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Nasal airway and malocclucion /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078


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  • 1. NASAL AIRWAY AND MALOCCLUSION INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. INTRODUCTION Nasal 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. www.indiandentalacademy.com
  • 3. REVIEW OF LITERATURE The 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 www.indiandentalacademy.com
  • 4. LINDER-ARONSON-1970-narrow dental arch and upright incisors due to adenoids. BUSHY-1974-Compared monzygotic twins with and without adenoids CASE-1984 DAVIS-1979 WOODSIDE &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. www.indiandentalacademy.com
  • 5. PHARYNX ANATOMY -NASOPHARYNX -ORO-PHARYNX -LARYNGOPHARYNX PHYSIOLOGIC MEASUREMENTS -TIDAL VOLUME-500ML -INSPIRATORY RESERVE VOLUME-3000ML. -VITAL CAPACUTY-4600ML. www.indiandentalacademy.com
  • 6. PHRYNX AND RADIOLOGIC VIEW-56 ATHANSIOU www.indiandentalacademy.com
  • 7. MOUTH BREATHING ETIOLOGY ANATOMICAL-DNS,CONGENITAL MICROGENIA PATHOLOGICAL-ADENOIDS,TONSILS, HABITUAL “ADENOID FACIES”—coined at GUY’S hospital,london constitutes the followinglong face constricted upper dental arch exposed upper incisors receded lower jaw short upper lip associated habits www.indiandentalacademy.com
  • 8. 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. www.indiandentalacademy.com
  • 9. 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. www.indiandentalacademy.com
  • 10. 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. www.indiandentalacademy.com
  • 11. 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. www.indiandentalacademy.com
  • 12. 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. www.indiandentalacademy.com
  • 13. EFFECTS OF OSA • SYMPTOMS during sleep – Snoring – Abnormal motor activity – Disturbed nocturnal sleep – Sensation of choking – Heart burn – Nocturia – Heavy sweating www.indiandentalacademy.com
  • 14. 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 www.indiandentalacademy.com
  • 15. DIAGNOSIS • Is by POLYSOMNOGRAPHY Measurements 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. www.indiandentalacademy.com
  • 16. TREATMENT Medical: Weight loss is beneficial Nasal vaso constriction sprays Withdrawal of respiratory depressing alcohol (antihistamines and tranquilizers) Surgical: • Uvulo palato pharnygoplasty • Tracheostomy • Expansion hyoid plasty • Mandibular advancement • Sectioning of hyoid www.indiandentalacademy.com
  • 17. 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 upper lower www.indiandentalacademy.com
  • 18. • 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 pattern increased ANB increased gonial angle decreased mandibular length steep MP angle over erupted upperwww.indiandentalacademy.com posterior segments
  • 19. airway www.indiandentalacademy.com
  • 20. OTHER DIAGNOSTIC TESTS • SPIROMETRY • OXIMETER- to evaluate oxy-Hb level • RHINOMANOMETRY-instrument used to measure nasal patency STEDMAN’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 www.indiandentalacademy.com
  • 21. SPIROMETER Spirometry 462-PHYSIO www.indiandentalacademy.com
  • 22. SNORT APPARATUS Rhino-snort www.indiandentalacademy.com
  • 23. OI,OE,NI,NE GRAPHS Rhino-graphs- www.indiandentalacademy.com
  • 24. 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. www.indiandentalacademy.com
  • 25. EXTENSION OF HEAD TO FACILIATE AIRWAY Head posturePg 7 petrovic www.indiandentalacademy.com
  • 26. 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. www.indiandentalacademy.com
  • 27. CHRONIC NASAL OBSTRUCTION MOUTH BREATHING &HEAD EXTENSION A D MANDIBLE &TONGUE ARE LOWERED E N FACIAL HT. INCREASES O I POSTERIOR TEETH SUPRA ERUPT D F ANRETIOR OPEN BITE &INCREASED OVERJET A C INCREASED CHEEK PRESSURE www.indiandentalacademy.com COLLAPSED DENTAL ARCHES I E S
  • 28. TREATMENT OPTIONS • TREATING THE ETIOLOGIC FACTORS: TONSILLECTOMY,ADENOIDECTOMY,CORRECTION OF DNS,NASAL POLYPS ORTHODONTIC: ORAL SCREEN RAPID MAXILLARY EXPANSION MANDIBULAR ADVANCEMENT SURGICAL : HYIOD BONE REPOSITIONING BI JAW ADVANCSMENT www.indiandentalacademy.com MANDIBULAR ADVANCEMENT
  • 29. TONSILLECTOMY-tonsils attain max. size during 9-10 yrs. of age,after which they regress in size, their removal enhances nasal pathway ORAL 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 www.indiandentalacademy.com
  • 30. RAPID MAXILLARY EXPANSION 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 www.indiandentalacademy.com
  • 31. 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 FACIES BISHARA-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 www.indiandentalacademy.com
  • 32. AIRWAY BEFORE &AFTER RPE www.indiandentalacademy.com
  • 33. 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 AIRWAY www.indiandentalacademy.com
  • 34. CONCLUSION IN 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
  • 35. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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