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Airway ortho 5 goals and prevention


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A series of lectures by Dr. Barry Raphael on Airway-focused orthodontics from 2013.
Chapter 5: The Goals of Airway Orthodontics and some of the approaches to preventing deficiencies in facial growth in young children.

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Airway ortho 5 goals and prevention

  1. 1. Airway OrthodonticsA lecture series prepared byDr. Barry RaphaelOf theRaphael Center for Integrative OrthodonticsClifton,“Goals and Prevention” - 20131Thursday, June 6, 13
  2. 2. •Animations are not included in this archive and mayaffect the meaning or intent of the slide•As the information in these presentations isconstantly evolving, please consider the date of creationwhen reviewing the material.2Thursday, June 6, 13
  3. 3. Airway-focused Orthodonticsfor the OrthodontistPart 2:The Solution• Goals of Treatment• Diagnostics• Prevention• Intervening Form• Intervening Function• Interdisciplinary Treatment• Cases3Thursday, June 6, 13
  4. 4. Airway-focused Orthodonticsfor the OrthodontistDr. Barry Raphaeldrbarry@alignmine.comwww.alignmine.comPart 2:The SolutionGoals of Treatment4Thursday, June 6, 13
  5. 5. The Goals of Treatment1. Long Term Stability :The Holy Grail of Orthodontics2. Neutral tooth positioning without interferences3. Balanced jaw mechanics4. Balanced facial and jaw shape, size and position5. Balanced, unstrained, muscular function6.Tongue on the palate at rest (Neutral Posture)7. Lips together in repose8. Nasal BreathingIn order to have Happiness… you need _________5Thursday, June 6, 13
  6. 6. The Priorities of Airway-CenteredMyofunctional Orthodontics1. Breathing through the nose2. Lips together at rest3. Correct tongue position4. No facial muscles moving on swallowing5. Optimal facial development6. Balanced Jaws7. Straight teeth8. Better Stability long term6Thursday, June 6, 13
  7. 7. Strategies forAirway-focused Orthodontics1. Thorough Diagnosis2. Prevention before intervention3. Intervene the Form4. Intervene the Function7Thursday, June 6, 13
  8. 8. Airway-focused Orthodonticsfor the OrthodontistMay 31, 2013Dr. Barry Raphaeldrbarry@alignmine.comwww.alignmine.comPart 2:The SolutionPrevention8Thursday, June 6, 13
  9. 9. Pre-natal care9Thursday, June 6, 13
  10. 10. Lingual Frenectomy10Thursday, June 6, 13
  11. 11. AttachmentLengthThe Frenum attachment•The most distal point on theventrum of the tongue to whichthe frenum attaches.•This serves as a tether-pointfor movement of the tongue.•It determines the most verticalextension of the tongue.•Measured from the tip of thetongue.11Thursday, June 6, 13
  12. 12. Normal Frenum• Full extension of tongue allowed• Can reach out past lower lip• Can touch upper incisal edges on wide open• Can rest against palate• Dorsum seals palate on swallow.tongueFrenum12Thursday, June 6, 13
  13. 13. N-Point and N-AngleThe tongue foldsNormalN-1N-2N-3N-413Thursday, June 6, 13
  14. 14. N-4 Frenum• attached to the tip of the tongue• Show a “Heart-Shape”• often affects speech.• Ironically,the shortest frenums don’t cause the greatest harmto the dentition.• don’t always create tongue thrust because the tongue tip is tieddown and thus cannot push the upper teeth up and out.14Thursday, June 6, 13
  15. 15. N-3 Frenum• shorter and stronger than an N-2,• creates sufficient force to distort the whole tongue• forming a pronounced “U” or “V” shape at the tip(Fig. 8).15Thursday, June 6, 13
  16. 16. N-2 Frenum• short lingual frenum,• Stronger than an N-1 and usually thick.• pulls on the tongue with sufficient force to form a sulcus atthe tip or on the underside of the tongue16Thursday, June 6, 13
  17. 17. N-1 Frenum• constrains the normal mobility• limits ability to reach the upper incisors• does not distort the shape of the tongue• Strong enough to hold down the dorsum ofthe tongue• preventing it from rising to shapethe palate.• narrow palate creates a short archperimeter,• crowding and rotations, crossbite, open bite,and anterior or lateral tongue thrust17Thursday, June 6, 13
  18. 18. Internal Frenum•The most undiagnosed form of ankylosis•Keeps the dorsum of the tongue down•Can be “created” by incomplete anterior frenotomies18Thursday, June 6, 13
  19. 19. Short Frenum can lead to• Difficulty nursing• Choking or gagging on food• Gingival recession• Diastema• Tooth rotation• Bone loss• Limitation of tongue mobility• Speech impairment (?)• Poor scaffolding for the growing maxilla19Thursday, June 6, 13
  20. 20. Lingual frenum and maxillary growthhypothesis1. Muscle determines the shape of bone2. Food is swallowed by vacuum force in the mouth3. To create the vacuum, the tongue seals the palate,creating pressure on the palate4. The palate takes its shape from this pressure5. If the tongue does not reach the palate, the palate willgrow narrow and tall.6. This is a LEADING CAUSE of non-skeletalmalocclusion20Thursday, June 6, 13
  21. 21. Lingual frenum andDental Development hypothesis1. The tongue can raise to the point of the frenumattachment.2. If locked, the tongue swings forward to create the oralvacuum3. The facial musculature must activate to finish the seal4. This places pressure on the anterior teeth5. Results in anterior open bite or crowding6. This is a LEADING Cause of dental relapse afterorthodontics.21Thursday, June 6, 13
  22. 22. FrenectomyFrom Paula Fabbie, COM22Thursday, June 6, 13
  23. 23. Frenx for OpenbiteFrom Paula Fabbie, COM23Thursday, June 6, 13
  24. 24. Internal FrenectomyFrom Paula Fabbie, COM24Thursday, June 6, 13
  25. 25. Internal Frenectomy25Thursday, June 6, 13
  26. 26. MUST DO P.T.PRE- AND POST-operative Mobility Exercises• Clucks• Caves• Palate Wipes•Waggle Spots and Waggle FlapsFrom Paula Fabbie, COM26Thursday, June 6, 13
  27. 27. Infant FrenectomyFrom Larry Kotlow, DDS27Thursday, June 6, 13
  28. 28. Breast-feeding28Thursday, June 6, 13
  29. 29. Difficulty Breast FeedingInfant Factors to considerA. No latchB. Un-sustained latchC. Slides off nippleD. Prolonged feedsE. Unsatisfied after prolonged feedsF. Falls asleep on the breastG. Gumming or chewing on the nippleH. Poor weight gain or Failure to thriveI .Unable to hold pacifier29Thursday, June 6, 13
  30. 30. Difficulty Breast FeedingMaternal Factors to considerA. Creased or blanched nipples after feeding: flattenedB. Cracked, bruised or blistered nipplesC. Bleeding nipplesD. Severe pain with latchE. Incomplete breast drainageF. Infected nipplesG. Plugged ductsH. Mastitis & nipple thrush30Thursday, June 6, 13
  31. 31. ADHD/Breastfeeding/Malocclusion/dental trauma/SDBUnderstanding the relationships betweenbreastfeeding, malocclusion, ADHD, sleep-disorderedbreathing and traumatic dental injuries.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]31Thursday, June 6, 13
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  41. 41. SourceChild and Adolescent Psychiatry, School of Medicine, Marmara University, Dept. Child and Adolescent Psychiatry, Istanbul, Turkey. Electronic disorder (ADHD), one of the most common neuropsychiatric disorders that present at young age, may occasionally beassociated with physical problems and disorders. Among them exists a group of oral-pharyngeal conditions with considerable clinical morbidity. Previousresearch that identified absence or short duration of breastfeeding in ADHD children has been reviewed. Essential nutritional factors in breast milk canaffect brain development and regulate the manifestation of ADHD symptoms. Low ferritin levels caused by insufficient breastfeeding may contribute toADHD susceptibility because of the role of iron in dopaminergic activity. Insufficient breast feeding and subsequently excessive bottle-feeding may lead toincreased rates of non-nutritive sucking habits, such as pacifier use and thumb-sucking, all of which are associated with the risk of development ofmalocclusions. Malocclusion refers to an unacceptable deviation from the ideal relationship of the upper and lower teeth and necessitates orthodontictreatment. Sleep-disordered breathing in children may present with neurocognitive symptoms that resemble ADHD and abnormal craniofacialdevelopments, as well as malocclusions, have been cited as part of the syndrome. Obesity, which is an outcome of insufficient breastfeeding, is a sharedcomorbidity of ADHD and sleep-disordered breathing. The risk of traumatic dental injury is higher in children with ADHD and presence of malocclusionsfurther increases the likelihood of dental injuries. In this review, certain oral-pharyngeal conditions relating to ADHD have been reviewed and links amongthem have been highlighted in a tentative explanatory model. More research that will provide increased awareness and clinical implications is needed.Copyright © 2012 Elsevier Ltd. All rights reserved.41Thursday, June 6, 13
  42. 42. Nutrition•Soft Processed and Pre-cooked foods•Limit muscular exercise and development•Fail to stimulate osseous development•Fail to develop muscular coordination42Thursday, June 6, 13
  43. 43. Hardening the Diet• start with fiber crackers• then fruits, fresh and dried• then vegetables• then small, cooked meat• progressively over 4 to 12 months, depending on child43Thursday, June 6, 13
  44. 44. Baby Led Weaning•Starting at 6mo•Give baby real food•Let them exploreand choose•Establish Chewingskills naturally44Thursday, June 6, 13
  45. 45. Chewing Gum1. Xylitol gum (gluten and sugar free)2.10 chews on one side3.10 chews on the other side4.Repeat 5 times5.THROW AWAY THE GUM45Thursday, June 6, 13
  46. 46. MyomunchieSoft, chewable, durableSqueeze for a count of 10, relax, repeat 10 times46Thursday, June 6, 13
  47. 47. Thera-bite WafersLancer Orthodontics47Thursday, June 6, 13
  48. 48. Habit Control48Thursday, June 6, 13
  49. 49. Oral FunctionsOral functions•Incision•Mastication•Digestion•Airway•Communicationspeechfacial expressionsexual interaction•Proprioceptiontastetactilitypleasure/endorphin•Defensebitingimmune systems•Parafunction• Occlusal wear patternsFrom eccentric movementsFrom interferencesFrom repetitive movements (bruxism)From protective posturing• Clenchinghypertrophic musculature• Soft Tissue Dysfunctionmouth open postureanterior tongue thrust (tongue cushioning)lateral tongue thrusttongue scallopingcheek bitinglip bitinglimited tongue movement (ankyloglossia)• SuckingDigitthumbfingerobjectblanketsleevepacifier• Gum chewing• Atypical movements of mandible•Parafunction49Thursday, June 6, 13
  50. 50. Parafunctions have a functionWhen there is a mechanical flaw in a body system, the restof the body will adapt to cope with it.Adaptations to a Flaw1) Pain and parasthesias2) Parafunctions3) Anatomic distortions“All parafunctions, even when destructive, are serving a purpose foradaptation. Every pattern of wear tells a story. Every malocclusion tells astory. Our job is to understand what it is. We are the Sherlock Holmes of themouth. “ - Gavin James50Thursday, June 6, 13
  51. 51. Oral Habits•Thumb Sucking• Pacifiers• Nail Biting•Tongue Sucking• Object Mouthing• Lip Biting• Chin-Leaning•Trichotillomania51Thursday, June 6, 13
  52. 52. Thumb suckingForpleasureandcomfort...To propopen theairwayTo relieve acranialstrainEach type needs a different approach52Thursday, June 6, 13
  53. 53. Pacifiers•Sucking habits are on the rise internationally• Pacifiers are recommended by AAP(?) to preventSIDS for up to 6 months•By then, habits are started•Many will convert to thumb53Thursday, June 6, 13
  54. 54. Don’t Let It Fester• Habits that continue past 12 months will start toaffect structure.• Damage from a pacifier starts after 2yo• Damage from a thumb after 3yoFrom Shari Green, COM54Thursday, June 6, 13
  55. 55. Give the Child Control•They must be ready.• Give them choices.• Use positive reinforcement.• Use “Reminders”• Include OMT.55Thursday, June 6, 13
  56. 56. Bruxism•Types of Bruxism•Daytime•Nighttime•Signs of Bruxism•Dental attrition•Muscle hypertrophy•Muscle tenderness•Etiology•Stress•Airway Obstruction56Thursday, June 6, 13
  57. 57. Bruxism and SDB•Apnea leads to...➡Hypoxia➡heart rate increase➡Autonomic activation➡Arousal➡Muscle activation and bruxing➡Pharangeal muscle flexion➡airway opening.57Thursday, June 6, 13
  58. 58. Jeff Rouse•Prosthodontist,•Bruxism is relief for airway problems.•Treat biology first, then do mechanicsBruxism and occlusal wear are airway issues58Thursday, June 6, 13
  59. 59. Adenectomy59Thursday, June 6, 13
  60. 60. Carole L. Marcus, MBBCh, Lee J. Brooks, MD, Sally Davidson Ward, MD,Kari A.Draper, MD, David Gozal, MD, Ann C. Halbower, MD, Jacqueline Jones, MD,Christopher Lehmann, MD, Michael S. Schechter, MD, MPH,Stephen Sheldon, MD,Richard N. Shiffman, MD, MCIS, and Karen Spruyt, PhDAmerican Academy of PediatricsSUBCOMMITTEE ONOBSTRUCTIVE SLEEP APNEA SYNDROMEDiagnosis and Management of ChildhoodObstructive Sleep Apnea Syndrome-Clinical Guidelines--Technical Report-, June 6, 13
  61. 61. Diagnosis and Management of ChildhoodObstructive Sleep Apnea Syndrome•Review of 350 relevant articles•The prevalence of OSAS ranged from 0% to 5.7%,•obesity being an independent risk factor.•OSAS was associated with• Cardiovascular•Growth deficits•Neurobehavioral abnormalities•Possibly inflammation.•Most diagnostic screening tests had low sensitivity andspecificity.•Treatment of OSAS resulted in improvements in behavior andattention and likely improvement in cognitive abilities.61Thursday, June 6, 13
  62. 62. History•Frequent snoring (≥3 nights/wk)•Labored breathing during sleep•Gasps/snorting noises/observedepisodes of apnea•Sleep enuresis (especiallysecondary enuresis)a•Sleeping in a seated position or withthe neck hyperextended•Cyanosis•Headaches on awakening•Daytime sleepiness•Attention-deficit/hyperactivitydisorder•Learning problemsPhysical examination•Underweight or overweight•Tonsillar hypertrophy•Adenoidal facies•Micrognathia/retrognathia•High-arched palate•Failure to thrive•HypertensionSymptoms and Signs of OSAS“There is no such thing asADHD...only ADHSyndrome and it’ssecondary to a poor night’s sleep”- Dr. Stephen Sheldon62Thursday, June 6, 13
  63. 63. The 8 KEY ACTIONSTATEMENTS1.Screening for OSAS•As part of routine health maintenance visits, clinicians should inquire whether the child or adolescentsnores2. Referral and Testing•Regular snoring or S&S should be referred for PSG, ENT eval, SM eval, or other tests (video, home study)•sensitivity and specificity of the history and physical examination are poor3. Tonsiloadenectomy• Has OSAS AND hypertrophy, the T&A is “first line of treatment.”4.High Risk T&A•Monitor Postoperatively5.Revaluation•Further treatment is necessary in approx 21% (in obese, 73%)6.CPAP•If T&A can’t be done or didn’t work•Compliance is a problem7.Weight Loss•If needed, with everything else8.Nasal Sprays•intranasal corticosteroids for children with mild OSAS (pre- or post T&A)63Thursday, June 6, 13
  64. 64. Rapid Maxillary ExpansionTwo case studies without controls (level IV)•Study 1•31 patients•4 months after RME, all patients had normalized AHI•Pirelli P, Saponara M, Guilleminault C., Rapid maxillary expansion in children withobstructive sleep apnea syndrome. Sleep. 2004;27(4):761–766• Study 2•14 eligible sleep center patients•a significant improvement in signs and symptoms of OSASas well as polysomnographic parameters•Villa MP, Malagola C, Pagani J, et al. Rapid maxillary expansion in children withobstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007;8(2):128–134Data were insufficient to recommend rapid maxillary expansion.64Thursday, June 6, 13
  65. 65. Rapid Maxillary ExpansionConclusions•“an orthodontic technique that holdspromise as an alternative treatment ofOSAS in children”•“maxillary expansion may be effectivein specially selected patients”•“data are insufficient to recommend itsuse at this time.”65Thursday, June 6, 13
  66. 66. Planas Direct TracksMaximum Intercuspation Therapeutic Position66Thursday, June 6, 13
  67. 67. Dr. German Ramirez67Thursday, June 6, 13
  68. 68. Shut your mouth andsave your life!68Thursday, June 6, 13
  69. 69. George Catlin• Lawyer, artist, amateur anthropologist•Documented native populations in North andSouth America•1870•“Shut Your Mouth and Save Your Life”• Book recommended by Edward Angle in 192569Thursday, June 6, 13
  70. 70. George Catlin - 1870•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 properbreathing.70Thursday, June 6, 13
  71. 71. George Catlin - 1870On mouth breathing at night:“That man knows not the pleasure of sleep; he rises in themorning more fatigued than when he retired to rest - takespills and remedies through the day, and renews his diseaseevery night.”71Thursday, June 6, 13