JMIR RESEARCH PROTOCOLS Fonseca et al

Protocol

Upper Airway Assessment in Cone-Beam Computed Tomography

for Screening of Obstructive Sleep Apnea Syndrome: Development
of an Evaluation Protocol in Dentistry

Catarina Fonseca1,2, MSc; Francisca Cavadas1, MSc; Patrícia Fonseca1,2, MSc, PhD
1
Faculty of Dental Medicine, Universidade Católica Portuguesa, Viseu, Portugal
2
Center for Interdisciplinary Research in Health, Viseu, Portugal

Corresponding Author:
Catarina Fonseca, MSc
Faculty of Dental Medicine
Universidade Católica Portuguesa
Estrada da Circunvalação
Viseu, 3504-505
Portugal
Phone: 351 232419500
Email: [email protected]

Abstract
Background: The upper airways are formed by the nasal cavities, pharynx, and larynx. There are several radiographic methods
that allow evaluation of the craniofacial structure. Upper airway analysis in cone-beam computed tomography (CBCT) may be
useful in diagnosing some pathologies such as obstructive sleep apnea syndrome (OSAS). OSAS prevalence has increased
significantly in recent decades, justified by increased obesity and average life expectancy. It can be associated with cardiovascular,
respiratory, and neurovascular diseases, diabetes, and hypertension. In some individuals with OSAS, the upper airway is
compromised and narrowed. Nowadays, CBCT is widely used in dentistry by clinicians. Its use for upper airway assessment
would be an advantage for screening some abnormalities related to an increased risk of pathologies such as OSAS. CBCT helps
to calculate the total volume of the airways and their area in different anatomical planes (sagittal, coronal, and transverse). It also
helps identify regions with the highest anteroposterior and laterolateral constriction of the airways. Despite its undoubted
advantages, airway assessment is not routinely performed in dentistry. There is no protocol that allows comparisons between
studies, which makes it difficult to obtain scientific evidence in this area. Hence, there is an urgent need to standardize the protocol
for upper airway measurement to help clinicians identify at-risk patients.
Objective: Our main aim is to develop a standard protocol for upper airway evaluation in CBCT for OSAS screening in dentistry.
Methods: To measure and evaluate the upper airways, data are obtained using Planmeca ProMax 3D (Planmeca). Patient
orientation is performed in accordance with the manufacturer's indications at the time of image acquisition. The exposure
corresponds to 90 kV, 8 mA, and 13,713 seconds. The software used for upper airway analysis is Romexis (version 5.1.O.R;
Planmeca). The images are exhibited in accordance with the field of view of 20.1×17.4 cm, size of 502×502×436 mm, and voxel
size of 400 μm.
Results: The protocol described and illustrated here allows for automatic calculation of the total volume of the pharyngeal
airspace, its area of greatest narrowing, its location, and the smallest anteroposterior and laterolateral dimensions of the pharynx.
These measurements are carried out automatically by the imaging software whose reliability is proven by the existing literature.
Thus, we could reduce the possible bias of manual measurement, aiming at data collection.
Conclusions: The use of this protocol by dentists will allow for standardization of the measurements and constitutes a valuable
screening tool for OSAS. This protocol may also be suitable for other imaging software. The anatomical points used as reference
are most relevant for standardizing studies in this field.
International Registered Report Identifier (IRRID): RR1-10.2196/41049

(JMIR Res Protoc 2023;12:e41049) doi: 10.2196/41049

https://www.researchprotocols.org/2023/1/e41049 JMIR Res Protoc 2023 | vol. 12 | e41049 | p. 1

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR RESEARCH PROTOCOLS Fonseca et al

KEYWORDS
cone-beam computed tomography; three-dimensional image; 3D image; airway obstructions; sleep medicine specialty; dentistry;
obstructive sleep apnea; protocol

not diagnosed [12-14]. The clinical presentation of OSAS

Introduction includes fatigue, daytime sleepiness, and snoring. If not treated,
The upper airways are formed by the nasal cavities, pharynx, it can be associated with cardiovascular (coronary artery disease,
and larynx. The pharynx (portion most susceptible to collapse) arrhythmias, hypertension, congestive heart failure, and stroke),
is divided into 3 parts: nasopharynx, oropharynx, and respiratory (exacerbation of asthma, respiratory dysfunction in
hypopharynx [1,2]. The nasopharynx begins in the choanae chronic obstructive pulmonary disease, pulmonary embolism,
(posterior opening of the nasal cavities) and ends on the hard and pulmonary hypertension), and neurological diseases
palate. The oropharynx ranges from the uvula to the epiglottis. (frustration, distress, neurocognitive dysfunctions, and attention
The hypopharynx spans the area from the epiglottis to the vocal deficit) and diabetes [4-11].
cords, where the trachea begins [1,2]. In OSAS, despite respiratory effort, there is a repetitive total or
There are several radiographic methods that allow the evaluation partial collapse of the upper airways. In normal situations, the
of craniofacial structure. Profile teleradiography, cone-beam genioglossal muscle contracts at each inspiration in order to
computed tomography (CBCT), axial computed tomography avoid the posterior movement of the tongue aided by the lift
(CT), and magnetic resonance imaging are some examples of and tensor muscles of the palate, geniohyoid, and
imaging modalities that allow for this evaluation. Among these stylopharyngeus [4-11]. Together, these muscles ensure
auxiliary diagnostic means and comparing those that are continuous air passage through the airways. However, in some
available to dentists, CBCT has demonstrated usefulness in 3D individuals, the upper airways are compromised and narrowed
evaluation of the airways. For example, the time and radiation as a result of the deposition of adipose tissue in the pharyngeal
exposure in CBCT are considerably shorter than those in CT muscles and parapharyngeal pathways or due to anomalies in
[1-3]. Profile teleradiography provides a quick 2D assessment the craniofacial structure [4-11].
of the upper airways but can only depict the 2D morphology One of the regions relevant to the pathophysiology of OSAS is
and has prone of numerous superimpositions [4-6]. the oropharynx. Steffy et al [1] related the constriction value of
Furthermore, CBCT images are not magnified and are recorded the oropharynx with the risk of developing OSAS. An area of
on a 1:1 scale, which permits accurate and direct dimensional <52 mm2 is considered as having a high risk of OSAS; 52-100
measurements [4-6]. Although a radiographic examination, mm2, intermediate risk; and >100 mm2, low risk [1,10].
CBCT has a far more favorable risk-to-benefit ratio. It helps Obstruction may arise at different levels of the oropharynx,
determine the total volume of the airways and their area in the being more frequent in the retropalatal, retroglossal, and
different anatomical planes (sagittal, coronal, and transverse) epiglottis areas [10,11].
and identify the regions with the highest anteroposterior and
laterolateral constriction of the airways [1]. Due to the severity of this syndrome, multidisciplinary
intervention is essential. The role of the dentist in OSAS is
Upper airway analysis in CBCT is useful to help diagnose some essentially 2-fold: contributing to early diagnosis and therapy.
pathologies such as the obstructive sleep apnea syndrome This clinician has the possibility to make a direct observation
(OSAS). of the palate’s soft and oropharyngeal tissues (eg, tonsil region
The OSAS is defined by repeated episodes, greater than 5 per and tongue), can identify breathing difficulties and breathing
hour, of partial or total obstruction of the upper airways during type (nasal or oral), and has easy access to the cervical region,
sleep, leading to airway obstruction (apnea) or reduced airflow which helps assess its volume or even measure the cervical
(hypopnea). An apnea event, by definition, should last at least perimeter [12]. Furthermore, according to the American
10 seconds and is usually associated with sleep or microarousal Academy of Dental Sleep Medicine, the dentist plays a key role
fragmentation. Hypopnea can be defined as a reduction in in screening and can help to reduce the number of undiagnosed
ventilation (at least 50%) with an oxygen desaturation of ≥4% or untreated patients with OSAS [13].
[4-11]. Currently, CBCT is used in dentistry. Its additional use for upper
This pathology has a relevant negative impact on patients' daily airway assessment would be an added value for the screening
lives and its prevalence has increased significantly in recent of some abnormalities related to an increased risk of OSAS.
decades worldwide, justified by increased obesity and average Studies on airway measurement methods have revealed that
life expectancy. Benjafield et al [12] estimated that around the there is no objective and consensual methodology [14,15], which
world, approximately 1 billion adults aged 30-69 years makes it difficult to obtain scientific evidence in this area. There
experience OSAS, of whom more than 45% (425 million) of is an urgent need to standardize the protocol and to develop a
adults present moderate to severe OSAS requiring treatment simple workflow for upper airway measurement, which is the
[8]. There is a wide geographical variation in the prevalence of aim of this study.
OSAS, with some countries having a prevalence above 50%.
OSAS is highly underrecognized, and it is estimated that 82%
of men and 93% of women with OSAS in the United States are

https://www.researchprotocols.org/2023/1/e41049 JMIR Res Protoc 2023 | vol. 12 | e41049 | p. 2

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR RESEARCH PROTOCOLS Fonseca et al

Data Collection
Methods
To measure and evaluate the upper airways, data were obtained
Ethical Considerations using Planmeca ProMax 3D (Planmeca) and in accordance with
This study was integrated in the project number 27 of the Faculty the manufacturer's indications regarding patient orientation at
of Dental Medicine, Catholic University of Portugal, and the time of image acquisition: with the patient standing and with
approved by the Ethics Committee for Health (272022; January his/her head oriented along 3 vertical references—the facial
21, 2022). The authors ensured conditions of anonymity and midline (glabella, subnasal, and mentum), endocant of the eye,
confidentiality that are required for such studies in Portugal. and the parietal bone (Figure 1). The patient’s head should also
be oriented along a horizontal reference—next to the chin. The
exposure corresponds to 90 kV, 8 mA, and 13,713 seconds.
Others imaging devices can be used to obtain the CBCT image.
Figure 1. Correct orientation of the planes according to the inclination of the airways.

Data collected through CBCT is intended to be used to develop and mark the first point at the level of the posterior nasal
a standard method or protocol for upper airway evaluation. spine (Figure 3).
3. Then, continue delimiting the airway following its curvature
To develop this protocol, we consulted the radiographic database
and mark a last point at the level of the middle of the fourth
of the Dental Clinic of the Faculty of Dental Medicine, Catholic
cervical vertebra (Figure 4).
University of Portugal, which has a Planmeca ProMax 3D 4. Select, again, the option “Extract airways,” and in the box
(Planmeca) device. We searched for patients who had complete
that appears with the name “Airways Tool” adjust the
CBCT (maxilla and mandible) images to perform the analysis.
variable that defines the airway limits (a standard
Data Analysis adjustment value should be used for all patients so that it
The software used for upper airway analysis is Romexis (version is possible to establish adjustments; in this case, the
5.1.O.R; Planmeca). The images are exhibited in accordance standardized value was 736). Then, the value of the total
with the field of view of 20.1×17.4 cm, size of 502×502×436 volume (“airway volume”) appears (Figure 5).
5. Place the cursor over the box where the total volume value
mm, and voxel size of 400 μm.
appears. In the same box will appear the value of the
The measurements performed for all the CBCT images were as minimum airway area (“min area”) (Figure 6).
follows: total volume of the pharyngeal airspace, its area and 6. Enlarge the window containing the axial plane and, from
its location, and the smaller dimensions of the anteroposterior the narrowest area of the airway, select in the box on the
and lateral pharynx (these measurements are illustrated in the right with the heading “Annotation” the tool “Measure
Results section). Length” and measure the anteroposterior and laterolateral
The protocol is as follows: dimensions (Figure 7).
7. Record all obtained values.
1. Activate the “Extract airways” tool in the box on the right
with the title “Adjust” (Figure 2). To ensure the reproducibility of the protocol, all researchers
2. Then, enlarge the sagittal cut window in the box that appears performed the measurements, and patients were categorized
on the “Airways Tool” screen to keep the threshold at 500 into those at risk for OSAS (highest anteroposterior and

https://www.researchprotocols.org/2023/1/e41049 JMIR Res Protoc 2023 | vol. 12 | e41049 | p. 3

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR RESEARCH PROTOCOLS Fonseca et al

laterolateral constriction of the airways of <52 mm2 or 52-100 mm2) or those at no risk (>100 mm2).
Figure 2. Selection of the tool "Extract Airways" and marking of the points following the curvature of the airways.

Figure 3. Keeping the threshold at 500 and marking the first point.

https://www.researchprotocols.org/2023/1/e41049 JMIR Res Protoc 2023 | vol. 12 | e41049 | p. 4

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR RESEARCH PROTOCOLS Fonseca et al

Figure 4. Delimitation of the airway following its curvature.

Figure 5. New selection of the option "Extract airways," and in the box that appears with the name "Airways Tool" the variable that defines the image
limit is adjusted (standardized value for all patients=736).

Đến C4 thì vướng nắp thanh quản -> auto minCSA

https://www.researchprotocols.org/2023/1/e41049 JMIR Res Protoc 2023 | vol. 12 | e41049 | p. 5

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR RESEARCH PROTOCOLS Fonseca et al

Figure 6. Calculation of the value of the total volume and the value of the minimum airway area ("min area").

Figure 7. Anteroposterior dimension measurement.

software whose reliability is proven by the existing literature

Results [16]. Thus, we reduce the possible bias of manual measurement,
To establish this protocol, CBCT images of 30 patients were aiming at data collection.
used (56% for males and 44% for females), and, in cases where
an area of <52 mm2 or 52-100 mm2 was detected, the patient
Discussion
was contacted and referred to the hospital for diagnostic Principal Findings
confirmation tests.
The literature revealed no consensual and objective methodology
No differences were found between measurements obtained by for upper airway measurement. The lack of standardization in
the different researchers following the protocol described. the definition of anatomical limits makes it impossible to
The protocol that the authors suggested for evaluation of the subsequently make comparisons between different studies
upper airways in CBCT allows for automatic calculation of the [19,20]. Recently, with the evolution of software, it is possible
total volume of the pharyngeal airspace, its area of greatest to perform upper airway measurement in a fast automatic
narrowing, its location, and the smallest anteroposterior and analysis in an accurate, reproductible, and practical way. Its
laterolateral dimensions of the pharynx [15-18]. The simplicity and speed allow this analysis to be adopted by all
measurement is performed automatically by the imaging professionals. It is important to note that simplicity is not

https://www.researchprotocols.org/2023/1/e41049 JMIR Res Protoc 2023 | vol. 12 | e41049 | p. 6

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR RESEARCH PROTOCOLS Fonseca et al

achieved in the detriment of any decrease in viability and examination. This threshold adapts the difference between the
reliability in the measurement of airways [16]. shades of gray in each voxel of the airway and the rest of the
area. However, in general, Zimmerman et al [19] verified, in a
The CBCT helps measure the total volume of the pharyngeal
systematic review, that most studies measuring the airways have
airspace, its area of greatest narrowing in 3 different anatomical
high intraexaminer reliability. Although in this study, no CBCT
planes (sagittal, coronal, and transversal), its location, and the
image was purposely acquired, currently, it is known that it is
smallest anteroposterior and laterolateral dimensions of the
a comprehensive examination that allows numerous
pharynx [14-16]. Steffy et al [1] related the constriction value
interpretations and simulations from a very low radiation dose.
of the oropharynx with the risk of developing OSAS. An area
Nevertheless, the ALARA (ie, As Low As Reasonably
of <52 mm2 is considered as having a high risk of OSAS; 52-100 Achievable) principle should be respected, reserving the
mm2, intermediate risk; and >100 mm2, low risk [1]. Compared execution of these examinations for cases in which they are
to the other radiographic methods described in the literature, strictly necessary [19,20].
usually available to the dentist, such as profile teleradiography
and CT, the CBCT, as previously mentioned, presents more However, despite these limitations and due to the automatic
advantages. It is possible to acquire the same or better images measurements performed by the system, this protocol in CBCT
with less radiation and less time of exposure. The assessment constitutes a good patient screening tool that will help
protocol for CBCT described herein constitutes a valuable standardize the measurements and ensure that they are
screening tool for OSAS, which allows clinicians to refer the performed in a reproductible, accurate, and simple way while
patient to the hospital for diagnosis confirmation. To establish the comfort of and benefit for the patients increases.
this protocol, CBCT images of 30 patients were used, and in Conclusions
cases where an area of <52 mm2 or 52-100 mm2 was detected, This protocol provides a new standardized tool to identify
the patient was contacted and referred to the hospital for patients at the risk of OSAS by using CBCT and contributes to
diagnostic confirmation tests. the detection of upper airway–related pathologies, such as
Limitations and Strengths OSAS, in patients visiting the dental clinics, using these devices
and software. This protocol will have a significant impact in
The protocol’s main limitations are related to the position at reducing the subdiagnosis of this pathology, contributing to its
which this examination is performed. The patient undergoes treatment and subsequently the prevention of serious
the examination in a standing position and not in a supine comorbidities associated with OSAS. Our protocol may also be
position, which may introduce false negatives here or cause a suitable for other imaging software. The anatomical points used
suspected hypothesis to be discarded. In addition, the step for reference are most relevant for standardizing studies in this
responsible for adjusting the threshold is characteristic of each field and for software evaluation to reduce bias.

Acknowledgments
This work is funded by National Funds through Fundação para a Ciência e a Tecnologia, IP (project UIDB/04279/2020).

Conflicts of Interest
None declared.

References
1. Steffy DD, Tang CS. Radiographic evaluation of sleep-disordered breathing. Radiol Clin North Am 2018 Jan;56(1):177-185.
[doi: 10.1016/j.rcl.2017.08.012] [Medline: 29157546]
2. Cavadas A, Fonseca P. O contributo do médico dentista para o diagnóstico precoce da Síndrome da Apneia Obstrutiva do
Sono Tese de Mestrado. Universidade Católica Portuguesa 2019. [doi: 10.11606/t.17.2019.tde-01082019-101646]
3. Alkhader M, Geijer M. Comparative analysis of the oropharyngeal airway in patients aged over 40 years: a cone beam
computed tomography study. Eur J Gen Dent 2021 Nov 01;8(03):76-79. [doi: 10.4103/ejgd.ejgd_117_19]
4. Ganguly DR, U DD, Misra DN, Singh DP. Obstructive sleep apnea: An oral and maxillofacial radiology perspective. Int
J Appl Dent Sci 2022 Oct 01;8(4):92-96. [doi: 10.22271/oral.2022.v8.i4b.1631]
5. Faber J, Faber C, Faber AP. Obstructive sleep apnea in adults. Dental Press J Orthod 2019 Aug 01;24(3):99-109 [FREE
Full text] [doi: 10.1590/2177-6709.24.3.099-109.sar] [Medline: 31390456]
6. Fonseca C, Fonseca P. Consulta de Medicina Dentária do Sono: Protocolo de Atuação Clínica. Católica Portuguesa para
obtenção do grau de Mestre em Medicina Dentária. 2022. URL: https://repositorio.ucp.pt/bitstream/10400.14/38578/1/
203048709.pdf [accessed 2023-04-26]
7. Lévy P, Kohler M, McNicholas WT, Barbé F, McEvoy RD, Somers VK, et al. Obstructive sleep apnoea syndrome. Nat
Rev Dis Primers 2015 Jun 25;1(1):15015. [doi: 10.1038/nrdp.2015.15] [Medline: 27188535]
8. Gottlieb DJ, Punjabi NM. Diagnosis and management of obstructive sleep apnea: a review. JAMA 2020 Apr
14;323(14):1389-1400. [doi: 10.1001/jama.2020.3514] [Medline: 32286648]

https://www.researchprotocols.org/2023/1/e41049 JMIR Res Protoc 2023 | vol. 12 | e41049 | p. 7

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR RESEARCH PROTOCOLS Fonseca et al

9. Lavigne G, Herrero Babiloni A, Beetz G, Dal Fabbro C, Sutherland K, Huynh N, et al. Critical issues in dental and medical
management of obstructive sleep apnea. J Dent Res 2020 Jan 08;99(1):26-35. [doi: 10.1177/0022034519885644] [Medline:
31702942]
10. Rundo JV. Obstructive sleep apnea basics. Cleve Clin J Med 2019 Sep 01;86(9 Suppl 1):2-9 [FREE Full text] [doi:
10.3949/ccjm.86.s1.02] [Medline: 31509498]
11. Arnaud C, Bochaton T, Pépin JL, Belaidi E. Obstructive sleep apnoea and cardiovascular consequences: pathophysiological
mechanisms. Arch Cardiovasc Dis 2020 May;113(5):350-358 [FREE Full text] [doi: 10.1016/j.acvd.2020.01.003] [Medline:
32224049]
12. Benjafield AV, Ayas NT, Eastwood PR, Heinzer R, Ip MSM, Morrell MJ, et al. Estimation of the global prevalence and
burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir Med 2019 Aug;7(8):687-698. [doi:
10.1016/s2213-2600(19)30198-5]
13. Lyons MM, Bhatt NY, Pack AI, Magalang UJ. Global burden of sleep-disordered breathing and its implications. Respirology
2020 Jul 21;25(7):690-702 [FREE Full text] [doi: 10.1111/resp.13838] [Medline: 32436658]
14. Duce B, Milosavljevic J, Hukins C. The 2012 AASM Respiratory Event Criteria increase the incidence of hypopneas in
an adult sleep center population. J Clin Sleep Med 2015 Dec 15;11(12):1425-1431 [FREE Full text] [doi: 10.5664/jcsm.5280]
[Medline: 26285111]
15. Salman S. Modern Management of Obstructive Sleep Apnea (1st edition). Jacksonville, FL: Springer International Publishing;
2019.
16. Kamaruddin N, Daud F, Yusof A, Aziz M, Rajion Z. Comparison of automatic airway analysis function of Invivo5 and
Romexis software. PeerJ 2019;7:e6319 [FREE Full text] [doi: 10.7717/peerj.6319] [Medline: 30697493]
17. Marya CM, Jain S, Nagpal R, Taneja P, Kataria S, Marya V. Obstructive sleep apnea: a dental perspective. IHRJ 2019 Nov
24;3(8):260-266. [doi: 10.26440/IHRJ/0308.11250]
18. Addy N, Bennett K, Blanton A, Dort L, Levine M, Postol K, et al. Policy statement on a dentist's role in treating sleep-related
breathing disorders. JDSM 2018 Jan 10;05(01):25-26. [doi: 10.15331/jdsm.6920]
19. Zimmerman J, Vora S, Pliska B. Reliability of upper airway assessment using CBCT. Eur J Orthod 2019 Jan
23;41(1):101-108. [doi: 10.1093/ejo/cjy058] [Medline: 30184085]
20. Zimmerman JN, Lee J, Pliska BT. Reliability of upper pharyngeal airway assessment using dental CBCT: a systematic
review. Eur J Orthod 2017 Oct 01;39(5):489-496. [doi: 10.1093/ejo/cjw079] [Medline: 27999121]

Abbreviations
CBCT: cone-beam computed tomography
CT: computed tomography
OSAS: obstructive sleep apnea syndrome

Edited by A Mavragani; submitted 13.07.22; peer-reviewed by M Pang, R Allana; comments to author 22.12.22; revised version
received 20.03.23; accepted 27.03.23; published 05.05.23
Please cite as:
Fonseca C, Cavadas F, Fonseca P
Upper Airway Assessment in Cone-Beam Computed Tomography for Screening of Obstructive Sleep Apnea Syndrome: Development
of an Evaluation Protocol in Dentistry
JMIR Res Protoc 2023;12:e41049
URL: https://www.researchprotocols.org/2023/1/e41049
doi: 10.2196/41049
PMID: 37145857

©Catarina Fonseca, Francisca Cavadas, Patrícia Fonseca. Originally published in JMIR Research Protocols
(https://www.researchprotocols.org), 05.05.2023. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The
complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this
copyright and license information must be included.

https://www.researchprotocols.org/2023/1/e41049 JMIR Res Protoc 2023 | vol. 12 | e41049 | p. 8

(page number not for citation purposes)
XSL• FO
RenderX