Nasal Airway and Malocclucion / Orthodontic Courses by Indian Dental Academy

NASAL AIRWAY AND
MALOCCLUSION
www.indiandentalacademy.com

INDIAN DENTAL ACADEMY

Leader in continuing dental education

INTRODUCTION
Nasal airway patency and malocclusion have long been
INTERRELATED.
It seems obvious that severe malocclusion must make it difficult for
the individual to breathe, incise, chew,swallow,and speak.THE
REVERSE OF THIS COULD ALSO BE TRUE!
Alterations or adaptations in function can be an etiologic factor for
malocclusion, by influencing the pattern of growth and development
and thereby resulting in malocclusion.

This seminar attempts to compile the views supporting and opposing
nasal obstruction as a cause for malocclusion.
REVIEW OF LITERATURE
The debate in orthodontics concerning the role of respiration in the etiology of
malocclusion and facial deformity dates back to over 100 years.
ROBERT 1843-nasal obstruction hindered palatal descent

SIEBENMANN-1897-associated adenoid blockage to narrow faces

MICHEL-1876 &BLOCK-1888-air flow prevented palatal descent

MEYER-1870-low tongue position and mouth breathing lead to unopposed buccal
forces on maxillary dentition

NEIVERT-1939-adenoids as cause to induce mouth breathing

SPRAWSON-1947-emphasized role of naso pharyngeal tissues

RICKETTS-1968-lack of nose function lead to improper palatal descent

LINDER-ARONSON-1970-narrow dental arch and upright incisors
due to adenoids.
BUSHY-1974-Compared monzygotic twins with and without
adenoids
CASE-1984
DAVIS-1979
WOODSIDE &LINDER-ARONSON-1979.1991-altered head
posture due to mouth breathing

Ulla Crouse & Warren et all- state that the nasal resistance
is 3.5-4.5cm H2O/L/sec. In bnormal individuals
The optimum nasal airway size is 0.4 cm
2
decreased in mouth
breathers, -there is long drape of velum, soft tissue pillars are
displaced medially, enlarged tonsils.
PHARYNX
ANATOMY
-NASOPHARYNX
-ORO-PHARYNX
-LARYNGOPHARYNX

PHYSIOLOGIC MEASUREMENTS
-TIDAL VOLUME-500ML
-INSPIRATORY RESERVE VOLUME-3000ML.
-VITAL CAPACUTY-4600ML.

PHRYNX AND
RADIOLOGIC VIEW-56
ATHANSIOU
MOUTH BREATHING
ETIOLOGY
ANATOMICAL-DNS,CONGENITAL MICROGENIA
PATHOLOGICAL-ADENOIDS,TONSILS,
HABITUAL

ADENOID FACIEScoined at GUYS hospital,london
constitutes the following-
long face
constricted upper dental arch
exposed upper incisors
receded lower jaw
short upper lip
associated habits

OBSTRUCTIVE SLEEP APNEA
Definition:
condition caused either by complete occlusion or partial
collapse of the upper airway despite the presence of
simultaneous respiratory effort. Cessation occurs at the
level of nostrils and mouth. Condition is considered
pathologic when the episodes last for at least ten seconds
and at a frequency of 30 times or more during 7 hrs. of
nocturnal sleep in REM and especially in non REM stages
of sleep.
TYPES
CENTRAL APNEA: cessation of diaphragmatic
excurtions
UPPER AIRWAY APNEA: obstruction to air flow pass
the oro pharynx but with persistent diaphragm movements.
MIXED APNEA: cessation of air flow and absent
respiratory effort early in the episode, followed by
unsuccessful attempts at respiration later in the episode.

PATHOGENESIS
Functional obstruction of oro pharynx seems to be caused
by recurrent closure of upper pharyngeal wall and posterior
movt. of the tongue.
There is a secondary downward movement of the soft
palate and hypo pharynx closure from abortive thoracic
and diaphragmatic respiratory movements.
The cause for upper pharynx collapse and pathogenesis of
day time somnolence remains to be explained.

Body position, sleep awake state and cervico cranio facial
morphology are important determinence of size and shape
0f the pharynx.
Cervico cranio dismorphology,obesity, alcoholism are
predisposing factors for pharyngeal air flow obstruction
during sleep.
Nocturnal sleep recording in these patients is characterized by
upto 100s of episodes of apnea with abrupt awakening,
the PO2 falls during apnea, the PCO2 rises and both are
reversed as the patient awakens and takes 4 or 5 breaths.
The cycle repeats as the patient laps into sleep.

ROLE OF GENIOGLOSSUS MUSCLE IN OSA
OSA is characterized by recurrent upper air way occlusion
during inspiration.
The genioglossus muscle is believed to contribute to this.
GG muscle activity has been demonstrated in phase with
inspiration during sleep.
Preferential activation of this muscle is correlated with
pharyngeal opening and resolution of apnea.
A dynamic relationship between supraglottic pressure and
GG muscle amplitude has been postulated to explain upper
airway occlusion in subjects with OSA.
EFFECTS OF OSA
SYMPTOMS during sleep
Snoring
Abnormal motor activity
Disturbed nocturnal sleep
Sensation of choking
Heart burn
Nocturia
Heavy sweating
SIGNS:
large tongue
elongated soft palate
reduced pharyngeal length
decreased posterior air space
increased gonial angle
increased upper and lower facial height
steep occlusal plane
elongated upper and lower incisors

DIAGNOSIS
Is by POLYSOMNOGRAPHY
Measurements are made to assess sleep stages of breathing
and gas exchange to detect sleep stages.
PSG ensures the no. of apnic episodes per hour of sleep
expressed by respiratory(Disturbance Index)measurements
of chest and abdominal efforts and oxygen saturation.
Airway measurement by cephalometric 3D imaging
lateral pharyngeal dimension.
TREATMENT
Medical:
Weight loss is beneficial
Nasal vaso constriction sprays
Withdrawal of respiratory depressing alcohol (antihistamines
and tranquilizers)
Surgical:
Uvulo palato pharnygoplasty
Tracheostomy
Expansion hyoid plasty
Mandibular advancement
Sectioning of hyoid
DIAGNOSIS OF MOUTH BREATHING
CLINICAL EXAMINATION:
-as patient to hold water in the mouth
-use double sided mouth mirror or cotton wisps
-facial pattern long face with incompetent lips not
necessary indicate mouth breathing pattern
CEPHALOMETRIC ANALYSIS:
- Mc NAMARA airway analysis
upper
lower
Upper pharyngeal width the point on posterior outline on
soft palate to closest point on pharyngeal wall 15 to 20
mm in width.values 2mm or less indicate airway
impairment
Lower pharyngeal width from point of intersection of
posterior border of tongue and inferior border of mandible
to the closet point on posterior pharyngeal wall 11 to
14mm.usually values are high due to anteriorly positioned
tongue as the adenoids are enlarged
OTHER CEPHALOMETRIC FINDINGS:
vertical growth pattern
increased ANB
increased gonial angle
decreased mandibular length
steep MP angle
over erupted upper posterior segments
airway
OTHER DIAGNOSTIC TESTS
SPIROMETRY
OXIMETER- to evaluate oxy-Hb level
RHINOMANOMETRY-instrument used to measure nasal
patency
STEDMANS medical dictionary defines it as study of
nasal obstruction and nasal airflow characteristics
PNEUMOTACHOGRAPH-device consisting of flow
meter, pressure-measuring manifold,and a recording
instrument
RESPIROMETRY-study of both nasal and oral
respiratory function
SNORT simultaneous nasal and oral respiratory
technique
Spirometry 462-PHYSIO

SPIROMETER
Rhino-snort
SNORT APPARATUS
Rhino-graphs-
OI,OE,NI,NE GRAPHS
EFFECTS OF AIRWAY OBSTRUCTIONS
HEAD POSTURE CHANGES:
BENI SOLOW and ANTJE TALLGREN
extension of the head in relation to the cervical
column was found in connection to large anterior facial ht.
And small post. Facial ht., small anterio-posterior
dimension, large mandibular inclination to anterior cranial
base & to nasal plane, facial retrognathism, large cranial
base angle and small naso-pharyngeal space.
RICKETTS(1968)-reported subjects with enlarged adenoid
with extension of head &forward and downwardly
positioned tongue.
NINIMA & COLE :noted 5 degree increase in cranio facial
angle associated with nasal obstruction.
Head posturePg 7 petrovic

EXTENSION OF HEAD TO FACILIATE AIRWAY
MANDUBULAR ROTATION:
In response to enlarged adenoids which occupy the
posterior pharyngeal space the tongue gets anteriorly
positioned leading to downward and backward rotation of
the mandible.
The ANB angle increases , MP angle increases, LAFH
increases-LONG FACE SYNDROME.
CHRONIC NASAL OBSTRUCTION

MOUTH BREATHING &HEAD EXTENSION

MANDIBLE &TONGUE ARE LOWERED

FACIAL HT. INCREASES

POSTERIOR TEETH SUPRA ERUPT

ANRETIOR OPEN BITE &INCREASED OVERJET

INCREASED CHEEK PRESSURE

COLLAPSED DENTAL ARCHES

A
D
E
N
O
I
D
F
A
C
I
E
S
TREATMENT OPTIONS
TREATING THE ETIOLOGIC FACTORS:
TONSILLECTOMY,ADENOIDECTOMY,CORRECTION OF
DNS,NASAL POLYPS
ORTHODONTIC:
ORAL SCREEN
RAPID MAXILLARY EXPANSION
MANDIBULAR ADVANCEMENT
SURGICAL :
HYIOD BONE REPOSITIONING
BI JAW ADVANCSMENT
MANDIBULAR ADVANCEMENT

TONSILLECTOMY-tonsils attain max. size during 9-10
yrs. of age,after which they regress in size, their removal
enhances nasal pathway
ORAL SCREEN:alters breathing from oral to nasal
progressive closure of holes preferred.
MANDIBULAR ADVANCEMENT:
LI U et al- A.O.1997 mandibular repositioning is most
effective in mild to moderate obstructive sleep apnea
Mandibular repositioning enhances retro pharyngeal air
space thereby increasing nasal airway patency

Respiratory factors for RPE
(Gray and Brogan)
anterior nasal stenosis
septal deformity
recurrent E.N.T./sinus inf.
allergic rhinitis
as a preliminary measure for septoplasty

RAPID MAXILLARY EXPANSION
Rpe effects nasal airway
Inflation of nasal passages resulting in increased air flow has been one
of the fascinating results of RPE. To the unfortunate pt.who is forced
to breathe thru his/her mouth such a treatment result is boon of
unestimatable value.
anterior nasal stenosis

reduced nasal airway

forced mouth breathing

faulty tongue posture &high arch palate

enlarged adenoids

ADENOID FACIES
BISHARA-the avg. increase in width of nasal cavity at its floor is about
1.9mm.,but can widen as much as 8-10mm.at the level of inferior
turbines

AIRWAY BEFORE &AFTER RPE
RPE activated

max. splits

ptyg.plates splay

max. moves down &forward

3-D-increase in nasal cavity

increase volume in floor of nose

site of inferior conchae

maximum respiratory air is seen

INCREASE IN AIRWAY
CONCLUSION
I N SPI TE OF THE LONG HI STORY OF RESEARCH
BETWEEN RESPI RATI ON AND MALOCCLUSI ON
ONLY NOW ARE WE HEADI NG I N THE RI GHT
DI RECTI ON. WI TH NEWER TECHNI QUES AS
SNORT, PNEUMOTOGRAPH FOR AI RFLOW
MEAUREMENT, PRECI SE VALUES I NDI CATI NG
EXTENT OF ORAL COMPONENT OF RESPI RATI ON
ARE AVAI LABLE.HENCE UNDUE RESORT TO
SURGI CAL EXCI SI ON OF ADENOI DS CAN BE
AVERTED.
MORE RESEARCH I S NEEDED I NTO PREVENTI VE
ASPECT OF OBSTRUCTED AI RWAYS !

Thank you

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