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rev port estomatol med dent cir maxilofac . 2018;59(2):67-74 69

to allow early diagnoses of disorders and plan the best inter- 2. Lip sealing without voluntary muscle contraction; 6,17
ventions accordingly. In this sense, based on a sample of young 3. A water in the mouth test, which assessed the time that
people with 12 to 15 years old, we aimed to a) compare occlusal, the participant could breathe with sealed lips (normal:
facial, and craniocervical postural characteristics according to ≥2 min), 6,17 to identify nasal breathing difficulty; and
the breathing pattern; b) study the association between occlusal 4. A mirror test, which involved placing an intraoral dis-
class and TMDs severity; c) and estimate the influence of the posable mirror under the nostrils 7,8,17 to gauge water
breathing pattern, head and neck posture, occlusal class and vapor formation (normal: mirror fogging).
facial pattern on the severity of TMDs and on the lower cervi-
cofacial ratio. Secondarily, we aimed to identify any prevalent We identified oral breathing when these assessments’ re-
17
differences in TMDs severity by gender, in the selected sample. sults deviated from the norm. Given the impossibility of con-
ducting complementary ear, nose, and throat tests, we decid-
ed to match nasal and oral breathing as indicators of
Materials and methods normality and change, respectively. In addition, we applied a
supplementary questionnaire and conducted observations to
This observational, cross -sectional, analytical study took identify any typical features of oral breathers. 2,5,7,8
place at two Portuguese schools between November 2015 and The dental occlusion was evaluated by analyzing the po-
April 2016, with a convenience sample of 139 individuals (81 sition of the first permanent molars and the presence of cross-
females and 58 males) aged from 12 to 15 years (13.0±0.72). bite and open bite according to Angle’s and Moyers’s (1991)
The minimum age was 12 years and the maximum 15 years. classification, respectively. 7,18 To minimize the possibility of
The most common age was 13 years (N=76), corresponding to bias, two investigators performed the evaluations.
54% of the sample and the least common was 15 years, in All participants were photographed to evaluate head and
only 2.2% of the sample (N=3). neck posture using photogrammetric analysis, with the help
The inclusion criteria were: the presence of definitive den- of Software for Postural Assessment, version 0.68. A 9×9 -cm
tition and being aged between 12 and 15 years. The exclusion checkered screen was used to set image calibration, as well as
®
criteria were: a history of orthodontic treatments, a history of a Sony Cyber -shot camera with 8.1 -megapixel resolution, a
physical therapy treatments related to cervico–craniofacial tripod with the same calibration parameters, and foam ana-
issues, ears, nose, and throat surgical interventions (e.g., nose, tomical markers for all participants. Participants were photo-
tonsils, adenoids), and the presence of neurological, orthope- graphed (males without shirts, females with tops) in an ortho-
dic, or craniofacial malformations. static position. Foam labels and stickers were used to set the
The participants’ parents or guardians were informed anatomical sites for analysis. The camera was placed 1.5 m
about the study and its objectives and procedures and asked away from the participant to capture his or her upper body,
to sign an informed consent, per the recommendations of the and three photographs were taken: a frontal view, a right -side
Declaration of Helsinki. The Ethics Committee of the Univer- view, and a left -side view (Figures 1 and 2).
sity Institute of Health Sciences (CESPU) approved the study. The following variables were used: horizontal head and
Clinical evaluation started with a functional matrix of data acromion alignment (frontal view), horizontal head alignment
from a short questionnaire and clinical observations, followed (C7), and vertical head alignment with the acromion (sagittal
by the evaluation of occlusion and posture via intraoral clinical plane), as shown in Figures 1 and 2.
examination and photographic analysis. Lastly, a question- Signs and symptoms of TMDs were classified according to
naire on TMDs was administered. 12,13 the Fonseca Anamnestic Index developed by Fonseca 14 and
Prior to data collection, a pilot study was performed to cal- based on the Helkimo Anamnesis Index. This index is recom-
12
culate the average time needed to assess each participant, mended for epidemiological studies due to its simplicity, as it
train the investigators responsible for data collection (S.V.; T.P.) includes 10 questions to be answered with “yes” (10 points),
on how to use the assessment protocol, and calculate the re- “no” (0 points), or “sometimes” (5 points), with only one answer
liability of the measurements. The pilot study was conducted for each question. According to their final scores, we classified
in two phases, separated by one week, with a total of 15 par- participants as having mild TMDs (20–40), moderate TMDs
ticipants (46% female) who did not participate in the primary (45–65), severe TMDs (70–100), or being TMDs -free (0–15). 14
sample but who presented similar characteristics. Inter - and The collected data were analyzed with the Statistical Pack-
intraobserver reliability assessed via intraclass correlation co- age for the Social Sciences for Macintosh, version 23.0.0.2 (IBM,
efficients (ICC) were 0.86 and 0.94, respectively, with Angle’s New York, NY, USA), considering a significance level of 5%. An
classification and an ICC=0.96 for the identification of land- exploratory study was conducted using descriptive statistics
marks necessary for postural analysis. Those results demon- of frequencies, central tendency (mean [M] or median [Med],
strated a good reliability of the measurements. according to variable distribution), and dispersion (standard
The functional assessments were conducted via four deviation [SD] or interquartile range [IR], according to variable
methods: distribution). The normal distribution analysis was performed
using the Kolmogorov–Smirnov test and Student’s t -test and
1. Questions addressed to participants and their parents Mann-Whitney U Test for variables with normal and non-
regarding whether the participant snored at night, -normal distribution, respectively.
drooled during sleep, slept with his or her mouth open, Proportions were compared using the chi -square test
among others; when conditions for its use were present, and the degree of