Comparison of Pharyngeal Airway Dimensions Between Nonsyndromic Cleft Lip and Palate Patients and Healthy Controls: A Systematic Review and Meta-Analysis
Restricted accessReview articleFirst published online May, 2026
Comparison of Pharyngeal Airway Dimensions Between Nonsyndromic Cleft Lip and Palate Patients and Healthy Controls: A Systematic Review and Meta-Analysis
This study aimed to evaluate the dimensions of pharyngeal airways among nonsyndromic cleft lip and palate (CLP) patients, comparing them with a healthy control group.
Design
Systematic review and meta-analysis.
Patients and Exposures
Patients with CLP.
Comparison
Patients without CLP.
Main Outcome Measures
Primary outcomes included the volume of different pharyngeal sections, total pharyngeal airway volume, and the minimum cross-sectional area of the pharynx. Secondary outcomes were to assess the effect of cleft type, age, and sex on pharyngeal airways.
Results
A comprehensive search of MEDLINE, Web of Science, EMBASE, Scopus, and Cochrane's CENTRAL (up to August 2023) identified 39 clinical studies meeting PECO criteria, with their risk of bias assessed using the Risk of Bias in Non-randomized Studies of Exposure tool. Of these, 33 were included in a random-effects inverse variance meta-analysis. The results indicated that nonsyndromic CLP patients demonstrated a significant reduction in the volumes of total pharyngeal airway (P = .01), velopharynx (P < .001), and oropharynx (P < .001) compared to healthy individuals. No significant differences were observed between groups regarding nasopharynx (P = .60) and hypopharynx (P = .36) regions. The minimum cross-sectional area was significantly smaller in CLP patients compared to healthy individuals (P = .02). The cleft type, age, and sex showed no significant effects on the extent of dimension reduction in pharyngeal airways (P > .05).
Conclusion
The pharyngeal airway dimensions, particularly in the middle sections (velopharynx and oropharynx), are significantly reduced in nonsyndromic CLP patients when compared to the healthy controls. Variations in CLP type, patient age, and sex do not significantly influence this decrease in dimensions.
MosseyPAModellB. Epidemiology of oral clefts 2012: an international perspective. Front Oral Biol. 2012;16(16):1-18. doi:10.1159/000337464
2.
PavriSForrestCR. Demographics of orofacial clefts in Canada from 2002 to 2008. Cleft Palate Craniofac J.2013;50(2):224-230. doi:10.1597/10-223
3.
PanamontaVPradubwongSPanamontaMChowchuenB. Global birth prevalence of orofacial clefts: a systematic review. J Med Assoc Thai. 2015;98(Suppl 7):S11-S21.
4.
VyasTGuptaPKumarSGuptaRGuptaTSinghHP. Cleft of lip and palate: a review. J Family Med Prim Care.2020;9(6):2621-2625. doi:10.4103/jfmpc.jfmpc_472_20
5.
BolandEMRossRJ. Recent advances in the study of sleep in the anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder. Psychiatr Clin North Am. 2015;38(4):761-776. doi:10.1016/j.psc.2015.07.005
6.
PorterVRBuxtonWGAvidanAY. Sleep, cognition and dementia. Curr Psychiatry Rep. 2015;17(12):97. doi:10.1007/s11920-015-0631-8
7.
Neelapu BC, Kharbanda OP, Sardana HK, Balachandran R, Sardana V, Kapoor P, Gupta A, Vasamsetti S. Craniofacial and upper airway morphology in adult obstructive sleep apnea patients: a systematic review and meta-analysis of cephalometric studies. Sleep Med Rev.2017;31(1):79-90. doi:10.1016/j.smrv.2016.01.007
8.
ZreaqatMHassanRSamsudinRStasYHanounA. Three-dimensional analysis of upper airways in class II malocclusion children with obstructive sleep apnea. J World Fed Orthod. 2022;11(5):156-163. doi:10.1016/j.ejwf.2022.08.001
9.
BicharaLMAraújoRCFlores-MirCNormandoD. Impact of primary palatoplasty on the maxillomandibular sagittal relationship in patients with unilateral cleft lip and palate: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2015;44(1):50-56. doi:10.1016/j.ijom.2014.08.004
10.
JahanbinAAhrariFSaeidiMMoeinifarASharifiF. The electrical activity of masseter and anterior temporal muscles in patients with unilateral cleft lip and palate. J Craniofac Surg. 2019;30(6):e547-e551. doi:10.1097/scs.0000000000005560
11.
Pimenta LA, de Rezende Barbosa GL, Pretti H, Almeida MA, de Souza MM, Almeida SM Three-dimensional evaluation of nasopharyngeal airways of unilateral cleft lip and palate patients. Laryngoscope.2015;125(3):736-739. doi:10.1002/lary.24895
12.
KariaHShrivastavSKariaAK. Three-dimensional evaluation of the airway spaces in patients with and without cleft lip and palate: a digital volume tomographic study. Am J Orthod Dentofacial Orthop.2017;152(3):371-381. https://doi.org/10.1016/j.ajodo.2016.12.026
13.
Kiaee B, Nucci L, Sarkarat F, Talaeipour AR, Eslami S, Amiri F, Jamilian A. Three-dimensional assessment of airway volumes in patients with unilateral cleft lip and palate. Prog Orthod. 2021;22(1):35. doi:10.1186/s40510-021-00382-4
14.
KuangWZhengJLiSYuanSHeHYuanW. Three-dimensional analysis of the pharyngeal airway volume and craniofacial morphology in patients with bilateral cleft lip and palate. Cleft Palate Craniofac J.2021;58(3):332-339. doi:10.1177/1055665620946982
15.
ZhangYWangYZhangYLiSWangLQianY. Cone-beam computed tomography evaluation of skeletal deformities and pharyngeal airway in Chinese Han individuals with nonsyndromic unilateral cleft lip and palate. Cleft Palate Craniofac J. 2020;57(1):65-72. doi:10.1177/1055665619860700
16.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev.2021;10(1):89. doi:10.1186/s13643-021-01626-4
17.
BehrbohmHKONawkaTSwiftAVerseT. Ear, Nose, and Throat Diseases With Head and Neck Surgery. 3rd ed. Stuttgart, Germany: Thieme; 2009, pp. 231-232.
18.
SinhaPHU. Malignant neoplasms of the oropharynx. In: FlintPWFHHaugheyBHLesperanceMMLundVJRobbinsKTThomasJR, eds. Cummings Otolaryngology Head and Neck Surgery. 7th ed. Amsterdam, Netherlands: Elsevier; 2021:1402.
DrakeRLVAMitchellAW. Grey’s Anatomy for Students. 3rd ed. Amsterdam, Netherlands: Elsevier; 2015, pp. 1040-1048.
21.
JeelaniWFidaMShaikhA. The duration of pubertal growth peak among three skeletal classes. Dental Press J Orthod.2016;21(5):67-74. doi:10.1590/2177-6709.21.5.067-074.oar
22.
Abdelkarim AZ, Khalifa AR, Hassan MG, Abdou A, Duman SB, Rezallah NN, Abdraboh AE, Ghoneima A. Three-dimensional assessment of the pharyngeal airway in growing versus non-growing subjects with/without cleft lip and palate. Anatomia. 2023;2(3):192-205.
23.
Al-FahdawiMAEl-KassabyMAFaridMMEl-FotouhMA. Cone beam computed tomography analysis of oropharyngeal airway in preadolescent nonsyndromic bilateral and unilateral cleft lip and palate patients. Cleft Palate Craniofac J. 2018;55(6):883-890. doi:10.1597/15-322
24.
Al-FahdawiMAFaridMMEl-FotouhMAEl-KassabyMA. Cone-beam computed tomography analysis of the nasopharyngeal airway in nonsyndromic cleft lip and palate subjects. Cleft Palate Craniofac J.2017;54(2):202-209. doi:10.1597/15-134
25.
Al-HoutGMorcosSElkadiA. Three dimensional assessment of the pharyngeal airway in a sample of Egyptian children with and without cleft lip and palate. Egypt Dent J.2016;62(1):177–183. doi:10.21608/edj.2016.92652
26.
AzeredoF. Three-Dimensional Evaluation of Oropharyngeal Airway in Cleft and Non-Cleft Patients After Maxillary Expansion. Porto Alegre, Brazil: Pontifical Catholic University of Rio Grande Do Sul; 2014.
27.
BarbosaI. Evaluation of the Oropharyngeal Dimensions of Individuals With Cleft Lip and Palate by Means of Cone Beam Computed Tomography. Salvador, Bahia: Federal University of Bahia; 2014.
28.
CelikogluMBuyukSKSekerciAEUcarFICantekinK. Three-dimensional evaluation of the pharyngeal airway volumes in patients affected by unilateral cleft lip and palate. Am J Orthod Dentofacial Orthop.2014;145(6):780-786. doi:10.1016/j.ajodo.2014.02.008
29.
CelikogluMUcarFISekerciAEBuyukSKErsozMSismanY. Assessment of pharyngeal airway volume in adolescent patients affected by bilateral cleft lip and palate using cone beam computed tomography. Angle Orthod. 2014;84(6):995-1001. doi:10.2319/121913-930.1
30.
ChenBZhangH. The study on the morphological changes of oropharynx in patients with complete unilateral cleft lip and palate after palatopharyngeal closure. Front Neurosci. 2022;16(16):997057. doi:10.3389/fnins.2022.997057
31.
DiwakarRSidhuMSJainSGroverSPrabhakarM. Three-dimensional evaluation of pharyngeal airway in complete unilateral cleft individuals and normally growing individuals using cone beam computed tomography. Cleft Palate Craniofac J. 2015;52(3):346-351. doi:10.1597/13-292
32.
ErtaşÜAtaolM. Evaluation of nasal airway volume of operated unilateral cleft lip and palate patients compared with skeletal class III individuals. Cleft Palate Craniofac J. 2019;56(1):15-20. doi:10.1177/1055665618774024
33.
EslamiNHoseini ZarchHJahanbinADarabiZMoayediS. Comparison of nasopharyngeal airway volume in cleft lip and palate patients with normal individuals using cone beam computed tomography. J Craniofac Surg. 2023;34(3):1111-1114. doi:10.1097/scs.0000000000009055
34.
GandedkarNHChngCKBasheerMAChenPYYeowVKL. Comparative evaluation of the pharyngeal airway space in unilateral and bilateral cleft lip and palate individuals with noncleft individuals: a cone beam computed tomography study. Cleft Palate Craniofac J. 2017;54(5):509-516. doi:10.1597/16-013
35.
JalaliE. A Morphological and Volumetric Airway Analysis of Patients With Mandibulofacial Abnormalities Using Cone Beam Computed Tomography. Storrs, US: University of Connecticut; 2015.
36.
KhalifaARashidAKhairyMAshourE. Assessment of pharyngeal airway in unilateral adult cleft lip and palate patients using three-dimensional methods. Egypt Dent J.2019;65(4):3143-3149. doi:10.21608/edj.2019.73991
37.
KuangWYWZhengJHeH. Three-dimensional analysis of the pharyngeal airway morphology of children with complete left CLP. Medical J Wuhan Univ. 2017;38(4):618-621. 650.
38.
Miller S, Neuhaus MT, Zimmerer R, Gellrich NC, Krimmel M, Aagaard E, Rustemeyer J. Three-dimensional analysis of the velopharyngeal region in patients with cleft palate and healthy individuals. Surg Radiol Anat. 2020;42(9):1033-1042. doi:10.1007/s00276-020-02526-3
39.
NemtoiADYPetcuAESusanuSGavrilescuSHabaD. Three-dimensional assessment of the pharyngeal airway and maxillary sinus volumes in individuals with non-syndromic cleft lip and palate. Int J Med Dent. 2015;19(3):225-231.
40.
PooleM. Pharyngeal Airway Assessment in Children With Non-Syndromic Cleft Palate and Cleft Lip and Palate: A CBCT Study. Ohio, US: The Ohio State University; 2021.
41.
RanaSDuggalRKharbandaO. Area and volume of the pharyngeal airway in surgically treated unilateral cleft lip and palate patient: a cone beam computed tomography study. J Cleft Lip Palate Craniofac Anomalies.2015;2(1):27. doi:10.4103/2348-2125.150741
42.
RumanliM. Three Dimensional Evaluation of Pharyngeal Airway Morphology in Individuals With Unilateral and Bilateral Cleft Lip and Palate. Diyarbakır, Turkey: Dicle University; 2017.
43.
SalehESalehJBeaucheminGEl-JalboutRBorsukDE. Velopharyngeal space assessment in patients undergoing Le fort 1 maxillary advancement. Plast Reconstr Surg Glob Open. 2020;8(11):e3232. doi:10.1097/gox.0000000000003232
44.
ShahidiSMomeni DanaieSOmidiM. Comparison of the pharyngeal airway volume between non-syndromic unilateral cleft palate and normal individuals using cone beam computed tomography. J Dent (Shiraz). 2016;17(3 Suppl):268-275.
45.
Steegman R, Schoeman A, Dieters A, Jongsma B, Jansma J, van der Meer J, Ren Y. Three-dimensional volumetric changes in the airway of growing unilateral complete cleft lip and palate patients after bone-anchored maxillary protraction. Am J Orthod Dentofacial Orthop. 2022;162(6):850-860. doi:10.1016/j.ajodo.2021.07.021
46.
SuYHLLiYQinJChenWHouW. Three-dimensional evaluation of the upper airway in patients with non-syndromic cleft lip and palate and skeletal class I population. Stomatology. 2019;39(8):697-700.
47.
Trindade-SuedamIKLimaTFCamposLDYaedúRYFFilhoHNTrindadeIEK. Tomographic pharyngeal dimensions in individuals with unilateral cleft lip/palate and class III malocclusion are reduced when compared with controls. Cleft Palate Craniofac J. 2017;54(5):502-508. doi:10.1597/15-124
48.
XuYGuoSJinHChenR. Three-dimensional computed tomography analysis of pharynx in juvenile patients with unrepaired isolated cleft palate. J Craniofac Surg.2020;31(2):432-435. doi:10.1097/scs.0000000000006143
49.
Xu Y, Zhao S, Shi J, Bai D, Li Y, Ma X. 3-dimensional computed tomographic analysis of the pharynx in adult patients with unrepaired isolated cleft palate. J Oral Maxillofac Surg. 2013;71(8):1424-1434. doi:10.1016/j.joms.2013.01.022
50.
Yoshihara M, Terajima M, Yanagita N, Sakamoto T, Matsunaga S, Hara T, Hasegawa T, Sato I. Three-dimensional analysis of the pharyngeal airway morphology in growing Japanese girls with and without cleft lip and palate. Am J Orthod Dentofacial Orthop.2012;141(4 Suppl):S92-101. doi:10.1016/j.ajodo.2011.09.011
51.
AgarwalAMarwahN. Assessment of the airway characteristics in children with cleft lip and palate using cone beam computed tomography. Int J Clin Pediatr Dent.2016;9(1):5-9. doi:10.5005/jp-journals-10005-1324
52.
CorreiaS. Influence of Cleft Lip and Palate on the Volume of the Upper Airway. Coimbra, Portugal: University of Coimbra; 2016.
53.
Rajion ZA, Al-Khatib AR, Netherway DJ, Samsudin AR, Hassan R, Noor NM. The nasopharynx in infants with cleft lip and palate. Int J Pediatr Otorhinolaryngol.2012;76(2):227-234. doi:10.1016/j.ijporl.2011.11.008
54.
SuYPYLiYLuoYHouWHanL. Analysis of upper airway symmetry between patients with non-syndromic cleft lip and palate and skeletal class I. Stomatology. 2022;42(7):617-621.
55.
TakahashiMYamaguchiTLeeMK, et al.Three-dimensional assessment of the pharyngeal airway in Japanese preschoolers with orofacial clefts. Laryngoscope.2020;130(2):533-540. doi:10.1002/lary.27957
56.
JakobsoneGNeimaneLKruminaG. Two- and three-dimensional evaluation of the upper airway after bimaxillary correction of class III malocclusion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2010;110(2):234-242. doi:10.1016/j.tripleo.2010.03.026
57.
LoweAAFleethamJAAdachiSRyanCF. Cephalometric and computed tomographic predictors of obstructive sleep apnea severity. Am J Orthod Dentofacial Orthop. 1995;107(6):589-595. doi:10.1016/s0889-5406(95)70101-x
58.
Durão AR, Pittayapat P, Rockenbach MI, Olszewski R, Ng S, Ferreira AP, Jacobs R. Validity of 2D lateral cephalometry in orthodontics: a systematic review. Prog Orthod. 2013;14(1):31. doi:10.1186/2196-1042-14-31
59.
BaumrindSFrantzRC. The reliability of head film measurements. 1. Landmark identification. Am J Orthod. 1971;60(2):111-127. doi:10.1016/0002-9416(71)90028-5
60.
MovahhedianNAkbarizadehFKhojastepourLSardarianARPakshirHRAhrariF. Assessment of mandibular characteristics in patients affected with β-thalassaemia major: a retrospective case-control study. Int Orthod. 2020;18(4):776-783. doi:10.1016/j.ortho.2020.06.008
61.
ZimmermanJNLeeJPliskaBT. Reliability of upper pharyngeal airway assessment using dental CBCT: a systematic review. Eur J Orthod.2017;39(5):489-496. doi:10.1093/ejo/cjw079
ArasIOlmezSDoganS. Comparative evaluation of nasopharyngeal airways of unilateral cleft lip and palate patients using three-dimensional and two-dimensional methods. Cleft Palate Craniofac J. 2012;49(6):e75-e81. doi:10.1597/12-004
64.
WermkerKJungSJoosUKleinheinzJ. Nasopharyngeal development in patients with cleft lip and palate: a retrospective case-control study. Int J Otolaryngol. 2012;2012(2012):458507. doi:10.1155/2012/458507
65.
ImamuraNOnoTHiyamaSIshiwataYKurodaT. Comparison of the sizes of adenoidal tissues and upper airways of subjects with and without cleft lip and palate. Am J Orthod Dentofacial Orthop. 2002;122(2):189-194. discussion 194-5.
66.
RoseEThissenUOttenJEJonasI. Cephalometric assessment of the posterior airway space in patients with cleft palate after palatoplasty. Cleft Palate Craniofac J. 2003;40(5):498-503. doi:10.1597/1545-1569_2003_040_0498_caotpa_2.0.co_2
67.
OosterkampBCRemmelinkHJPruimGJHoekemaADijkstraPU. Craniofacial, craniocervical, and pharyngeal morphology in bilateral cleft lip and palate and obstructive sleep apnea patients. Cleft Palate Craniofac J. 2007;44(1):1-7. doi:10.1597/05-175
68.
FarronatoGKairyteLGianniniLGalbiatiGMasperoC. How various surgical protocols of the unilateral cleft lip and palate influence the facial growth and possible orthodontic problems? Which is the best timing of lip, palate and alveolus repair? Literature review. Stomatologija. 2014;16(2):53-60.
69.
JayaramRHuppaC. Surgical correction of cleft lip and palate. Front Oral Biol. 2012;16(16):101-110. doi:10.1159/000337664
70.
SinhaSPBajracharyaMHuangC-SKoEW-C. Does cleft lip and palate affect the severity of malocclusion?Clin Oral Investig.2023;27(12):7557-7567. doi:10.1007/s00784-023-05345-z
71.
Nicholas JungbauerWPouporeNSNguyenSACarrollWWPechaPP. Obstructive sleep apnea in children with nonsyndromic cleft palate: a systematic review. J Clin Sleep Med.2022;18(8):2063-2068. doi:10.5664/jcsm.10020
72.
SteegmanRHogeveenFSchoemanARenY. Cone beam computed tomography volumetric airway changes after orthognathic surgery: a systematic review. Int J Oral Maxillofac Surg. 2023;52(1):60-71. doi:10.1016/j.ijom.2022.05.013
73.
ShokriARamezaniKAfsharAPoorolajalJRamezaniN. Upper airway changes following different orthognathic surgeries, evaluated by cone beam computed tomography: a systematic review and meta-analysis. J Craniofac Surg.2021;32(2):e147-e152. doi:10.1097/scs.0000000000006940
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