Obstructive sleep apnea (OSA)

In a healthy sleeping child, the mouth is

typically closed, the oral cavity is

collapsed, and the nasopharynx and

hypopharynx are patent with minimal

wall motion

Obstructive Sleep Apnea in Pediatric Patients

UPPER AIRWAY OBSTRUCTION • Correct normal resistance is 2 to 3.5 cm H2O/L/Sec and

results in high tracheobronchial airflow which enhances the oxygenation of the most peripheral pulmonary alveoli.

• Mouth breathing causes a lower velocity of incoming air and eliminates nasal resistance. Low pulmonary compliance results .

• According to blood gas studies, mouth breathers have 20% higher partial pressure of carbon dioxide and 20% lower partial pressures of oxygen in the blood, linked to their lower pulmonary compliance and reduced velocity.

Upper Airway Resistance Syndrome

• Upper Airway Resistance Syndrome or UARS is a sleep disorder characterized by airway resistance to breathing during sleep. The primary symptoms include daytime sleepiness and excessive fatigue.

Adenoids

• The adenoids are absent at birth and then rapidly proliferate during infancy. The adenoids reach their maximum size between 2 and 10 years of age and then begin to progressively decrease in size beginning in the teenage years.

• Adenoids larger in size than 12 mm and associated with interim collapse of the posterior nasopharynx on the cine MR images should be considered enlarged.

Adenoids

• The adenoids, along with the tonsils, help prevent agents such as bacteria and viruses from entering the body. The adenoids are made up of a group of blood cells that create antibodies. Antibodies are proteins that neutralize foreign substances in the body. When infection or inflammation occurs, the adenoids can enlarge. Since they are seated at the back of the nasal cavity, the swollen adenoids can block airflow through the nose.

Enlarged Adenoids and Their Symptoms

• Breathing through the mouth instead of the nose most of the time

• Nose sounds "blocked" when the person speaks

• Noisy breathing during the day

• Recurrent ear infections

• Snoring at night

• Breathing stops for a few seconds at night during snoring or loud breathing (sleep apnea)

facial growth

• The age of four (4), 60 percent of the craniofacial skeleton has reached its adult size. By the age of twelve, 90 percent of facial growth has already occurred.

• By age seven (7) the majority of the growth and development of the maxilla is complete and by age nine (9) the majority of the growth and development of the mandible is complete.

Facial growth is coupled with adenoidal growth

UPPER AIRWAY OBSTRUCTION AND MOUTH BREATHING

• Upper airway obstruction and mouth breathers demonstrated considerable backward and downward rotation of the mandible, increased overjet, increase in the mandible plane angle, a higher palatal plane, and narrowing of both upper and lower arches at the level of canines and first molars compared to the nasal breathers group.

Adenoidal hypertrophy

• The adenoids, along with the tonsils, help prevent agents such as bacteria and viruses from entering the body. The adenoids are made up of a group of blood cells that create antibodies. Antibodies are proteins that neutralize foreign substances in the body. When infection or inflammation occurs, the adenoids can enlarge. Since they are seated at the back of the nasal cavity, the swollen adenoids can block airflow through the nose.

Obstruction of upper airways Contributing factors

• Contributing factors in the obstruction of upper airways include: anatomical airway constriction, developmental anomalies, macroglossia, enlarged tonsils and adenoids, nasal polyps and allergic rhinitis.

• Enlarged adenoids as the major contributing factor.

Adenoid hypertrophy and the development of skeletal dental

abnormalities.

• Airway obstruction, resulting from nasal cavity or pharynx blockage, results in postural modifications such as open lips, lowered tongue position, anterior and posteroinferior rotation of the mandible, and a change in head posture. These modifications take place in an effort to stabilize the airway.

Enlarged adenoids

• Enlarged adenoids correlated with the open mouth position.(AJR Am J Roentgenol. 2002 Aug;179(2):503-8 )

• The nasopharynx and hypopharynx changes only minimally with respiration any motion greater than 5 mm should be considered abnormal.

• Adenoid enlargement most likely does play a role in the development of obstruction in obstructive sleep apnea.

Develop of the midface

• The relationship between the naso-maxillary complex and the cranial base is significant for aesthetic reasons and proper facial bone, muscle and soft tissue support.

• An improper airway will affect the global individual growth.

• Additionally, muscle adaptions affect dentoskeletal development. The integration of the musculoskeletal system affects respiration, mastication, deglutition, and speech.

Facial growth

• This basic understanding of facial growth and development is relevant as adenoidal tissue enlargement coincides with major facial growth, i.e. they occur simultaneously.

• Facial growth may be restricted by abnormal development of adenoidal tissue resulting in abnormal swallowing and breathing patterns.

Habitual mouth breathing may result in muscular and postural anomalies

• Facial structures are modified by postural alterations in soft tissue that produce changes in the equilibrium of pressure exerted on teeth and the facial bones . Additionally, during mouth breathing, muscle alterations affect mastication, deglutition and phonation because other muscles are relied upon.

Dentofacial changes associated with nasal airway blockage

• Mouth breathers, often exhibited narrow V-shaped dental arches.

• This narrow jaw is a result of mouth breathers keeping their lips apart and their tongue position low. The imbalance between the tongue pressure, and the muscles in the cheek, result in cheek muscles compressing the alveolar process in the premolar region. Simultaneously, the lower jaw postures back. These simultaneous actions have been termed the compressor theory

The relationship of airway obstruction and dentofacial

structures

黃奇卿醫師 中華民國美容醫學專科醫師

口腔暨顏面美學重建醫學會理事長 台北醫學大學臨床講師

DDS ,Taipei Medical University Chairman of the Facial Beauty & Dento-maxillofacial esthetics reconstruction

medical Society , Taiwan Specialty in Chinese Society of Cosmetic surgery and anti-aging medicine

The relationship of airway obstruction and dentofacial structures

• Airway obstruction, coupled with loss of lingual and palatal pressure of the tongue, produces alterations in the maxilla. The positioning of the tongue also plays an important role in mandibular development. The tongue displaced downward can lead to a retrognathic mandible; and an interposed tongue can lead to anterior occlusal anomalies.

The relationship of airway obstruction and dentofacial structures

• maxillary changes can be viewed in the transverse direction, producing a narrow face and palate often linked with cross bite; in the anteroposterior direction, producing maxillary retrusion; and in the vertical direction causing an increase in palatal inclination as related to the cranial base and excessive increases of the lower anterior face height.

• The most commonly found occlusal alterations are cross bite (posterior and/or anterior), open bite, increased over jet, and retroclination of the maxillary and mandibular incisors.

• Correct nasal breathing facilitates normal growth and development of the craniofacial complex .

• Important motor functions such as chewing and swallowing depend largely on normal craniofacial development.

• Any restriction to the upper airway passages can cause nasal obstruction possibly resulting in various dentofacial and skeletal alterations.

• 1. The cranial base must develop properly;

• 2. The naso-maxillary complex must grow down and forward from the cranial base;

• 3. The maxilla must develop in a linear and lateral fashion;

• 4. A patent airway must develop properly.

UPPER AIRWAY OBSTRUCTION AND MOUTH BREATHING

• Upper airway obstruction and mouth breathers demonstrated considerable backward and downward rotation of the mandible, increased overjet, increase in the mandible plane angle, a higher palatal plane, and narrowing of both upper and lower arches at the level of canines and first molars compared to the nasal breathers group.

Adenoidal hypertrophy

• The adenoids, along with the tonsils, help prevent agents such as bacteria and viruses from entering the body. The adenoids are made up of a group of blood cells that create antibodies. Antibodies are proteins that neutralize foreign substances in the body. When infection or inflammation occurs, the adenoids can enlarge. Since they are seated at the back of the nasal cavity, the swollen adenoids can block airflow through the nose.

obstruction of upper airways Contributing factors

• Contributing factors in the obstruction of upper airways include: anatomical airway constriction, developmental anomalies, macroglossia, enlarged tonsils and adenoids, nasal polyps and allergic rhinitis.

• Enlarged adenoids as the major contributing factor.

Teeth grinding in children

• We always said “a lot of kids grind their teeth but they will grow out of it, do not to worry about it”.

• The consequences of teeth grinding in children are often manifested in behavioural problems due to the constant nocturnal arousals. Research has found that children with bruxism have a tendency towards anxiety, stress and hyperactivity. It is also strongly associated with Attention Deficit Hyperactivity Disorder (ADHD).

Children and Bruxism

• Teeth grinding causes nocturnal arousals and is classified as a sleep disorder, however it is also a response to nocturnal arousals that are associated with other sleep disorders. It is a very common complaint of children with mouth breathing, adenotonsillar hypertrophy, obstructive sleep apnoea (OSA), dental occlusion and psycholgical problems. It is also linked to craniomandibular disorders including headaches and temporomandibular joint discomfort.

The incidence of bruxism in allergic children

• There is a correlation between bruxism and upper airway obstruction.

• The cause is obstruction of the eustacian tube (ear tube) by enlarged adenoidal tissue. Bruxing, or movement of the jaw from side to side while in contact with the teeth, relieves pressure by activation of a muscle near the opening of the ear tube (the medial pterygoid).

• As the child moves their jaw from side to side, the little muscle pulls on the ear tube opening, allowing pressure release .

RME

• Maxillary constriction in particular has been postulated to play a role in the pathophysiology of OSA because of its association with low tongue posture that may contribute to the orophayrnx airway narrowing (Subtelny 1954).

• Pirelli et al. grouped 31 children with OSA and followed them up to 4 months after RME treatment. All of these children had their apnea-hypoapnea index decreased while their mean maxillary cross sectional width expanded to about 4.5mm.

Habitual mouth breathing may result in muscular and postural anomalies

• Facial structures are modified by postural alterations in soft tissue that produce changes in the equilibrium of pressure exerted on teeth and the facial bones . Additionally, during mouth breathing, muscle alterations affect mastication, deglutition and phonation because other muscles are relied upon.

Mouth breathing - adenoid face

Long and narrow head

Dental Malocclusion

Droopy lower lip

Upper lip that is shorter then

normal

Gummy smile

Flattened cheek

Dark Circles Under Eyes

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蕭郁庭