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NASAL AIRWAY AND MALOCCLUSION
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INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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INTRODUCTIONNasal airway patency and malocclusion have long been INTERRELATED. It seems obvious that severe malocclusion must make it difficult for the individual to breathe, incise, chew,swallow,and speak.THE REVERSE OF THIS COULD ALSO BE TRUE!Alterations or adaptations in function can be an etiologic factor for malocclusion, by influencing the pattern of growth and development and thereby resulting in malocclusion.
This seminar attempts to compile the views supporting and opposing nasal obstruction as a cause for malocclusion.
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REVIEW OF LITERATUREThe debate in orthodontics concerning the role of respiration in the etiology of malocclusion and facial deformity dates back to over 100 years.ROBERT –1843-nasal obstruction hindered palatal descent
SIEBENMANN-1897-associated adenoid blockage to narrow faces
MICHEL-1876 &BLOCK-1888-air flow prevented palatal descent
MEYER-1870-low tongue position and mouth breathing lead to unopposed buccal forces on maxillary dentition
NEIVERT-1939-adenoids as cause to induce mouth breathing
SPRAWSON-1947-emphasized role of naso pharyngeal tissues
RICKETTS-1968-lack of nose function lead to improper palatal descent
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LINDER-ARONSON-1970-narrow dental arch and upright incisors due to adenoids.
BUSHY-1974-Compared monzygotic twins with and without adenoids
CASE-1984DAVIS-1979WOODSIDE &LINDER-ARONSON-1979.1991-altered head
posture due to mouth breathing
Ulla Crouse & Warren et all- state that the nasal resistance is 3.5-4.5cm H2O/L/sec. In bnormal individuals
The optimum nasal airway size is 0.4 cm2 – decreased in mouth breathers, -there is long drape of velum, soft tissue pillars are displaced medially, enlarged tonsils.
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PHARYNXANATOMY
-NASOPHARYNX-ORO-PHARYNX-LARYNGOPHARYNX
PHYSIOLOGIC MEASUREMENTS-TIDAL VOLUME-500ML-INSPIRATORY RESERVE VOLUME-3000ML.-VITAL CAPACUTY-4600ML.
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PHRYNX AND RADIOLOGIC VIEW-56 ATHANSIOU
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MOUTH BREATHINGETIOLOGY
ANATOMICAL-DNS,CONGENITAL MICROGENIAPATHOLOGICAL-ADENOIDS,TONSILS,HABITUAL
“ADENOID FACIES”—coined at GUY’S hospital,londonconstitutes the following-long faceconstricted upper dental archexposed upper incisorsreceded lower jawshort upper lipassociated habits
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OBSTRUCTIVE SLEEP APNEA
• Definition: condition caused either by complete occlusion or partial
collapse of the upper airway despite the presence of simultaneous respiratory effort. Cessation occurs at the level of nostrils and mouth. Condition is considered pathologic when the episodes last for at least ten seconds and at a frequency of 30 times or more during 7 hrs. of nocturnal sleep in REM and especially in non REM stages of sleep.
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TYPES
• CENTRAL APNEA: cessation of diaphragmatic excurtions
• UPPER AIRWAY APNEA: obstruction to air flow pass the oro pharynx but with persistent diaphragm movements.
• MIXED APNEA: cessation of air flow and absent respiratory effort early in the episode, followed by unsuccessful attempts at respiration later in the episode.
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PATHOGENESIS
• Functional obstruction of oro pharynx seems to be caused by recurrent closure of upper pharyngeal wall and posterior movt. of the tongue.
• There is a secondary downward movement of the soft palate and hypo pharynx closure from abortive thoracic and diaphragmatic respiratory movements.
• The cause for upper pharynx collapse and pathogenesis of day time somnolence remains to be explained.
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Body position, sleep awake state and cervico cranio facial morphology are important determinence of size and shape 0f the pharynx.
Cervico cranio dismorphology,obesity, alcoholism are predisposing factors for pharyngeal air flow obstruction during sleep.
Nocturnal sleep recording in these patients is characterized by upto 100’s of episodes of apnea with abrupt awakening, the PO2 falls during apnea, the PCO2 rises and both are reversed as the patient awakens and takes 4 or 5 breaths. The cycle repeats as the patient laps into sleep.
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ROLE OF GENIOGLOSSUS MUSCLE IN OSA
• OSA is characterized by recurrent upper air way occlusion during inspiration.
• The genioglossus muscle is believed to contribute to this.• GG muscle activity has been demonstrated in phase with
inspiration during sleep.• Preferential activation of this muscle is correlated with
pharyngeal opening and resolution of apnea.• A dynamic relationship between supraglottic pressure and
GG muscle amplitude has been postulated to explain upper airway occlusion in subjects with OSA.
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EFFECTS OF OSA
• SYMPTOMS during sleep– Snoring– Abnormal motor activity – Disturbed nocturnal sleep– Sensation of choking– Heart burn – Nocturia– Heavy sweating
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SIGNS:– large tongue – elongated soft palate– reduced pharyngeal length – decreased posterior air space– increased gonial angle– increased upper and lower facial height – steep occlusal plane – elongated upper and lower incisors
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DIAGNOSIS
• Is by POLYSOMNOGRAPHYMeasurements are made to assess sleep stages of breathing
and gas exchange to detect sleep stages.PSG ensures the no. of apnic episodes per hour of sleep
expressed by respiratory(Disturbance Index)measurements of chest and abdominal efforts and oxygen saturation.
• Airway measurement by cephalometric 3D imaging – lateral pharyngeal dimension.
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TREATMENTMedical: Weight loss is beneficialNasal vaso constriction spraysWithdrawal of respiratory depressing alcohol (antihistamines
and tranquilizers)Surgical:• Uvulo palato pharnygoplasty • Tracheostomy• Expansion hyoid plasty• Mandibular advancement • Sectioning of hyoid
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DIAGNOSIS OF MOUTH BREATHING
• CLINICAL EXAMINATION:-as patient to hold water in the mouth-use double sided mouth mirror or cotton wisps-facial pattern – long face with incompetent lips not necessary indicate mouth breathing pattern
• CEPHALOMETRIC ANALYSIS:- Mc NAMARA airway analysis
upperlower
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• Upper pharyngeal width – the point on posterior outline on soft palate to closest point on pharyngeal wall – 15 to 20 mm in width.values 2mm or less indicate airway impairment
• Lower pharyngeal width from point of intersection of posterior border of tongue and inferior border of mandible to the closet point on posterior pharyngeal wall – 11 to 14mm.usually values are high due to anteriorly positioned tongue as the adenoids are enlarged
• OTHER CEPHALOMETRIC FINDINGS:vertical growth patternincreased ANB increased gonial angledecreased mandibular lengthsteep MP angle over erupted upper posterior segments
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airway
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OTHER DIAGNOSTIC TESTS
• SPIROMETRY• OXIMETER- to evaluate oxy-Hb level • RHINOMANOMETRY-instrument used to measure nasal
patencySTEDMAN’S medical dictionary defines it as “study of nasal obstruction and nasal airflow characteristics
PNEUMOTACHOGRAPH-device consisting of flow meter, pressure-measuring manifold,and a recording instrument
• RESPIROMETRY-study of both nasal and oral respiratory function
SNORT – simultaneous nasal and oral respiratory technique
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Spirometry 462-PHYSIO
SPIROMETER
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Rhino-snort
SNORT APPARATUS
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Rhino-graphs-
OI,OE,NI,NE GRAPHS
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EFFECTS OF AIRWAY OBSTRUCTIONS
• HEAD POSTURE CHANGES:BENI SOLOW and ANTJE TALLGREN
extension of the head in relation to the cervical column was found in connection to large anterior facial ht. And small post. Facial ht., small anterio-posterior dimension, large mandibular inclination to anterior cranial base & to nasal plane, facial retrognathism, large cranial base angle and small naso-pharyngeal space.
RICKETTS(1968)-reported subjects with enlarged adenoid with extension of head &forward and downwardly positioned tongue.
NINIMA & COLE :noted 5 degree increase in cranio facial angle associated with nasal obstruction.
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Head posturePg 7 petrovic
EXTENSION OF HEAD TO FACILIATE AIRWAY
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MANDUBULAR ROTATION:In response to enlarged adenoids which occupy the posterior pharyngeal space the tongue gets anteriorly positioned leading to downward and backward rotation of the mandible.The ANB angle increases , MP angle increases, LAFH increases-LONG FACE SYNDROME.
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CHRONIC NASAL OBSTRUCTION
MOUTH BREATHING &HEAD EXTENSION
MANDIBLE &TONGUE ARE LOWERED
FACIAL HT. INCREASES
POSTERIOR TEETH SUPRA ERUPT
ANRETIOR OPEN BITE &INCREASED OVERJET
INCREASED CHEEK PRESSURE
COLLAPSED DENTAL ARCHES
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TREATMENT OPTIONS
• TREATING THE ETIOLOGIC FACTORS: TONSILLECTOMY,ADENOIDECTOMY,CORRECTION OF
DNS,NASAL POLYPSORTHODONTIC:
ORAL SCREENRAPID MAXILLARY EXPANSIONMANDIBULAR ADVANCEMENT
SURGICAL :HYIOD BONE REPOSITIONINGBI JAW ADVANCSMENTMANDIBULAR ADVANCEMENT
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TONSILLECTOMY-tonsils attain max. size during 9-10 yrs. of age,after which they regress in size, their removal enhances nasal pathwayORAL SCREEN:alters breathing from oral to nasal –progressive closure of holes preferred.
MANDIBULAR ADVANCEMENT:LIU et al- A.O.1997 mandibular repositioning is most effective in mild to moderate obstructive sleep apnea Mandibular repositioning enhances retro pharyngeal air space thereby increasing nasal airway patency
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Respiratory factors for RPE– (Gray and Brogan)• anterior nasal stenosis• septal deformity• recurrent E.N.T./sinus inf.• allergic rhinitis• as a preliminary measure for septoplasty
RAPID MAXILLARY EXPANSION
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Rpe effects –nasal airway• Inflation of nasal passages resulting in increased air flow has been one of the fascinating
results of RPE. To the unfortunate pt.who is forced to breathe thru’ his/her mouth such a treatment result is boon of unestimatable value. anterior nasal stenosis
reduced nasal airway
forced mouth breathing
faulty tongue posture &high arch palate
enlarged adenoids
ADENOID FACIESBISHARA-the avg. increase in width of nasal cavity at it’s floor is about 1.9mm.,but can
widen as much as 8-10mm.at the level of inferior turbines
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AIRWAY BEFORE &AFTER RPE
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RPE activated
max. splits
ptyg.plates splay
max. moves down &forward
3-D-increase in nasal cavity
increase volume in floor of nose
site of inferior conchae
maximum respiratory air is seen
INCREASE IN AIRWAYwww.indiandentalacademy.com
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CONCLUSIONIN SPITE OF THE LONG HISTORY OF RESEARCH BETWEEN RESPIRATION AND MALOCCLUSION ONLY NOW ARE WE HEADING IN THE RIGHT DIRECTION. WITH NEWER TECHNIQUES AS SNORT, PNEUMOTOGRAPH FOR AIRFLOW MEAUREMENT, PRECISE VALUES INDICATING EXTENT OF ORAL COMPONENT OF RESPIRATION ARE AVAILABLE.HENCE UNDUE RESORT TO SURGICAL EXCISION OF ADENOIDS CAN BE AVERTED.
MORE RESEARCH IS NEEDED INTO PREVENTIVE ASPECT OF OBSTRUCTED AIRWAYS !www.indiandentalacademy.com
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Thank you
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