Malocclusion caused by nasal airway

NASAL AIRWAY AND
MALOCCLUSION
www.indiandentalacademy.com

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.

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

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.

PHARYNX
ANATOMY
-NASOPHARYNX
-ORO-PHARYNX
-LARYNGOPHARYNX
PHYSIOLOGIC MEASUREMENTS
-TIDAL VOLUME-500ML
-INSPIRATORY RESERVE VOLUME-3000ML.
-VITAL CAPACUTY-4600ML.

PHRYNX AND
RADIOLOGIC VIEW-56
ATHANSIOU

MOUTH BREATHING
ETIOLOGY
ANATOMICAL-DNS,CONGENITAL MICROGENIA
PATHOLOGICAL-ADENOIDS,TONSILS,
HABITUAL
“ADENOID FACIES”—coined at GUY’S hospital,london
constitutes the following-
long face
constricted upper dental arch
exposed upper incisors
receded lower jaw
short upper lip
associated habits

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.

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.

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.

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.

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.

EFFECTS OF OSA
• SYMPTOMS during sleep
– Snoring
– Abnormal motor activity
– Disturbed nocturnal sleep
– Sensation of choking
– Heart burn
– Nocturia
– Heavy sweating

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

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.

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

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

• 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 upper posterior segmentswww.indiandentalacademy.com

airway

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

Spirometry 462-PHYSIO
SPIROMETER

Rhino-snort
SNORT APPARATUS

Rhino-graphs-
OI,OE,NI,NE GRAPHS

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.

Head posturePg 7 petrovic
EXTENSION OF HEAD TO FACILIATE AIRWAY

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.

CHRONIC NASAL OBSTRUCTION
MOUTH BREATHING &HEAD EXTENSION
MANDIBLE &TONGUE ARE LOWERED
FACIAL HT. INCREASES
POSTERIOR TEETH SUPRA ERUPT
ANRETIOR OPEN BITE &INCREASED OVERJET
INCREASED CHEEK PRESSURE
COLLAPSED DENTAL ARCHES
AA
DD
EE
NN
OO
II
DD
FF
AA
CC
II
EE
SS

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
MANDIBULAR ADVANCEMENTwww.indiandentalacademy.com

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

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
RAPID MAXILLARY EXPANSION

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

AIRWAY BEFORE &AFTER RPE

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

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

YEN SWASA KATREAA !-
NEE VARUM PATHAI PARTHU
OUIR THANGEE NAN IRUPEAAN !!

Malocclusion caused by nasal airway

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Malocclusion caused by nasal airway