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Airway OrthodonticsA lecture series prepared byDr. Barry RaphaelOf theRaphael Center for Integrative OrthodonticsClifton, ...
•Animations are not included in this archive and mayaffect the meaning or intent of the slide•As the information in these ...
Airway-focused Orthodonticsfor the OrthodontistMay 31, 2013Dr. Barry Raphaeldrbarry@alignmine.comwww.alignmine.comPart 2:T...
Orthodontic Diagnostics• Medical History• Clinical Exam• Mounted Casts• Pan• Ceph• Facial and Intra-oral Pictures4Thursday...
Airway Diagnostics•A shotgun approach• Pick and choose what will be helpful to you•Add these elements to your normal routi...
History Taking• Medical/Myofunctional History• Sleep Scale• Home Observation• Systems Review Worksheet6Thursday, June 6, 13
Myofunctional HistoryMedical History Eating AgeEruption Early N Late Chewing Difficult Sloppy Digestive N Prob-lems Food A...
Sleep Scale•© Regents of theUniversity of Michigan2006Score = #Y / (# Y + #N).>.33 = significantChild’s Name: ____________...
Child’s Name: ______________________________ Study ID #: ___________Person completing form: _____________________ Date: __...
Home Observation•Private EyesheetThere are many things about your childʼshealth that are important to know, but that Iofte...
Home Observation•Private EyesheetThere are many things about your childʼshealth that are important to know, but that Iofte...
Home Observation•Private EyesheetWhile sitting around (watching TV, in thecar), does your child:put “things” in the mouth ...
Home Observation•Private Eyesheetyour childʼsnow, but that Ioffice. Also, theremay not haveur childʼs teeth oracking thesea...
Home Observation•Private Eyesheetents if you want.ching TV, in theh alot (toys,nails, etc.)____________n a littleout of th...
Home Observation•Private Eyesheet•Medical Hxon backsideThere are many things about your childʼshealth that are important t...
MFO Treatment WorksheetTrainerReferralIssue:What I am looking forActionPriority16Thursday, June 6, 13
MFO Treatment Worksheet17Thursday, June 6, 13
MFO Treatment Worksheet18Thursday, June 6, 13
MFO Treatment Worksheet19Thursday, June 6, 13
MFO Treatment Worksheet20Thursday, June 6, 13
MFO Treatment Worksheet21Thursday, June 6, 13
MFO Treatment Worksheet22Thursday, June 6, 13
MFO Treatment Worksheet23Thursday, June 6, 13
MFO Treatment Worksheet24Thursday, June 6, 13
MFO Treatment Worksheet25Thursday, June 6, 13
MFO Treatment Worksheet26Thursday, June 6, 13
MFO Treatment Worksheet27Thursday, June 6, 13
MFO Treatment Worksheet28Thursday, June 6, 13
MFO Treatment Worksheet29Thursday, June 6, 13
MFO Treatment Worksheet30Thursday, June 6, 13
MFO Treatment Worksheet31Thursday, June 6, 13
MFO Treatment Worksheet32Thursday, June 6, 13
Clinical Exam*Rough Order of Examination•Body•Breathing•Head•Face•Mouth•Teeth*To be added to yournormal routine33Thursday,...
PostureBodyStatureHeight _________Weight _________Posture (Shoes Off)FrontalFeet : PronationHips levelShoulder LevelEye/Ea...
Ankle Rotation35Thursday, June 6, 13
P Ex: BodyBodyStatureHeight _________Weight _________Posture (Shoes Off)FrontalFeet : PronationHips levelShoulder LevelEye...
Bowling Ball on a Stick37Thursday, June 6, 13
Platysma and supra hyoids retract the mandible38Thursday, June 6, 13
39Thursday, June 6, 13
Another product of modern life40Thursday, June 6, 13
Posture Analysis41Thursday, June 6, 13
Posture Analysis42Thursday, June 6, 13
Posture Analysis43Thursday, June 6, 13
44Thursday, June 6, 13
45Thursday, June 6, 13
Posture ProVPosture analysis system•By Dr. JoeVentura•www.posturepro.com46Thursday, June 6, 13
Breathing• Premise1. Breathing is a prime imperative for survival2. Tongue on palate is a prime imperative for facial deve...
Nasopharyngeal ObstructionFromKent Lauson“Straight Talk about Crooked Teeth”48Thursday, June 6, 13
Nasopharyngeal Obstruction and its effectsEnlarged Tonsils& AdenoidsNasal ConstrictionDeviated NasalSeptumEnlarged Turbina...
Breathing Physiology50Thursday, June 6, 13
MB lowers CO2 storesWhy is this important?Because children who are chronic mouth breatherswill have difficulty breathing th...
52RESPIRATIONWhy do we breathe? To deliver oxygen to body cells To remove excess CO252Thursday, June 6, 13
CHEMICALBALANCEto stay in balance the bodyrequires the following:5.0%	 OXYGEN6.5% CARBON DIOXIDEThere is more than enoughO...
54OXYGENBody requirement 5%Atmospheric content 21% Oxygen does not have to be stored. It is always available Has only on...
55CARBON DIOXIDEBody requirement 6.5% or 40mm HgAtmospheric content 0.03% Has to be produced by the body and stored Stor...
HOW TO MAKE CO2every time you move orexercise, your bodyproduces CO2.every time you eat, digestfood or make any enzymes,ho...
57CARBON DIOXIDEHas 4 major functions in the body1. Facilitates release of oxygen from haemoglobin2.Maintains pH by buffer...
  O2 TRANSPORT SYSTEM1. Facilitates release of oxygen from haemoglobin58Thursday, June 6, 13
THE BOHREFFECTDiscovered byChristian Bohr aDanish Physiologistin 1903CHRISTIAN BOHR 1855-19111. Facilitates release of oxy...
THE BOHR EFFECTThe Bohr Effect states that as CO2 levels in arterialblood drop, the strength of the bond between oxygenand ...
!pH 14!alkalinepH 7.8cells diepH 7.0!neutralpH 6.8cells diepH 0!acidic!THE pH - CO2 linkAcidosis AlkalosisThe optimal pH r...
Hypocapnia also prevents the pH ofarterial blood reaching the optimal level of7.35 for oxygen release and results in lowSa...
Hypocapnia is consistently lowCO2.Hypocapnia causes spasm ofsmooth muscle tubes in an attemptto reduce the loss of CO2.Thi...
Konstantin Buteyko (1923-2003)• The Buteyko Breathing Method•Russian Physiologist•Worked with Asthmatics• Mouth breathing ...
Checking Breathing• Lip Posture• Mirror test• Nostril Shape•Breathing Mode•Breathing Rate•Manipulations for obstructions•_...
Check Breathing•“Hold lips closed for 2 minutes”66Thursday, June 6, 13
Checking Breathing• Glatzel Mirror test67Thursday, June 6, 13
Checking Breathing•Breathing• Rate• 10-14• 15-20• >22• Movements• Chest• Diaphragm• Soundslooking for chronic hyperventila...
Checking Breathing•Nose• Nasal Hump• retrusive maxilla69Thursday, June 6, 13
Checking Breathing•Nose• Nasal Crease• allergic salute70Thursday, June 6, 13
Checking Breathing•Nose• Nares• Width• Flare on breathing71Thursday, June 6, 13
The “Sniff” TestTurbulence creates negative pressuredistal to the obstruction.“Keep your lips closed. Breath in through yo...
Checking Breathing•Manipulations•_______’s sign - pull the nose•Anterior Repositioning• Supine Breathing• Upright Breathin...
Control Pause•Time between exhalation and first diaphragmatic urgeto breath• Should be > 40 seconds for optimal health• Ove...
Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip ...
Indicator Line76Thursday, June 6, 13
Maxillary Height• Indicator Line (Mew)• Distance from most anterior point on nose to upperincisal edge• Age + 23• A variab...
From the tip of the Central...78Thursday, June 6, 13
...To the Forwardmost Tip of the Nose41mm79Thursday, June 6, 13
Indicator Line42mm12 yo maleIdeal IL = 35mm35mm Watch duringtreatment forincrease ordecreaseWatch duringgrowth for>1mm inc...
`Take another look...81Thursday, June 6, 13
Incisor falls faster than the nose......with vertical growth...and Retractive/Extrusive MechanicsIndicator Line82Thursday,...
Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip ...
Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip ...
Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip ...
Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip ...
Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip ...
Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip ...
Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip ...
Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip ...
Face: Joints91Thursday, June 6, 13
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampat...
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampat...
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampat...
Start “Clucks”, to CavesFrom Paula Fabbie, COM95Thursday, June 6, 13
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampat...
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.Palatal Vault1. Shape2.Color5.Malampa...
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.Palatal Vault1. Shape2.Color5.Malampa...
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampat...
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampat...
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampat...
Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampat...
Face: Lips• Lips• At Rest• Open• Partially Open• Closed• On Closure• Relaxed• Tight• Mentalis Active• vermillion height• U...
Face: Lips• Lips• Entrapment• look for protrusive incisors or excess OJ• Protrusion• Interlabial line• center up• flat• cen...
Face: Shape•Mandible• Retrognathic• Normal• Prognathic105Thursday, June 6, 13
Face: Smile/Esthetics• Smile/Esthetics• Look at the “shape” ofthe dentition as a whole,not at individual teeth• Tooth/Ging...
Imaging• Photography•Videography• Cephalometrics• 3D Imaging107Thursday, June 6, 13
Photography•Tonsils• Malampati• Lingual Frenum• Mid-face• Bolton Profile Comparisons•108Thursday, June 6, 13
Photography•Tonsils• Malampati• Lingual Frenum• Mid-face• Bolton Profile Comparisons•109Thursday, June 6, 13
Face: Ears•Ears• Rotation• In• Out110Thursday, June 6, 13
Face: Eyes• Eyes• Width• Symmetry• Venous pooling (“allergic shiners,dark undereyes)111Thursday, June 6, 13
Face: SymmetryStrong Side Weak SideMasseter Stronger WeakerEye brow Higher LowerEye size Larger SmallerNasolabial fold Sha...
Face: Nose•Nose• Nasal “Hump”• retrusive maxilla• Nasal Crease• allergic salute• Nares• Width• Flare on breathing113Thursd...
Maxillary TangentIndicates better pneumatization of the maxillary sinuses114Thursday, June 6, 13
Maxillary Depth115Thursday, June 6, 13
Face: Maxilla• Maxilla• Fullness• Submental view• Use stick held behind uppercanines• Full• Flat• Retrusive• Excess orbita...
Photography•Tonsils• Malampati• Lingual Frenum• Mid-face• Bolton Profile Comparisons•117Thursday, June 6, 13
Brush-Bolton since 1928118Thursday, June 6, 13
SOFT TISSUE DYSFUNCTIONWith Poor Tongue SupportComparison of Unsupported vs Supported Growth119Thursday, June 6, 13
120Age 8Age 9Age 15Age 13Age 11Bolton Norms120Thursday, June 6, 13
Boy Age 11ContactContactResize Rotate121Thursday, June 6, 13
“Normal” is conservativeA-pointStillretrognathic122Thursday, June 6, 13
10yoM123Thursday, June 6, 13
12yF124Thursday, June 6, 13
7-2yM125Thursday, June 6, 13
S. S. 7-6yo girl126Thursday, June 6, 13
U’’127Thursday, June 6, 13
C.P. 8-2M128Thursday, June 6, 13
Thinking Through Treatment Goals8-0 yo M129Thursday, June 6, 13
Bolton Normal130Thursday, June 6, 13
Growth Prediction131Thursday, June 6, 13
Extraction132Thursday, June 6, 13
Functional133Thursday, June 6, 13
Myofunctional134Thursday, June 6, 13
Biobloc135Thursday, June 6, 13
Treatment Goals136Thursday, June 6, 13
Photography•Tonsils• Malampati• Lingual Frenum• Mid-face• Bolton Profile Comparisons• Mandibular Advancement137Thursday, Ju...
Videography•Any camera will do138Thursday, June 6, 13
OMESOral Myology Examination with Scores139Thursday, June 6, 13
OMESOral Myology Examination with Scores140Thursday, June 6, 13
OMESOral Myology Examination with Scores141Thursday, June 6, 13
OMESOral Myology Examination with Scores142Thursday, June 6, 13
Watchingfor signsof STDysVideo143Thursday, June 6, 13
HomeVideos144Thursday, June 6, 13
Watch theMuscles•Reverse Swallow•Tongue Thrust•Hypermentalis•Lip Entrapment•Facial Muscles Active•Buccinator compression•A...
Learning to Read the Face146Thursday, June 6, 13
What is wrong with these children?Only correct diagnosis can lead tocorrect treatment Videos courtesy of Dr. John Flutter1...
What do you see?• Open mouth posture• Long lower third• Eye shadows•Allergic crease•Anterior Tongue Thrust•Anterior Open B...
What do you see?• Shoulder Breathing• Open mouth posture• Facial muscles active onswallow• Head dip on swallow• Stuffy Nos...
What do you see?•Temporal bone rotation• Open Mouth Posture• Blows cheeks• Lip activity on swallow• Cheek activity• Hyperm...
What do you see?• Lips active on swallow• Open Mouth Posture• Mentalis action onswallow• Contraction ofBuccinator on swall...
What do you see?• Blows out cheeks• Hypermentalis•Tight lip muscles onswallow• Lateral mandibular shift• Bimaxillary Retru...
What do you see?• Lateral Head tilt•Temporal Rotation• Long lower 1/3•Assymetical upper lipmovement• Mentalis• Eye Shadows...
Cephalometrics154Thursday, June 6, 13
3D Imaging155Thursday, June 6, 13
Functional Exams• Lip Tone Testing• Capnometry• Sleep Screening156Thursday, June 6, 13
Lip Tone Testing157Thursday, June 6, 13
Iowa158Thursday, June 6, 13
159Thursday, June 6, 13
160Thursday, June 6, 13
161Thursday, June 6, 13
Time at 50% Max162Thursday, June 6, 13
Trigger Pull•Lip Strength Testing•Trigger Pull163Thursday, June 6, 13
Lip Shield3mm Mouthguard Material164Thursday, June 6, 13
Trigger Pullwww.lymanproducts.com165Thursday, June 6, 13
166Thursday, June 6, 13
Average of 3 Pulls167Thursday, June 6, 13
CO2 Monitoring•Blood Gas•Capnometer•Pulse oximeter168Thursday, June 6, 13
Capnometry•www.betterphysiology.com•Measures Lung CO2•Normal = 40mgHg•Lung CO2 = Blood CO2•Blood CO2•Respiration Rate•Bloo...
Capnometer170Thursday, June 6, 13
Capnometer35 mmHg171Thursday, June 6, 13
CapnoTrainer172Thursday, June 6, 13
Habitual Nasal BreathingMeditative Nasal Breathing173Thursday, June 6, 13
Sleep Screening174Thursday, June 6, 13
Sleep Apnea in Eight Children“The nocturnal polygraphic monitoringshowed that all eight childrenpresented not only abnorma...
Cardio-Pulmonary CouplingDr. Robert Thomas“ Surrogate sleep information can be acquired from theelectrocardiogram (ECG) us...
•Heart RateVariabilityAn algorithm calculating changes in the RRi over timeHeart RateVariability177Thursday, June 6, 13
Cardio-Pulmonary CouplingDr. Robert ThomasHeart RateVariabilityHigh Freq CouplingLow Freq CouplingVery Low Freq CouplingRe...
Sleep SpectrogramHigh Freq CouplingLow Freq CouplingVery Low Freq Coupling179Thursday, June 6, 13
Sleep Quality IndexStable SleepUnstable SleepSQI = HFC:LFC180Thursday, June 6, 13
Sleep Quality Index• 8yo maleStable SleepUnstable SleepSQI = 10181Thursday, June 6, 13
Sleep Quality Index•8yo boy w SnoringStable SleepUnstable SleepSQI = .98182Thursday, June 6, 13
183Thursday, June 6, 13
184Thursday, June 6, 13
SleepImage M1 monitor• Monitor•Carry Case• Software (PC)• Reports• Scheduling• Help• Cable• Batteries supplied• Patches su...
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Airway ortho 6 diagnostics

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A series of lectures by Dr. Barry Raphael on Airway-focused orthodontics.
Chapter 6 Some diagnostic protocols to be added to standard orthodontic protocols.

Published in: Health & Medicine
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Airway ortho 6 diagnostics

  1. 1. Airway OrthodonticsA lecture series prepared byDr. Barry RaphaelOf theRaphael Center for Integrative OrthodonticsClifton, NJ.www.alignmine.comwww.myobracenj.com“Diagnostics” - 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 OrthodontistMay 31, 2013Dr. Barry Raphaeldrbarry@alignmine.comwww.alignmine.comPart 2:The SolutionDiagnostics3Thursday, June 6, 13
  4. 4. Orthodontic Diagnostics• Medical History• Clinical Exam• Mounted Casts• Pan• Ceph• Facial and Intra-oral Pictures4Thursday, June 6, 13
  5. 5. Airway Diagnostics•A shotgun approach• Pick and choose what will be helpful to you•Add these elements to your normal routine•History Taking•Clinical Exam•Imaging•Functional Exams5Thursday, June 6, 13
  6. 6. History Taking• Medical/Myofunctional History• Sleep Scale• Home Observation• Systems Review Worksheet6Thursday, June 6, 13
  7. 7. Myofunctional HistoryMedical History Eating AgeEruption Early N Late Chewing Difficult Sloppy Digestive N Prob-lems Food Allergies _______________ BreastFed _________ mos Pacifier to age _____ SippyCupHabits Finger Thumb OralFixation Pacifier Nail Other___________Airway recurrent ear infections Y recurrent sinus infections Y T&A Y Rx’dSleeping mouth posture open closed Snoring Y Apnea Dx’dAllergies to____________________________ Tested? Y M.D. _________________________Meds ____________________________Symptoms Nasal Skin Breathing Family HxAsthma Y Dx’d M.D._________________________ Meds___________________Precautions __________________________________________________________Family Hx_____________________________________________________________When things are "normal" do you have trouble breathing? Y NTriggers _____________________ Last Episode date ______________________ Outcome _________Intensity Mild Mod Severe Frequency Intermittent PersistentPhysical Exam: Height _______ Weight _________Posture: Feet Hips level R L High Shoulders Level R L HighSpinal curvature Head balance Forward Neutral BehindFacial Shape Brachy Meso Dolico Ears N In Out Eyes Wide N Narrow RHigh LHigh PoolingNose Hump Crease Nares Flare Maxilla Full Flat OrbitalShow To bridge ______mmLower 1/3 Long N Short Lips At Rest Open Partial Closed LipsClosed Relaxed Tight MentalisVermillion larger U Equal L Entrapment L Protrusion U L Interlabial Line Center Up Flat DownUpper lip Short N Mand Retro N Prog Smile Display Incisor Gummy Narrow Corridors CantSTD Examination7Thursday, June 6, 13
  8. 8. Sleep Scale•© Regents of theUniversity of Michigan2006Score = #Y / (# Y + #N).>.33 = significantChild’s Name: ______________________________ Study ID #: ___________Person completing form: _____________________ Date: ____/____/____Please answer these questions regarding the behavior of your child during sleep and wakefulness. Thequestions apply to how your child acts in general during the past month, not necessarily during the past fewdays since these may not have been typical if your child has not been well. You should circle the correctresponse or print your answers neatly in the space provided. A “Y” means “yes,” “N” means “no,” and“DK” means “don’t know.”1. WHILE SLEEPING, DOES YOUR CHILD:Snore more than half the time?………………………………………...…. ……..Y N DK A2Always snore? ………………………………………………………………..Y N DK A3Snore loudly? …………………………………………………………………Y N DK A4Have “heavy” or loud breathing? …………………………………….…………..Y N DK A5Have trouble breathing, or struggle to breathe? …………………….……………Y N DK A62. HAVE YOU EVER SEEN YOUR CHILD STOP BREATHING DURINGTHE NIGHT? ……………………………………………………………………….Y N DK A73. DOES YOUR CHILD:Tend to breathe through the mouth during the day?…………………………….Y N DK A24Have a dry mouth on waking up in the morning? …..………………...Y N DK A25Occasionally wet the bed? ……………………………………………...Y N DK A324. DOES YOUR CHILD:Wake up feeling unrefreshed in the morning? ………………………………….Y N DK B1Have a problem with sleepiness during the day? ………………….……….…...Y N DK B25. HAS A TEACHER OR OTHER SUPERVISOR COMMENTED THAT YOURCHILD APPEARS SLEEPY DURING THE DAY? …………………………….…Y N DK B46. IS IT HARD TO WAKE YOUR CHILD UP IN THE MORNING? …………….…Y N DK B67. DOES YOUR CHILD WAKE UP WITH HEADACHES IN THE MORNING?…..Y N DK B78. DID YOUR CHILD STOP GROWING AT A NORMAL RATE ATANY TIME SINCE BIRTH? …………………………………………………….….Y N DK B99. IS YOUR CHILD OVERWEIGHT? ………………………………………………...Y N DK B2210. THIS CHILD OFTEN:Does not seem to listen when spoken to directly. ……………………………....Y N DK C3Has difficulty organizing tasks and activities. …………………….…………...Y N DK C5Is easily distracted by extraneous stimuli. ………………………….…………...Y N DK C8Fidgets with hands or feet or squirms in seat. ……………………………….....Y N DK C10Is “on the go” or often acts as if “driven by a motor”. …………………………Y N DK C14Interrupts or intrudes on others (eg., butts into conversations or games). ………Y N DK C18Thank you!© Regents of the University of Michigan 2006Score = #Y / (# Y + #N). >.33 = significantPediatric Sleep Questionnaire: Sleep-Disordered Breathing SubscaleLicensed to: the raphael center for integrative orthodontics0701298Thursday, June 6, 13
  9. 9. Child’s Name: ______________________________ Study ID #: ___________Person completing form: _____________________ Date: ____/____/____Please answer these questions regarding the behavior of your child during sleep and wakefulness. Thequestions apply to how your child acts in general during the past month, not necessarily during the past fewdays since these may not have been typical if your child has not been well. You should circle the correctresponse or print your answers neatly in the space provided. A “Y” means “yes,” “N” means “no,” and“DK” means “don’t know.”1. WHILE SLEEPING, DOES YOUR CHILD:Snore more than half the time?………………………………………...…. ……..Y N DK A2Always snore? ………………………………………………………………..Y N DK A3Snore loudly? …………………………………………………………………Y N DK A4Have “heavy” or loud breathing? …………………………………….…………..Y N DK A5Have trouble breathing, or struggle to breathe? …………………….……………Y N DK A62. HAVE YOU EVER SEEN YOUR CHILD STOP BREATHING DURINGTHE NIGHT? ……………………………………………………………………….Y N DK A73. DOES YOUR CHILD:Tend to breathe through the mouth during the day?…………………………….Y N DK A24Have a dry mouth on waking up in the morning? …..………………...Y N DK A25Occasionally wet the bed? ……………………………………………...Y N DK A324. DOES YOUR CHILD:Wake up feeling unrefreshed in the morning? ………………………………….Y N DK B1Have a problem with sleepiness during the day? ………………….……….…...Y N DK B2Pediatric Sleep Questionnaire: Sleep-Disordered Breathing SubscaleLicensed to: the raphael center for integrative orthodontics0701299Thursday, June 6, 13
  10. 10. Home Observation•Private EyesheetThere are many things about your childʼshealth that are important to know, but that Ioften donʼt get to see at the office. Also, thereare signs to look for that you may not haveknown were connected to your childʼs teeth orhealth. By looking for and tracking these“signs and symptoms”, we can get a betterhandle on the problem and watch forresolution.You donʼt have to spend a lot of time with this.Just watch for certain things at different timesof day. Try not to let your child know they arebeing watched. You want to see the mostnatural behaviors.Check off what you see. If youʼre not sure,check it anyway. Make comments if you want.While sitting around (watching TV, in thecar), does your child:put “things” in the mouth alot (toys,sleeves, pencils, fingernails, etc.)______________________________lick or suck on the lipshave the lips apart, even a littlestick or dart the tongue out of themouthhave the tongue resting between theteethlean the cheek on a handbreath with his mouth open, even a littlebitmake noises when breathinghave trouble sitting stillWhile talking, does your child:talk very fasttalk very slowlygasp for airhave a lisptake speech lessonsDuring a meal, does your child:gasp for air while eatingstick his tongue between his teethwhen swallowingstick the tongue out to meet thedrinking glassdrink alot while eatingmake noises when chewingeat sloppilytake a breath before drinkingpuff the cheeks out when drinkingmake the lips purse when swallowingmake the chin “crinkle” whenswallowingbob the head when swallowinghave trouble sitting stillWhile sleeping, does your child:have the mouth opensnorewet the bedtoss and turntilt the head backwake up frequentlyhave frequent nightmareshave abnormal sleep issuesgrind the teethhave trouble waking upwake with darker circles under eyesDr. Raphaelʼs Parentʼs Private-Eye Home SheetRaphael PES v1.1 201110Thursday, June 6, 13
  11. 11. Home Observation•Private EyesheetThere are many things about your childʼshealth that are important to know, but that Ioften donʼt get to see at the office. Also, thereare signs to look for that you may not haveknown were connected to your childʼs teeth orhealth. By looking for and tracking these“signs and symptoms”, we can get a betterhandle on the problem and watch forresolution.You donʼt have to spend a lot of time with this.Just watch for certain things at different timesof day. Try not to let your child know they arebeing watched. You want to see the mostnatural behaviors.Check off what you see. If youʼre not sure,check it anyway. Make comments if you want.During agaspstickwhestickdrinkdrinkmakeat stakepuffmakmakswalbobhaveWhile sleDr. Raphaelʼs Parentʼs Private11Thursday, June 6, 13
  12. 12. Home Observation•Private EyesheetWhile sitting around (watching TV, in thecar), does your child:put “things” in the mouth alot (toys,sleeves, pencils, fingernails, etc.)______________________________lick or suck on the lipshave the lips apart, even a littlestick or dart the tongue out of themouthhave the tongue resting between theteethlean the cheek on a handbreath with his mouth open, even a littlebitmake noises when breathinghave trouble sitting stillWhile talking, does your child:talk very fasttalk very slowlygasp for airhave a lisptake speech lessonsWhile shasnwetostiltwahahagrihawa12Thursday, June 6, 13
  13. 13. Home Observation•Private Eyesheetyour childʼsnow, but that Ioffice. Also, theremay not haveur childʼs teeth oracking thesean get a betterwatch fort of time with this.at different timesld know they aresee the mostuʼre not sure,ments if you want.During a meal, does your child:gasp for air while eatingstick his tongue between his teethwhen swallowingstick the tongue out to meet thedrinking glassdrink alot while eatingmake noises when chewingeat sloppilytake a breath before drinkingpuff the cheeks out when drinkingmake the lips purse when swallowingmake the chin “crinkle” whenswallowingbob the head when swallowinghave trouble sitting stillaelʼs Parentʼs Private-Eye Home Sheet13Thursday, June 6, 13
  14. 14. Home Observation•Private Eyesheetents if you want.ching TV, in theh alot (toys,nails, etc.)____________n a littleout of thebetween thendpen, even a littleathingild:While sleeping, does your child:have the mouth opensnorewet the bedtoss and turntilt the head backwake up frequentlyhave frequent nightmareshave abnormal sleep issuesgrind the teethhave trouble waking upwake with darker circles under eyes14Thursday, June 6, 13
  15. 15. Home Observation•Private Eyesheet•Medical Hxon backsideThere are many things about your childʼshealth that are important to know, but that Ioften donʼt get to see at the office. Also, thereare signs to look for that you may not haveknown were connected to your childʼs teeth orhealth. By looking for and tracking these“signs and symptoms”, we can get a betterhandle on the problem and watch forresolution.You donʼt have to spend a lot of time with this.Just watch for certain things at different timesof day. Try not to let your child know they arebeing watched. You want to see the mostnatural behaviors.Check off what you see. If youʼre not sure,check it anyway. Make comments if you want.While sitting around (watching TV, in thecar), does your child:put “things” in the mouth alot (toys,sleeves, pencils, fingernails, etc.)______________________________lick or suck on the lipshave the lips apart, even a littlestick or dart the tongue out of themouthhave the tongue resting between theteethlean the cheek on a handbreath with his mouth open, even a littlebitmake noises when breathinghave trouble sitting stillWhile talking, does your child:talk very fasttalk very slowlygasp for airhave a lisptake speech lessonsDuring a meal, does your child:gasp for air while eatingstick his tongue between his teethwhen swallowingstick the tongue out to meet thedrinking glassdrink alot while eatingmake noises when chewingeat sloppilytake a breath before drinkingpuff the cheeks out when drinkingmake the lips purse when swallowingmake the chin “crinkle” whenswallowingbob the head when swallowinghave trouble sitting stillWhile sleeping, does your child:have the mouth opensnorewet the bedtoss and turntilt the head backwake up frequentlyhave frequent nightmareshave abnormal sleep issuesgrind the teethhave trouble waking upwake with darker circles under eyesDr. Raphaelʼs Parentʼs Private-Eye Home SheetRaphael PES v1.1 201115Thursday, June 6, 13
  16. 16. MFO Treatment WorksheetTrainerReferralIssue:What I am looking forActionPriority16Thursday, June 6, 13
  17. 17. MFO Treatment Worksheet17Thursday, June 6, 13
  18. 18. MFO Treatment Worksheet18Thursday, June 6, 13
  19. 19. MFO Treatment Worksheet19Thursday, June 6, 13
  20. 20. MFO Treatment Worksheet20Thursday, June 6, 13
  21. 21. MFO Treatment Worksheet21Thursday, June 6, 13
  22. 22. MFO Treatment Worksheet22Thursday, June 6, 13
  23. 23. MFO Treatment Worksheet23Thursday, June 6, 13
  24. 24. MFO Treatment Worksheet24Thursday, June 6, 13
  25. 25. MFO Treatment Worksheet25Thursday, June 6, 13
  26. 26. MFO Treatment Worksheet26Thursday, June 6, 13
  27. 27. MFO Treatment Worksheet27Thursday, June 6, 13
  28. 28. MFO Treatment Worksheet28Thursday, June 6, 13
  29. 29. MFO Treatment Worksheet29Thursday, June 6, 13
  30. 30. MFO Treatment Worksheet30Thursday, June 6, 13
  31. 31. MFO Treatment Worksheet31Thursday, June 6, 13
  32. 32. MFO Treatment Worksheet32Thursday, June 6, 13
  33. 33. Clinical Exam*Rough Order of Examination•Body•Breathing•Head•Face•Mouth•Teeth*To be added to yournormal routine33Thursday, June 6, 13
  34. 34. PostureBodyStatureHeight _________Weight _________Posture (Shoes Off)FrontalFeet : PronationHips levelShoulder LevelEye/Ear level“Your posture is related to the way you carry your jaw. In fact, there was once anorthodontist that could correct your teeth just by correcting your posture.”34Thursday, June 6, 13
  35. 35. Ankle Rotation35Thursday, June 6, 13
  36. 36. P Ex: BodyBodyStatureHeight _________Weight _________Posture (Shoes Off)FrontalFeet : PronationHips levelShoulder LevelEye/Ear levelLateralSpinal curvatureShoulders/ScapulaHead balanceEar to Ankle and ShoulderForwardNeutralBehind36Thursday, June 6, 13
  37. 37. Bowling Ball on a Stick37Thursday, June 6, 13
  38. 38. Platysma and supra hyoids retract the mandible38Thursday, June 6, 13
  39. 39. 39Thursday, June 6, 13
  40. 40. Another product of modern life40Thursday, June 6, 13
  41. 41. Posture Analysis41Thursday, June 6, 13
  42. 42. Posture Analysis42Thursday, June 6, 13
  43. 43. Posture Analysis43Thursday, June 6, 13
  44. 44. 44Thursday, June 6, 13
  45. 45. 45Thursday, June 6, 13
  46. 46. Posture ProVPosture analysis system•By Dr. JoeVentura•www.posturepro.com46Thursday, June 6, 13
  47. 47. Breathing• Premise1. Breathing is a prime imperative for survival2. Tongue on palate is a prime imperative for facial development.3. Nasal breathing is important for:1. Better breathing2. Better Facial Development•Therefore, a child must be able to breathe through the nosecomfortably for the face and teeth to grow properly.47Thursday, June 6, 13
  48. 48. Nasopharyngeal ObstructionFromKent Lauson“Straight Talk about Crooked Teeth”48Thursday, June 6, 13
  49. 49. Nasopharyngeal Obstruction and its effectsEnlarged Tonsils& AdenoidsNasal ConstrictionDeviated NasalSeptumEnlarged TurbinatesCysts, Polyps &TumorsAllergic RhinitisNASOPHARYNGEAL OBSTRUCTIONBlockage of Eustachian Tubes Mouth Breathing Lowered Tongue Posture Mandible with lowered and retruded posture Forward head and shoulder postureAccumulation ofpathogens inEustachian TubesOtitis media(middle earinfection)Hearing LossInflamed andenlarged turbinates& nasal passagesFrequent colds &sore throats,respiratoryinfectionsDiseaseLowered O2IntakeBehaviordisordersReducedenergyReducedmentalcapacityADDADHDSIDSPulmonaryHypertensionCardiacHypertensionGingivitis, chappedlips, bad breath,dry mouth,high decay rateBucco-lingualmaxillary muscleimbalanceHypertrophiedpalatal tissues (notongue pressure)Constricted andunderdeveloped maxillaConstricted nasal cavityLack of space for tongueConstricted, retruded andunderdeveloped mandibleAirway Obstruction:dorsum oftongue against oropharyngealwall or soft paltateObstructiveSleepApneaSnoringSleep CycleDysfunctionDaytimeDrowsinessReducedQuality of LifeMalocclusion,crowding, overbite,crossbite, loss ofvertical dimensionPoor facialappearancePoor selfimageAnti-socialbehaviorDifficultyeatingPoorNutritionSusceptibilityto diseaseExcess verticaldevelopmentHighV-shapedpalateConstrictednasal cavityMouthbreathingincreasedLoweredtonguepostureAnterioropen bitePoor lipsealGummysmileTongue ThrustNeck musclestrainNeck aches,headachesLoss of lordoticcurve of cervicalspineSpeech problems,lisps, hyponasality Malocclusion, openbite, long facesyndrome,prognathismCraniomandibulardysfunctionMay result in lackof skeletal musclestrength andcoordinationBruxismTMJ DysfunctionTMJ condyle anddisc displacementTMJ degenerationand osteoarthritisNeuro-musculardysfuntionMyofascial paindysfunction syndromeHeadaches, neck aches, ear pain,ringing/fullness, hearing loss, visualproblems, limited or painful openingof jaw, neurologic disorders such asParkinson’s,Tourette’s syndrome49Thursday, June 6, 13
  50. 50. Breathing Physiology50Thursday, June 6, 13
  51. 51. MB lowers CO2 storesWhy is this important?Because children who are chronic mouth breatherswill have difficulty breathing through their nose….Here’s the long story...Thanks to John Flutter for slides...51Thursday, June 6, 13
  52. 52. 52RESPIRATIONWhy do we breathe? To deliver oxygen to body cells To remove excess CO252Thursday, June 6, 13
  53. 53. CHEMICALBALANCEto stay in balance the bodyrequires the following:5.0% OXYGEN6.5% CARBON DIOXIDEThere is more than enoughO2 but we haveto make and storeour own CO2NITROGEN 78%OXYGEN 21%OTHER GASES 0.97%CARBON DIOXIDE 0.03%Air53Thursday, June 6, 13
  54. 54. 54OXYGENBody requirement 5%Atmospheric content 21% Oxygen does not have to be stored. It is always available Has only one use in the body and that is to regenerate cells54Thursday, June 6, 13
  55. 55. 55CARBON DIOXIDEBody requirement 6.5% or 40mm HgAtmospheric content 0.03% Has to be produced by the body and stored Stored in the lungs at 6.5%Stored in arterial blood at 40mm Hg pressureProduced as a by product of exercise and digestion55Thursday, June 6, 13
  56. 56. HOW TO MAKE CO2every time you move orexercise, your bodyproduces CO2.every time you eat, digestfood or make any enzymes,hormones or other thingsthat the body requires, youproduce CO2.This is stored in the lungsand the blood for future use.56Thursday, June 6, 13
  57. 57. 57CARBON DIOXIDEHas 4 major functions in the body1. Facilitates release of oxygen from haemoglobin2.Maintains pH by buffering with bicarbonate or carbonic acid3.Prevents smooth muscle from going into spasm4.Triggers breathing by activating the medullary sensor57Thursday, June 6, 13
  58. 58.   O2 TRANSPORT SYSTEM1. Facilitates release of oxygen from haemoglobin58Thursday, June 6, 13
  59. 59. THE BOHREFFECTDiscovered byChristian Bohr aDanish Physiologistin 1903CHRISTIAN BOHR 1855-19111. Facilitates release of oxygen from haemoglobin59Thursday, June 6, 13
  60. 60. THE BOHR EFFECTThe Bohr Effect states that as CO2 levels in arterialblood drop, the strength of the bond between oxygenand hemoglobin tightens resulting in reduced Oxygenavailability to cells.This affects stamina and recovery - both essential foroptimal health and performance.1. Facilitates release of oxygen from haemoglobin60Thursday, June 6, 13
  61. 61. !pH 14!alkalinepH 7.8cells diepH 7.0!neutralpH 6.8cells diepH 0!acidic!THE pH - CO2 linkAcidosis AlkalosisThe optimal pH range for efficient oxygen transport is 7.45 to create the oxyhaemoglobinbond and 7.35 to release the oxyhaemoglobin bond.The natural pH buffers are Bicarbonate and Carbonic Acid which are both made from CO2stored in the body.Low CO2 = Low Buffer = Low oxygen saturation = Low energy = Poor recovery2.Maintains pH by buffering with bicarbonate or carbonic acid61Thursday, June 6, 13
  62. 62. Hypocapnia also prevents the pH ofarterial blood reaching the optimal level of7.35 for oxygen release and results in lowSaO2.This in turn reduces oxygen flow to tissuesand is the major cause of chronictiredness.Oxygen reduction to the brain causesproblems ranging from periods of“blankness”, poor memory, headachesand multiple other problems brought aboutby poor oxygen flow.Two minutes of overbreathing is enough toreduce brain oxygen content by up to40%.  Hypocapnia causes low SaO22.Maintains pH by buffering with bicarbonate or carbonic acid62Thursday, June 6, 13
  63. 63. Hypocapnia is consistently lowCO2.Hypocapnia causes spasm ofsmooth muscle tubes in an attemptto reduce the loss of CO2.This is the major cause ofshortness of breath as experiencedwith “asthma” and the ubiquitouslynamed EIA or Exercise InducedAsthma.It also causes spasm in all othersmooth muscle tubes in the bodyand is one of the major culprits indisorders of the circulatory anddigestive systems.    3. Prevents smooth muscle from going into spasm63Thursday, June 6, 13
  64. 64. Konstantin Buteyko (1923-2003)• The Buteyko Breathing Method•Russian Physiologist•Worked with Asthmatics• Mouth breathing LOWERS Carbondioxide blood levels too far. Oxygennot processed properly.•Reduced breathing relieves symptoms•Variations•Patrick McKeown•Roger Price•Artour RakhimovHyperventilation affects everything64Thursday, June 6, 13
  65. 65. Checking Breathing• Lip Posture• Mirror test• Nostril Shape•Breathing Mode•Breathing Rate•Manipulations for obstructions•_______’s sign - pull the bridge•Anterior Repositioning• Supine Breathing• Upright Breathing (Wall)• Control Pause65Thursday, June 6, 13
  66. 66. Check Breathing•“Hold lips closed for 2 minutes”66Thursday, June 6, 13
  67. 67. Checking Breathing• Glatzel Mirror test67Thursday, June 6, 13
  68. 68. Checking Breathing•Breathing• Rate• 10-14• 15-20• >22• Movements• Chest• Diaphragm• Soundslooking for chronic hyperventilationlooking for chronic hyperventilationThis can be done by theassistant , while the patientisn’t watching68Thursday, June 6, 13
  69. 69. Checking Breathing•Nose• Nasal Hump• retrusive maxilla69Thursday, June 6, 13
  70. 70. Checking Breathing•Nose• Nasal Crease• allergic salute70Thursday, June 6, 13
  71. 71. Checking Breathing•Nose• Nares• Width• Flare on breathing71Thursday, June 6, 13
  72. 72. The “Sniff” TestTurbulence creates negative pressuredistal to the obstruction.“Keep your lips closed. Breath in through your nose ashard and fast as you can”72Thursday, June 6, 13
  73. 73. Checking Breathing•Manipulations•_______’s sign - pull the nose•Anterior Repositioning• Supine Breathing• Upright Breathing (Wall)• Control Pause73Thursday, June 6, 13
  74. 74. Control Pause•Time between exhalation and first diaphragmatic urgeto breath• Should be > 40 seconds for optimal health• Overbreathers often < 10 seconds• Reduced-breathing exercises build up tolerance toCO274Thursday, June 6, 13
  75. 75. Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip closure75Thursday, June 6, 13
  76. 76. Indicator Line76Thursday, June 6, 13
  77. 77. Maxillary Height• Indicator Line (Mew)• Distance from most anterior point on nose to upperincisal edge• Age + 23• A variable number, but important to watch over time.77Thursday, June 6, 13
  78. 78. From the tip of the Central...78Thursday, June 6, 13
  79. 79. ...To the Forwardmost Tip of the Nose41mm79Thursday, June 6, 13
  80. 80. Indicator Line42mm12 yo maleIdeal IL = 35mm35mm Watch duringtreatment forincrease ordecreaseWatch duringgrowth for>1mm increase /year80Thursday, June 6, 13
  81. 81. `Take another look...81Thursday, June 6, 13
  82. 82. Incisor falls faster than the nose......with vertical growth...and Retractive/Extrusive MechanicsIndicator Line82Thursday, June 6, 13
  83. 83. Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip closure7.Maximum Opening8.Tongue-to-Spot Opening Norm =18-20mm83Thursday, June 6, 13
  84. 84. Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip closure7.Maximum Opening8.Tongue-to-Spot Opening Double Upper Lip84Thursday, June 6, 13
  85. 85. Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip closure7.Maximum Opening8.Tongue-to-Spot Opening85Thursday, June 6, 13
  86. 86. Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip closure7.Maximum Opening8.Tongue-to-Spot Opening86Thursday, June 6, 13
  87. 87. Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip closure87Thursday, June 6, 13
  88. 88. Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip closure88Thursday, June 6, 13
  89. 89. Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip closure89Thursday, June 6, 13
  90. 90. Facial Measurement Routine1.Indicator Line2.Upper lip3.Lower Lip to chin4.Competence at rest5.Incisal show6.Strain on lip closure7.Lip Condition90Thursday, June 6, 13
  91. 91. Face: Joints91Thursday, June 6, 13
  92. 92. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampati6.Uvula7.Tonsil Grading92Thursday, June 6, 13
  93. 93. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampati6.Uvula7.Tonsil Grading93Thursday, June 6, 13
  94. 94. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampati6.Uvula7.Tonsil Grading 50% of Max Opening94Thursday, June 6, 13
  95. 95. Start “Clucks”, to CavesFrom Paula Fabbie, COM95Thursday, June 6, 13
  96. 96. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampati6.Uvula7.Tonsil GradingModern Average:Paleo Average:35mm50mm96Thursday, June 6, 13
  97. 97. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.Palatal Vault1. Shape2.Color5.Malampati6.Uvula7.Tonsil Grading97Thursday, June 6, 13
  98. 98. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.Palatal Vault1. Shape2.Color5.Malampati6.Uvula7.Tonsil GradingPalatal CyanosisProper contact of the tongue on the palate and the negativepressure causes proper oxygenation of the palatal tissue.Lack of pressure of the tongue and the positive air pressure inhibitsoxygenation and the palate will look cyanotic - yellowish/blueish ina caucasian.98Thursday, June 6, 13
  99. 99. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampati6.Uvula7.Tonsil Grading99Thursday, June 6, 13
  100. 100. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampati6.Uvula7.Tonsil Grading100Thursday, June 6, 13
  101. 101. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampati6.Uvula7.Tonsil Grading101Thursday, June 6, 13
  102. 102. Intraoral Measurement Routine1.Maximum Opening2.Tongue To Spot Opening3.Molar Width4.PalatalVault1. Shape2.Color5.Malampati6.Uvula7.Tonsil Grading102Thursday, June 6, 13
  103. 103. Face: Lips• Lips• At Rest• Open• Partially Open• Closed• On Closure• Relaxed• Tight• Mentalis Active• vermillion height• Upper larger• Equal• Lower larger• Chapped/Dry(The mentalis muscle works onlyunder conscious control. The lips willbe apart at rest and sleep in thosechildren who use the mentalis muscleto bring the lips together. )(lips apart = low tongueposture = narrowretrognathic upper arch)Thick flaccid lips (good for Hollywood and kissing) are unexerciseddue to open mouth posture. Indicate mouth breathing.Air passing over lips w mouth breathing driesthem out. Licking makes them worse.103Thursday, June 6, 13
  104. 104. Face: Lips• Lips• Entrapment• look for protrusive incisors or excess OJ• Protrusion• Interlabial line• center up• flat• center down• Upper lip lengthmay shorten with chronicmouth breathingLip will be sucked into contactwith tongue on swallowing =crowding lower incisors andamount of lip sucked in isproportional to overjet104Thursday, June 6, 13
  105. 105. Face: Shape•Mandible• Retrognathic• Normal• Prognathic105Thursday, June 6, 13
  106. 106. Face: Smile/Esthetics• Smile/Esthetics• Look at the “shape” ofthe dentition as a whole,not at individual teeth• Tooth/Gingival Display• Lip line, smile line• Arch width• Tilt of posterior teeth(B-L)• Curvature of archestoward posterior• Buccal Corridors• Occlusal Cant106Thursday, June 6, 13
  107. 107. Imaging• Photography•Videography• Cephalometrics• 3D Imaging107Thursday, June 6, 13
  108. 108. Photography•Tonsils• Malampati• Lingual Frenum• Mid-face• Bolton Profile Comparisons•108Thursday, June 6, 13
  109. 109. Photography•Tonsils• Malampati• Lingual Frenum• Mid-face• Bolton Profile Comparisons•109Thursday, June 6, 13
  110. 110. Face: Ears•Ears• Rotation• In• Out110Thursday, June 6, 13
  111. 111. Face: Eyes• Eyes• Width• Symmetry• Venous pooling (“allergic shiners,dark undereyes)111Thursday, June 6, 13
  112. 112. Face: SymmetryStrong Side Weak SideMasseter Stronger WeakerEye brow Higher LowerEye size Larger SmallerNasolabial fold Shallower DeeperLip Wider ThinnerMento-labial fold Fuller Deeper112Thursday, June 6, 13
  113. 113. Face: Nose•Nose• Nasal “Hump”• retrusive maxilla• Nasal Crease• allergic salute• Nares• Width• Flare on breathing113Thursday, June 6, 13
  114. 114. Maxillary TangentIndicates better pneumatization of the maxillary sinuses114Thursday, June 6, 13
  115. 115. Maxillary Depth115Thursday, June 6, 13
  116. 116. Face: Maxilla• Maxilla• Fullness• Submental view• Use stick held behind uppercanines• Full• Flat• Retrusive• Excess orbital show116Thursday, June 6, 13
  117. 117. Photography•Tonsils• Malampati• Lingual Frenum• Mid-face• Bolton Profile Comparisons•117Thursday, June 6, 13
  118. 118. Brush-Bolton since 1928118Thursday, June 6, 13
  119. 119. SOFT TISSUE DYSFUNCTIONWith Poor Tongue SupportComparison of Unsupported vs Supported Growth119Thursday, June 6, 13
  120. 120. 120Age 8Age 9Age 15Age 13Age 11Bolton Norms120Thursday, June 6, 13
  121. 121. Boy Age 11ContactContactResize Rotate121Thursday, June 6, 13
  122. 122. “Normal” is conservativeA-pointStillretrognathic122Thursday, June 6, 13
  123. 123. 10yoM123Thursday, June 6, 13
  124. 124. 12yF124Thursday, June 6, 13
  125. 125. 7-2yM125Thursday, June 6, 13
  126. 126. S. S. 7-6yo girl126Thursday, June 6, 13
  127. 127. U’’127Thursday, June 6, 13
  128. 128. C.P. 8-2M128Thursday, June 6, 13
  129. 129. Thinking Through Treatment Goals8-0 yo M129Thursday, June 6, 13
  130. 130. Bolton Normal130Thursday, June 6, 13
  131. 131. Growth Prediction131Thursday, June 6, 13
  132. 132. Extraction132Thursday, June 6, 13
  133. 133. Functional133Thursday, June 6, 13
  134. 134. Myofunctional134Thursday, June 6, 13
  135. 135. Biobloc135Thursday, June 6, 13
  136. 136. Treatment Goals136Thursday, June 6, 13
  137. 137. Photography•Tonsils• Malampati• Lingual Frenum• Mid-face• Bolton Profile Comparisons• Mandibular Advancement137Thursday, June 6, 13
  138. 138. Videography•Any camera will do138Thursday, June 6, 13
  139. 139. OMESOral Myology Examination with Scores139Thursday, June 6, 13
  140. 140. OMESOral Myology Examination with Scores140Thursday, June 6, 13
  141. 141. OMESOral Myology Examination with Scores141Thursday, June 6, 13
  142. 142. OMESOral Myology Examination with Scores142Thursday, June 6, 13
  143. 143. Watchingfor signsof STDysVideo143Thursday, June 6, 13
  144. 144. HomeVideos144Thursday, June 6, 13
  145. 145. Watch theMuscles•Reverse Swallow•Tongue Thrust•Hypermentalis•Lip Entrapment•Facial Muscles Active•Buccinator compression•Anterior Lisp•Mouthbreathing145Thursday, June 6, 13
  146. 146. Learning to Read the Face146Thursday, June 6, 13
  147. 147. What is wrong with these children?Only correct diagnosis can lead tocorrect treatment Videos courtesy of Dr. John Flutter147Thursday, June 6, 13
  148. 148. What do you see?• Open mouth posture• Long lower third• Eye shadows•Allergic crease•Anterior Tongue Thrust•Anterior Open Bite• Lisp•Akyphisia•Takes breath beforeswallow•Throws head back toswallow•Left ear high and rotatedout• Dull eyesAlso look for:T&AAllergiesLingual FrenumPronated Feet and Rotated PelvisHypocapnia12 things148Thursday, June 6, 13
  149. 149. What do you see?• Shoulder Breathing• Open mouth posture• Facial muscles active onswallow• Head dip on swallow• Stuffy Nose• Gothic Arch• Breathing Beforedrinking•Anterior Tongue Thrust• Nostrils visible fromfront•Right ear highAlso look for:FrenumBruxismT&AHypocapnia10 things149Thursday, June 6, 13
  150. 150. What do you see?•Temporal bone rotation• Open Mouth Posture• Blows cheeks• Lip activity on swallow• Cheek activity• Hypermentalis•Anterior tongue thrust• Larger lower lip• Muscular definitionbelow lower lip border• Bigger, higher right eye•Tiny nostrilsAlso look for:FrenumT&ATongue between teeth on swallow11 things150Thursday, June 6, 13
  151. 151. What do you see?• Lips active on swallow• Open Mouth Posture• Mentalis action onswallow• Contraction ofBuccinator on swallow• Lip Entrapment• Left Ear rotation• Muscular definitionaround lipsAlso look for:Forward Head PostureScalloping on Tongue7 things151Thursday, June 6, 13
  152. 152. What do you see?• Blows out cheeks• Hypermentalis•Tight lip muscles onswallow• Lateral mandibular shift• Bimaxillary Retrusion• Concave profileAlso look for:Tongue between teethClass II div 2Tongue Scalloping6 things152Thursday, June 6, 13
  153. 153. What do you see?• Lateral Head tilt•Temporal Rotation• Long lower 1/3•Assymetical upper lipmovement• Mentalis• Eye Shadows• Midface deficiency• Blows cheeks• Lower lip eversion• Small Oral apertureAlso look for:Tongue ScallopingHighVaultFrenumT&A10 things153Thursday, June 6, 13
  154. 154. Cephalometrics154Thursday, June 6, 13
  155. 155. 3D Imaging155Thursday, June 6, 13
  156. 156. Functional Exams• Lip Tone Testing• Capnometry• Sleep Screening156Thursday, June 6, 13
  157. 157. Lip Tone Testing157Thursday, June 6, 13
  158. 158. Iowa158Thursday, June 6, 13
  159. 159. 159Thursday, June 6, 13
  160. 160. 160Thursday, June 6, 13
  161. 161. 161Thursday, June 6, 13
  162. 162. Time at 50% Max162Thursday, June 6, 13
  163. 163. Trigger Pull•Lip Strength Testing•Trigger Pull163Thursday, June 6, 13
  164. 164. Lip Shield3mm Mouthguard Material164Thursday, June 6, 13
  165. 165. Trigger Pullwww.lymanproducts.com165Thursday, June 6, 13
  166. 166. 166Thursday, June 6, 13
  167. 167. Average of 3 Pulls167Thursday, June 6, 13
  168. 168. CO2 Monitoring•Blood Gas•Capnometer•Pulse oximeter168Thursday, June 6, 13
  169. 169. Capnometry•www.betterphysiology.com•Measures Lung CO2•Normal = 40mgHg•Lung CO2 = Blood CO2•Blood CO2•Respiration Rate•Blood Buffering•Release of O2 in Tissues•Smooth Muscle Tone169Thursday, June 6, 13
  170. 170. Capnometer170Thursday, June 6, 13
  171. 171. Capnometer35 mmHg171Thursday, June 6, 13
  172. 172. CapnoTrainer172Thursday, June 6, 13
  173. 173. Habitual Nasal BreathingMeditative Nasal Breathing173Thursday, June 6, 13
  174. 174. Sleep Screening174Thursday, June 6, 13
  175. 175. Sleep Apnea in Eight Children“The nocturnal polygraphic monitoringshowed that all eight childrenpresented not only abnormal sleeppatterns, but also abnormalrespiration and cardiac rhythm duringsleep.”Christian Guilleminault, et.al.Pediatrics 1976;58;23175Thursday, June 6, 13
  176. 176. Cardio-Pulmonary CouplingDr. Robert Thomas“ Surrogate sleep information can be acquired from theelectrocardiogram (ECG) using cardiopulmonary coupling (CPC).CPC integrates mathematically heart rate variability (HRV)andrespiration, which are strongly modulated by electrocortical activity.”An electrocardiogram-based technique to assesscardiopulmonary coupling during sleep.Thomas RJ, Mietus JE, Peng CK, Goldberger AL.Sleep 2005;28:1151-61.176Thursday, June 6, 13
  177. 177. •Heart RateVariabilityAn algorithm calculating changes in the RRi over timeHeart RateVariability177Thursday, June 6, 13
  178. 178. Cardio-Pulmonary CouplingDr. Robert ThomasHeart RateVariabilityHigh Freq CouplingLow Freq CouplingVery Low Freq CouplingRespiratory rateElectrocortical Modulation178Thursday, June 6, 13
  179. 179. Sleep SpectrogramHigh Freq CouplingLow Freq CouplingVery Low Freq Coupling179Thursday, June 6, 13
  180. 180. Sleep Quality IndexStable SleepUnstable SleepSQI = HFC:LFC180Thursday, June 6, 13
  181. 181. Sleep Quality Index• 8yo maleStable SleepUnstable SleepSQI = 10181Thursday, June 6, 13
  182. 182. Sleep Quality Index•8yo boy w SnoringStable SleepUnstable SleepSQI = .98182Thursday, June 6, 13
  183. 183. 183Thursday, June 6, 13
  184. 184. 184Thursday, June 6, 13
  185. 185. SleepImage M1 monitor• Monitor•Carry Case• Software (PC)• Reports• Scheduling• Help• Cable• Batteries supplied• Patches supplied• PhD reads reports$185/monthwww.sleepimage.com185Thursday, June 6, 13

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