nasal airway and malocclucion / orthodontic courses by indian dental academy

NASAL AIRWAY AND MALOCCLUSION

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INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

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.


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


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.


PHARYNXANATOMY

-NASOPHARYNX-ORO-PHARYNX-LARYNGOPHARYNX

PHYSIOLOGIC MEASUREMENTS-TIDAL VOLUME-500ML-INSPIRATORY RESERVE VOLUME-3000ML.-VITAL CAPACUTY-4600ML.


PHRYNX AND RADIOLOGIC VIEW-56 ATHANSIOU


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


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.


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.


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.


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.


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.


EFFECTS OF OSA

• SYMPTOMS during sleep– Snoring– Abnormal motor activity – Disturbed nocturnal sleep– Sensation of choking– Heart burn – Nocturia– Heavy sweating


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


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.


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


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


• 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


airway


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


Spirometry 462-PHYSIO

SPIROMETER


Rhino-snort

SNORT APPARATUS


Rhino-graphs-

OI,OE,NI,NE GRAPHS


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.


Head posturePg 7 petrovic

EXTENSION OF HEAD TO FACILIATE AIRWAY


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.


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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II

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CC

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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


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


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


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


AIRWAY BEFORE &AFTER RPE


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

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

Thank you

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nasal airway and malocclucion / orthodontic courses by indian dental academy

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