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Dr. Barry Raphael gives an overview of a new subspecialty in orthodontics call Airway Orthodontics. This segment provides the rationale for this paradigm shift. (Animations and movies not included).
Citation preview
!
dr. barry raphael the raphael center for integrative education
!
www.learnairwayortho.com drbarry@learnairwayortho.com
Airway-focused Dentistry Mini-Residency
Introduction to Airway Orthodontics
Can you hear me now?
Let’s turn off ringers...
•
2013
Sabuncuoglu O., Med Hypotheses. 2013 Jan 7. pii: S0306-9877(12)00566-X. doi: 10.1016/j.mehy.2012.12.017. [Epub ahead of print]
RO since1983 (31 years...yikes)
Bucknell University 1974 University of Pennsylvania DMD1978
(Three Years in General Practice) Fairleigh-Dickenson University Ortho 1983
Right out of school
Functional Orthodontics
Frankel
Bionator
Twin Block
MARA
Herbst
2008
Soft Tissue Dysfunction is THE cause of malocclusion
Myofunctional Research Co.
Spring, 2009 MRC meeting, Chicago > Terry Carlyle
September, 2009 MRC conference, Coral Gables, Fl.
Myofunctional Orthodontics
Chris Farrell
John Flutter
German Ramierez
Damien O’Brien
Myofunctional Research Co. Rancho Cucamonga
2008-2012
• Oral Myology Basic Course • Joy Moeller • NYC 2011 • LA 2012
Oral Myology
Oral Myology: Levels 2, 3 Kim Benkert Clifton 2012
Habit Cessation Shari Green Clifton, 2013
Biobloc OrthotropicsBBO Mini-residency
Bill Hang Agora Hills
2012-13
BBO Intensive Drs. John and Mike Mew
LSFO 2013
Breathing and SleepButeyko Mentorship
The Breathing Center Woodstock
2010
Breathing Well Programme John Flutter
2010 Ortho-Postural Training Roger Price
2013
Sleep Dentistry Michael Gelb, et.al
NYU 2012,2013
Cranial Osteopathy
Advanced Dento-cranial Orthopedics Bob Walker
2014
ALF, The Team Approach Jim Bronson
2013
Cranial Academy: Basic Course
January 2014
Teaching
Mt. Sinai Pedo Residency Ali Attaie
2010-2014
Montefiore Ortho Residency Tony Maganzini
2012
2009-Present
Golf
0
7.5
15
22.5
30
1983 2006 2013 2014
It’s about the Airway
BTW….I lost 30lbs
“It’s all about Barry And The World of Mouthbreathing”
• Honorarium and Travel Expenses but no vested interest in Myofunctional Research Co. !
• Director, Raphael Center for Integrative Education
Disclosure
Recommended Reading
1.A New Paradigm!1. Airway and Breathing Dysfunction 2. Soft Tissue Dysfunction 3. Chronic Diseases of Lifestyle 4. Malocclusion and Retractive Orthodontics
2. Clinical Application (Session 3)!1.Diagnostics 2.Prevention 3.Undoing the Damage 4.Establishing Good Habits 5.Interdisciplinary Treatment
Airway Orthodontics
Feedback
I agree I like
I disagree I have a problem I have a question
Shelter from the!
Storm
HVAC!Comfortable Environment
Family Living Together
Decor and Activity
“The Roof is Leaking”
“The A/C is broken. I can’t
sleep.”
“Mommy, Lisa’s hogging
bathroom!”
“This place is a mess!”
Chronic Diseases of
Lifestyle
Airway and Breathing
Inefficiency
Soft Tissue Dysfunction
Malocclusion and
OrthodonticsAirway-focused
Pathology
Airway Orthodontics
Chronic Diseases of
Lifestyle
Soft Tissue Dysfunction
Malocclusion and
OrthodonticsAirway-focused
Pathology
Airway and Breathing
Dysfunction
Airway Orthodontics
The Spectrum of SDB
Snoring 8-10%
Normal Prevalence:
OSAS 1-3%
UARS ?
Anatomic Determinants of SleepDisordered Breathing Across the Spectrum of Clinical and Nonclinical Male Subjects* Jerome A. Dempsey, PhD; James B. Skatrud, MD; Anthony J. Jacques, BS; Stanley J. Ewanowski, PhD; B. Tucker Woodson, MD; Pamela R. Hanson, DDS, MS; and Brian Goodman, PhD
CHEST September 2002 vol. 122no. 3 840-851
•Craniofacial morphology and obesity are independent risk factors for apnea
•Maxillary depth predicts AHI
•Jaw shape explains susceptibility to AHI from weight gain
Small maxilla + obesity = 3x SDB Small maxilla + non-obese = 5-7x SDB
• Short maxilla means smaller airway
• Narrow maxilla puts nasopharynx at risk for collapse with loss of muscle tone
Anatomic Determinants of SleepDisordered Breathing Across the Spectrum of Clinical and Nonclinical Male Subjects* Jerome A. Dempsey, PhD; James B. Skatrud, MD; Anthony J. Jacques, BS; Stanley J. Ewanowski, PhD; B. Tucker Woodson, MD; Pamela R. Hanson, DDS, MS; and Brian Goodman, PhD
CHEST September 2002 vol. 122no. 3 840-851
•Risk Factors for Increase AHI (Apnea-Hypopnea Index) • Age • BMI • Position of Hyoid Bone • Size of Airway (and resistance to flow)!• Neck Circumference
OSA Risk Factors
Analysis of anatomical and functional determinants of obstructive sleep apnea. Aihara K, et. al ,Sleep Breath. 2012 Jun;16(2):473-81. Epub 2011 May 15.
Which is easier to breathe through?
Which would you trust most?
Which would you rather have?
Analysis of anatomical and functional determinants of obstructive sleep apnea. Aihara K, et. al ,Sleep Breath. 2012 Jun;16(2):473-81. Epub 2011 May 15.
Narrow, irregular airway >
> increased shear forces >
> negative pressure pulls on soft tissue >
> tissue pulling and trauma (snoring) >
> impairment of mechanoreceptors >
> uncoordinated diaphragm and upper airway muscle contraction >
>DISORDERED BREATHING
Narrow Airway Dynamics
Powell N, Guilleminault C. “Abnormal pharyngeal airflow in obstructive sleep apnea using computational fluid dynamics: Feasibility study.” Proceeding of the 9th World Congress on Sleep Apnea (Seoul, Korea) 2009
Morphology and SDB in children
“Abnormal craniofacial morphology, but not excess body fat, is associated with an increased risk of having SDB in 6–8-year-old children.”
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752
• 491 Finnish children 6–8 years of age
• studied: BMI, occlusion, sleep survey
• Looked for: Frequent snoring, apeas, open-mouth posture
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752
Morphology and SDB in children
Risk Factor Incidence
Obesity 0
Tonsilar Hypertrophy 3.7x
Crossbite 3.3x
Convex Facial Profile 2.6x
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752
Morphology and SDB in children
“A simple model of necessary clinical examinations (i.e. facial profile, dental occlusion
and tonsils) is recommended to recognize children with an increased risk of SDB.”
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752
Morphology and SDB in children
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752
Morphology and SDB in children
Everyday in my practice...
Form problems
Associations between sleep-disordered breathing symptoms and facial and dental morphometry, assessed with screening , Hyunh, et.al., AJODO, 2011, 140:762-70
Sleep Disordered Breathing associated with:
Long and narrow face High mandibular plane angle
Narrow palate Severe crowding
Swollen Tonsils and Adenoids Allergies
Frequent Colds and Infections Habitual Mouth Breathing
Function problems
•16% had long facial form!
•86% had convex profiles (mandible set back from maxilla)!
•Over 50% had daytime mouth open posture
Associations between sleep-disordered breathing symptoms and facial and dental morphometry, assessed with screening , Hyunh, et.al., AJODO, 2011, 140:762-70
Of the 600 orthodontic patients with SDB...
The smallest space behind the tongue (minAx) is the best predictor of NP airway volume
Small mandible: small airway
Airway volume for different dentofacial skeletal patterns!Hakan Ela and Juan Martin Palomob, Am J Orthod Dentofacial Orthop 2011;139:e511-e521
Pharyngeal Airspace is Smaller in Mouthbreathers
Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children Alves, M, et.al., Int J Ped ORL 75 (2011) 1195–1199
Cone Beam and Airway analysis tool
• Exam for Mouthbreathing
• the habitual posture of the lips (apart, even slightly)
• size and shape of the nostrils
• control reflex of the Alar Nasalis
• Glatzel mirror test
• Rhinoscopy
• Adenoid hypertrophy
25 Mouth breathers, 25 Nasal breathers, Avg 8-9 y/o
Pharyngeal Airspace is Smaller in Mouthbreathers
Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children Alves, M, et.al., Int J Ped ORL 75 (2011) 1195–1199
Mouth breather Nasal breather
Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children Alves, M, et.al., Int J Ped ORL 75 (2011) 1195–1199
Pharyngeal Airspace is Smaller in Mouthbreathers
The Importance of Airway in Children
“In this large, population-based, longitudinal study, early-life SDB symptoms had strong, persistent
statistical effects on subsequent behavior in childhood. !
Findings suggest that SDB symptoms may require attention as early as the first year of life.”
Snoring and SDB is dangerous in infants
Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years!Karen Bonuck, PhD,a Katherine Freeman, DrPH,b!Ronald D. Chervin, MD, MS,c and Linzhi Xu, PhDa
PEDIATRICS Volume 129, Number 4, April 2012
“The 2 clusters with peak symptoms before 18 months that resolve thereafter still predicted
40% to 50% increased odds of behavior problems at 7 years.”
“...early childhood SDB effects may only become apparent years later.”
Snoring and SDB is dangerous in infants
Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years!Karen Bonuck, PhD,a Katherine Freeman, DrPH,b!Ronald D. Chervin, MD, MS,c and Linzhi Xu, PhDa
PEDIATRICS Volume 129, Number 4, April 2012
Nighttime symptoms of SDB in kids• Abnormal sleeping position • Bruxism • Chronic, heavy snoring • Delayed sleep onset • Difficulty breathing • Difficulty waking up in AM • Drooling • Enuresis • Frequent awakenings • Insomnia
• Bed Dread • Mouth breathing!• Nocturnal migraine • Nocturnal sweating • Periodic Limb Movement • Restless sleep • Sleep talking • Sleep terror • Sleep walking • Witnessed apnea
Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years!Karen Bonuck, PhD,a Katherine Freeman, DrPH,b Ronald D. Chervin, MD, MS,c and Linzhi Xu, PhDa!
PEDIATRICS Volume 129, Number 4, April 2012
Daytime symptoms of SDB in kids• Morning headache • Mouthbreathing • Morning thirst • Excessive fatigue • Abnormal shyness,
withdrawn, and depressive presentation
• Behavioral problems
• ADHD pattern • Aggressiveness • Irritability • Poor concentration • Learning difficulties • Memory impairment • Poor academic
performance
Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years!Karen Bonuck, PhD,a Katherine Freeman, DrPH,b Ronald D. Chervin, MD, MS,c and Linzhi Xu, PhDa!
PEDIATRICS Volume 129, Number 4, April 2012
Damage to Cognitive Function
Childhood OSA is associated with •Deficits of IQ •Deficit of executive function •Possible neuronal injury in the hippocampus and frontal cortex.
Childhood Obstructive Sleep Apnea Associates with Neuropsychological Deficits and Neuronal Brain Injury Ann C. Halbower, et.al, PLoS Medicine,August 2006 | Volume 3 | Issue 8 | e301
Death, nasomaxillary complex, and sleep in young children Caroline Rambaud & Christian Guilleminault, European Journal of Pediatrics DOI 10.1007/s00431-012-1727-3 Pub Online: April 11, 2012
“all children present a visually recognizable abnormal high and narrow hard palate”
Abrupt Sleep-associated Death• chronic indicators of abnormal sleep • enlargement of upper airway soft tissues • a narrow, small nasomaxillary complex, with or
without mandibular retroposition
• Maxillary Retrusion • Midface Deficiency • Maxillary Hyperdivergency • Long Face Syndrome • Adenoid Facies • Bimaxillary Retrusion • Craniofacial Dystropy
The small maxilla is a major factor in Sleep Disordered Breathing
What causes it?
• The shape of the face determines the shape of the pharyngeal airway
• The smaller the airway, the easier it is to obstruct • Obstructed breathing affects the growing brain
Take Home Message:
Chronic Diseases of
Lifestyle
Airway and Breathing
Dysfunction
Malocclusion and
OrthodonticsAirway-focused
Pathology
Soft Tissue Dysfunction
Airway Orthodontics
Daniel E. Lieberman
“….there is much circumstantial evidence that jaws and faces do not grow to the same size that they used to…” - Daniel Lieberman
The Gothic Arch The Roman Arch
The “Modern” Maxilla
How do you build an arch?
The Roman Arch
No scaffold?
When the tongue rests in the roof of the mouth the teeth erupt around the tongue forming a
normal shaped and sized jaw.
The tongue is the scaffold for the upper jaw
Those children who breathe through the mouth or have the lips apart at rest will not have the
tongue in the roof of the mouth. All of these children will have
an underdeveloped upper jaw.
It will not be big enough for all of the teeth and when the adult teeth erupt they will be crooked.
Harvold’s Monkies
Posture changes Teeth
Lowered mandibular posture, tongue protrusion, and open biteOpen mouth posture retained for 1 year after nose reopened. Facial features retained
• “Orthotropics” • Normal growth of maxilla > Down and Forward • Dysfunctional growth > Down and Narrow • “Maxillary undergrowth is such a constant
feature of modern malocclusion” - AJODO,1979 • Biobloc Therapy
John Mew’s Tropic Premise
“Because the genetic control of skeletal growth is not precise,
the articulation of the teeth and jaws depends upon additional guidance from oral posture.”
John Mew’s Tropic Premise
“ If the tongue at rest is against the palate with the lips lightly sealed and the teeth in or near contact, there will be ideal facial and dental development…something RARE in industrialized societies…”
John Mew’s Tropic Premise
If the tongue is chronically held away from the palate… …the maxilla collapses in all three dimensions.
The Tropic Premise
If the mandible keeps up: Class I Crowded
Then the Mandible Adapts
Mouthbreathing and/or tongue thrust hinders growth : Class II
Then the Mandible Adapts
Low Tongue keeps mandible growing forward: Class III
Then the Mandible Adapts
The Tropic Premise
The Tropic Premise
Craniofacial Dystrophy
Maxilla is Down and Back
The Mandible is Retrognathic
Nasal Cartilage Collapse
Insufficient Mid-Facial Support
2008
Soft Tissue Dysfunction is THE cause of
malocclusion
Soft Tissue Dysfunction is THE cause of malocclusion
The Maxilla and Upper Dentition take the Shape of the Muscles and Muscular Functions that Surround them.
Craniofacial Dystrophy
Soft Tissue Dysfunction is THE cause of malocclusion
“Bone sets the tone but tissue is the issue”
- Mark Cruz
Open Mouth Posture !is the most common and significant
Soft Tissue Dysfunction In children today.
Chronic hyperventilation Hypocapnia Bi-maxillary Dystrophy!Reverse swallow Facial muscle dysfunction Lymph swelling Nasal obstruction Frequent ear infection Snoring SDB, UARS, OSA Learning Dx Heart rate variability Enuresis Poor posture Malocclusion Gingivitis Halitosis
Open Mouth PostureBirth trauma Cranial strains Poor posture Bottle feeding Soft diet Processed foods Immune challenges Oxidative stress Heat Hyperventilation Stress reactions Habits Dental pain Ankyloglossia Macroglossia
• The tongue is the scaffold for the growing maxilla (nature’s
palate expander • Soft Tissue Dysfunction is the cause of Craniofacial Dystrophy • Open Mouth Posture is the most common and significant soft
tissue dysfunction in children today. • Craniofacial Dystrophy is a developmental problem • In CFD, BOTH jaws are retruded
Take Home Message
Airway Orthodontics
Chronic Diseases of
Lifestyle
Airway and Breathing
Dysfunction
Soft Tissue Dysfunction
Malocclusion and
OrthodonticsAirway-focused
Pathology
5,000 years ago When caries and malocclusion
were rare!
There was a time...
Kevin Boyd
Peter Gluckman
Neese and Williams Scott Gilbert
Clark Spencer Larsen
Are we developing the way our genes mean us to be?Darwinian Dentistry
Me...
Who said…•The cause of modern man’s maladies is his lack of “a quiet and natural sleep”.
•Proper breathing regulates digestion and circulation to every part of the body.
•Improper breathing brings imbalance and disease.
•The nostrils are intended to measure and temper the air in support of proper breathing.
George Catlin
George Catlin
“Shut Your Mouth and Save Your Life” 1870
“Shut Your Mouth and Save Your Life” 1870
“That man knows not the pleasure of sleep; he rises in the morning more fatigued than when he retired to rest - takes pills and remedies through the day, and renews his disease every night.”
Weston Price
1870-1948
Nutrition and Physical Degeneration Weston A. Price, DDS, 1939
Malocclusion is a product of the diet of industrialized societies
Obesity Hypertension
Cardiovascular Disease Type 2 Diabetes
Fatty Liver Disease Some Cancers Osteoporosis Depression
The Results of the Mismatch Between Genes and the Environment
Chronic Non-Communicable Diseases of Civilization Western Lifestyle Diseases
Metabolic Syndrome Asthma Autism
Asperger’s Alzheimers ADD/ADHD
Chronic Back Pain
Caries!
Malocclusion!
Sleep Apnea
Its not just Growth and Development
!
Its Growth, Development and Adaptation
!
The Missing Link in Orthodontics Today...
If Malocclusion is caused by Growth and Development...
Genotype Phenotype
Total Growth
If Malocclusion is caused by Growth and Development and Adaptation...
Genotype Phenotype
Total Growth
!
!
!
!
An example of “adaptation”
One of them has crooked teeth.
Another set of twins
3 August 2003 3 August 2003
RHYS - 10Y 11MHow did these teeth get this way?
Different genes than his brother…
1 March 2007 1 March 2007
RHYS - 14Y 5M Four years later, after successful MFO
Text
(Treatment by Dr. Chris Farrell)
RHYS - 16 AUGUST 2007 KYLE - 16 AUGUST 2007
TRAINER BWS MYOBRACE MINIMAL SWA
RHYS & KYLE - 13Y 8MDid genetics make the teeth crooked?
Did genetics fix the face?
• Anthropology informs us that malocclusion is an adaptation - a consequence - of contact with the modern environment
• Genetic predispositions can be influenced by a change in the environment
Take Home Message
….for better or for worse.
Chronic Diseases of
Lifestyle
Airway and Breathing
Dysfunction
Soft Tissue Dysfunction
Airway-focused Pathology
Malocclusion and
Orthodontics
Airway Orthodontics
!
”... more often than is recognized, the peculiarities of lip function may have been the cause of forcing the teeth into the malpositions they occupy”.
Edward H. Angle
1855-1930
From “Malocclusion” 1907Edward H. Angle
Light intermittent forces can affect skeletal growth
Crozat Philosophy and Appliance•Preserve the natural dentition and •Develop the bony structures •Assist the natural shape of the face and jaws to develop to their full biologic potential. •Overall health and well being of the patient
Edward Angle vs Calvin Case
Witzig vs McNamara
NewConn 2009 Extraction vs Non-extraction Debate
The Extraction Wars
1855-1930
5-10% extraction rateV. Kokich F. Bogdan
Passive-Self Ligation
The Damon System
“to match each phase of treatment with the natural force systems of normal growth and development…”
Non-extraction
Non-extraction
Non-extraction
18 Months
26 Months
Non-extraction
Non-extraction
Finding room for all the teeth is not a problem if you start early enough and try to mimic what nature intended.
Protractive vs. Retractive Orthodontics
What is the correct treatment for this?
Craniofacial Dystrophy
Bimax retrusion
Successful dental result
Failed Profile Result
Successful dental result
Failed Profile Result
Everyday in my practice...
What is the appropriate treatment for a Collapsed Maxilla?
Treatment
Headgear?
Class II Elastics?
Mandibular Advancment Appliance? (Herbst, Twin Block,MARA with reciprocal anchorage)
Extractions ?
Treatment
Retraction affects the airway
Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood Makoto Kikuchi, Sleep and Breathing Published online: 17 November 2005©
Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood Makoto Kikuchi, Sleep and Breathing Published online: 17 November 2005©
Retraction affects the airway
Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of Class I bimaxillary protrusion!Qingzhu Wanga; Peizeng Jiab; Nina K. Andersonc; Lin Wangd; Jiuxiang Line,Angle Orthodontist, Vol 00, No 0, 0000 !
(pre-publication 2012)
“the dimension of the velopharynx, glossopharynx, and hypopharynx were
decreased after maximal retraction of anterior teeth with extraction of four premolars…”
“Any factors that can influence the posture and position of tongue and
soft palate may displace them backward and
encroach upon {the pharynx}.”
“the more the incisors were retracted, the more the pharyngeal
airway was reduced.”
Retraction affects the airway
Bilateral SSRO: “the pharyngeal airway was constricted significantly at the oropharyngeal and hypopharyngeal levels at both the short-term and the long-term follow-ups”
Effects of bimaxillary surgery and mandibular setback surgery on pharyngeal airway measurements in patients with Class III skeletal deformities!Fengshan Chen, Kazuto Terada, Yongmei Hua, Isao Saito American !
Journal of Orthodontics & Dentofacial OrthopedicsVolume 131, Issue 3 , Pages 372-377, March 2007
Retraction affects the airway
Sagitall Split Ramus Osteotomy
Lefort I plus SSRO: “bimaxillary surgery rather than only mandibular setback surgery is preferable to correct a Class III deformity to prevent narrowing of the pharyngeal airway space
Backed into a corner...
•
Retraction Orthodontics
If Retraction Mechanics has the potential to hinder the airway, how much retraction is OK?
If snoring is likely to lead to obstruction someday, how much snoring is “normal” for a child?
• Orthodontics is about the teeth • Orthopedics is about the bones • Orthotropics is about the direction of growth • Most orthodontic technique are Retractive - even
“functional appliances” - and work against forward growth
Take Home Message
Chronic Diseases of
Lifestyle
Airway and Breathing
Dysfunction
Soft Tissue Dysfunction
Malocclusion and
OrthodonticsAirway-focused Orthodontics
Airway Orthodontics
“If it were possible to improve faces to the disadvantage of the teeth, where would our duty lie?” -AJODO, 1979
John Mew
Esthetics? Proper Breathing?
Remember the Airway!“Consequently the most important
missing diagnosis is the airway. !
Nevertheless, breathing is the most important action for human beings to live; we forgot the airway to make a diagnosis
of the orthodontic patients.”
Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood Makoto Kikuchi, Sleep and Breathing Published online: 17 November 2005©
Treatment Goals Based on Upper Incisor (UI)
Incisor Goals
Type 4 Treatment: Retract/Extrude UI
Extraction Orthodontics, Retraction Ortho, Distalization Ortho
Incisor Goals
Type 3 Treatment: Maintain UI
Functional Orthodontics, Expansion Orthodontics, Distalization Ortho
Incisor Goals
Type 2 Treatment: Expansion enough to uncrowd
Myofunctional Ortho, Myofunctional Therapy, Crozat, ALF, Expansion Orthodontics
Incisor Goals
Type 1 Treatment: Place U1 in ideal position
Biobloc Orthotropics, Orthognathic Surgery, Distraction Osteogenesis
Protraction affects the airway
From Dr. K. Li
Effect of mono- and bimaxillary advancement on pharyngeal airway volume: cone-beam computed tomography evaluation.!Hernández-Alfaro F, Guijarro-Martínez R, Mareque-Bueno J.J Oral Maxillofac Surg. 2011 Nov;69(11):e395-400. Epub 2011 Jul 27
The pharyngeal airway gets larger !
The average percentage of increase was: 69.8% with MMA 78.3% with Mandibular Advancement 37.7% with Maxillary Advancement
Protraction affects the airway
From Dr. K. Li
• MMA 100% successful !
• Results similar to CPAP
Maxillomandibular Advancement Surgery in a Site-Specific Treatment Approach for Obstructive Sleep Apnea!in 50 Consecutive Patients*!
Jeffrey R. Prinsell, DMD, MD, CHEST / 116 / 6 / DECEMBER, 1999
Protraction affects the airway
• 25 x 11 year olds • Reverse Pull HG, 350 g, 14h/d for 6 months • Follow-up 4 years post-treatment • 2D analysis only (cephs)
“...the maxilla continued to grow forward after treatment, which was maintained in the long-term observation.”
“improved the nasopharyngeal and oropharyngeal airway dimensions initially, …. was maintained at long-term follow-up.”
Protraction affects the airway
Effects of Maxillary Protraction and Fixed Appliance Therapy on the Pharyngeal Airway !Emine Kaygısız et.al., Angel Orthodontist, Volume 79, Issue 4 (July 2009)
Mandibular Advancement
Appliances open the airway by bringing the tongue forward.
Mandibular advancement devices are an alternative and valid treatment for pediatric obstructive sleep apnea syndrome. Maria Pia Villa, Silvia Miano, Alessandra Rizzoli,Sleep Breath (2012) 16:971–976
Protraction affects the airway
Mandibular advancement devices are an alternative and valid treatment for pediatric obstructive sleep apnea syndrome. Maria Pia Villa, Silvia Miano, Alessandra Rizzoli,Sleep Breath (2012) 16:971–976
Expansion affects the airway
RME may relieve nasal breathing problems by increasing the transverse dimensions of the maxilla, which in turn widens the nasal cavity.
Mandibular advancement devices are an alternative and valid treatment for pediatric obstructive sleep apnea syndrome. Maria Pia Villa, Silvia Miano, Alessandra Rizzoli,Sleep Breath (2012) 16:971–976
“Orthodontic therapy should be encouraged in pediatric OSAS, and an early approach may permanently modify nasal breathing
and respiration, thereby preventing obstruction of the upper airway.”
Protraction affects the airway
• 53 patients, avg 12 years old • Biobloc treatment for avg 20 months • Posterior airway measured on ceph
Evalutation of the Posterior Airway Space Following Biobloc Therapy: Geometric Morphometrics. G. Dave Singh, Ana Barcia-Motta, William Hange, Cranio April 2007, (25:2)
Orthotropics affects the airway
31% Increase in nasopharynx area 23% Increase in oropharynx area 9% Increase in hypopharynx area
Repenting for past sins affects the airway
Repenting for past sins affects the airway
What really matters is whether treatment increases, or at least does not reduce, the tongue space.
- Bill Hang
Orthodontics in the 21st Century
Conventional!Orthodontics
Airway!Orthodontics
Genetic Tooth-Focused
Esthetics Primary Treating Symptoms
Airway Ignorant
Adaptation Muscle-Focused
Esthetics Secondary Treating Causes Airway Concious
Form Function
Orthodontics
Myofunctional
Conventional!Orthodontics
Airway!Orthodontics
The Health/Pathology Spiral
Form
Form
Function
Function
Function
Declining HealthImproving Health
A Pathology Cycle
Declining Health
FunctionMouthBreathing and
Low Tongue
FormLong FaceFunction Weak MMuscles
FormNarrow Palate
Function Deviate Swallow
FormSwollen T&A
Crooked Teeth Form
Breaking The Cycle
Declining Health
FunctionMouthBreathing and
Low Tongue
FormLong FaceFunction Weak MMuscles
FormNarrow Palate
FunctionSwallowing with Active
Facial MusclesCrooked Teeth
Form
FormSwollen T&A
Conventional Orthodontics
Backed into a corner...
Stuck with Retractive Orthodontics
Breaking The Cycle
Declining Health
FunctionMouthBreathing and
Low Tongue
FormLong FaceFunction Weak MMuscles
FormNarrow Palate
FunctionSwallowing with Active
Facial MusclesCrooked Teeth
Form
FormSwollen T&A
Airway-Centric Orthodontist
• Chad M. Ruoff & Christian Guilleminault • Sleep Breath, 2011, pub online, May 11
Orthodontics and Pediatric OSA
“Although dentists and orthodontia recognize the importance of evaluating and treating OSA,
they have yet to realize how well-positioned they are for the prevention of sleep-disordered
breathing (SDB).”
The “environment plays an important role in the development of SDB. Therefore, manipulation of
environmental factors may decrease the development of OSA.
!
There is a need to better define these environmental factors and predict those at risk
for the development of OSA so that orthodontists and dentists can both treat and prevent OSA.”
• Chad M. Ruoff & Christian Guilleminault • Sleep Breath, 2011, pub online, May 11
Orthodontics and Pediatric OSA
Dr. Stephen Sheldon Professor of Pediatrics, Northwest University School of Medicine Director, Sleep Medicine Lurie Children’s Hospital, Chicago
Defining Environmental Factors
•Chronic Naso-pharyngeal Obstruction •Tongue form aberrations (Frenum and tongue-tie) •Open Mouth Rest Posture •Myofunctional disorders (Swallowing, chewing,etc.) •Chronic Hyperventilation and Hypocapnia •Breathing Disordered Sleep (OSA, UARS, snoring) •Bruxism and parafunctions •TMD and facial pain components •Cranial and postural issues • Malocclusion
Airway-Related Craniofacial Dysfunctions
• Early Feeding and Nutrition • Allergies, Asthma, URT infections • Posture • Airway, Breathing, and Sleep Disorders • Soft Tissue Dysfunctions (Tongue Thrust, Open
Mouth)
Treating the Cause
Instead of crooked teeth being The Problem, They are just a SYMPTOM of something larger
• Adult SDB and OSA
• Narrow Jaws and Faces
• Soft Tissue Dysfunction
• Early Parafunctional Habits, esp Open Mouth Posture
• Environmental Stressors
• CPAP, MARA,UPPP, SurgWhere’s the best
place to start treatment? Here?
Or H
ere?
Treating the Cause
• The primary goal of Airway Orthodontics is to enhance and protect the NP airway.
• It is always Form AND Function, spiraling in time. • AO intervenes with Form AND Function. • AO addresses the Causes of malocclusion • Malocclusion is a Symptom of another Imbalance • Malocclusion is the body’s Solution to an imbalance
elsewhere in the body.
Take Home Message
Chronic Diseases of
Lifestyle
Airway and Breathing
Dysfunction
Soft Tissue Dysfunction
Malocclusion and
OrthodonticsAirway-focused Orthodontics
Airway Orthodontics
Address!Stress
Airway and Breathing
First
Fix!Function
Fix!Form
• In session Three we will learn • The Goals of Airway Orthodontics (Breathe through the…) • The Strategies of Airway Orthodontics (An ounce of…) • The Techniques of AO (This is not you father’s palate expander) • Ways to bring AO into your practice.
More to come….
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