UPPER AIRWAY CONSTRICTION
&
ITS EFFECT ON GROWTH AND TREATMENT

INDIAN DENTAL ACADEMY
Leader in continuing dental educatio...
CONTENTS
1.HISTORY
2.UPPER AIRWAY STRUCTURE – PARTS
3.RESPIRATORY MECHANICS
4.CAUSES OF UPPER AIRWAY CONSTRICTION
5.NASO –...
INTRODUCTION

Human beings are normally nasal breathers. The nasal and oral cavities
serve as pathways for respiratory air...
HISTORY
According to Angle, 1907, Cl II DI malocclusion is always accompanied and
atleast in its early stages aggravated, ...
Harvold in 1973 simulated hypertrophied adenoids in primates with acrylic
blocks and found that within 9-15 months the pal...
STRUCTURE OF UPPER AIRWAY
The structures of upper airway are the nose
and the pharynx with its 3 divisions (ie,
nasopharyn...
RESPIRATORY MECHANICS
When the diaphragm contracts, its dome moves downwards
into the abdomen, thus enlarging the thoracic...
AIRFLOW MECHANICS
Air flows from one region to another because of a difference in pressure
between the two regions. There ...
PATHOLOGIES CAUSING CONSTRICTION
Nose
Choanal atresia,nasal septal deviation, hypertrophy of turbinates, Polyposis,
Dermoi...
NASO – REPIRATORY FUNCTION AND CRANIOFACIAL GROWTH
Dentofacial morphology can be altered by nasorespiratory
obstruction de...
3 mechanisms were found by which adenoid-mouth breathing relationship
influences the etiology of facial form and dentition...
The airpressure theory described by Kantorowicz (1916) and James &
Hastings (1932) holds that a change to mouth breathing ...
Although the literature is replete with statements that airway impairment
alters facial and dental growth, there is substa...
HEAD POSTURE
The extended head posture which was observed in mouth breathers is found
to influence the position of the man...
SOFT TISSUE STRETCHING HYPOTHESIS (Solow and Kreiborg `77)
An extension of the head in relation to the cervical column wou...
DIAGNOSIS
Parents may fail to appreciate symptoms in their children.Accordingly, to be
alerted to the possibility of chron...
HISTORY AND PHYSICAL EXAMINATION
The general well-being of the child, including growth and development, must
be determined...
A complete examination of the head and neck is performed.
• Resting mouth position is noted.
• "Adenoid facies" is charact...
Evaluation of the voice quality includes as assessment of nasality and clarity.
Having the child to speak words that enhan...
CLASSIFICATION OF RESPIRATORY OBSTRUCTION
Respiratory obstruction can occur due to adenoids or as result tonsils
both.The ...
THE LONG FACE SYNDROME
In 1872, C.V. Tomes coined the term
“Adenoid Facies” or „Long Face Syndrome‟
to describe the dentof...
The "long face syndrome" is often associated with crossbite, tension nose,
and a Class-II (mandibular retrognathic) occlus...
PROPOSED SEQUENCE OF EVENTS as described by Principato

Prolonged periods of oral respiration lead to extensive eruption o...
DENTOFACIAL DEFORMITIES AND MOUTHBREATHING
One or all of the three neuromuscular responses must be present for
malocclusio...
Mouth breathing is thought to predispose to the development of the "long face
syndrome" or "adenoid facies”. Vig et al. fo...
ROLE OF TONSILS AND ADENOIDS IN THE
OBSTRUCTION OF RESPIRATION
The tonsils and adenoids are composed of
lymphatic tissues....
The purpose of the tonsils and adenoids
The tonsils and adenoids are thought to assist the body in its defense against
inc...
INVOLUTION OF ADENOIDS
The adenoids are small at birth .The adenoids enlarge and eventually outstrip
the growth of the nas...
Tonsillitis and Its Symptoms
Tonsillitis is an infection in one or both
tonsils. One sign is swelling of the
tonsils. Othe...
Enlarged Adenoids and Their Symptoms

Breathing through the mouth instead of the nose most of the time
Nose sounds "blocke...
RHINITIS
Allergy is by far the most common and important cause of nasal obstruction.
Allergy must be screened out first. A...
Classification
Allergic rhinitis
Symptoms develop when persons inhale airborne antigens (allergens) to which
they have bee...
2.Nonallergic rhinitis with nasal eosinophilia syndrome (NARES) is
characterized by perennial symptoms, an older average a...
SEQUELA OF UPPER AIRWAY OBSTRUCTION
Some of the effects of impaired nasal respiration reported are: Abnormal
facial develo...
MUSCLES AND NASAL AIRWAY RESISTANCE
Vargervik et al.found that tonic electromyographic activity of digastric muscle
and ge...
Obstruction of the nasal airway in the cat significantly inhibited the
masseteric stretch reflex and discharges of massete...
INVESTIGATION
ASSESSMENT OF NASAL AIRWAY STRUCTURE
Structural abnormalities of the nose may be evaluated objectively by cl...
Cephalometry
The roentgenographic ratings is the gold standard during investigations
because roentgenographic assessment c...
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DISADVANTAGES
1.There is the geometric limitation that a cephalogram produces only a twodimensional representation of the ...
In 1987, Weimert published a study of 1360 patients referred to
otolaryngologists by orthodontists. Most patients had unde...
Fiberoptic rhinoscopy is the insertion of a flexible telescope into the
nasal cavity which allows the detailed visualizati...
Video nasopharyngeal endoscopy allows direct visualization and dynamic
evaluation of the nasopharynx, including details su...
2. cephalometric radiography gives high sensitivity but low for specificity in
diagnosing hypertrophy of the inferior and ...
ASSESSMENT OF NASAL AIR FLOW AND RESISTANCE
Dynamic measurements of nasal congestion include nasal peak flow,
rhinomanomet...
This technique involves measuring the peak inspiratory nasal airflow with a
modified peak flow device (eg nasal inspirator...
2.Rhinomanometry
Rhinomanometry, the measurement of nasal airway resistance, is probably the
test most frequently performe...
Anterior and posterior rhinomanometry differ in the location of the transducer
used to measure posterior pharyngeal pressu...
Gurley and Vig reported a technique , which for the first time enabled the direct
and simultaneous measurement of inspired...
Vig reported that it is not surprising to find the statistical correlations between
visually determined mouthbreathing and...
3.Acoustic Rhinometry
Acoustic rhinometry, evaluates nasal obstruction by analyzing reflected sound
waves introduced throu...
4.Plethysmograph
Niinima et al quantified nasal and oral
airflow simultaneously with a nasal
mask attached to a
pneumotach...
5.CT & MRI
The limiting factor, that
determines the capacity for
airflow is the minimal crosssectional area of the passage...
Attempts are being made to quantitate the adenoid mass and
pharyngeal space by linear measurement and/or surface calculati...
Other Dynamic Methods To Measure Nasal Patency
Chilled mirrors or other polished surfaces The patient exhales through the
...
RHINITIS INVESTIGATION

Skin-prick test - most sensitive allergy test;
total serum IgE - poor sensitivity and specificity;...
TREATMENT
TONSILLECTOMY AND ADENOIDECTOMY
Over 75% of tonsil/adenoid operations are performed on children less than
15 yea...
TONSILLECTOMY INDICATIONS
Recurrent tonsillitis defined by a history of atleast 7 episodes in the preceding
year, or 5 epi...
Early intervention to correct nasal obstruction may lead to reversal of the
associated craniofacial changes. Normalization...
Linder-Aronson reported in children who had adenoidectomy &returned to
nasal breathing had demonstrated craniofacial growt...
TURBINATE RESECTION
Hypertrophy of the erectile tissue of the turbinates due to rhinitis or other
causes can be treated by...
SEPTOPLASTY
Although controversy still exist over whether nasal deformities in children
can be safely corrected without di...
CONGENITAL MALFORMATIONS
Congenital malformations such as choanal stenosis and rarely unilateral
atresia may be missed ear...
RHINITIS
Allergy treatment is based upon three general modalities:
environmental control or avoidance of offending substan...
ORTHODONTIC TREATMENT
Orthodontic treatment is directed towards the prevention and correction of the
malocclusion or to an...
PREVENTION – MYOFUNCTIONAL APPLIANCES
Oral myofunctional therapy has been shown to be effective in correcting oral
myofunc...
Oral myofunctional therapy has two main goals:
establishing an oral/facial resting posture with the tongue away from the t...
.

Children as young as four years of age may benefit Habits such as mouth
breathing, reverse swallowing and thumb sucking...
RAPID MAXILLARY EXPANSION
Brown, a rhinologist, was a vigorous supporter of midpalatal suture opening for
the purpose of o...
Rapid maxillary expansion (RME) broadens the maxillary arch which also
serves to widen the nasal vault and improve nasal p...
RME and nasal airflow.
Anatomically, there is an increase in the width of the nasal cavity immediately
following expansion...
Hershey, Stewart, and Warren, and Turbyfill reported a reduction of nasal
airway resistance by an average of 45% to 53% wi...
Mean cross-sectional nasal cavity
enlargements of between 1.4 mm and 4 mm for
rapid expansion, 0.8 mm for a quad helix, an...
ORTHOGNATHIC SURGERY
If the difference between the maxillary and the mandibular unit length is greater
than 16mm at the ag...
Even indirect evidence of forward movement of the base of the tongue, as a
consequence of mandibular advancement with eith...
ROLE OF ORTHODONTIST
In 1987, Weimert published a study of 1360 patients referred to
otolaryngologists by orthodontists be...
As a referring doctor, one has to decide between allergist, ENT, pediatrician
or sleep lab. Referrals should always be for...
Bushey`74 has differentiated the different facial types and adenoid/tonsil
enlargement and proposed different treatment mo...
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CONCLUSION
Evaluation of children with nasal obstruction and dental abnormalities
requires a multidisciplinary approach an...
Thank you
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Upper airway constiction and its effects on growth & develop /certified fixed orthodontic courses by Indian dental academy

  1. 1. UPPER AIRWAY CONSTRICTION & ITS EFFECT ON GROWTH AND TREATMENT INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. CONTENTS 1.HISTORY 2.UPPER AIRWAY STRUCTURE – PARTS 3.RESPIRATORY MECHANICS 4.CAUSES OF UPPER AIRWAY CONSTRICTION 5.NASO – REPIRATORY FUNCTION AND CRANIOFACIAL GROWTH 6.HEAD POSTURE 7.DIAGNOSIS 8. HISTORY AND PHYSICAL EXAMINATION 9.CLASSIFICATION OF RESPIRATORY OBSTRUCTION 10.LONG FACE SYNDROME 11.MOUTHBREATHING AND DENTOFACIAL DEFORMITIES 12.ROLE OF TONSILS AND ADENOIDS 13.RHINITIS 14.SEQUELA OF UPPER AIRWAY CONSTRICTION 15.MUSCLES IN IMPAIRED NASAL AIRWAY 16.INVESTIGATIONS 17.TREATMENT ADENOIDECTOMY AND TONSILLECTOMY SEPTOPLASTY & TURBINATE RESECTION RHINITIS ORTHODONTIC TREATMENT – Myofunctional appliances RAPID MAXILLARY EXPANSION ORTHOGNATHIC SURGERY 18.ROLE OF ORTHODONTISTS www.indiandentalacademy.com 19.CONCLUSION
  3. 3. INTRODUCTION Human beings are normally nasal breathers. The nasal and oral cavities serve as pathways for respiratory airflow. Ordinarily, the inspiratory and expiratory airstreams are channeled through the nose because the mouth is usually closed. However, in some individuals, because of nasal airway inadequacy or habit, the oral cavity becomes the predominant route for the passage of respiratory airflow. www.indiandentalacademy.com
  4. 4. HISTORY According to Angle, 1907, Cl II DI malocclusion is always accompanied and atleast in its early stages aggravated, if not caused by mouth breathing due to some form of nasal obstructions. Derichsweiler (1956) argued against nasal obstruction being a primary etiologic factor in dentofacial deformity. Watson and Colleagues (1968) are also of similar opinion and suggested that when resistance was high mouth opening invariably resulted, but skeletal deformity did not always occur. Korkhaus (1960) on the other hand, suggested that maxillary arch form is a primary factor in determining nasal cavity size and hence breathing mode. Linder-Aronson (1970) and Tully (1966) described a special facial type “Adenoid facies” as characteristics of persons with enlarged adenoids and mouthbreathers. Hunter (1971) did not find a relationship between allergic rhinitis and malocclusion, but demonstrated that frequency of mouthbreathing increases as nasal airway resistance increases www.indiandentalacademy.com
  5. 5. Harvold in 1973 simulated hypertrophied adenoids in primates with acrylic blocks and found that within 9-15 months the palatal vault increased in height creating an anterior open bite. Sten Linder-Aronsen‟s study of human children establishes correlation that conditions which can obstruct nasal air flow may cause deviations in craniofacial growth, particularly increased face height. Vig, et al. found that the long-faced group had a higher mean value of nasal resistance but that the individual range of variation was too great. In an assessment of anteroposterior relationships, Watson, et al. found that the magnitude of nasal resistance and the subject‟s anterior-posterior skeletal classification were independent of one another. www.indiandentalacademy.com
  6. 6. STRUCTURE OF UPPER AIRWAY The structures of upper airway are the nose and the pharynx with its 3 divisions (ie, nasopharynx, oropharynx, hypopharynx). Changes in the dimensions of the respiratory tract i.e. constriction will decrease the airflow(Solow and Greieve`79) Nose: The internal nasal valve, the septum, and the choana are areas of special concern. Nasopharynx: This area is particularly important in children because the adenoids are commonly hypertrophied, producing obstruction. Oropharynx: The soft palate, tonsils, palatoglossal and palatopharyngeal arches, and the tongue are structures of concern. Hypopharynx: The base of the tongue is the most influential structure in this area. www.indiandentalacademy.com
  7. 7. RESPIRATORY MECHANICS When the diaphragm contracts, its dome moves downwards into the abdomen, thus enlarging the thoracic cavity. Simultaneously, the inspiratory muscles move the rib cage upward and outward, also increase the volume of the thoracic cavity. This enlarges the volume of air within the lungs, pressure falls below atmospheric and air is drawn into the expanding lungs. While inspiration is an active process involving muscles, normal expiration is a passive event. As the thorax and lungs spring back to their original sizes, pulmonary air becomes temporarily compressed so that its pressure exceeds atmospheric and air flows from the lungs to the outside. www.indiandentalacademy.com
  8. 8. AIRFLOW MECHANICS Air flows from one region to another because of a difference in pressure between the two regions. There is a pressure differential (drop) in the direction of airflow. The relationship between this pressure drop and airflow depends upon Reynolds number. Rn = P ~d / Where p is the density, ~ is air velocity, d is the diameter of the structure and is the density of the air. When Rn < 2000. the flow is smooth or laminar. Laminar  P = K1 V (P – Pressure, K1 – proportionality constant which includes air viscosity and length and radius of the str, and v is airflow) When Rn > 2000, airflow is turbulent. Turbulent  P = K2 V2 www.indiandentalacademy.com
  9. 9. PATHOLOGIES CAUSING CONSTRICTION Nose Choanal atresia,nasal septal deviation, hypertrophy of turbinates, Polyposis, Dermoid cyst, Tumors Nasopharynx Adenoidal hypertrophy ,Stenosis,Pharyngeal flap for cleft palate,Tumors , Mouth and oropharynx Hypertrophied tonsils, Macroglossia , Micrognathia, Epignathus, Temporomandibular joint ankylosis Larynx Tracheal atresia,Intrinsic tracheal lesions,Extrinsic compression (goiter),Laryngeal and tracheal webs,Kimura disease (Okami, 2003) www.indiandentalacademy.com
  10. 10. NASO – REPIRATORY FUNCTION AND CRANIOFACIAL GROWTH Dentofacial morphology can be altered by nasorespiratory obstruction depending on the magnitude, duration & time of occurrence. Quinn in 1978 reiterated that mouth breathing is one of the early symptoms of unnatural acts of breathing and that dramatic deformities of the face, jaws and dentition can be caused by inability to breathe through the nose properly. Ricketts in 1979 stated that when there is a lack of function in the nose, there can be a growth inhibition. Under normal function in breathing, a pressure develops.In the abnormal, this pressure is changed to vacuum and the maxillary complex is sucked inward, restricting the basal cone. www.indiandentalacademy.com
  11. 11. 3 mechanisms were found by which adenoid-mouth breathing relationship influences the etiology of facial form and dentition 1.Compression 2.Disuse atrophy – theory of inactivity 3.Altered air pressure In 1918, Norlund introduced the „compression theory‟ which stated that constriction of the maxillary arch is related to the absence of the lateralizing pressure of the tongue against the palate. In response to nasal obstruction, the tongue drops and the medializing effects of the buccal musculature is left unopposed. The effect is further enhanced by a pressure differential across the hard palate in the absence of nasal airflow, leading to a narrow, higharched palate. Norlund also put forward the „theory of inactivity‟, according to which there is reduced growth of the nasal cavity, due to its inactivity, as suggested by Korner (1891) and Bentzen (1903). www.indiandentalacademy.com
  12. 12. The airpressure theory described by Kantorowicz (1916) and James & Hastings (1932) holds that a change to mouth breathing causes the normal negative pressure in the anteriorly sealed oral cavity produced by nasal respiration to be lost, and the palate thus is not carried downward with the growth of the maxillary alveolar process. The excavation theory proposed by Bloch (1903) and Michel (1908) states that an upward stream of oral airflow presses on the palate leading to higher palatal vault. Recent study by Chang proposed that the degree of impact caused by nasal obstruction may vary with different facial types. A brachycephalic or broad faced pattern with strong facial musculature and a deep bite may be less affected by nasal obstruction, whereas dolicocephalic faces . with narrow, more elongated pattern may be more susceptible www.indiandentalacademy.com
  13. 13. Although the literature is replete with statements that airway impairment alters facial and dental growth, there is substantial evidence to the contrary. Conversely, Bushey found no relationship between nasal respiration and linear measurements of the adenoids on lateral skull cephalograms before and after surgical removal of the tonsils and adenoids. As opposed to these studies, Kingsley (1989) noted normal craniofacial development in children with severe nasal obstruction and Whitaker described severe palate malformations in patients who had undergone adenoidectomy at an early . age More recent findings suggest that nasal-oral breathing per se is not necessarily harmful to craniofacial growth. However, in instances where the nasopharyngeal or oropharyngeal airspace is small, exaggerated postural responses in obligatory mouthbreathers may be detrimental to craniofacial growth. www.indiandentalacademy.com
  14. 14. HEAD POSTURE The extended head posture which was observed in mouth breathers is found to influence the position of the mandible. The SN/vertical angle was found to be less in patients with extended head posture . Schwarz in his studies in 1926,1931 found that the extension of the head in relation to the body, particularly during sleep, led to the distal displacement of the mandible and the development of class II M.O. Bjork (1955, ‟60, ‟61) noticed that individuals with a flattened cranial base and a retrognathic facial type carried their head in an extended position, while those with a marked bend of the cranial base and a prognathic facial type carried their head in a lower position. Solow and Tallgren (1976) observed that subjects who had a large cranio-cervical angulation resembled that of subjects who had a large mandibular plane inclination. This suggests that the factors responsible for the postural differences may also be responsible for differences in mandibular plane inclination and facial type. www.indiandentalacademy.com
  15. 15. SOFT TISSUE STRETCHING HYPOTHESIS (Solow and Kreiborg `77) An extension of the head in relation to the cervical column would entail the passive stretching of the facial soft tissue layer draping the face and neck.The effect of this would be slight backward and downward forces exerted by the soft tissue layer on the facial skeleton thereby restraining the forward and increasing the downward component of the maxillary and mandibular growth relative to the cranial base . www.indiandentalacademy.com
  16. 16. DIAGNOSIS Parents may fail to appreciate symptoms in their children.Accordingly, to be alerted to the possibility of chronic nasal obstruction in children and to assess its severity, clinicians often must rely on their own observations of clinical signs. The cause of nasal obstruction in children can usually be determined by a thorough history and physical exam. The goals of the evaluation are to determine specific causes of problems, the severity of the obstruction, and the presence of associated medical complications www.indiandentalacademy.com
  17. 17. HISTORY AND PHYSICAL EXAMINATION The general well-being of the child, including growth and development, must be determined. • Pertinent past history include birth trauma, early childhood trauma, previous hospitalizations, medications, and surgical history. •Sleep history may often reveal loud irregular snoring, restless sleep, abnormal sleep position, and nocturnal mouth breathing. Enuresis may also be present. Swallowing difficulties may be noted. •Voice quality (degree of nasality) and clarity, daytime hypersomnolence, and school/behavioral difficulties should be evaluated. •History of rhinorrhea, epistaxis and allergy should be noted. www.indiandentalacademy.com
  18. 18. A complete examination of the head and neck is performed. • Resting mouth position is noted. • "Adenoid facies" is characterized by an open mouth, dull facial appearance, and short upper lip. This is nonspecific for chronic nasal obstruction. • Other craniofacial anomalies may be associated with these symptoms including cleft palate, Down syndrome, etc. •Tonsillar hypertrophy, macroglossia and oropharyngeal masses should be evaluated •The nasal cavity was inspected for the presence of secretions, edema and erythema of the nasal mucosa . •The ears should be evaluated as otitis media certainly is associated with nasal obstruction problems. • Bony nasal anomalies, external masses, pits, etc. should be evaluated. www.indiandentalacademy.com
  19. 19. Evaluation of the voice quality includes as assessment of nasality and clarity. Having the child to speak words that enhance nasality such as lemon, milkman, Mickey Mouse, ninety nine, bananas are normally nasal transmitted words and words such as baseball and Jack are normally non-nasal transmitted words. In a hyponasal child, resonance is poor even with the nostrils open, and closing of the nostrils results in little or no reduction in resonance. Mouth breathing, particularly in children, does not ,always signify severe nasal obstruction www.indiandentalacademy.com
  20. 20. CLASSIFICATION OF RESPIRATORY OBSTRUCTION Respiratory obstruction can occur due to adenoids or as result tonsils both.The obstruction can be intermittent, when it is caused by acute inflammation or persistent due to chronic inflammation. •Mild obstruction is characterized by snoring and distortion of speech. •Moderate obstruction – features of mild featuresof disturbance in sleep and apnoea. •Severe obstruction – more pronounced degrees of signs and symptoms noted in moderate obstruction and also periods of O.S.A www.indiandentalacademy.com
  21. 21. THE LONG FACE SYNDROME In 1872, C.V. Tomes coined the term “Adenoid Facies” or „Long Face Syndrome‟ to describe the dentofacial changes associated with chronic nasal airway obstruction.Any condition that causes nasal obstruction could lead to this typical facial morphology. This syndrome is characterized by an increased LAFH,increased dentoalveolar height,gummy smile,high arched palate ,steep mandibular plane,excess incisal show,anterior marginal gingivitis and long-standing nasal obstruction may lead to "disuse atrophy" of the lower lateral cartilages , resulting in as slit-like external nose with a narrow nasal vault. www.indiandentalacademy.com
  22. 22. The "long face syndrome" is often associated with crossbite, tension nose, and a Class-II (mandibular retrognathic) occlusion. Another group of children develop Class-III occlusion (mandibular prognathic) occlusion which may be due to anterior displacement of the tongue due to tonsillar hypertrophy. This creates a pressure affects on the lingual aspect of the lower dental arch, causing a prognathic mandible and undererupted lower teeth. Children who have hypertrophied adenoids, tonsils and inferior turbinates develop long face syndrome 30 percent of the time. In contrast, children with normal respiratory airways develop long face syndrome 2 percent of the time. www.indiandentalacademy.com
  23. 23. PROPOSED SEQUENCE OF EVENTS as described by Principato Prolonged periods of oral respiration lead to extensive eruption of the posterior molars which exerts a downward vector of force on the mandible, causing the lower jaw to rotate down and back in a "clockwise" direction. Because of the backward mandible rotation, retrognathia and open bite deformities are common. With a lowered tongue position, the lateral expansile forces of the tongue on the palate are lost, and the unopposed medial forces of the buccinator and masseter muscles leads to a narrow, high arched palate. The incomplete lateral expansion of the maxilla often leads to a unilateral or posterior crossbite. www.indiandentalacademy.com
  24. 24. DENTOFACIAL DEFORMITIES AND MOUTHBREATHING One or all of the three neuromuscular responses must be present for malocclusion and altered skeletal relationship to occur. 1.Altered mandibular posture-Mandible rotates down and back in response to the etiologic factor. 2.Altered tongue posture-Tongue moves superiorly and anteriorly in response to the etiologic factor. 3.Extended head posture-The mandible is held in position while the cranium and maxilla rotate upward. www.indiandentalacademy.com
  25. 25. Mouth breathing is thought to predispose to the development of the "long face syndrome" or "adenoid facies”. Vig et al. found that there was an increase in anterior open bites, lower face height, and a tendency to hold the head higher. The open mouth breathing position often results in an unusually long narrow appearance. In order to breath through the mouth the lower jaw is dropped, the head is tilted back and the tongue is lowered from contact with the palate and protruded to provide a greater oral airway. Tooth crowding, narrow palate, high palatal vault, asymmetrical growth of the upper and lower jaws and/or an abnormal swallowing pattern are often noted. www.indiandentalacademy.com
  26. 26. ROLE OF TONSILS AND ADENOIDS IN THE OBSTRUCTION OF RESPIRATION The tonsils and adenoids are composed of lymphatic tissues. Together, they are part of a ring of glandular tissue (Waldeyer's ring) encircling the back of the throat. The tonsils are the two masses of tissue on either side of the oropharynx. The adenoids are located high in the nasopharynx behind the nose and soft palate and, unlike the tonsils, are not easily visible through the mouth. www.indiandentalacademy.com
  27. 27. The purpose of the tonsils and adenoids The tonsils and adenoids are thought to assist the body in its defense against incoming bacteria and viruses by helping the body to form antibodies. However, this function may only be important during the first year of life. In fact, there is no evidence to support a significant role of the tonsils and adenoids in immunity. www.indiandentalacademy.com
  28. 28. INVOLUTION OF ADENOIDS The adenoids are small at birth .The adenoids enlarge and eventually outstrip the growth of the nasopharyngeal space at 3-5 years,thereby reducing the nasopharyngeal size.After the age of 5,expansion of the bony nasophayngeal space continues due to the maxillary growth.Percentile distance curve for the amount of soft tissue and adenoids on the posterior pharyngeal wall show a peak at age 5 and 10 to 11 years.Thereafter, a steady decline in these tissues occurs as the child matures with the concurrent increase in the nasopharyngeal area .If these tissues do not atrophy,the patient may be at a risk of developing dentofacial abnormalities.TourneAJO`91 In boys the area of the nasopharyngeal soft tissue is constant after the age of 6 while in girls this area decreases slowly from 9 to 19 years of age(Jeans) seminar in orthoMar 2004 www.indiandentalacademy.com
  29. 29. Tonsillitis and Its Symptoms Tonsillitis is an infection in one or both tonsils. One sign is swelling of the tonsils. Other signs or symptoms are: Redder than normal tonsils A white or yellow coating on the tonsils A slight voice change due to swelling Sore throat Uncomfortable or painful swallowing Swollen lymph nodes (glands) in the neck Fever Bad breath The root of the tongue pushes large tonsils against the posterior pharyngeal wall, causing constriction or obstruction during articulation with the tongue in the back of the mouth.Guttural voice quality as an associated clinical finding in children with large tonsils has been reported www.indiandentalacademy.com
  30. 30. Enlarged Adenoids and Their Symptoms Breathing through the mouth instead of the nose most of the time Nose sounds "blocked" when the person speaks Noisy breathing during the day Recurrent ear infections Snoring at night Breathing stops for a few seconds at night during snoring or loud breathing (sleep apnea) www.indiandentalacademy.com
  31. 31. RHINITIS Allergy is by far the most common and important cause of nasal obstruction. Allergy must be screened out first. Allergy is an exagerrated normal protective response to proteins and large polypeptide molecules which ordinarily do not warrant such an extreme response. Clinical evaluation History- itch, sneezing and rhinorrhoea are usually early symptoms; congestion presents later; itch affects soft palate and external auditory canal; sneezing often occurs , sinus congestion, mouth breathing and disturbed sleep patterns; conjunctivitis can accompany nasal symptoms. Examination.-Allergic facies – pallor allergic shiners, allergic mannerisms - allergic salute; nose - swollen and mucoid; throat - inflamed with lymphoid follicles (cobblestones or granular pharyngitis); ears - otitis media with effusion www.indiandentalacademy.com
  32. 32. Classification Allergic rhinitis Symptoms develop when persons inhale airborne antigens (allergens) to which they have been previously exposed and have made IgE antibodies. These include salivary proteins, horse dander, murine urinary proteins, pollens, house dust mite feces, and mold spores. These IgE antibodies bind to IgE receptors on mast cells in the respiratory mucosa and to basophils in the peripheral blood. When IgE molecules on their surface are bridged by allergen, mast cells release preformed, granule-associated chemical mediators. They also generate other mediators and cytokines that lead to nasal inflammation and, with continued allergen exposure, chronic symptoms. www.indiandentalacademy.com
  33. 33. 2.Nonallergic rhinitis with nasal eosinophilia syndrome (NARES) is characterized by perennial symptoms, an older average age than in patients with allergic rhinitis (39 years vs 25 years), and less nasal itching and sneezing. Formation of IgE to inhalant allergens is unusual. The clear nasal secretions contain > 25% eosinophfls. Fifty percent of patients with NARES have sinusitis, 33% have nasal polyps, and 14% have asthma. 3.Vasomotor rhinitis is a common form of perennial nonallergic rhinitis associated with chronic nasal congestion intensified by rapid changes in temperature and relative humidity, odors due to nasal autonomic nervous system dysfunction. Patients have little nasal itching or sneezing and often no family history of allergy, but headaches, anosmia, and sinusitis are common. www.indiandentalacademy.com
  34. 34. SEQUELA OF UPPER AIRWAY OBSTRUCTION Some of the effects of impaired nasal respiration reported are: Abnormal facial development, headaches, malocclusion, poor sleep, sore throats, excessive daytime sleepiness, dry mouth, frequent infections, earaches and sinus problems. It may cause significant problems such as.: 1. Dento-facial abnormalities 2. Hypersomnolent O.S.A syndrome 3. Alveolar hypoventilation 4.Pulmonary hypertension and cor pulmonale www.indiandentalacademy.com
  35. 35. MUSCLES AND NASAL AIRWAY RESISTANCE Vargervik et al.found that tonic electromyographic activity of digastric muscle and geniohyoid muscle was seen in nasal airway obstructed animals. Vargervik et al. found that the masseteric stretch reflex, plays an important role in controlling mandibular position.The masseteric muscle may function as an accessory respiratory muscle when the nasal airway is threatened. Basner et al.showed greater EMG activity in the genioglossus muscle during nasal respiration than during oral respiration .Mathew et al.demonstrated that the inspiratory activity of the genioglossus muscle was increased by nasal obstruction,although there was no significant change in diaphragm EMG activity www.indiandentalacademy.com
  36. 36. Obstruction of the nasal airway in the cat significantly inhibited the masseteric stretch reflex and discharges of masseteric motor units but did not affect the EMG activity of the diaphragm. Takashi Ono, Yasuo Ishiwata suggested that masseteric electromyographic activity is inhibited during masseteric muscle contraction in the rat.oral respiration and that the gsystem is involved in this inhibition. AJO1998 Electromyographic signals from the ala nasi, orbicularis oris superior, genioglossus, mylohyoid muscles, and the diaphragm were recorded by fine-wire electrodes. Results showed that when resistance was gradually increased, nasal breathing resulted in a greater increase in muscle activity than did tracheal breathing ,except in the diaphragm. Hyung-Geun Song AJO 2001 www.indiandentalacademy.com
  37. 37. INVESTIGATION ASSESSMENT OF NASAL AIRWAY STRUCTURE Structural abnormalities of the nose may be evaluated objectively by clinical examination,roentgenographic investigations, fiberoptic rhinoscopy, rhinostereoscopy, or radiologic studies (CT and MRI). RADIOGRAPHS 1. Panoramic radiographs gives an idea about the nasal septum and the nasal cavities 2.Sinus xrays are used to view the maxillary and other sinuses 3.Most commonly used are the lateral cephalograms www.indiandentalacademy.com
  38. 38. Cephalometry The roentgenographic ratings is the gold standard during investigations because roentgenographic assessment constitutes the only generally available, objective, noninvasive means of estimating the extent of encroachment by the adenoid on the nasopharyngeal airway. It is also the case that roentgenographic assessments have been found to correlate well with the volume of adenoid tissue observed or removed at surgery. Although positive correlations between airflow and airway measurements have been made on cephalometric radio-graphs, the three-dimensional aspects have been neglected. www.indiandentalacademy.com
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  41. 41. DISADVANTAGES 1.There is the geometric limitation that a cephalogram produces only a twodimensional representation of the space involved. 2.The nasal airway is a convoluted and anatomically irregular structure and by superimposition and lack of soft-tissue detail this is obscured on traditional lateral or frontal cephalograms. Preferably the xrays are to be taken with the subjects maintaining their natural head position without the use of cephalostat. www.indiandentalacademy.com
  42. 42. In 1987, Weimert published a study of 1360 patients referred to otolaryngologists by orthodontists. Most patients had undergone PA and lateral cephalometric examinations which are utilized by orthodontists .They found evidence nasal obstruction in 72% of cases and they reported a 96% correlation between the adenoid size on x-rays and intraoperatively. Others feel cephalometric analysis is a useful screening exam but have not shown them to consistently predict adenoid size and degree of obstruction (Poole 1980). www.indiandentalacademy.com
  43. 43. Fiberoptic rhinoscopy is the insertion of a flexible telescope into the nasal cavity which allows the detailed visualization of the posterior two thirds of the nose not visible with a nasal speculum inserted into the anterior nares. Disadvantages It is unlikely to detect structural or mucosal displacement of the medial or lateral wall of the nasal valve < 1 ram, a distance that nonetheless may exponentially affect nasal resistance or patency. These changes in resistance and airflow are readily detectable by rhinomanometry or acoustic rhinometry. Rhinostereoscopy uses a precise surgical microscope to make direct and noninvasive topographic measurements of the nasal mucosa. www.indiandentalacademy.com
  44. 44. Video nasopharyngeal endoscopy allows direct visualization and dynamic evaluation of the nasopharynx, including details such as color, texture, and volume. These images can also be recorded on videotape or in a digital format. Daniel studied the degree of diagnostic reproducibility between lateral cephalometric radiography and nasopharyngeal videoendoscopy and found that lateral cephalometric radiography appears to be sufficiently reproducible for diagnosing hypertrophy of the middle and inferior turbinates and of the region caudal to the inferior turbinate www.indiandentalacademy.com
  45. 45. 2. cephalometric radiography gives high sensitivity but low for specificity in diagnosing hypertrophy of the inferior and middle turbinates when compared with nasopharyngeal endoscopy. 3. nasopharyngeal videoendoscopy is sufficiently reproducible for diagnosing anterior and posterior septal deviation and hypertrophy of the inferior and middle turbinates, but its ability to diagnose rhinitis is limited 4.nasopharyngeal videoendoscopy is more suitable for diagnosing diverse obstructions of nasopharyngeal origin.Daniel AJO 2001 www.indiandentalacademy.com
  46. 46. ASSESSMENT OF NASAL AIR FLOW AND RESISTANCE Dynamic measurements of nasal congestion include nasal peak flow, rhinomanometry, and acoustic rhinometry. 1.Nasal Peak Flow Nasal peak flow test is inexpensive, easy to perform and can be done at home. However, it is highly effort dependent, and results may vary widely, especially between patients.Nasal peak flow measurements correlate well with measurements of resistance and have their greatest usefulness in the detection of large changes in nasal patency in individual subjects. www.indiandentalacademy.com
  47. 47. This technique involves measuring the peak inspiratory nasal airflow with a modified peak flow device (eg nasal inspiratory flowmeter;pneumotachograph).As the air flows across the flowmeter the pressure drops and is recorded by the tranducer. An abnormal peak flow should prompt consideration of more detailed . studies, such as rhinomanometry or acoustic rhinometry www.indiandentalacademy.com
  48. 48. 2.Rhinomanometry Rhinomanometry, the measurement of nasal airway resistance, is probably the test most frequently performed because it measures both flow and resistance. It is classically divided into passive or active phases, and into anterior or posterior rhinomanometry. 1.Active rhinomanometry requires the subject to generate airflow through the nose by their own effort. Active rhinomanometry is a quick test to perform, and the International Committee on Standardization of Rhinomanometry recommends it for most studies. 2.Passive rhinomanometry utilizes external generation of a constant flow of air at a given pressure and requires no respiratory effort. www.indiandentalacademy.com
  49. 49. Anterior and posterior rhinomanometry differ in the location of the transducer used to measure posterior pharyngeal pressure. Anterior rhinomanometry may be 'affected by deformation of the anterior nares and/or valves, nasal cycling, and by the instrument inserted to the nares for measurement. Posterior rhinomanometry does not have these disadvantages, but is more expensive and requires more patient cooperation, with approximately 15% of subjects being unable to place the probe properly in the oral cavity. It is an excellent tool for determining the degree of airflow obstruction before and after surgical procedures and medical interventions . 2.It may also help to distinguish functional causes of upper airway obstruction from structural causes. www.indiandentalacademy.com
  50. 50. Gurley and Vig reported a technique , which for the first time enabled the direct and simultaneous measurement of inspired and expired air, both orally and nasally. The technique is called SNORT, an acronym which stands for Simultaneous Nasal Oral Respirometric Technique. Using a custom fitted face mask with separate valves attached to the nose and mouth and attached to a flow meter, air pressure transducer, recorder and computer, it can give the nasal versus the oral inspiration, expiration and their ratios. SNORT permits the objective quantification of the ratio of oral to nasal airflow and permits a numerical determination of both normal and pathological states of breathing mode. www.indiandentalacademy.com
  51. 51. Vig reported that it is not surprising to find the statistical correlations between visually determined mouthbreathing and NRR-values to be inconsistent throughout the experimental literature Angle 1990 Luc P.M. Tourne. Principato has established age-related norms of nasal resistance using an anterior rhinomanometric technique. Normal nasal resistance for an adult is 2.5 to 3.5 cm of water per liter per second. At readings above 7.0 at rest, an individual must go to mouth breathing to get adequate air. Between 4.0 and 7.0, orthodontic intervention is the treatment of choice. Above 7.0, surgery is usually considered. www.indiandentalacademy.com
  52. 52. 3.Acoustic Rhinometry Acoustic rhinometry, evaluates nasal obstruction by analyzing reflected sound waves introduced through the nares. • It is generally easy to perform, is noninvasive, and does not require patient cooperation like many of the other evaluation procedures. • It produces an image that reflects variations in the cross-sectional dimensions of the nasal cavity and closely approximates nasal cavity volume and minimal cross-sectional area. • The short measurement period makes this procedure easy to use in all patients, even children. www.indiandentalacademy.com
  53. 53. 4.Plethysmograph Niinima et al quantified nasal and oral airflow simultaneously with a nasal mask attached to a pneumotachograph and “head-out” exercise body plethysmograph. The airflow was derived by subtracting nasal from total respiratory volume. Most of the subjects switched from purely nasal to oronasal breathing when exercise caused the total respiratory volume to increase. www.indiandentalacademy.com
  54. 54. 5.CT & MRI The limiting factor, that determines the capacity for airflow is the minimal crosssectional area of the passage. This narrowest portion can occur at any point along the nasopharyngeal trajectory and can only be accurately visualized by computed tomography. Eg Newtom generated computed tomography www.indiandentalacademy.com
  55. 55. Attempts are being made to quantitate the adenoid mass and pharyngeal space by linear measurement and/or surface calculation as a complement to the clinical examination..eg MRI MRI www.indiandentalacademy.com
  56. 56. Other Dynamic Methods To Measure Nasal Patency Chilled mirrors or other polished surfaces The patient exhales through the nose against a polished surface held close to the nostrils, and dimensions of the two resulting areas of condensation are noted and compared. Camera recordings of thermographic surfaces or calibration by concentric markings on the condensing surface enhances this technique. Oscillometry measures impedance in order to calculate NR. A loudspeaker is applied first to the nostrils and then to the mouth to generate sinusoidal oscillations that are superimposed on normal breathing. The difference between the two impedance measurements provides data for resistance calculations www.indiandentalacademy.com
  57. 57. RHINITIS INVESTIGATION Skin-prick test - most sensitive allergy test; total serum IgE - poor sensitivity and specificity; allergen-specific IgE tests- more accurate X-rays - used primarily for detection of complications; endoscopy. www.indiandentalacademy.com
  58. 58. TREATMENT TONSILLECTOMY AND ADENOIDECTOMY Over 75% of tonsil/adenoid operations are performed on children less than 15 years of age, and 60% on children under 6 years of age. The usual age of children undergoing of this surgery is five years. INDICATIONS FOR SURGERY Tonsillectomy and adenoidectomy, either in combination or separately, are most frequently performed to correct • Recurrent or chronic throat infection • Hypertrophy • Recurrent attacks of otitis media or chronic otitis media with effusion. www.indiandentalacademy.com
  59. 59. TONSILLECTOMY INDICATIONS Recurrent tonsillitis defined by a history of atleast 7 episodes in the preceding year, or 5 episodes in each of the last 2 years, or 3 episodes in each of the last 3 years. Chronic tonsillitis persisting for atleast 6 months despite intensive antibiotic therapy. ADENOIDECTOMY Persistent obstruction – due to enlarged adenoids Recurrent otitis medial with effusion CONTRAINDICATIONS Velopharyngeal incompetent patients Patients with bleeding disorder www.indiandentalacademy.com
  60. 60. Early intervention to correct nasal obstruction may lead to reversal of the associated craniofacial changes. Normalization of face form following adenoidectomy in a child can take five years. Delay in intervention may result in unsuccessful orthodontic treatment which may require orhthognathic surgery at an older age. If chronic mouth breathing persists or recurs after adenoidectomy, allergic rhinitis with turbinate hypertrophy should be ruled out. If a submucous cleft palate is identified, the surgery must be weighed against possible complications. www.indiandentalacademy.com
  61. 61. Linder-Aronson reported in children who had adenoidectomy &returned to nasal breathing had demonstrated craniofacial growth changes. There was a relatively greater increase in the upper incisor inclination during the first year after adenoidectomy along with the normalization of the lower incisor The arch width and nasopharynx showed an increase during the 1st year postoperatively.The size of the ML/NL angle was found to decrease after a change from mouth to nose breathing. As opposed to these studies, Kingsley (1989) noted normal craniofacial development in children with severe nasal obstruction and Whitaker described severe palate malformations in patients who had undergone . adenoidectomy at an early age www.indiandentalacademy.com
  62. 62. TURBINATE RESECTION Hypertrophy of the erectile tissue of the turbinates due to rhinitis or other causes can be treated by turbinate resection, electrocautery, or cryosurgery .Recently, the introduction of lasers and radiofrequency ablation are used . www.indiandentalacademy.com
  63. 63. SEPTOPLASTY Although controversy still exist over whether nasal deformities in children can be safely corrected without disrupting the normal nasal growth pattern, this concern is being overcome by the increased recognition that prolonged nasal obstruction can result in significant abnormalities in the growing child. A sublabial approach to septoplasty in children has provided excellent exposure and involves in removing minimal septal cartilage so as to avoid the collapse of the nose. A reasonable approach is to favor early repair in the severely affected child in whom complications are present (obstructive apnea) or in patients in whom the facial growth is over. www.indiandentalacademy.com
  64. 64. CONGENITAL MALFORMATIONS Congenital malformations such as choanal stenosis and rarely unilateral atresia may be missed early in life. Bilateral choanal atresia is usually identified in the neonatal period. Radiologic evaluation of the nose and nasopharynx by CT scanning is helpful in establishing the diagnosis as well as the extent of disease. Choanal stenosis or atresia would be repaired by transpalatal approach with prolonged stenting. www.indiandentalacademy.com
  65. 65. RHINITIS Allergy treatment is based upon three general modalities: environmental control or avoidance of offending substances Medications such as steroids and antihistamines immunotherapy (allergy shots). Probably the most important thing a concerned dentist can do to help prevent allergy is to counsel and educate mothers on the importance of breast-feeding. If mothers must bottle-feed, the dental profession can begin the education process by recommending use of soy formulas which are not as allergenic. According to a six-year study be Glaser, bottle fed children have four times as many respiratory conditions as breast fed children. www.indiandentalacademy.com
  66. 66. ORTHODONTIC TREATMENT Orthodontic treatment is directed towards the prevention and correction of the malocclusion or to an adaptation of the dentition to the existing skeletal pattern or its predicted future growth which are obtained through the use of extractions,headgear therapy and classII elastics. www.indiandentalacademy.com
  67. 67. PREVENTION – MYOFUNCTIONAL APPLIANCES Oral myofunctional therapy has been shown to be effective in correcting oral myofunctional disorders such as tongue thrust swallow, improper tongue and mouth resting posture, improper use of muscles of the mouth, tongue, and lips for chewing and swallowing, and late thumb/finger sucking habits. www.indiandentalacademy.com
  68. 68. Oral myofunctional therapy has two main goals: establishing an oral/facial resting posture with the tongue away from the teeth, against the palate, and lips together establishing oral, lingual, and facial muscle patterns which promote correct function of these structures during drinking, and chewing, collecting and swallowing of food. These goals are accomplished by a series of exercises which focus first on retraining the oral, lingual and facial muscles so that the correct rest postures may be achieved; and then utilizing these new muscle patterns for habituating the correct labial/lingual rest postures and correct chewing and swallowing. www.indiandentalacademy.com
  69. 69. . Children as young as four years of age may benefit Habits such as mouth breathing, reverse swallowing and thumb sucking are corrected along with the alignment of the developing teeth. This will help future orthodontic treatment by making it less complex and decreasing the need for extractions. www.indiandentalacademy.com
  70. 70. RAPID MAXILLARY EXPANSION Brown, a rhinologist, was a vigorous supporter of midpalatal suture opening for the purpose of overcoming nasal stenosis. Widening the upper jaw enlarges the nasal airway and at the same time corrects lower jaw development gives the tongue more space and enhances the flow of air in the throat. Maxillary deficiency or constriction of the maxillary dental arch, concomitant with a high palatal vault, is a manifestation of a skeletal development syndrome. This syndrome evidences certain rhinologic as well as dental characteristics. Some of the more typical features of this syndrome are (1) decrease in nasal permeability resulting from nasal stenosis, (2) elevation of the nasal floor, (3) mouth breathing, (4) bilateral dental maxillary cross-bite along with a high palatal vault, and (5) because of enlargement of the nasal turbinates, a decrease in nasal airway size. www.indiandentalacademy.com
  71. 71. Rapid maxillary expansion (RME) broadens the maxillary arch which also serves to widen the nasal vault and improve nasal patency. The treatment is nonoperative and can be accomplished in about 3 weeks in patients 3 to 20 years of age. RMA alone is seldom sufficient to improve severe cases of nasal obstruction.. Donald Timms, in a study of 26 patients treated with Rapid Maxillary Expansion, reported a 37 percent mean drop in nasal resistance with 7 mm of expansion. In another larger study of children with a previous history respiratory disease treated with Rapid Maxillary Expansion, 82 percent reported improvement in number of upper respiratory tract infections and 60 percent reported improvement of allergic rhinitis. www.indiandentalacademy.com
  72. 72. RME and nasal airflow. Anatomically, there is an increase in the width of the nasal cavity immediately following expansion, particularly at the floor of the nose adjacent to the midpalatal suture. As the maxillae separate, the outer walls of the nasal cavity move laterally. The total effect is an increase in the intranasal capacity. The nasal cavity width gain averages 1.9 mm, but can widen as much as 8 to 10 mm at the level of the inferior turbinates, while the more superior areas might move . medially. AJO 1987 Bishara and Staley A number of rhinologists, including Gray, Braun, and Kressner, indicate that RME, in addition to its widening procedure, results in correction of septal deformity as a result of the lowering of the floor of the nasal cavity www.indiandentalacademy.com
  73. 73. Hershey, Stewart, and Warren, and Turbyfill reported a reduction of nasal airway resistance by an average of 45% to 53% with RME. Wertz concluded that opening the midpalatal suture for the purpose of increasing nasal permeability cannot be justified unless the obstruction is shown to be in the lower anterior portion of the nasal cavity and accompanied by a relative maxillary arch width deficiency. Graber believes that the claims of improved nasal breathing apparently as a result of RME are most likely only temporary. Spontaneous regression of lymphoid tissues during growth automatically improves nasal breathing, even if nothing is done to the palate. Therefore, it can be concluded that the effect of RME on the nasal airway will to a great extent depend on the cause, location, and the severity of the nasal obstruction www.indiandentalacademy.com
  74. 74. Mean cross-sectional nasal cavity enlargements of between 1.4 mm and 4 mm for rapid expansion, 0.8 mm for a quad helix, and 0.5 mm for a removable appliance have been reported. Rapid expansion exerts its effect by dilating the anterior nares, through the preferential expansion of the anteroinferior aspect of the nasal cavity. If, for example, the obstruction is posterior, rapid expansion will have little effect. Therefore expansion remains an unpredictable way of improving the nasal airway. Rhinometric studies after RME indicate that there is no increase in percentage of nasal breathing, nor is there a predictable decrease in nasal resistance www.indiandentalacademy.com
  75. 75. ORTHOGNATHIC SURGERY If the difference between the maxillary and the mandibular unit length is greater than 16mm at the age of 12 in classII malocclusion and greater than 29mm at the age of 12 in class III dysplasias,surgical intervention is necessary. Surgical superior impaction of the maxilla has become an accepted treatment for the correction of vertical maxillary excess and it does reduce nasal resistance, but it does not increase the percentage of nasal airflow. The nearer the patient is to completion of growth, the less likely it is that the long-term outcome will be affected by continuing growth. A mean decrease in nasal resistance has been demonstrated after surgical maxillary impaction. It has been speculated that this change may be associated with the common postoperative increase in interalar width and widening of the external nares, which result in an opening of the liminal valve. www.indiandentalacademy.com
  76. 76. Even indirect evidence of forward movement of the base of the tongue, as a consequence of mandibular advancement with either protrusive appliances or orthognathic surgery,can still be inconclusive as the hyoid bone seems to move anteriorly with surgical advancement, but it subsequently moves back toward its preoperative position, yet remarkably its relationship with the cervical spine remains constant. The reason for this seems to involve an alteration of head posture, and cervical column angulation, which probably occurs as a physiologic adaptation to maintain the airway.Similarly, even though the tongue elongates anteriorly, and thickens posteriorly subsequent to surgical mandibular advancement, in the long term it also returns towards its preoperative shape. Therefore, in summary, the evidence of nasal airway improvement, after either maxillary expansion or mandibular advancement as reviewed, still remains too incomplete to offer substantiation. AJO 1994 Jul Chate www.indiandentalacademy.com
  77. 77. ROLE OF ORTHODONTIST In 1987, Weimert published a study of 1360 patients referred to otolaryngologists by orthodontists because of suspicion of nasal obstruction. Although it was not a solid scientific study, the findings suggest that orthodontists can effectively screen for nasal obstruction. The most common reasons for referral were: dentofacial characteristics suggestive of upper airway obstruction, inability to retain a dental appliance, and unsatisfactory results from an orthodontic program. Dentists are important as both referrers and treating doctors. As referrers, one has to know when and whom to refer. Allergies generally must be treated first, before consideration of any surgery. The greatest number of surgical failures are in allergic patients. The greatest number of orthodontic relapses are in patients who have not had their breathing problems successfully treated.. www.indiandentalacademy.com
  78. 78. As a referring doctor, one has to decide between allergist, ENT, pediatrician or sleep lab. Referrals should always be for an evaluation by the specialist of choice, accompanied by a note of one‟s findings. Orthodontic therapy is affected by the function of the lips, tongue, and masticatory musculature, all of which may accommodate to nasal obstruction in ways which can effect occlusion. Effective orthodontic therapy may require the elimination of the nasal obstruction to allow for normalization of the facial musculature surrounding the dentition. According to Meredith, the growth of the face (excluding the mandible) is completed at a relatively early age. 60% of craniofacial development takes place during the first 4 years of life and 90% by age 12. Development of the mandible is not complete until around age 18. Based on these observations, any intervention to open the airway must take place at an early age. www.indiandentalacademy.com
  79. 79. Bushey`74 has differentiated the different facial types and adenoid/tonsil enlargement and proposed different treatment modalities. www.indiandentalacademy.com
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  81. 81. CONCLUSION Evaluation of children with nasal obstruction and dental abnormalities requires a multidisciplinary approach and a clear cooperation between the orthodontists ,pediatricians, and otolaryngologists is imperative. The orthodontists must be familiar with the dental literature regarding dentofacial development and basic concepts of orthodontic intervention so as to provide optimal care for pediatric patients as they have an opportunity to examine and institute treatment to the patients at a very early age. www.indiandentalacademy.com
  82. 82. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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