Airway ortho 1 the three airway problems

Airway Orthodontics
A lecture series prepared by
Dr. Barry Raphael
Of the
Raphael Center for Integrative Orthodontics
Clifton, NJ.
www.alignmine.com
www.myobracenj.com
“Three Airway Problems” - 2013
Thursday, June 6, 13

•Animations not included in this archive
•As the information in these presentations is
constantly evolving, please consider the date of creation
when reviewing the material.

Three Airway Problems
1. Children are having trouble breathing.
2. Orthodontists are having trouble breathing.
3. Healthcare is having trouble breathing.

Troubled Breathing: Children
“not congested”
“snoring”
Open Mouth
Flaccid Lips
“ever so slightly”

What are Eli’s Ishes?
Issue Consequences
• Sleep Disordered Breathing
• Swollen Tonsils and Adenoids
• Neck Hyperﬂexion
• Mouth Breathing
• Chronic Hyperventilation
• Open Mouth Posture
Fragmented, unrestorative sleep
Obstructed N-P Airway
Muscular and Sutural Strain
Reduced Air Conditioning
Hypocapnia (Low CO2)
Maxillary Dysplasia

OSAS and swollen Tonsils
•Tonsils swell > narrowed airway > airway collapses > OSAS

Signs of OSA
frequency
Mouth breathing

One year ago...

“In this large, population-based, longitudinal study,
early-life SDB symptoms had strong, persistent
statistical effects on subsequent behavior in
childhood.
Findings suggest that SDB symptoms may require
attention as early as the ﬁrst year of life.”
Sleep-Disordered Breathing in a Population-Based
Cohort: Behavioral Outcomes at 4 and 7 Years
Karen Bonuck, PhD, Katherine Freeman, DrPH,
Ronald D. Chervin, MD, MS, and Linzhi Xu, PhD
PEDIATRICS Volume 129, Number 4, April 2012

“The 2 clusters with peak symptoms
before 18 months that resolve
thereafter still predicted 40% to 50%
increased odds of behavior problems
at 7 years.”
Sleep-Disordered Breathing in a Population-Based
Cohort: Behavioral Outcomes at 4 and 7 Years
“...early childhood SDB effects may
only become apparent years later.”

ATH and OSAS
• 140 children with OSA
•Avg 4.5yo
•AHI ~ 17
• Low pO2 ~ 80%

Airway Stenosis
• Normal:A&T hypertrophy peaks at age 5-6
• In OSA, hypertropy at all ages
•Airway stenosis caused by
•A&T Hypertropy
• Skeletal Abnormality
• Hypertrophy > Stenosis > Mouth Breathing > Skeletal
abnormatility > OSA

Airway Stenosis
•“ In addition to soft tissue factors, skeletal abnormality
should be considered a cause of upper airway stenosis”
So which is it? Does a blocked airway cause poor
growth, or does poor growth block the airway?

Associations between sleep-
disordered breathing symptoms
and facial and dental morphometry,
assessed with screening examinations
Hyunh, et.al.,AJODO, 2011, 140:762-70
SDB associated with: Swollen Tonsils and Adenoids
Long and narrow face
Allergies
Frequent Colds and Infections
Habitual Mouth Breathing
Dolicofacial shape
High mandibular plane angle
Narrow palate
Severe crowding

Nighttime symptoms of SDB in kids
•Abnormal sleeping position
•Chronic, heavy snoring
•Delayed sleep onset
•Difﬁculty breathing
•Difﬁculty waking up in AM
•Drooling
•Enuresis
•Frequent awakenings
•Insomnia
•Mouth breathing
•Nocturnal migraine
•Nocturnal sweating
•Periodic Limb movement
•Restless sleep
•Sleep talking
•Sleep terror
•Sleep walking
•Witnessed apnea

Daytime symptoms of SDB in kids
•Morning headache
•Mouthbreathing
•Morning thirst
•Excessive fatigue
•Abnormal shyness,
withdrawn, and
depressive
presentation
•Behavioral problems
•ADHD pattern
•Aggressiveness
•Irritability
•Poor concentration
•Learning difﬁculties
•Memory impairment
•Poor academic
performance

Of the 600 orthodontic patients...
16% had long facial form
86% had convex proﬁles ( retrusive mandible)
Over 50% had daytime mouth open posture

Anatomic Determinants of SleepDisordered Breathing Across the
Spectrum of Clinical and Nonclinical Male Subjects*
•Apnea occurs due to craniofacial morphology and obesity,
each with their contributions
•The most important cephalometric variable in predicting AHI
severity was the horizontal dimension of the maxilla
•SDB increased ﬁvefold to sevenfold in non-obese
subjects and threefold in obese subjects
CHEST September 2002 vol. 122no. 3 840-851
Jerome A. Dempsey, PhD; James B. Skatrud, MD;Anthony J. Jacques, BS;
Stanley J. Ewanowski, PhD; B.Tucker Woodson, MD;
Pamela R. Hanson, DDS, MS; and Brian Goodman, PhD

Anatomic Determinants of SleepDisordered Breathing Across the
Spectrum of Clinical and Nonclinical Male Subjects*
•It is the maxilla that determines the effective
horizontal dimension of the pharynx, and in
particular the upper pharynx.
•A constricted maxilla places the upper pharynx
(pharyngeal isthmus) at increased risk of collapse
with loss of muscle tone.

Dental Arch Morphology
in Children with SDB
Finland,
41 children with OSA
41 children with snoring
41 children with no obstruction
Ortho exam and 13 study cast measurements
K.Pirilä-Parkkinen,et.al.,European Journal of Orthodontics 31 (2009) 160–167

OSA children have...
• Signiﬁcantly more:
• Increased Overjet
• Decreased Overbite
• Narrow Maxillary Arches
• Shorter Mandibular Arches
•Somewhat more:
•Assymetric Arches (Cl II subdivision)
• Mandibular Crowding
•Anterior Open Bite
“...can be explained by long-term changes in the
position of the head, mandible, and tongue in order
to maintain airway adequacy during sleep.”

Caroline Rambaud & Christian Guilleminault
European Journal of Pediatrics
DOI 10.1007/s00431-012-1727-3
Pub Online:April 11, 2012
Death, nasomaxillary complex,
and sleep in young children
Abrupt sleep associated death in seven children
with good pre-mortem history

Findings in all 7 cases
All had chronic indicators of abnormal sleep
1.enlargement of upper airway soft tissues
2.a narrow, small nasomaxillary complex,
with or without mandibular retroposition

“all children present a visually
recognizable abnormal high and
narrow hard palate”
What can we do to help our children breathe better?

Connecting the Dots
• Adult SDB and OSA
• Narrow Jaws and Faces
• Soft Tissue Dysfunction
• Early Parafunctional Habits, esp Open Mouth Posture
• Environmental Stressors
• CPAP, MARA,UPPP, Surg
Where’s the best
place to start
treatment? Here?
OrHere?

Troubled Breathing: Orthodontists
• Social-six orthodontics
• CAD-CAM techniques
• Permanent Retention
• Pendulum Thinking
•The Battle within the profession

“My two front teeth
stick out….they’re
right THERE”

How can we offer patients
what they want without
giving them less than our
best?

If we no longer have to
spend time on mechanics,
what can we do with the
extra time to improve what
we do?

Which is more stable? Now?

Why is malocclusion so stable?
•Malocclusion is a Solution to provide Equilibrium and
Homeostasis

Stack the Blocks
Rule:The Teal block
should go right on top
of theYellow block
for best stability

Stack the Blocks
Rule:The Teal block
of the yellow block
for best stability

Why is correction so unstable?
Homeostasis
•When we “correct” the occlusion, we disturb the equilibrium

Stack the Blocks
Malocclusion: one
solution to be in
equilibrium

Nature’s Solution:
Adaptation (Malocclusion)

Orthodontic’s Solution
RetainerRule:The Teal block
of the yellow block
for best stability

Homeostasis
•If we “rebalance” the occlusion, we disturb the equilibrium
•There are always unintended consequences, even if subclinical
Relapse
Occlusal Wear
Occlusal Trauma
Bruxism
Joint Derangement
Referred Pain
Sleep Apnea
Assorted physical ailments

Airway Orthodontics
Teeth and Occlusion
Tongue, MM,TMJ
Cranial and Cervical
Whole Body (resp,
circ, musc-skel, etc)

•Malocclusion is a Solution to provide Equilibrium and Homeostasis
•If we “rebalance” the occlusion, we disturb the equilibrium
•There are always unintended consequences, even if subclinical...
•We must make compensations elsewhere (respiratory, musculo-
skeletal, neurological, circulatory systems)
How can we make straight teeth as
stable as crooked teeth?
By looking at what made them stable?

Extraction Non-extraction
One-Phase Two-Phase
Form Function

The Extraction Wars
Edward Angle vs Calvin Case
Witzig vs McNamara
NewConn 2009 Extraction vs Non-extraction Debate
1855-1930
5-10% extraction rate

Tom Graber
AJO, 1963
“The Three M’s:
Muscles, Malformation, and Malocclusion
The Two Groups of Disciples:
Edward Angle: Edgewise Expansionists
Calvin Case: Extractionists
Must take muscles into account or
you’re missing the problem.
1917-2007

Tom Graber
•…they ignored “the balancing effect of
contiguous muscle on the role of growth and
development”
•“…muscle plays a dominant role, affecting our
manipulations whether we like it or not”.
•“controlling abnormal perio-oral muscle
function” crucial in treatment
•We must consider homeostasis, postural rest
position, and the effect of function on the teeth
and bones.
1917-2007

One-Phase Two-Phase

Verdict: Phase I doesn’t help
• Prospective Randomized Control Trial
• Class II severe overjet (>7)mm
• Early treatment with Headgear or Bionator
• Improvements shown in Phase I
• Improvements disappeared after braces put on
Am J Orthod Dentofacial Orthop. 2004 Jun;125(6):657-67.
Outcomes in a 2-phase randomized clinical trial of early Class II treatment.
Tulloch JF, Proffit WR, Phillips C.
Conclusion: Don’t bother with Phase I
treatment since both treatments turn
out equally well.

Conclusion: Don’t bother with Phase I
treatment since both treatments turn
out equally well.
Is it possible that
both protocols….
•… missed the etiology of the Class II malocclusion
•… fail to control the etiology during treatment
•… move the maxilla in the wrong direction
•… even their “early” treatments start too late
inadequate.

Is it possible that...
•… malocclusion is not predetermined, but occurs as a
result of things that happen to us throughout early life?
•… those things that happen can be modiﬁed so the
outcome can be modiﬁed too?
•… thus reducing the need for correction?
Question:What are we waiting for a 7mm
overjet to occur before we begin our PRCT?

Which came ﬁrst?
The
Chicken
The Egg
Makes...
Grows into...

No eggs, no chickens

No chickens, no eggs

No eggs, no breakfast

No chickens, no nuggets.

The Spiral
The
Chicken
The Egg
The Egg
The Egg
The
Chicken
It’s not “Which Came First”, it’s “What Comes Next?”

The Spiral of Health
Form Function
Orthodontics
Myofunctional

Form
Form
Function
Function
Function
Declining HealthImproving Health

Form
Form
Function
Function
Function
Improving Health
Nasal Breathing
Patent Airway
Tongue on Palate
Wide Palate
Proper Swallowing
FormStraight Teeth

A Pathology Cycle
Declining Health
Function
MouthBreathing and
Low Tongue
FormLong Face
Function Weak MMuscles
FormNarrow Palate
Function Deviate Swallow
FormSwollen T&A
Crooked Teeth
Form

Breaking The Cycle
Declining Health
Function
MouthBreathing and
Low Tongue
FormLong Face
FormNarrow Palate
Function
Swallowing with Active
Facial Muscles
Crooked
Teeth
Form
FormSwollen T&A
Conventional Orthodontics

Backed into a corner...
•
Changing Function is not mechanical!

Breaking The Cycle
Declining Health
Function
MouthBreathing and
Low Tongue
FormLong Face
FormNarrow Palate
Function
Swallowing with Active
Facial Muscles
Crooked
Teeth
Form
FormSwollen T&A
Airway-Centric Orthodontist
How can we improve 21st century
orthodontics to be more
comprehensive?

• The Battle within the profession

A letter from a GP...
•“Hi. This is so timely. I received a report from a cranio-
facia/TMD pain specialist of one of my patients who... was
referred by the orthodontist that treated her... I originally
referred the patient to the orthodontist who I used to
respect...I met with him...about my concern for her
extensive mandibular retrusion. He blew off my concerns
and now she is having TMD issues after his headgear
directed treatment…. I felt that she should be treated
early on but he waited until she was into her mixed
dentition once her overjet increased to 11mm! Of course
the headgear would protect the problem and in his opinion
he attained a great outcome except for the fact that she
now has TMD. I am going to screen her with the HRPO.”

What GP’s think of the RO
• Most orthodontists extract frequently
• Extractions cause TMJ
• Extractions ruin the face
• Many sleep apnea patients have had extractions
• Braces cause decalciﬁcation
• Braces cause root resorption
• Orthodontic treatment is unstable and needs
permanent retention

“Your Life, Your Smile”
Campaign
“Maintain the educational message on the two to
three years' additional education required to
become an orthodontist”

What GP’s think of orthodontics
• Malocclusion is a modern disease
• Malocclusion is a symptom of a greater imbalance
• You need to treat the imbalance (etiology)
•The mouth is part of the body
• Many malocclusions can be prevented

Finding the Middle Ground
So it is said that if you know your enemies and know
yourself, you can win a hundred battles without a single loss.
If you only know yourself, but not your opponent, you may
win or may lose.
If you know neither yourself nor your enemy, you will always
endanger yourself.
Sun Tzu - “The Art of War”

Troubled Breathing: Healthcare
• Economics:
• Politics :
• Medical Education
• EBD vs First-Follower

• Economics: “Sickcare” cannot keep up
with CNDC’s
• Politics

Obesity
Hypertension
Cardiovascular Disease
Type 2 Diabetes
Fatty Liver Disease
Some Cancers
Osteoporosis
Arthritis
Chronic Non-Communicable Diseases of Civilization
Western Lifestyle Diseases
Metabolic Syndrome
Asthma
Autism
Asperger’s
Alzheimers
ADD/ADHD
Depression
Chronic Back Pain
Is there a better approach to treating
preventable diseases than symptomatic tx?

• Economics:
• Politics :Everyone deserves healthcare but
everyone wants free healthcare.
What does our population NEED
to achieve a long and healthy life?

• Economics:
• Politics :
• Medical Education is lacking in three areas:
• Nutrition
• Sleep
• Evolution
•EBD vs First-Follower
How do we bring to the healthcare profession
the knowledge and desire to prevent disease?

• Economics:
• Politics :
• Medical Education is lacking in three areas:
• Nutrition
• Sleep
• Evolution
•EBD vs First-Follower
The ethical dilemma of being a practitioner.

Evidence-based
Dentistry
• Every day we make a thousand decisions
• Only a small fraction have evidence to support them
• Ethics: How we choose to answer the rest

Ethics-based Dentistry
•ADA and ACD codes
• How do we make decisions about issues for which there
is no precedent?
• How do we evaluate someone who claims to have an
answer that hasn’t been tested?
• How do we deal with the leading edge of knowledge?
•Where does the leading edge become the bleeding edge?
• How does someone with a new idea come to have it be
worthy of being veriﬁed by evidence?
Autonomy
Beneﬁcence
Compassion
Competence
Integrity
Justice
Professionalism
Tolerance
Veracity

First Follower

Airway ortho 1 the three airway problems

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