluded that 
between 20 to 50 years of age, there 
is a gradual decrease of airway 
dimension noted both behind the 
tongue as well as and posterior to the 
soft palate [14]. In other studies, it 
was reported that pharyngeal 
structures continue to grow rapidly 
until 13 years of age and a quiescent 
period was noted between the ages 
of 14 to 18 years which meant that 
the variation of airway size of this age 
group was minimal [15, 16]. Thus, in 
this study, age was standardized by 
taking samples with ages ranging 
from 14 to 20 years to minimize 
variation due to growth. 

The volume of tongue is determined 
by factors such as size of mandibular 
arch, maxillary width, vertical facial 
height and combined vertical and 
horizontal position of chin and 
symphysis. It has been an accepted 
fact that increases in volume of soft 
tissue induces increase in 
osteogenesis at the growth site of the 
bone. Earlier the volume of tongue 
was measured with the help of lateral 
cephalogram which basically 

determines the 2-dimensional size of 
the tongue. Lui et al evaluated the 
volume of tongue with the help of 
contrast agent such as barium [17]. 
Vig and Cohen compared sagittal area 
of the tongue to that sagittal area of 
the oral cavity with the help of bony 
landmarks [18]. Few other studies 
have evaluated the size of the tongue 
by direct measurement but those 
were not able to measure the 
posterior limit of the tongue. Bandy 
and Hunter measured the volume of 
tongue by water displacement 
method [19]. In the present study, 
the tongue volume was measured 
with defined landmarks based on a 
previous study conducted by Liegeois 
et al.[20] In our study the tongue 
volume was measured with the help 
of 3D dolphin software. Studies have 
proved that Dolphin imaging was 
effective in measurements and had 
better prediction compared to the 
other imaging software [7]. 

The influence of oral function on 
growth has been a topic of discussion 
in orthodontics for decades. Initial 
studies related to airway were started 
in the early 1970s. Since then, it has 
been a subject of great interest for 
the orthodontist to evaluate any 
correlation associated with airway 
and structures associated with it, 
especially the tongue because of its 
close proximity [21]. In this study the 
pharyngeal airway was considered as 
a whole with defined landmarks 
instead of dividing it into upper 
middle and lower compartments. This 
was done to ensure ease of 

computing and to avoid errors in 
volume determination by adding 
more landmarks to the study. This 
was done in accordance with the 
study by Kyung Min OH [22]. 

In this study the volume of airway 
was greater in skeletal Class I 
malocclusion. This was in accordance 
with the studies conducted by 
Palamo et al who proved that the 
oropharyngeal and nasopharyngeal 
airway volumes of Class II patients 
were smaller when compared with 
Class I and Class III patients [23]. 
Similarly another study conducted by 
Deepthi et al had proved that there 
was a negative correlation between 
airway volume with ANB angle, 
implying that class II skeletal base 
patients had lesser airway volume 
[24]. Studies conducted by Frieties et 
all had shown that there was no 
statistically significant difference in 
airway volume in different 
malocclusion but there was 
statistically significant difference in 
patients exhibiting vertical and 
horizontal growth pattern where 
vertical growth pattern had lesser 
volume of airway as compared to 
horizontal [25]. It was also observed 
that the position of the mandible with 
respect to the cranial base had an 
effect on the pharyngeal airway 
volume. This may be due to the fact 
that if the Class II skeletal pattern is 
caused by the mandible being 
retrognathic, the overall 
oropharyngeal airway space will be 
reduced. In the current study, the 
distinction has not been made based 

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Evalua&on of Tongue Volume and Airway Volume in Skeletal Class I and Class II Pa&ents using Cone Beam Tomography- A Cross Sec&onal Study 
  
 

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on whether the skeletal Class II 
pattern is caused by mandibular 
retrognathism of by maxillary 
prognathism. The degree of jaw 
discrepancy was relatively less in the 
selected samples as the ANB value of 
the selected Class II samples ranged 
between 50-70. Hence the effect of 
significant mandibular retro position 
requires further investigation as it 
might have further influence on 
airway morphology and volume.  

In the present study the ‘r’ value of 
0.4596 depicts strong positive 
correlation between tongue volume 
and airway volume in skeletal Class I 
subjects, similarly ‘r’ value of 0.3211 
indicates strong positive correlation 
between tongue volume and airway 
volume in skeletal Class II subjects. 
There was not much literature found   
comparing the correlation between 
tongue volume and airway volume in 
skeletal Class I and skeletal Class II. 

In this study it was found there was a 
statistically significant difference 
between the tongue volume in 
skeletal Class I and skeletal Class II 
malocclusion indicating that the 
tongue volume was greater in skeletal 
Class I malocclusion compared to 
skeletal Class II malocclusion. This 
was in agreement with a previous 
study’s findings [26]. In another study 
it was shown that that there was no 
statistical difference between size of 
the tongue and airway volume in 
relation to different skeletal pattern 
[27]. This was in contradiction to the 
present study where the volume of 
tongue and airway was greater in 

skeletal Class I samples compared to 
skeletal Class II samples. 

These limitations of this study were 
that the sample did not have an equal 
proportion of males and females and 
was limited with respect to age range 
considered. The future prospects for 
research are to conduct a similar 
study in a larger sample size, to 
include different age brackets and 
compare between them, and to 
compare between sexes. 

Conclusion 

The present study was concluded that 
the mean tongue volume (45.32mm3) 
and mean airway volume 
(15058.5mm3) were greater in 
samples exhibiting skeletal Class I 
malocclusion compared to Class II 
samples. A strong positive correlation 
exists between tongue volume and 
airway volume in skeletal Class I and 
skeletal Class II subjects.  

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