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Airway Mini-residency: Intro to Airway Orthodontics

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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).

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).

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  • 1. ! dr. barry raphael the raphael center for integrative education ! www.learnairwayortho.com drbarry@learnairwayortho.com Airway-focused Dentistry Mini-Residency Introduction to Airway Orthodontics
  • 2. Can you hear me now? Let’s turn off ringers...
  • 3. • 2013
  • 4. 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]
  • 5. RO since1983 (31 years...yikes) Bucknell University 1974 University of Pennsylvania DMD1978 (Three Years in General Practice) Fairleigh-Dickenson University Ortho 1983
  • 6. Right out of school
  • 7. Functional Orthodontics Frankel Bionator Twin Block MARA Herbst
  • 8. 2008 Soft Tissue Dysfunction is THE cause of malocclusion
  • 9. Myofunctional Research Co.
  • 10. Spring, 2009 MRC meeting, Chicago > Terry Carlyle September, 2009 MRC conference, Coral Gables, Fl.
  • 11. Myofunctional Orthodontics Chris Farrell John Flutter German Ramierez Damien O’Brien Myofunctional Research Co. Rancho Cucamonga 2008-2012
  • 12. • 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
  • 13. Biobloc Orthotropics BBO Mini-residency Bill Hang Agora Hills 2012-13 BBO Intensive Drs. John and Mike Mew LSFO 2013
  • 14. Breathing and Sleep Buteyko 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
  • 15. Cranial Osteopathy Advanced Dento-cranial Orthopedics Bob Walker 2014 ALF, The Team Approach Jim Bronson 2013 Cranial Academy: Basic Course January 2014
  • 16. Teaching Mt. Sinai Pedo Residency Ali Attaie 2010-2014 Montefiore Ortho Residency Tony Maganzini 2012 2009-Present
  • 17. Golf 0 7.5 15 22.5 30 1983 2006 2013 2014
  • 18. It’s about the Airway BTW….I lost 30lbs “It’s all about Barry And The World of Mouthbreathing”
  • 19. • Honorarium and Travel Expenses but no vested interest in Myofunctional Research Co. ! • Director, Raphael Center for Integrative Education Disclosure
  • 20. Recommended Reading
  • 21. 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
  • 22. Feedback I agree I like
 I disagree I have a problem I have a question
  • 23. 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 Orthodontics Airway-focused Pathology Airway Orthodontics
  • 24. Chronic Diseases of Lifestyle Soft Tissue Dysfunction Malocclusion and Orthodontics Airway-focused Pathology Airway and Breathing Dysfunction Airway Orthodontics
  • 25. The Spectrum of SDB Snoring 8-10% Normal Prevalence: OSAS 1-3% UARS ?
  • 26. 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
  • 27. • 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
  • 28. •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.
  • 29. Which is easier to breathe through?
  • 30. Which would you trust most?
  • 31. 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.
  • 32. 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
  • 33. 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
  • 34. • 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
  • 35. 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
  • 36. “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
  • 37. Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752 Morphology and SDB in children
  • 38. Everyday in my practice...
  • 39. 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
  • 40. •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...
  • 41. 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
  • 42. 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
  • 43. • 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
  • 44. 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
  • 45. The Importance of Airway in Children
  • 46. “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
  • 47. “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
  • 48. 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
  • 49. 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
  • 50. 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
  • 51. 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
  • 52. • 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?
  • 53. • 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:
  • 54. Chronic Diseases of Lifestyle Airway and Breathing Dysfunction Malocclusion and Orthodontics Airway-focused Pathology Soft Tissue Dysfunction Airway Orthodontics
  • 55. 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
  • 56. The Gothic Arch The Roman Arch The “Modern” Maxilla
  • 57. How do you build an arch? The Roman Arch
  • 58. No scaffold?
  • 59. 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
  • 60. 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.
  • 61. Harvold’s Monkies
  • 62. Posture changes Teeth Lowered mandibular posture, tongue protrusion, and open biteOpen mouth posture retained for 1 year after nose reopened. Facial features retained
  • 63. • “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
  • 64. “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
  • 65. “ 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
  • 66. If the tongue is chronically held away from the palate… …the maxilla collapses in all three dimensions. The Tropic Premise
  • 67. If the mandible keeps up: Class I Crowded Then the Mandible Adapts
  • 68. Mouthbreathing and/or tongue thrust hinders growth : Class II Then the Mandible Adapts
  • 69. Low Tongue keeps mandible growing forward: Class III Then the Mandible Adapts
  • 70. The Tropic Premise
  • 71. The Tropic Premise
  • 72. Craniofacial Dystrophy Maxilla is Down and Back The Mandible is Retrognathic Nasal Cartilage Collapse Insufficient Mid-Facial Support
  • 73. 2008 Soft Tissue Dysfunction is THE cause of malocclusion
  • 74. 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
  • 75. Open Mouth Posture ! is the most common and significant Soft Tissue Dysfunction In children today.
  • 76. 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 Posture Birth trauma Cranial strains Poor posture Bottle feeding Soft diet Processed foods Immune challenges Oxidative stress Heat Hyperventilation Stress reactions Habits Dental pain Ankyloglossia Macroglossia
  • 77. • 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
  • 78. Airway Orthodontics Chronic Diseases of Lifestyle Airway and Breathing Dysfunction Soft Tissue Dysfunction Malocclusion and Orthodontics Airway-focused Pathology
  • 79. 5,000 years ago When caries and malocclusion were rare! There was a time...
  • 80. 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...
  • 81. 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
  • 82. George Catlin “Shut Your Mouth and Save Your Life” 1870
  • 83. “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.”
  • 84. Weston Price 1870-1948 Nutrition and Physical Degeneration Weston A. Price, DDS, 1939 Malocclusion is a product of the diet of industrialized societies
  • 85. 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
  • 86. Its not just Growth and Development ! Its Growth, Development and Adaptation ! The Missing Link in Orthodontics Today...
  • 87. If Malocclusion is caused by Growth and Development... Genotype Phenotype Total Growth
  • 88. If Malocclusion is caused by Growth and Development and Adaptation... Genotype Phenotype Total Growth
  • 89. ! ! ! ! An example of “adaptation”
  • 90. Identical twins with different habits Dr. John Mew orthotropics.co.uk
  • 91. One of them has crooked teeth. Another set of twins
  • 92. 3 August 2003 3 August 2003 RHYS - 10Y 11MHow did these teeth get this way? Different genes than his brother…
  • 93. 1 March 2007 1 March 2007 RHYS - 14Y 5MFour years later, after successful MFO Text (Treatment by Dr. Chris Farrell)
  • 94. 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?
  • 95. • 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.
  • 96. Chronic Diseases of Lifestyle Airway and Breathing Dysfunction Soft Tissue Dysfunction Airway-focused Pathology Malocclusion and Orthodontics Airway Orthodontics
  • 97. ! ”... 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
  • 98. From “Malocclusion” 1907 Edward H. Angle
  • 99. 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
  • 100. Edward Angle vs Calvin Case Witzig vs McNamara NewConn 2009 Extraction vs Non-extraction Debate The Extraction Wars 1855-1930 5-10% extraction rate V. Kokich F. Bogdan
  • 101. Passive-Self Ligation The Damon System “to match each phase of treatment with the natural force systems of normal growth and development…”
  • 102. Non-extraction
  • 103. Non-extraction
  • 104. Non-extraction
  • 105. 18 Months 26 Months Non-extraction
  • 106. Non-extraction
  • 107. Finding room for all the teeth is not a problem if you start early enough and try to mimic what nature intended.
  • 108. Protractive vs. Retractive Orthodontics
  • 109. What is the correct treatment for this? Craniofacial Dystrophy
  • 110. Bimax retrusion
  • 111. Successful dental result
  • 112. Failed Profile Result
  • 113. Successful dental result
  • 114. Failed Profile Result
  • 115. Everyday in my practice...
  • 116. What is the appropriate treatment for a Collapsed Maxilla? Treatment
  • 117. Headgear?
  • 118. Class II Elastics?
  • 119. Mandibular Advancment Appliance? (Herbst, Twin Block,MARA with reciprocal anchorage)
  • 120. Extractions ? Treatment
  • 121. 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©
  • 122. 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
  • 123. 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
  • 124. 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
  • 125. Backed into a corner... • Retraction Orthodontics
  • 126. If Retraction Mechanics has the potential to hinder the airway, how much retraction is OK?
  • 127. If snoring is likely to lead to obstruction someday, how much snoring is “normal” for a child?
  • 128. • 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
  • 129. Chronic Diseases of Lifestyle Airway and Breathing Dysfunction Soft Tissue Dysfunction Malocclusion and Orthodontics Airway-focused Orthodontics Airway Orthodontics
  • 130. “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?
  • 131. 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©
  • 132. Treatment Goals Based on Upper Incisor (UI)
  • 133. Incisor Goals Type 4 Treatment: Retract/Extrude UI Extraction Orthodontics, Retraction Ortho, Distalization Ortho
  • 134. Incisor Goals Type 3 Treatment: Maintain UI Functional Orthodontics, Expansion Orthodontics, Distalization Ortho
  • 135. Incisor Goals Type 2 Treatment: Expansion enough to uncrowd Myofunctional Ortho, Myofunctional Therapy, Crozat,ALF, Expansion Orthodontics
  • 136. Incisor Goals Type 1 Treatment: Place U1 in ideal position Biobloc Orthotropics, Orthognathic Surgery, Distraction Osteogenesis
  • 137. Protraction affects the airway From Dr. K. Li
  • 138. 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
  • 139. • 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
  • 140. • 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)
  • 141. 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
  • 142. 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.
  • 143. 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
  • 144. • 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
  • 145. Repenting for past sins affects the airway
  • 146. 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
  • 147. 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
  • 148. Form Function Orthodontics Myofunctional Conventional! Orthodontics Airway! Orthodontics
  • 149. The Health/Pathology Spiral Form Form Function Function Function Declining HealthImproving Health
  • 150. A Pathology Cycle Declining Health Function MouthBreathing and Low Tongue FormLong Face Function Weak MMuscles FormNarrow Palate Function Deviate Swallow FormSwollen T&A Crooked Teeth Form
  • 151. Breaking The Cycle Declining Health Function MouthBreathing and Low Tongue FormLong Face Function Weak MMuscles FormNarrow Palate Function Swallowing with Active Facial Muscles Crooked Teeth Form FormSwollen T&A Conventional Orthodontics
  • 152. Backed into a corner... Stuck with Retractive Orthodontics
  • 153. Breaking The Cycle Declining Health Function MouthBreathing and Low Tongue FormLong Face Function Weak MMuscles FormNarrow Palate Function Swallowing with Active Facial Muscles Crooked Teeth Form FormSwollen T&A Airway-Centric Orthodontist
  • 154. • 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).”
  • 155. 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
  • 156. Dr. Stephen Sheldon Professor of Pediatrics, Northwest University School of Medicine Director, Sleep Medicine Lurie Children’s Hospital, Chicago
  • 157. Defining Environmental Factors
  • 158. •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
  • 159. • 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
  • 160. • Adult SDB and OSA • Narrow Jaws and Faces • Soft Tissue Dysfunction • Early Parafunctional Habits, esp Open Mouth Posture • Environmental Stressors • CPAP, MARA,UPPP, Surg Where’s the best place to start treatment? Here? OrHere? Treating the Cause
  • 161. • 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
  • 162. Chronic Diseases of Lifestyle Airway and Breathing Dysfunction Soft Tissue Dysfunction Malocclusion and Orthodontics Airway-focused Orthodontics Airway Orthodontics Address! Stress Airway and Breathing First Fix! Function Fix! Form
  • 163. • 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….