Nrf 1

NASO-RESPIRATORY FUNCTIONNASO-RESPIRATORY FUNCTION
AND GROWTH, SLEEP APNEAAND GROWTH, SLEEP APNEA
www.indiandentalacademy.com

CONTENTSCONTENTS
 IntroductionIntroduction
 AnatomyAnatomy
 Mechanism of BreathingMechanism of Breathing
 DiagnosisDiagnosis
 Animal studiesAnimal studies
 Human studiesHuman studies
 Relationships between dentofacialRelationships between dentofacial
deformities and nasal airway inadequacydeformities and nasal airway inadequacy

IntroductionIntroduction
 Nasal and oral cavities serve as pathwaysNasal and oral cavities serve as pathways
for respiratory airflow.for respiratory airflow.
 Inspiratory and expiratory air streams areInspiratory and expiratory air streams are
channeled through nose.channeled through nose.
 Nasal airway inadequacy – oral breathingNasal airway inadequacy – oral breathing
results.results.
 Conflicting views regarding closeConflicting views regarding close
relationship b/n dentofacial deformities andrelationship b/n dentofacial deformities and
nasal inadequacy.nasal inadequacy.

AnatomyAnatomy

Inspiratory & expiratory musclesInspiratory & expiratory muscles

Mechanism of breathingMechanism of breathing

RESPIRATORY PHYSIOLOGYRESPIRATORY PHYSIOLOGY
Pulmonary alveoli and respiratory tract.Pulmonary alveoli and respiratory tract.
FunctionFunction
 Exchange of OExchange of O22 and COand CO22 between environment andbetween environment and
body cells.body cells.
 OO22 – intercellular metabolism.– intercellular metabolism.
 COCO22 – End product.– End product.
 Exchange through alveoliExchange through alveoli
 Alveolar membrane permits O2 and CO2Alveolar membrane permits O2 and CO2
transport.transport.

AlveoliAlveoli

 Rhythmic activity – alters the level of gasesRhythmic activity – alters the level of gases
– alveoli and pulmonary capillaries -– alveoli and pulmonary capillaries - ↓↓
pressure gradients.pressure gradients.
 Respiratory tract results in transfer betweenRespiratory tract results in transfer between
alveoli and environment.alveoli and environment.
 Respiratory tract – nasal and oral passagesRespiratory tract – nasal and oral passages
which connect pharynx, larynx and trachea.which connect pharynx, larynx and trachea.
 Trachea – BronchiTrachea – Bronchi
BronchiolesBronchioles

Airway ResistanceAirway Resistance

Airway ResistanceAirway Resistance
 Changes in dimensions of respiratory tract -Changes in dimensions of respiratory tract - ↓↓
airflow e.g. enlarged adenoids and tonsils.-airflow e.g. enlarged adenoids and tonsils.-
Solow(79)Solow(79)
 Compensatory mechanismsCompensatory mechanisms
Respiratory muscles – increased work –change inRespiratory muscles – increased work –change in
intrapulmonary pressure.intrapulmonary pressure.
Modification of respiration by sensory feed back.Modification of respiration by sensory feed back.

Sensory feedbackSensory feedback
Sensory receptorsSensory receptors
Respiratory tractRespiratory tract
Cardiovascular system- baroreceptorsCardiovascular system- baroreceptors
Joints- increase pulm ventilationJoints- increase pulm ventilation
Pulmonary stretch receptorsPulmonary stretch receptors

 Chemoreceptors most affectted.Chemoreceptors most affectted.
 Monitor levels of O2 and CO2.Monitor levels of O2 and CO2.
Carotid bodies – O2 sensitiveCarotid bodies – O2 sensitive
Aortic bodiesAortic bodies
Ventral surface of medulla – CO2 sensitiveVentral surface of medulla – CO2 sensitive
Obstruction of upper airway –Obstruction of upper airway –
↓↓ airflow and O2 conc. – inspirationairflow and O2 conc. – inspiration
↓↓ airflow and inc CO2 conc. – expirationairflow and inc CO2 conc. – expiration
Transient hypoxia – Neural receptor stimulated.Transient hypoxia – Neural receptor stimulated.

Neuromuscular controlNeuromuscular control

DiagnosisDiagnosis
 Nasal breathers – lips touch lightly at restNasal breathers – lips touch lightly at rest
Nares dilate on command inspiration.Nares dilate on command inspiration.
Mouth breathers –Mouth breathers – lips parted at restlips parted at rest
nares maintain sizenares maintain size
 Use of a two surface steel mirrorUse of a two surface steel mirror
Use of a cotton butterfly.Use of a cotton butterfly.

DiagnosisDiagnosis

Craniofacial Adaptation to NasalCraniofacial Adaptation to Nasal
obstruction – Rhythmicityobstruction – Rhythmicity
 Animal Experiments:Animal Experiments:
Aim: Determine which craniofacial muscles wereAim: Determine which craniofacial muscles were
rhythmically active, discharging periodically withrhythmically active, discharging periodically with
primary respiratory muscles.primary respiratory muscles.
 16 muscles surveyed – 4 regions.16 muscles surveyed – 4 regions.
Mandibular elevatorsMandibular elevators
Mandibular depressorsMandibular depressors
TongueTongue
Facial musclesFacial muscles
Fine wires – placed intramuscularlyFine wires – placed intramuscularly
Electromyographic records takenElectromyographic records takenwww.indiandentalacademy.com

Longterm AdaptationLongterm Adaptation
 16 adult rhesus monkeys.16 adult rhesus monkeys.
 8-experimental and 8-controls8-experimental and 8-controls
Results – Control - No rhythmic activity inResults – Control - No rhythmic activity in
jaw elevator muscles.jaw elevator muscles.
Experimental - rhythmic activity –Experimental - rhythmic activity –
temporalis, masseter, medial pterygoid,temporalis, masseter, medial pterygoid,
suprahyoid, genioglossus, orbicularis oris.suprahyoid, genioglossus, orbicularis oris.

Rhythmicity during EarlyRhythmicity during Early
adaptationadaptation
 26 young rhesus monkeys –26 young rhesus monkeys –
13 mouth breathers – 13 controls.13 mouth breathers – 13 controls.
Results: Experimental group – rhythmicity inResults: Experimental group – rhythmicity in
1. muscles of upper lip and1. muscles of upper lip and
tonguetongue
2.2. Geniohyoid, digastric, temporalis,Geniohyoid, digastric, temporalis,
zygomaticus, medial and lateralzygomaticus, medial and lateral
pterygoid.pterygoid.

ELECTROMYOGRAPHYELECTROMYOGRAPHY
 It is a test that measures muscle response toIt is a test that measures muscle response to
nervous stimulation(electrical activitynervous stimulation(electrical activity
within muscle fiber)within muscle fiber)

Patterns of RhythmicityPatterns of Rhythmicity
 Craniofacial muscles –Craniofacial muscles –
2 discharge patterns.2 discharge patterns.
 Primary respiratoryPrimary respiratory
muscles – 1 dischargemuscles – 1 discharge
pattern.pattern.
 Diaphragm – SlowlyDiaphragm – Slowly
builds – max-tension.builds – max-tension.
 Lip ,nares and tongueLip ,nares and tongue
muscle attain max-muscle attain max-
tension immediately.tension immediately.

 To summarize rhythmic activity correlated withTo summarize rhythmic activity correlated with
respiration is normally present in five craniofacialrespiration is normally present in five craniofacial
muscles – control animals.muscles – control animals.
 Experimental animals – adapt to oral respiration –Experimental animals – adapt to oral respiration –
four additional muscles involved.four additional muscles involved.
 This reflexivity induces changes in neuromuscularThis reflexivity induces changes in neuromuscular
function of craniofacial muscles.function of craniofacial muscles.
inducing periodicity in dischargeinducing periodicity in discharge
initiating a sustained tonic dischargeinitiating a sustained tonic discharge

Growth in the sagittal depth of bony nasopharynx inGrowth in the sagittal depth of bony nasopharynx in
relation to some other facial variablesrelation to some other facial variables
Sten Linder - AronsonSten Linder - Aronson
 Size of nasopharynx important – mode ofSize of nasopharynx important – mode of
breathingbreathing
 Lymphoid tissue – posterior wall ofLymphoid tissue – posterior wall of
nasopharynx.nasopharynx.
 Adenoid vegetationsAdenoid vegetations
 Size of adenoids – crucialSize of adenoids – crucial

 Difference of opinionsDifference of opinions
 Rosenberger 1934 – nasopharynxRosenberger 1934 – nasopharynx ↑↑ in conjunctionin conjunction
with growth of the cranial base.with growth of the cranial base.
 Brodie 1941 – depth established during the firstBrodie 1941 – depth established during the first
year or two of life – constant afterwards.year or two of life – constant afterwards.
 King 1952 – examined nasopharyngealKing 1952 – examined nasopharyngeal
dimensions from 3 months to 16 years – similardimensions from 3 months to 16 years – similar
views.views.

 In contrast Subtelny 1957 – SerialIn contrast Subtelny 1957 – Serial
cephalometric study of 30 subjectscephalometric study of 30 subjects →→
- Nasopharynx- Nasopharynx ↑↑ from 3 years to 17 yearsfrom 3 years to 17 years
- First 11 years periods of apparent increase- First 11 years periods of apparent increase
/ decrease/ decrease
- After 12 years – steady increase- After 12 years – steady increase

 Handelman and Osborne 1976 –Handelman and Osborne 1976 –
nasopharyngeal depth constant in femalesnasopharyngeal depth constant in females
 In Males increased moderately from 3In Males increased moderately from 3
years, 9 months to maturity.years, 9 months to maturity.

 MaterialsMaterials – longitudinal– longitudinal
study – 6 to 20 yearsstudy – 6 to 20 years
children.children.
 140 boys and 120 girls –140 boys and 120 girls –
Burlington GrowthBurlington Growth
Center.Center.
 MethodMethod
variables measured:variables measured:
- Ba-S- Ba-S
- S-N- S-N
- Ba-ptm- Ba-ptm
- Ba-N- Ba-N
- Ptm-Sn- Ptm-Sn
- Sn-Gn- Sn-Gn
- N-Sn- N-Sn www.indiandentalacademy.com

 ResultsResults
Males – steady increase in sagittal depthMales – steady increase in sagittal depth
of nasopharynx – 6-20 yrsof nasopharynx – 6-20 yrs
6-12 yrs – 2.4mm6-12 yrs – 2.4mm
12-18 yrs – 4.7mm12-18 yrs – 4.7mm
Females – Growth of nasopharynx afterFemales – Growth of nasopharynx after
16 years negligible.16 years negligible.
6-12 yrs – 3.5mm6-12 yrs – 3.5mm
12-18 yrs – 1.6mm12-18 yrs – 1.6mm

 Results – HighestResults – Highest
correlation coefficient b/ncorrelation coefficient b/n
depth of nasopharynx anddepth of nasopharynx and
length of total cranial baselength of total cranial base
––
r =r = 0.63 - 0.750.63 - 0.75
..
 Very weak correlation b/nVery weak correlation b/n
depth of nasopharynx anddepth of nasopharynx and
length of maxillalength of maxilla
r=0.18 – 0.40r=0.18 – 0.40
CorrelationsCorrelations donedone

No correlation b/n depth of nasopharynx and facial heightsNo correlation b/n depth of nasopharynx and facial heights

 In earlier investigations – Linder AronsonIn earlier investigations – Linder Aronson
1972- sagittal depth of bony nasopharynx1972- sagittal depth of bony nasopharynx
influenced by mode of breathing.influenced by mode of breathing.
 Mouth breathers nasopharynx smaller.Mouth breathers nasopharynx smaller.
 Nasopharynx normalized – followingNasopharynx normalized – following
change to nose breathing.change to nose breathing.

SummarySummary
1.1. Sagittal depth of nasopharynxSagittal depth of nasopharynx ↑↑ in small steadyin small steady
increments upto 16 yrs of age in females and 20increments upto 16 yrs of age in females and 20
yrs in males.yrs in males.
2.2. The velocity of sagittal depthThe velocity of sagittal depth ↑↑ peaked – 12 topeaked – 12 to
14 yrs in males –14 yrs in males –
3.3. In females –In females – ↓↓ after 12 yrs of ageafter 12 yrs of age
4.4. There was great variation among individualThere was great variation among individual
velocity curves in both the age at which itvelocity curves in both the age at which it
peaked and magnitude of growth increments.peaked and magnitude of growth increments.
5.5. Sagittal depth of bony nasal pharynx isSagittal depth of bony nasal pharynx is
relatively independent of other cephalometricrelatively independent of other cephalometric
dimensions of the facial complex.dimensions of the facial complex.

Relationships between dentofacialRelationships between dentofacial
- Conflicting topicConflicting topic
- Judgement of mode ofJudgement of mode of
breathingbreathing

- Most prevalent view – mouthbreathing –Most prevalent view – mouthbreathing –
associated withassociated with
Retrognathic mandibleRetrognathic mandible
Protruding maxillary anterior teethProtruding maxillary anterior teeth
High palatal vaultHigh palatal vault
Constricted maxillary archConstricted maxillary arch
Flaccid and short upper lip.Flaccid and short upper lip.
Dull appearanceDull appearance

 Angle 1907 –Angle 1907 –
– ““This form of malocclusion is always accompanied andThis form of malocclusion is always accompanied and
atleast in its early stages, aggravated, if indeed notatleast in its early stages, aggravated, if indeed not
caused by mouth breathing due to some form of nasalcaused by mouth breathing due to some form of nasal
obstructions”.obstructions”.
Hunter 1971 – Did not find a relationship b/n allergicHunter 1971 – Did not find a relationship b/n allergic
rhinitis and malocclusion.rhinitis and malocclusion.
Linder Aronson, Aschan – Enlarged adenoids - AdenoidLinder Aronson, Aschan – Enlarged adenoids - Adenoid
faciesfacies
Moffat 1963 – Related protrusion of maxillary incisors toMoffat 1963 – Related protrusion of maxillary incisors to
mouth breathing.mouth breathing.

Harvold 1973 – Palatal anatomy and impairedHarvold 1973 – Palatal anatomy and impaired
nasal breathing related.nasal breathing related.
Korkhaus 1960 – Maxillary arch form importantKorkhaus 1960 – Maxillary arch form important
in determining nasal cavity sizein determining nasal cavity size  and henceand hence
breathing modebreathing mode

 Derichsweiler 1956 – contradicts nasal obstructionDerichsweiler 1956 – contradicts nasal obstruction
as a primary etiologic factor in dentofacialas a primary etiologic factor in dentofacial
deformity.deformity.
 Choanal atresiaChoanal atresia
 Watson 1968 – mouth breathing – not alwaysWatson 1968 – mouth breathing – not always
associated with skeletal deformity.associated with skeletal deformity.
23% of mouth breathers due to habit rather23% of mouth breathers due to habit rather
than physiologic need.than physiologic need.
Relationships between dentofacial deformitiesRelationships between dentofacial deformities
and nasal airway inadequacyand nasal airway inadequacy

To summarizeTo summarize
- Malocclusion may or may not be associatedMalocclusion may or may not be associated
with an inadequate nasal airway.with an inadequate nasal airway.
- Certain nasal or nasopharyngealCertain nasal or nasopharyngeal
abnormalities may produce a mouthabnormalities may produce a mouth
breathing pattern.breathing pattern.

Maxillary expansion and nasal airwayMaxillary expansion and nasal airway
resistanceresistance
- Hershey et al 1976 – 45% reduction in nasalHershey et al 1976 – 45% reduction in nasal
airway resistance after RMEairway resistance after RME
- Turby fill – 1976 – 53% decrease in airwayTurby fill – 1976 – 53% decrease in airway
resistance in 17 subjects.resistance in 17 subjects.

Craniocervical angulation and nasalCraniocervical angulation and nasal
respiratory resistancerespiratory resistance
 Solow Thompson – Changed craniofacialSolow Thompson – Changed craniofacial
morphology – due to changed head posturemorphology – due to changed head posture
..
 Schwarz 1926 – Head bent backwards i.r.t.Schwarz 1926 – Head bent backwards i.r.t.
neck in nasal obstruction.neck in nasal obstruction.
 Ricketts 68, Koski 75, Quinn and PickrellRicketts 68, Koski 75, Quinn and Pickrell
78 – similar views.78 – similar views.www.indiandentalacademy.com

Head posture and craniofacialHead posture and craniofacial
morphologymorphology
Bjork 1961 –Bjork 1961 –
– Retrognathic facial type – head in extended position.Retrognathic facial type – head in extended position.
– Prognathic facial type – head in lower positionPrognathic facial type – head in lower position
Bench 1963Bench 1963 – neck -curved in square faces– neck -curved in square faces
Straight – long faces.Straight – long faces.
Sallow and Tallgren 1976Sallow and Tallgren 1976 – of the posture variables– of the posture variables
the craniocervical angulation showed the mostthe craniocervical angulation showed the most
comprehensive correlation with craniofacialcomprehensive correlation with craniofacial
morphology.morphology.

 Extended head position –Extended head position –
-- Large inclinationLarge inclination
of mandibleof mandible
Small post and large antSmall post and large ant
facial heightsfacial heights
Facial retrognathismFacial retrognathism

 Average craniofacial morphology inAverage craniofacial morphology in
persons who had a large craniocervicalpersons who had a large craniocervical
angulation resembled to those persons whoangulation resembled to those persons who
had a large mandibular plane angle.had a large mandibular plane angle.

Soft tissues stretching hypothesisSoft tissues stretching hypothesis
 Solow and Kreiborg 1977 – posturallySolow and Kreiborg 1977 – posturally
induced stretching of the facial soft tissueinduced stretching of the facial soft tissue
layer might influence craniofaciallayer might influence craniofacial
morphological development.morphological development.
 Extension of head – entails a passiveExtension of head – entails a passive
stretching of the facial soft tissue layerstretching of the facial soft tissue layer
draping the face and the neck.draping the face and the neck.
 Slight backward and downward forcesSlight backward and downward forces

Soft tissues stretching hypothesisSoft tissues stretching hypothesis

ConclusionsConclusions
1.1. Before adenoidectomy a large craniocercivalBefore adenoidectomy a large craniocercival
angulation was seen in connection with aangulation was seen in connection with a
large nasalrespiratory resistance.large nasalrespiratory resistance.
2.2. After adenoidectomy reduction of theAfter adenoidectomy reduction of the
craniocervical angulation occurred in childrencraniocervical angulation occurred in children
in whom nasal respiratory resistance wasin whom nasal respiratory resistance was
reduced.reduced.

Nasorespiratory function andNasorespiratory function and
Craniofacial growth-Linder AronsonCraniofacial growth-Linder Aronson
 Distinction between mouth and noseDistinction between mouth and nose
breathersbreathers
 Mouth breathingMouth breathing
» Refers to those individuals who have a certainRefers to those individuals who have a certain
degree of nose breathing capacity but, for onedegree of nose breathing capacity but, for one
reason or another, breathe mainly through thereason or another, breathe mainly through the
mouth.mouth.
Conditions - E.g. Bilateral Chonanalatresi, alea nasiConditions - E.g. Bilateral Chonanalatresi, alea nasi
insufficiency – pure mouth breathers.insufficiency – pure mouth breathers.
Reduced nasal respiratory function – pts with enlargedReduced nasal respiratory function – pts with enlarged
adenoidal massesadenoidal masses

Effects of reduced nasal respiratory function on theEffects of reduced nasal respiratory function on the
development of facial skeleton and occlusiondevelopment of facial skeleton and occlusion
 Last 100 yrs – lot of researchLast 100 yrs – lot of research
 Wilhelm Meyer 1868 – patients with reduced nasalWilhelm Meyer 1868 – patients with reduced nasal
respiration – poor hearing & poor general health.respiration – poor hearing & poor general health.
 Tomes 1872 – mouth breathers- narrow dental arches (v-Tomes 1872 – mouth breathers- narrow dental arches (v-
shape).shape).
 Nordlund 1918 – theory of compressionNordlund 1918 – theory of compression
- Disturbance of balance b/n tongue and cheek musculature- Disturbance of balance b/n tongue and cheek musculature
 Korner 1891 – mouth breathingKorner 1891 – mouth breathing
1. Narrow dental arches.1. Narrow dental arches.
2. Underdevelopment of nasal cavity.2. Underdevelopment of nasal cavity.
3. Reduced maxillary size.3. Reduced maxillary size.

 Woodside 1968 –Woodside 1968 – Obstructed nasal ventilation –Obstructed nasal ventilation –
Class II malocclusionClass II malocclusion..
 Harvold et al 1973-79 –Harvold et al 1973-79 – Animal experimentsAnimal experiments
--change to mouth breathing--change to mouth breathing
narrowing of the maxilla.narrowing of the maxilla.
post rotation of mandiblepost rotation of mandible ..
Nordlund, Brash et alNordlund, Brash et al
Reduced nasal breathing result of existing facialReduced nasal breathing result of existing facial
and dental morphologyand dental morphology..

Adenoid facesAdenoid faces
 Associated with long history of mouth breathing.Associated with long history of mouth breathing.
 C/F:C/F:
– Open mouth posture.Open mouth posture.
– Flattened nose.Flattened nose.
– Pinched nostrils.Pinched nostrils.
– Short upper lip.Short upper lip.
– Voluminous and pouting lower lip.Voluminous and pouting lower lip.
– Vacant facial expression.Vacant facial expression.
– Proclined upper incisors.Proclined upper incisors.
– V-shape upper jaw – high palatal vault.V-shape upper jaw – high palatal vault.
– Skeletal Class II relationship.Skeletal Class II relationship.

Adenoid facesAdenoid faces

Effects on the dentition& facial skeletonEffects on the dentition& facial skeleton
of a change from mouth to noseof a change from mouth to nose
breathing-Linder Aronsonbreathing-Linder Aronson
19731973

 5 yr follow up study of children undergone5 yr follow up study of children undergone
adenoidectomies to clear obstructed nasaladenoidectomies to clear obstructed nasal
passages.passages.
 Purpose – Examine effects of a change in thePurpose – Examine effects of a change in the
mode of breathing onmode of breathing on
1. U/L incisal inclination1. U/L incisal inclination
2. Upper arch width2. Upper arch width
3. Sagittal depth of nasopharynx.3. Sagittal depth of nasopharynx.
4. Anterior facial height.4. Anterior facial height.
5. Inclination of the maxilla to mandible.5. Inclination of the maxilla to mandible.
Sample: 41 children – changed from mouth to noseSample: 41 children – changed from mouth to nose
breathing.breathing.
54 children – control54 children – control

Method:Method:
Children examined 1 and 5 yrs post opChildren examined 1 and 5 yrs post op

ResultsResults
Upper incisalUpper incisal
inclinationinclination
-- Relatively greaterRelatively greater
increase in upper incisorincrease in upper incisor
inclination.inclination.
- Normalization of upper- Normalization of upper
incisor inclination to SN-incisor inclination to SN-
during the five yearduring the five year
postop periodpostop period
..

ResultsResults
Inclination of the lowerInclination of the lower
incisorsincisors
 Greater change duringGreater change during
first year post-opfirst year post-op
 Next 4yrs no significantNext 4yrs no significant
changechange
 Normalization of lowerNormalization of lower
incisors inclination occurincisors inclination occur
during the 1during the 1stst
year post-opyear post-op

ResultsResults
Changes in archChanges in arch
widthwidth
 11stst
year greatest change 0.year greatest change 0.
9mm – statistically9mm – statistically
significant.significant.
 Normalization of archNormalization of arch
width took placewidth took place
following adenoidectomyfollowing adenoidectomy

ResultsResults
Effect on theEffect on the
nasopharynxnasopharynx
Normalization of theNormalization of the
depth of nasopharynxdepth of nasopharynx
occurs during the 1occurs during the 1stst
yryr
post-oppost-op

ResultsResults
Effect onEffect on
maxillomandibularmaxillomandibular
angleangle
 11stst
yr post-op – 0.4° -yr post-op – 0.4° -
not significantnot significant
 Next 5 yrs - greaterNext 5 yrs - greater
changechange
 ML/MN angleML/MN angle ↓↓ afterafter
change from mouth tochange from mouth to
nose breathing.nose breathing.

Mechanisms of change in dentition &Mechanisms of change in dentition &
facial morphologyfacial morphology

Changes in head postureChanges in head posture
 Mouth breathers – unconsciously maintain anMouth breathers – unconsciously maintain an
extended head posture.extended head posture.
 16 pts – undergone adenoidectomy16 pts – undergone adenoidectomy
16 pts – controls16 pts – controls
Method:Method:
Inclination of SN – measured relative to a verticalInclination of SN – measured relative to a vertical
reference line.reference line.
SN / vert angle – decreased in extended headSN / vert angle – decreased in extended head
posture.posture.

 Patients evaluated – before and 1 monthPatients evaluated – before and 1 month
after surgery.after surgery.
 Pt in a relaxed position infront of mirror –Pt in a relaxed position infront of mirror –
outside the cephalostat.outside the cephalostat.
 Light cross as a referenceLight cross as a reference
 Pencil mark following the horizontal line ofPencil mark following the horizontal line of
light cross.light cross.
..

Results:Results:
 Significant differencesSignificant differences
in the size of SN/Vertin the size of SN/Vert
angle beforeangle before
adenoidectomy.adenoidectomy.
 No difference afterNo difference after
adenoidectomy b/nadenoidectomy b/n
two groupstwo groups

Implications:Implications:
 Mouth breathers smallMouth breathers small
SN/Vert angleSN/Vert angle
 Large value for lowerLarge value for lower
facial height.facial height.

Pierre Robin syndromePierre Robin syndrome

The role of tonsils and adenoidsThe role of tonsils and adenoids
in the obstruction of respirationin the obstruction of respiration
 Tonsillectomy and adenoidectomy - inTonsillectomy and adenoidectomy - in
combination or separatelycombination or separately
 1 Recurrent or chronic throat infection.1 Recurrent or chronic throat infection.
2 Hypertrophy2 Hypertrophy
3 Recurrent attacks of acute otitis media.3 Recurrent attacks of acute otitis media.
Chronic otitis media with effusion.Chronic otitis media with effusion.

PrevalencePrevalence
 Upper resp infection – peaked – 1 & 6 years andUpper resp infection – peaked – 1 & 6 years and
significantlysignificantly ↓↓ thereafter.thereafter.
 Hypertrophy of tonsils and adenoids – more common inHypertrophy of tonsils and adenoids – more common in
boys – under 6 yrsboys – under 6 yrs
..
 Hypertrophy tonsils –twice in adult female.Hypertrophy tonsils –twice in adult female.
 Otitis media – 2Otitis media – 2ndnd
common disease in childhood.common disease in childhood.
 All these conditions -All these conditions - ↓↓ - after 6 yrs.- after 6 yrs.

Urgent indications for surgery:Urgent indications for surgery:
--Alveolar hypoventilationAlveolar hypoventilation
-Tonsil enlargement – difficulty in swalowing.-Tonsil enlargement – difficulty in swalowing.
Tonsillectomy –– foll conditionsTonsillectomy –– foll conditions
1) Recurrent tonsillitis1) Recurrent tonsillitis
2) Chronic tonsillitis2) Chronic tonsillitis
Adenoidectomy indicated in –Adenoidectomy indicated in –
persistent nasal obstructionpersistent nasal obstruction
recurrent otitis media with effusion.recurrent otitis media with effusion.

Factors influencing the degree ofFactors influencing the degree of
obstructionobstruction
 Degree of obstruction is primarily related to theDegree of obstruction is primarily related to the
size of the tonsils and adenoids relative to theirsize of the tonsils and adenoids relative to their
surr compartment.surr compartment.
 Recurrent chronic inflammation –Recurrent chronic inflammation – ↑↑ the degree ofthe degree of
obstruction.obstruction.
 Acute rhinitis – moderately obstructing adenoids -Acute rhinitis – moderately obstructing adenoids -
markedmarked ↓↓ in nasal airflow.in nasal airflow.
 Body position –Body position –
Recumbency in general –Recumbency in general – ↑↑ upper airwayupper airway
obstructionobstruction

Anatomic factors –Anatomic factors –
–Affect the degree of obstructionAffect the degree of obstruction
–Syndromes – e.g. Downs syndrome – extremeSyndromes – e.g. Downs syndrome – extreme
form – respiratory compromise.form – respiratory compromise.
-Anatomic variation –-Anatomic variation –
pedunculated tonsilspedunculated tonsils
-Deformity of nasal cavity-Deformity of nasal cavity
e.g. septal deviation, Choanal stenosise.g. septal deviation, Choanal stenosis

Methods of assessing degree ofMethods of assessing degree of
respiratory obstructionrespiratory obstruction
 Thorough history & physical examination –Thorough history & physical examination –
Sleeping habitsSleeping habits
SnoringSnoring
Mouth breathingMouth breathing
Distortion of speechDistortion of speech
HypersomniaHypersomnia
HeadachesHeadaches
LethargyLethargy
Weight gainWeight gain
NightmaresNightmares
Difficulty in awakeningDifficulty in awakening
Physical examination – head neck, chest & abdomen areasPhysical examination – head neck, chest & abdomen areas

Adenoid inspection:Adenoid inspection:
1) Direct inspection through the nasal cavities1) Direct inspection through the nasal cavities
Topical decongestantTopical decongestant
2) Right angle telescope2) Right angle telescope
3) Flexible fibreoptic nasopharyngoscope3) Flexible fibreoptic nasopharyngoscope
Tonsil inspectionTonsil inspection

ClassificationClassification
1 ± tonsils not visible behind the ant pillar1 ± tonsils not visible behind the ant pillar
2 ± tonsils visible just beyond the pillar2 ± tonsils visible just beyond the pillar
3 ± tonsils are almost touching3 ± tonsils are almost touching
4 ± tonsils meet in the midline4 ± tonsils meet in the midline
Radiographic films – lateral,Radiographic films – lateral,
posterioanterior & submento vertexposterioanterior & submento vertex
viewsviews

Mandibular growth direction followingMandibular growth direction following
adenoidectomy – Linder Aronson – AJO 1989adenoidectomy – Linder Aronson – AJO 1989
 Materials: 38 Swedish children – 38 controlsMaterials: 38 Swedish children – 38 controls
Age: 7-12 yrsAge: 7-12 yrs
After adenoidectomyAfter adenoidectomy
Method:Method:
Serial cephalometric studySerial cephalometric study
Post-operative assessmentPost-operative assessment

ResultsResults
 Experimental group – initially – steeper MPExperimental group – initially – steeper MP
angles, longer lower face heightsangles, longer lower face heights
 5 yrs postoperative – more horizontal5 yrs postoperative – more horizontal
growth patterngrowth pattern

Association of lip posture & the dimensions of tonsilsAssociation of lip posture & the dimensions of tonsils
and sagittal air way with facial morphologyand sagittal air way with facial morphology
- Trotman et al – Angle Orthod 1997- Trotman et al – Angle Orthod 1997
 MethodMethod:: clinical & ceph data – 207 childrenclinical & ceph data – 207 children
(adenoid or tonsil problems)(adenoid or tonsil problems)
 ConclusionsConclusions::
– More open lip posture - backwardly rotatedMore open lip posture - backwardly rotated
face &face & ↑↑ lower face height.lower face height.
– Reduced airway size – backward relocation ofReduced airway size – backward relocation of
max & mand.max & mand.
..

Effects of maxillary protraction on craniofacialEffects of maxillary protraction on craniofacial
structures and upper airway dimensions –structures and upper airway dimensions –
Shigetoshi et al – Angle Orthod 2002Shigetoshi et al – Angle Orthod 2002
 Aim: To examine the effect of max. protractionAim: To examine the effect of max. protraction
appliance on upper airway dimensions.appliance on upper airway dimensions.
 Material: - 25 pts – mean age 9.8yrsMaterial: - 25 pts – mean age 9.8yrs
Class III malocclusionClass III malocclusion
Method:Method:
Lateral cephalogram evaluationLateral cephalogram evaluation
Conclusions:Conclusions:
The max growth had significant positive effectThe max growth had significant positive effect
on the superior airway dimension.on the superior airway dimension.www.indiandentalacademy.com

1.1. ↑↑ in max growthin max growth
2.2. Inhibition of mand growthInhibition of mand growth
3.3. Clockwise rotation of mandible.Clockwise rotation of mandible.

Does the timing & method of RME have an effectDoes the timing & method of RME have an effect
on the changes in nasal dimension – Karaman,on the changes in nasal dimension – Karaman,
Bascifti – Angle Orthod 2002Bascifti – Angle Orthod 2002
 Aim: To assess the effects of RME onAim: To assess the effects of RME on
nasopharyngeal areanasopharyngeal area
 Sample:Sample:
30 pts – perm dent.30 pts – perm dent.
Max. constriction and post crossbiteMax. constriction and post crossbite
Method:Method:
Lateral & frontal cephalograms – before &Lateral & frontal cephalograms – before &
after RMEafter RME

ResultsResults
 Respiratory areaRespiratory area ↑↑
 Nasal cavity width & max. width -Nasal cavity width & max. width - ↑↑
 Decrease in nasal airway resistanceDecrease in nasal airway resistance
 MP suture seperated -MP suture seperated - ↑↑ in the internasalin the internasal
volumevolume
 Nasal resistance decreased & respiratoryNasal resistance decreased & respiratory
areaarea ↑↑ after RMEafter RME

Comparison of nasopharyngeal endoscopy & lateralComparison of nasopharyngeal endoscopy & lateral
cephalometric radiography in diagnosis ofcephalometric radiography in diagnosis of
nasopharyngeal airway obstruction –nasopharyngeal airway obstruction –
Daniel Filho – AJO 2001Daniel Filho – AJO 2001
 Aim:Aim:
2 methods of diagnosing nasopharyngeal2 methods of diagnosing nasopharyngeal
airway obstruction were comparedairway obstruction were compared
 Material:Material:
30 orthodontic pts – 7-12 yrs30 orthodontic pts – 7-12 yrs
Mouth breathersMouth breathers
 Method : Nasopharyngeal endoscopy &Method : Nasopharyngeal endoscopy &
radiographic examination – same dayradiographic examination – same day

 Lateral cephalometric radiography – sufficientlyLateral cephalometric radiography – sufficiently
reproducible for diagnosing hypertrophy of the middlereproducible for diagnosing hypertrophy of the middle
and inferior turbinatesand inferior turbinates
..
 Lateral cephalometric radiography – overestimatesLateral cephalometric radiography – overestimates
turbinate hypertrophy – false positive findings.turbinate hypertrophy – false positive findings.
 Nasopharyngeal videoendoscopy – more suitable inNasopharyngeal videoendoscopy – more suitable in
diagnosing obstruction of nasopharyngeal origin.diagnosing obstruction of nasopharyngeal origin.
Nasal septal deviationsNasal septal deviations
Hypertrophy of the inferior & middle turbinatesHypertrophy of the inferior & middle turbinates

Cleft palate studiesCleft palate studies
 12 yr old female – submucous cleft, nasal12 yr old female – submucous cleft, nasal
speech.speech.
 Velopharyngeal flap – to reduceVelopharyngeal flap – to reduce
nasopharyngeal leakage.nasopharyngeal leakage.
 5 yrs postop change from nose to mouth5 yrs postop change from nose to mouth
breathing.breathing.
 Marked opening overbite & increase inMarked opening overbite & increase in
lower face heightlower face height

 Subtelny 1978 –Subtelny 1978 –
Pharyngeal flap surgery – 24 childrenPharyngeal flap surgery – 24 children
Results:Results:
Chin position downward & backwardChin position downward & backward
No difference in growth of mandibleNo difference in growth of mandible
 Warren 1975 –velopharyngeal flap surgeryWarren 1975 –velopharyngeal flap surgery
Increased resistance to nose breathingIncreased resistance to nose breathing

Comparison of the sizes of adenoidal tissuesComparison of the sizes of adenoidal tissues
and upper airways of subjects with andand upper airways of subjects with and
without CLCP - Imawaruwithout CLCP - Imawaru
ShigetoshiShigetoshi
AJO Aug 2002AJO Aug 2002
 SampleSample
 1. 90 juvenile with CLP(CLP/J)1. 90 juvenile with CLP(CLP/J)
90 controls – control/J90 controls – control/J
2. 40 adolescents with CLP – CLP/A2. 40 adolescents with CLP – CLP/A
40 controls – control/A40 controls – control/A

 MethodMethod – measurements using Lat. Ceph– measurements using Lat. Ceph
 ResultsResults – Adenoid tissue– Adenoid tissue
significantly larger in CLP/J than insignificantly larger in CLP/J than in
control/Jcontrol/J
no significant difference betn CLP/A &no significant difference betn CLP/A &
control/Acontrol/A
adenoids smaller in CLP/A than in CLP/Jadenoids smaller in CLP/A than in CLP/J

Upper AirwayUpper Airway
 Significantly smaller in CLP/J than inSignificantly smaller in CLP/J than in
control/Jcontrol/J
 Significantly smaller in CLP/A than inSignificantly smaller in CLP/A than in
control/Acontrol/A
 CLP/A- increased airway than CLP/JCLP/A- increased airway than CLP/J
 Control/A larger than control/JControl/A larger than control/J
 Larger adenoids in CLP/J group decreasedLarger adenoids in CLP/J group decreased
to a smaller size with agingto a smaller size with aging

Sleep ApneaSleep Apnea
 Defn – It is defined as an intermittentDefn – It is defined as an intermittent
cessation of air flow at the nose and mouthcessation of air flow at the nose and mouth
during sleep.during sleep.
 10 sec duration – imp.10 sec duration – imp.
 Sleep apnea syndrome – refers to a clinicalSleep apnea syndrome – refers to a clinical
disorder that arises from recurrent apneasdisorder that arises from recurrent apneas
during sleep.during sleep.

EtiologyEtiology
 Loss of muscle toneLoss of muscle tone
 Obstruction of nasal passagesObstruction of nasal passages
 Large tonsilsLarge tonsils
 Large tongueLarge tongue
 Retrognathic mandibleRetrognathic mandible
 ObesityObesity
 AlcoholAlcohol
 Sedative medicationsSedative medications

ClassificationClassification
 1. Central1. Central
 2. Obstructive2. Obstructive
 3. Mixed3. Mixed

PathogenesisPathogenesis
 Occlusion at the level of oropharynxOcclusion at the level of oropharynx
 Progressive asphyxia – brief arousal fromProgressive asphyxia – brief arousal from
sleep – airway restored – sleep.sleep – airway restored – sleep.
 400-500 times per night400-500 times per night
 Critical subatmospheric pressureCritical subatmospheric pressure
 Sleep – reduces the activity of upper airwaySleep – reduces the activity of upper airway
musclesmuscles
 Alcohol – imp. CofactorAlcohol – imp. Cofactor
 depressant actiondepressant action

 Anatomic disturbances – adenotonsillarAnatomic disturbances – adenotonsillar
hypertrophyhypertrophy
 retrognathiaretrognathia
 macroglossiamacroglossia
 ObesityObesity
 SnoringSnoring

Clinical featuresClinical features
 Behavioral disturbancesBehavioral disturbances
 Fragmentation of sleepFragmentation of sleep
 Nocturnal cerebral hypoxiaNocturnal cerebral hypoxia
 Excessive day time sleepinessExcessive day time sleepiness
 Intellectual impairmentIntellectual impairment
 Memory lossMemory loss
 Impotence – in menImpotence – in men

manifestationsmanifestations
 Bradycardia – during apneaBradycardia – during apnea
 Tachycardia – 90 – 120 beats/minTachycardia – 90 – 120 beats/min

PrevalencePrevalence
 Increases with ageIncreases with age
 More prevalent in womenMore prevalent in women
 Moderate obesityModerate obesity
 Mild to moderate hypertensionMild to moderate hypertension

DiagnosisDiagnosis
 Definitive investigationsDefinitive investigations
– Poly somnographyPoly somnography
– Arterial O2 saturationArterial O2 saturation
– Heart rateHeart rate

TreatmentTreatment

herbstherbst

Modified functional appliance forModified functional appliance for
treatment of sleep apneatreatment of sleep apnea
 Sleep apnea – sleep with mouth openSleep apnea – sleep with mouth open
 Reduced tonicity of genioglossal mucsle-Reduced tonicity of genioglossal mucsle-
tongue sucked backtongue sucked back
 Diagnosis - best by pulmonologistDiagnosis - best by pulmonologist

New appliance – NAPANew appliance – NAPA
 Nocturnal airway patency applianceNocturnal airway patency appliance
 Mechanism –Mechanism –
– Posturing the tongue more anteriorlyPosturing the tongue more anteriorly
– Inhibiting wide jaw openingInhibiting wide jaw opening
– Assuring adequate air intake when nasalAssuring adequate air intake when nasal
obstruction existsobstruction exists

ConstructionConstruction
 Constructed using wire and acrylicConstructed using wire and acrylic

Case reportCase report
 5 OSA patients – polysomnography5 OSA patients – polysomnography
 Results – substantial reduction in no. ofResults – substantial reduction in no. of
apneas/hrapneas/hr
 All 5 ptns – improvement in sleepAll 5 ptns – improvement in sleep

summarysummary
 Mandible was protruded to advance theMandible was protruded to advance the
tongue to the posterior pharyngeal walltongue to the posterior pharyngeal wall
 Genioglossus originates from the innerGenioglossus originates from the inner
surface of the mandibular symphysissurface of the mandibular symphysis
 ¾ distance b/w centric occlusion and full¾ distance b/w centric occlusion and full
protrusion was selectedprotrusion was selected
 5-7 mm of protrusion5-7 mm of protrusion
 Oral breathing beak – ptns with nasalOral breathing beak – ptns with nasal
congestioncongestion

 Ptns – clench their teeth 3 times for 5 secsPtns – clench their teeth 3 times for 5 secs
every morn. – relaxes the lat.pty muscleevery morn. – relaxes the lat.pty muscle

Removable Herbst appliance forRemovable Herbst appliance for
treatment OSA – Ernest A.Ridertreatment OSA – Ernest A.Rider
 16 SA ptns16 SA ptns
 Plunger mechanismPlunger mechanism
 Sustained pharyngeal patencySustained pharyngeal patency
 AdvancementAdvancement
– Edge to edge positionEdge to edge position

ResultsResults
 70 – 100 % improvement – 12 ptns70 – 100 % improvement – 12 ptns

Therapeutic efficacy of an oralTherapeutic efficacy of an oral
appliance in the treatment of OSA –appliance in the treatment of OSA –
2 yr follow up2 yr follow up
 Purpose – the long term efficacy ofPurpose – the long term efficacy of
Karwetzky activatorKarwetzky activator

resultsresults
 T1 -T1 -

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