airway mini-residency: intro to airway orthodontics

!

dr. barry raphael the raphael center for integrative education

!

www.learnairwayortho.com [email protected]

Airway-focused Dentistry Mini-Residency

Introduction to Airway Orthodontics

mailto:[email protected]

Can you hear me now?

Let’s turn off ringers...

•

2013

Sabuncuoglu O., Med Hypotheses. 2013 Jan 7. pii: S0306-9877(12)00566-X. doi: 10.1016/j.mehy.2012.12.017. [Epub ahead of print]

http://www.ncbi.nlm.nih.gov/pubmed?term=Sabuncuoglu%20O%5BAuthor%5D&cauthor=true&cauthor_uid=23306004

http://www.ncbi.nlm.nih.gov/pubmed/23306004#

RO since1983 (31 years...yikes)

Bucknell University 1974 University of Pennsylvania DMD1978

(Three Years in General Practice) Fairleigh-Dickenson University Ortho 1983

Right out of school

Functional Orthodontics

Frankel

Bionator

Twin Block

MARA

Herbst

2008

Soft Tissue Dysfunction is THE cause of malocclusion

Myofunctional Research Co.

Spring, 2009 MRC meeting, Chicago > Terry Carlyle

September, 2009 MRC conference, Coral Gables, Fl.

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien O’Brien

Myofunctional Research Co. Rancho Cucamonga

2008-2012

• Oral Myology Basic Course • Joy Moeller • NYC 2011 • LA 2012

Oral Myology

Oral Myology: Levels 2, 3 Kim Benkert Clifton 2012

Habit Cessation Shari Green Clifton, 2013

Biobloc OrthotropicsBBO Mini-residency

Bill Hang Agora Hills

2012-13

BBO Intensive Drs. John and Mike Mew

LSFO 2013

Breathing and SleepButeyko Mentorship

The Breathing Center Woodstock

2010

Breathing Well Programme John Flutter

2010 Ortho-Postural Training Roger Price

2013

Sleep Dentistry Michael Gelb, et.al

NYU 2012,2013

Cranial Osteopathy

Advanced Dento-cranial Orthopedics Bob Walker

2014

ALF, The Team Approach Jim Bronson

2013

Cranial Academy: Basic Course

January 2014

Teaching

Mt. Sinai Pedo Residency Ali Attaie

2010-2014

Montefiore Ortho Residency Tony Maganzini

2012

2009-Present

Golf

0

7.5

15

22.5

30

1983 2006 2013 2014

It’s about the Airway

BTW….I lost 30lbs

“It’s all about Barry And The World of Mouthbreathing”

• Honorarium and Travel Expenses but no vested interest in Myofunctional Research Co. !

• Director, Raphael Center for Integrative Education

Disclosure

Recommended Reading

1.A New Paradigm!1. Airway and Breathing Dysfunction 2. Soft Tissue Dysfunction 3. Chronic Diseases of Lifestyle 4. Malocclusion and Retractive Orthodontics

2. Clinical Application (Session 3)!1.Diagnostics 2.Prevention 3.Undoing the Damage 4.Establishing Good Habits 5.Interdisciplinary Treatment

Airway Orthodontics

Feedback

I agree I like

I disagree I have a problem I have a question

Shelter from the!

Storm

HVAC!Comfortable Environment

Family Living Together

Decor and Activity

“The Roof is Leaking”

“The A/C is broken. I can’t

sleep.”

“Mommy, Lisa’s hogging

bathroom!”

“This place is a mess!”

Chronic Diseases of

Lifestyle

Airway and Breathing

Inefficiency

Soft Tissue Dysfunction

Malocclusion and

OrthodonticsAirway-focused

Pathology

Airway Orthodontics

Chronic Diseases of

Lifestyle


Malocclusion and


Pathology


Dysfunction

Airway Orthodontics

The Spectrum of SDB

Snoring 8-10%

Normal Prevalence:

OSAS 1-3%

UARS ?

Anatomic Determinants of SleepDisordered Breathing Across the Spectrum of Clinical and Nonclinical Male Subjects* 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

CHEST September 2002 vol. 122no. 3 840-851

•Craniofacial morphology and obesity are independent risk factors for apnea

•Maxillary depth predicts AHI

•Jaw shape explains susceptibility to AHI from weight gain

Small maxilla + obesity = 3x SDB Small maxilla + non-obese = 5-7x SDB

• Short maxilla means smaller airway

• Narrow maxilla puts nasopharynx at risk for collapse with loss of muscle tone

Anatomic Determinants of SleepDisordered Breathing Across the Spectrum of Clinical and Nonclinical Male Subjects* 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

CHEST September 2002 vol. 122no. 3 840-851

•Risk Factors for Increase AHI (Apnea-Hypopnea Index) • Age • BMI • Position of Hyoid Bone • Size of Airway (and resistance to flow)!• Neck Circumference

OSA Risk Factors

Analysis of anatomical and functional determinants of obstructive sleep apnea. Aihara K, et. al ,Sleep Breath. 2012 Jun;16(2):473-81. Epub 2011 May 15.

Which is easier to breathe through?

Which would you trust most?

Which would you rather have?

Analysis of anatomical and functional determinants of obstructive sleep apnea. Aihara K, et. al ,Sleep Breath. 2012 Jun;16(2):473-81. Epub 2011 May 15.

Narrow, irregular airway >

> increased shear forces >

> negative pressure pulls on soft tissue >

> tissue pulling and trauma (snoring) >

> impairment of mechanoreceptors >

> uncoordinated diaphragm and upper airway muscle contraction >

>DISORDERED BREATHING

Narrow Airway Dynamics

Powell N, Guilleminault C. “Abnormal pharyngeal airflow in obstructive sleep apnea using computational fluid dynamics: Feasibility study.” Proceeding of the 9th World Congress on Sleep Apnea (Seoul, Korea) 2009

Morphology and SDB in children

“Abnormal craniofacial morphology, but not excess body fat, is associated with an increased risk of having SDB in 6–8-year-old children.”

Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752

• 491 Finnish children 6–8 years of age

• studied: BMI, occlusion, sleep survey

• Looked for: Frequent snoring, apeas, open-mouth posture



Risk Factor Incidence

Obesity 0

Tonsilar Hypertrophy 3.7x

Crossbite 3.3x

Convex Facial Profile 2.6x



“A simple model of necessary clinical examinations (i.e. facial profile, dental occlusion

and tonsils) is recommended to recognize children with an increased risk of SDB.”



Everyday in my practice...

Form problems

Associations between sleep-disordered breathing symptoms and facial and dental morphometry, assessed with screening , Hyunh, et.al., AJODO, 2011, 140:762-70

Sleep Disordered Breathing associated with:

Long and narrow face High mandibular plane angle

Narrow palate Severe crowding

Swollen Tonsils and Adenoids Allergies

Frequent Colds and Infections Habitual Mouth Breathing

Function problems

•16% had long facial form!

•86% had convex profiles (mandible set back from maxilla)!

•Over 50% had daytime mouth open posture

Associations between sleep-disordered breathing symptoms and facial and dental morphometry, assessed with screening , Hyunh, et.al., AJODO, 2011, 140:762-70

Of the 600 orthodontic patients with SDB...

The smallest space behind the tongue (minAx) is the best predictor of NP airway volume

Small mandible: small airway

Airway volume for different dentofacial skeletal patterns!Hakan Ela and Juan Martin Palomob, Am J Orthod Dentofacial Orthop 2011;139:e511-e521

Pharyngeal Airspace is Smaller in Mouthbreathers

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children Alves, M, et.al., Int J Ped ORL 75 (2011) 1195–1199

Cone Beam and Airway analysis tool

• Exam for Mouthbreathing

• the habitual posture of the lips (apart, even slightly)

• size and shape of the nostrils

• control reflex of the Alar Nasalis

• Glatzel mirror test

• Rhinoscopy

• Adenoid hypertrophy

25 Mouth breathers, 25 Nasal breathers, Avg 8-9 y/o



Mouth breather Nasal breather



The Importance of Airway in Children

“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.”

Snoring and SDB is dangerous in infants

Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years!Karen Bonuck, PhD,a Katherine Freeman, DrPH,b!Ronald D. Chervin, MD, MS,c and Linzhi Xu, PhDa

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.”

“...early childhood SDB effects may only become apparent years later.”

Snoring and SDB is dangerous in infants

Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years!Karen Bonuck, PhD,a Katherine Freeman, DrPH,b!Ronald D. Chervin, MD, MS,c and Linzhi Xu, PhDa


Nighttime symptoms of SDB in kids• Abnormal sleeping position • Bruxism • Chronic, heavy snoring • Delayed sleep onset • Difficulty breathing • Difficulty waking up in AM • Drooling • Enuresis • Frequent awakenings • Insomnia

• Bed Dread • Mouth breathing!• Nocturnal migraine • Nocturnal sweating • Periodic Limb Movement • Restless sleep • Sleep talking • Sleep terror • Sleep walking • Witnessed apnea

Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years!Karen Bonuck, PhD,a Katherine Freeman, DrPH,b Ronald D. Chervin, MD, MS,c and Linzhi Xu, PhDa!


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

Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years!Karen Bonuck, PhD,a Katherine Freeman, DrPH,b Ronald D. Chervin, MD, MS,c and Linzhi Xu, PhDa!


Damage to Cognitive Function

Childhood OSA is associated with •Deficits of IQ •Deficit of executive function •Possible neuronal injury in the hippocampus and frontal cortex.

Childhood Obstructive Sleep Apnea Associates with Neuropsychological Deficits and Neuronal Brain Injury Ann C. Halbower, et.al, PLoS Medicine,August 2006 | Volume 3 | Issue 8 | e301

Death, nasomaxillary complex, and sleep in young children Caroline Rambaud & Christian Guilleminault, European Journal of Pediatrics DOI 10.1007/s00431-012-1727-3 Pub Online: April 11, 2012

“all children present a visually recognizable abnormal high and narrow hard palate”

Abrupt Sleep-associated Death• chronic indicators of abnormal sleep • enlargement of upper airway soft tissues • a narrow, small nasomaxillary complex, with or

without mandibular retroposition

• Maxillary Retrusion • Midface Deficiency • Maxillary Hyperdivergency • Long Face Syndrome • Adenoid Facies • Bimaxillary Retrusion • Craniofacial Dystropy

The small maxilla is a major factor in Sleep Disordered Breathing

What causes it?

• The shape of the face determines the shape of the pharyngeal airway

• The smaller the airway, the easier it is to obstruct • Obstructed breathing affects the growing brain

Take Home Message:

Chronic Diseases of

Lifestyle


Dysfunction

Malocclusion and


Pathology


Airway Orthodontics

Daniel E. Lieberman

“….there is much circumstantial evidence that jaws and faces do not grow to the same size that they used to…” - Daniel Lieberman

The Gothic Arch The Roman Arch

The “Modern” Maxilla

How do you build an arch?

The Roman Arch

No scaffold?

When the tongue rests in the roof of the mouth the teeth erupt around the tongue forming a

normal shaped and sized jaw.

The tongue is the scaffold for the upper jaw

Those children who breathe through the mouth or have the lips apart at rest will not have the

tongue in the roof of the mouth. All of these children will have

an underdeveloped upper jaw.

It will not be big enough for all of the teeth and when the adult teeth erupt they will be crooked.

Harvold’s Monkies

Posture changes Teeth

Lowered mandibular posture, tongue protrusion, and open biteOpen mouth posture retained for 1 year after nose reopened. Facial features retained

• “Orthotropics” • Normal growth of maxilla > Down and Forward • Dysfunctional growth > Down and Narrow • “Maxillary undergrowth is such a constant

feature of modern malocclusion” - AJODO,1979 • Biobloc Therapy

John Mew’s Tropic Premise

“Because the genetic control of skeletal growth is not precise,

the articulation of the teeth and jaws depends upon additional guidance from oral posture.”


“ If the tongue at rest is against the palate with the lips lightly sealed and the teeth in or near contact, there will be ideal facial and dental development…something RARE in industrialized societies…”


If the tongue is chronically held away from the palate… …the maxilla collapses in all three dimensions.

The Tropic Premise

If the mandible keeps up: Class I Crowded

Then the Mandible Adapts

Mouthbreathing and/or tongue thrust hinders growth : Class II


Low Tongue keeps mandible growing forward: Class III


The Tropic Premise

Craniofacial Dystrophy

Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Mid-Facial Support

2008

Soft Tissue Dysfunction is THE cause of

malocclusion


The Maxilla and Upper Dentition take the Shape of the Muscles and Muscular Functions that Surround them.



“Bone sets the tone but tissue is the issue”

- Mark Cruz

Open Mouth Posture !is the most common and significant

Soft Tissue Dysfunction In children today.

Chronic hyperventilation Hypocapnia Bi-maxillary Dystrophy!Reverse swallow Facial muscle dysfunction Lymph swelling Nasal obstruction Frequent ear infection Snoring SDB, UARS, OSA Learning Dx Heart rate variability Enuresis Poor posture Malocclusion Gingivitis Halitosis

Open Mouth PostureBirth trauma Cranial strains Poor posture Bottle feeding Soft diet Processed foods Immune challenges Oxidative stress Heat Hyperventilation Stress reactions Habits Dental pain Ankyloglossia Macroglossia

• The tongue is the scaffold for the growing maxilla (nature’s

palate expander • Soft Tissue Dysfunction is the cause of Craniofacial Dystrophy • Open Mouth Posture is the most common and significant soft

tissue dysfunction in children today. • Craniofacial Dystrophy is a developmental problem • In CFD, BOTH jaws are retruded

Take Home Message

Airway Orthodontics

Chronic Diseases of

Lifestyle


Dysfunction


Malocclusion and


Pathology

5,000 years ago When caries and malocclusion

were rare!

There was a time...

Kevin Boyd

Peter Gluckman

Neese and Williams Scott Gilbert

Clark Spencer Larsen

Are we developing the way our genes mean us to be?Darwinian Dentistry

Me...

Who said…•The cause of modern man’s maladies is his lack of “a quiet and natural sleep”.

•Proper breathing regulates digestion and circulation to every part of the body.

•Improper breathing brings imbalance and disease.

•The nostrils are intended to measure and temper the air in support of proper breathing.

George Catlin

George Catlin

“Shut Your Mouth and Save Your Life” 1870

“Shut Your Mouth and Save Your Life” 1870

“That man knows not the pleasure of sleep; he rises in the morning more fatigued than when he retired to rest - takes pills and remedies through the day, and renews his disease every night.”

Weston Price

1870-1948

Nutrition and Physical Degeneration Weston A. Price, DDS, 1939

Malocclusion is a product of the diet of industrialized societies

Obesity Hypertension

Cardiovascular Disease Type 2 Diabetes

Fatty Liver Disease Some Cancers Osteoporosis Depression

The Results of the Mismatch Between Genes and the Environment

Chronic Non-Communicable Diseases of Civilization Western Lifestyle Diseases

Metabolic Syndrome Asthma Autism

Asperger’s Alzheimers ADD/ADHD

Chronic Back Pain

Caries!

Malocclusion!

Sleep Apnea

Its not just Growth and Development

!

Its Growth, Development and Adaptation

!

The Missing Link in Orthodontics Today...

If Malocclusion is caused by Growth and Development...

Genotype Phenotype

Total Growth

If Malocclusion is caused by Growth and Development and Adaptation...

Genotype Phenotype

Total Growth

!

!

!

!

An example of “adaptation”

Identical twins with different habits

Dr. John Mew orthotropics.co.uk

http://orthotropics.co.uk

One of them has crooked teeth.

Another set of twins

3 August 2003 3 August 2003

RHYS - 10Y 11MHow did these teeth get this way?

Different genes than his brother…

1 March 2007 1 March 2007

RHYS - 14Y 5M Four years later, after successful MFO

Text

(Treatment by Dr. Chris Farrell)

RHYS - 16 AUGUST 2007 KYLE - 16 AUGUST 2007

TRAINER BWS MYOBRACE MINIMAL SWA

RHYS & KYLE - 13Y 8MDid genetics make the teeth crooked?

Did genetics fix the face?

• Anthropology informs us that malocclusion is an adaptation - a consequence - of contact with the modern environment

• Genetic predispositions can be influenced by a change in the environment

Take Home Message

….for better or for worse.

Chronic Diseases of

Lifestyle


Dysfunction


Airway-focused Pathology

Malocclusion and

Orthodontics

Airway Orthodontics

!

”... more often than is recognized, the peculiarities of lip function may have been the cause of forcing the teeth into the malpositions they occupy”.

Edward H. Angle

1855-1930

From “Malocclusion” 1907Edward H. Angle

Light intermittent forces can affect skeletal growth

Crozat Philosophy and Appliance•Preserve the natural dentition and •Develop the bony structures •Assist the natural shape of the face and jaws to develop to their full biologic potential. •Overall health and well being of the patient

Edward Angle vs Calvin Case

Witzig vs McNamara

NewConn 2009 Extraction vs Non-extraction Debate

The Extraction Wars

1855-1930

5-10% extraction rateV. Kokich F. Bogdan

Passive-Self Ligation

The Damon System

“to match each phase of treatment with the natural force systems of normal growth and development…”

Non-extraction

18 Months

26 Months

Non-extraction

Non-extraction

Finding room for all the teeth is not a problem if you start early enough and try to mimic what nature intended.

Protractive vs. Retractive Orthodontics

What is the correct treatment for this?


Bimax retrusion

Successful dental result

Failed Profile Result

Successful dental result

Failed Profile Result

Everyday in my practice...

What is the appropriate treatment for a Collapsed Maxilla?

Treatment

Headgear?

Class II Elastics?

Mandibular Advancment Appliance? (Herbst, Twin Block,MARA with reciprocal anchorage)

Extractions ?

Treatment

Retraction affects the airway

Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood Makoto Kikuchi, Sleep and Breathing Published online: 17 November 2005©

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of Class I bimaxillary protrusion!Qingzhu Wanga; Peizeng Jiab; Nina K. Andersonc; Lin Wangd; Jiuxiang Line,Angle Orthodontist, Vol 00, No 0, 0000 !

(pre-publication 2012)

“the dimension of the velopharynx, glossopharynx, and hypopharynx were

decreased after maximal retraction of anterior teeth with extraction of four premolars…”

“Any factors that can influence the posture and position of tongue and

soft palate may displace them backward and

encroach upon {the pharynx}.”

“the more the incisors were retracted, the more the pharyngeal

airway was reduced.”


Bilateral SSRO: “the pharyngeal airway was constricted significantly at the oropharyngeal and hypopharyngeal levels at both the short-term and the long-term follow-ups”

Effects of bimaxillary surgery and mandibular setback surgery on pharyngeal airway measurements in patients with Class III skeletal deformities!Fengshan Chen, Kazuto Terada, Yongmei Hua, Isao Saito American !

Journal of Orthodontics & Dentofacial OrthopedicsVolume 131, Issue 3 , Pages 372-377, March 2007


Sagitall Split Ramus Osteotomy

Lefort I plus SSRO: “bimaxillary surgery rather than only mandibular setback surgery is preferable to correct a Class III deformity to prevent narrowing of the pharyngeal airway space

http://www.ajodo.org/article/S0889-5406(06)01459-4/abstract#




http://www.ajodo.org/issues?issue_key=S0889-5406(07)X0127-6

Backed into a corner...

•

Retraction Orthodontics

If Retraction Mechanics has the potential to hinder the airway, how much retraction is OK?

If snoring is likely to lead to obstruction someday, how much snoring is “normal” for a child?

• Orthodontics is about the teeth • Orthopedics is about the bones • Orthotropics is about the direction of growth • Most orthodontic technique are Retractive - even

“functional appliances” - and work against forward growth

Take Home Message

Chronic Diseases of

Lifestyle


Dysfunction


Malocclusion and

OrthodonticsAirway-focused Orthodontics

Airway Orthodontics

“If it were possible to improve faces to the disadvantage of the teeth, where would our duty lie?” -AJODO, 1979

John Mew

Esthetics? Proper Breathing?

Remember the Airway!“Consequently the most important

missing diagnosis is the airway. !

Nevertheless, breathing is the most important action for human beings to live; we forgot the airway to make a diagnosis

of the orthodontic patients.”


Treatment Goals Based on Upper Incisor (UI)

Incisor Goals

Type 4 Treatment: Retract/Extrude UI

Extraction Orthodontics, Retraction Ortho, Distalization Ortho

Incisor Goals

Type 3 Treatment: Maintain UI

Functional Orthodontics, Expansion Orthodontics, Distalization Ortho

Incisor Goals

Type 2 Treatment: Expansion enough to uncrowd

Myofunctional Ortho, Myofunctional Therapy, Crozat, ALF, Expansion Orthodontics

Incisor Goals

Type 1 Treatment: Place U1 in ideal position

Biobloc Orthotropics, Orthognathic Surgery, Distraction Osteogenesis

Protraction affects the airway

From Dr. K. Li

Effect of mono- and bimaxillary advancement on pharyngeal airway volume: cone-beam computed tomography evaluation.!Hernández-Alfaro F, Guijarro-Martínez R, Mareque-Bueno J.J Oral Maxillofac Surg. 2011 Nov;69(11):e395-400. Epub 2011 Jul 27

The pharyngeal airway gets larger !

The average percentage of increase was: 69.8% with MMA 78.3% with Mandibular Advancement 37.7% with Maxillary Advancement


From Dr. K. Li

• MMA 100% successful !

• Results similar to CPAP

Maxillomandibular Advancement Surgery in a Site-Specific Treatment Approach for Obstructive Sleep Apnea!in 50 Consecutive Patients*!

Jeffrey R. Prinsell, DMD, MD, CHEST / 116 / 6 / DECEMBER, 1999


• 25 x 11 year olds • Reverse Pull HG, 350 g, 14h/d for 6 months • Follow-up 4 years post-treatment • 2D analysis only (cephs)

“...the maxilla continued to grow forward after treatment, which was maintained in the long-term observation.”

“improved the nasopharyngeal and oropharyngeal airway dimensions initially, …. was maintained at long-term follow-up.”


Effects of Maxillary Protraction and Fixed Appliance Therapy on the Pharyngeal Airway !Emine Kaygısız et.al., Angel Orthodontist, Volume 79, Issue 4 (July 2009)

http://www.angle.org/toc/angl/79/4

Mandibular Advancement

Appliances open the airway by bringing the tongue forward.

Mandibular advancement devices are an alternative and valid treatment for pediatric obstructive sleep apnea syndrome. Maria Pia Villa, Silvia Miano, Alessandra Rizzoli,Sleep Breath (2012) 16:971–976



Expansion affects the airway

RME may relieve nasal breathing problems by increasing the transverse dimensions of the maxilla, which in turn widens the nasal cavity.


“Orthodontic therapy should be encouraged in pediatric OSAS, and an early approach may permanently modify nasal breathing

and respiration, thereby preventing obstruction of the upper airway.”


• 53 patients, avg 12 years old • Biobloc treatment for avg 20 months • Posterior airway measured on ceph

Evalutation of the Posterior Airway Space Following Biobloc Therapy: Geometric Morphometrics. G. Dave Singh, Ana Barcia-Motta, William Hange, Cranio April 2007, (25:2)

Orthotropics affects the airway

31% Increase in nasopharynx area 23% Increase in oropharynx area 9% Increase in hypopharynx area

Repenting for past sins affects the airway

Repenting for past sins affects the airway

What really matters is whether treatment increases, or at least does not reduce, the tongue space.

- Bill Hang

Orthodontics in the 21st Century

Conventional!Orthodontics

Airway!Orthodontics

Genetic Tooth-Focused

Esthetics Primary Treating Symptoms

Airway Ignorant

Adaptation Muscle-Focused

Esthetics Secondary Treating Causes Airway Concious

Form Function

Orthodontics

Myofunctional

Conventional!Orthodontics

Airway!Orthodontics

The Health/Pathology Spiral

Form

Form

Function

Function

Function

Declining HealthImproving Health

A Pathology Cycle

Declining Health

FunctionMouthBreathing and

Low Tongue

FormLong FaceFunction Weak MMuscles

FormNarrow Palate

Function Deviate Swallow

FormSwollen T&A

Crooked Teeth Form

Breaking The Cycle

Declining Health


Low Tongue


FormNarrow Palate

FunctionSwallowing with Active

Facial MusclesCrooked Teeth

Form

FormSwollen T&A

Conventional Orthodontics

Backed into a corner...

Stuck with Retractive Orthodontics

Breaking The Cycle

Declining Health


Low Tongue


FormNarrow Palate

FunctionSwallowing with Active

Facial MusclesCrooked Teeth

Form

FormSwollen T&A

Airway-Centric Orthodontist

• Chad M. Ruoff & Christian Guilleminault • Sleep Breath, 2011, pub online, May 11

Orthodontics and Pediatric OSA

“Although dentists and orthodontia recognize the importance of evaluating and treating OSA,

they have yet to realize how well-positioned they are for the prevention of sleep-disordered

breathing (SDB).”

The “environment plays an important role in the development of SDB. Therefore, manipulation of

environmental factors may decrease the development of OSA.

!

There is a need to better define these environmental factors and predict those at risk

for the development of OSA so that orthodontists and dentists can both treat and prevent OSA.”

• Chad M. Ruoff & Christian Guilleminault • Sleep Breath, 2011, pub online, May 11

Orthodontics and Pediatric OSA

Dr. Stephen Sheldon Professor of Pediatrics, Northwest University School of Medicine Director, Sleep Medicine Lurie Children’s Hospital, Chicago

Defining Environmental Factors

•Chronic Naso-pharyngeal Obstruction •Tongue form aberrations (Frenum and tongue-tie) •Open Mouth Rest Posture •Myofunctional disorders (Swallowing, chewing,etc.) •Chronic Hyperventilation and Hypocapnia •Breathing Disordered Sleep (OSA, UARS, snoring) •Bruxism and parafunctions •TMD and facial pain components •Cranial and postural issues • Malocclusion

Airway-Related Craniofacial Dysfunctions

• Early Feeding and Nutrition • Allergies, Asthma, URT infections • Posture • Airway, Breathing, and Sleep Disorders • Soft Tissue Dysfunctions (Tongue Thrust, Open

Mouth)

Treating the Cause

Instead of crooked teeth being The Problem, They are just a SYMPTOM of something larger

• Adult SDB and OSA

• Narrow Jaws and Faces

• Soft Tissue Dysfunction

• Early Parafunctional Habits, esp Open Mouth Posture

• Environmental Stressors

• CPAP, MARA,UPPP, SurgWhere’s the best

place to start treatment? Here?

Or H

ere?

Treating the Cause

• The primary goal of Airway Orthodontics is to enhance and protect the NP airway.

• It is always Form AND Function, spiraling in time. • AO intervenes with Form AND Function. • AO addresses the Causes of malocclusion • Malocclusion is a Symptom of another Imbalance • Malocclusion is the body’s Solution to an imbalance

elsewhere in the body.

Take Home Message

Chronic Diseases of

Lifestyle


Dysfunction


Malocclusion and

OrthodonticsAirway-focused Orthodontics

Airway Orthodontics

Address!Stress


First

Fix!Function

Fix!Form

• In session Three we will learn • The Goals of Airway Orthodontics (Breathe through the…) • The Strategies of Airway Orthodontics (An ounce of…) • The Techniques of AO (This is not you father’s palate expander) • Ways to bring AO into your practice.

More to come….

airway mini-residency: intro to airway orthodontics

Health & Medicine

smaller airway narrow

soft tissue tissue

sleep breath

sleep apnea seoul

retractive orthodontics

breathing center woodstock

phd james

phd chest