Naso respiratory function and growth sleep apnea /certified fixed orthodontic courses by Indian dental academy

NASO-RESPIRATORY FUNCTION
AND GROWTH, SLEEP APNEA
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

1


2

CONTENTS
Introduction
 Anatomy
 Mechanism of Breathing
 Diagnosis
 Animal studies
 Human studies
 Relationships between dentofacial
deformities and nasal airway inadequacy



3

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


4

Anatomy


5

Anatomy


6

Inspiratory & expiratory muscles


7

Mechanism of breathing


8

RESPIRATORY PHYSIOLOGY
Pulmonary alveoli and respiratory tract.

Function






Exchange of O2 and CO2 between environment and
body cells.
O2 – intercellular metabolism.
CO2 – End product.
Exchange through alveoli
Alveolar membrane permits O2 and CO2
transport.

9

Alveoli


10

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


11


12

Airway Resistance


13

Airway Resistance




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


14

Sensory feedback
Sensory receptors
Respiratory tract
Cardiovascular system- baroreceptors
Joints- increase pulm ventilation
Pulmonary stretch receptors


15




Chemoreceptors most affectted.
Monitor levels of O2 and CO2.
Carotid bodies – O2 sensitive
Aortic bodies
Ventral surface of medulla – CO2 sensitive

Obstruction of upper airway –
↓ airflow and O2 conc. – inspiration
↓ airflow and inc CO2 conc. – expiration
Transient hypoxia – Neural receptor stimulated.

16

Neuromuscular control


17

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


18

Diagnosis


19

Diagnosis


20

Craniofacial Adaptation to Nasal
obstruction – Rhythmicity
Animal Experiments:
Aim: Determine which craniofacial muscles were
rhythmically active, discharging periodically with
primary respiratory muscles.
 16 muscles surveyed – 4 regions.
Mandibular elevators
Mandibular depressors
Tongue
Facial muscles
Fine wires – placed intramuscularly
21
Electromyographic records taken


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


22

Rhythmicity during Early
adaptation
26 young rhesus monkeys –
13 mouth breathers – 13 controls.
Results: Experimental group – rhythmicity in
1. muscles of upper lip and
tongue
2. Geniohyoid, digastric, temporalis,
zygomaticus, medial and lateral
pterygoid.



23


24

ELECTROMYOGRAPHY


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


25

Patterns of Rhythmicity






Craniofacial muscles –
2 discharge patterns.
Primary respiratory
muscles – 1 discharge
pattern.
Diaphragm – Slowly
builds – max-tension.
Lip ,nares and tongue
muscle attain maxtension immediately.

26



To summarize rhythmic activity correlated with
respiration is normally present in five craniofacial
muscles – control animals.



Experimental animals – adapt to oral respiration –
four additional muscles involved.



This reflexivity induces changes in neuromuscular
function of craniofacial muscles.
inducing periodicity in discharge
initiating a sustained tonic discharge

27

Growth in the sagittal depth of bony nasopharynx in
relation to some other facial variables
Sten Linder - Aronson

Size of nasopharynx important – mode of
breathing
 Lymphoid tissue – posterior wall of
nasopharynx.
 Adenoid vegetations




Size of adenoids – crucial

28



Difference of opinions



Rosenberger 1934 – nasopharynx ↑ in conjunction
with growth of the cranial base.



Brodie 1941 – depth established during the first
year or two of life – constant afterwards.



King 1952 – examined nasopharyngeal
dimensions from 3 months to 16 years – similar
views.


29



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


30

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


31



Materials – longitudinal



study – 6 to 20 years
children.
140 boys and 120 girls –
Burlington Growth
Center.



Method
variables measured:
- Ba-S
- S-N
- Ba-ptm
- Ba-N
- Ptm-Sn
- Sn-Gn
- N-Sn www.indiandentalacademy.com

32



Results
Males – steady increase in sagittal depth
of nasopharynx – 6-20 yrs
6-12 yrs – 2.4mm
12-18 yrs – 4.7mm
Females – Growth of nasopharynx after
16 years negligible.
6-12 yrs – 3.5mm
12-18 yrs – 1.6mm

33

Correlations done


Results – Highest
correlation coefficient b/n
depth of nasopharynx and
length of total cranial base
–
r = 0.63 - 0.75
.



Very weak correlation b/n
depth of nasopharynx and
length of maxilla
r=0.18 – 0.40

34

No correlation b/n depth of nasopharynx and facial heights


35

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


36


37

Summary
1.
Sagittal depth of nasopharynx ↑ in small steady
increments upto 16 yrs of age in females and 20
yrs in males.
2.
The velocity of sagittal depth ↑ peaked – 12 to
14 yrs in males –
3.
In females – ↓ after 12 yrs of age
4.
There was great variation among individual
velocity curves in both the age at which it
peaked and magnitude of growth increments.
5.
Sagittal depth of bony nasal pharynx is
relatively independent of other cephalometric
dimensions of the facial complex.

38

Relationships between dentofacial
-

Conflicting topic

-

Judgement of mode of
breathing


39

-

Most prevalent view – mouthbreathing –
associated with
Retrognathic mandible
Protruding maxillary anterior teeth
High palatal vault
Constricted maxillary arch
Flaccid and short upper lip.
Dull appearance

40



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


41

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


42

Relationships between dentofacial deformities
and nasal airway inadequacy





Derichsweiler 1956 – contradicts nasal obstruction
as a primary etiologic factor in dentofacial
deformity.
Choanal atresia
Watson 1968 – mouth breathing – not always
associated with skeletal deformity.
23% of mouth breathers due to habit rather
than physiologic need.


43

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


44

Maxillary expansion and nasal airway
resistance
-

Hershey et al 1976 – 45% reduction in nasal
airway resistance after RME
Turby fill – 1976 – 53% decrease in airway
resistance in 17 subjects.


45

Craniocervical angulation and nasal
respiratory resistance


Solow Thompson – Changed craniofacial
morphology – due to changed head posture

.


Schwarz 1926 – Head bent backwards i.r.t.
neck in nasal obstruction.



Ricketts 68, Koski 75, Quinn and Pickrell
78 – similar views.

46

Head posture and craniofacial
morphology
Bjork 1961 –
– Retrognathic facial type – head in extended position.
– Prognathic facial type – head in lower position

Bench 1963 – neck -curved in square faces
Straight – long faces.

Sallow and Tallgren 1976 – of the posture variables
the craniocervical angulation showed the most
comprehensive correlation with craniofacial
morphology.

47



Extended head position –
- Large inclination
of mandible
Small post and large ant
facial heights
Facial retrognathism


48



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


49

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


50

Soft tissues stretching hypothesis


51

Conclusions
1.

2.

Before adenoidectomy a large craniocercival
angulation was seen in connection with a
large nasalrespiratory resistance.
After adenoidectomy reduction of the
craniocervical angulation occurred in children
in whom nasal respiratory resistance was
reduced.


52

Nasorespiratory function and
Craniofacial growth-Linder Aronson
Distinction between mouth and nose
breathers
 Mouth breathing


» Refers to those individuals who have a certain
degree of nose breathing capacity but, for one
reason or another, breathe mainly through the
mouth.
Conditions - E.g. Bilateral Chonanalatresi, alea nasi
insufficiency – pure mouth breathers.
Reduced nasal respiratory function – pts with enlarged
adenoidal masses

53

Effects of reduced nasal respiratory function on the
development of facial skeleton and occlusion


Last 100 yrs – lot of research



Wilhelm Meyer 1868 – patients with reduced nasal
respiration – poor hearing & poor general health.



Tomes 1872 – mouth breathers- narrow dental arches (vshape).



Nordlund 1918 – theory of compression
- Disturbance of balance b/n tongue and cheek musculature



Korner 1891 – mouth breathing
1. Narrow dental arches.
2. Underdevelopment of nasal cavity.

3. Reduced maxillary size.

54

Woodside 1968 – Obstructed nasal ventilation –
Class II malocclusion.
 Harvold et al 1973-79 – Animal experiments


--change to mouth breathing
narrowing of the maxilla.
post rotation of mandible

.

Nordlund, Brash et al
Reduced nasal breathing result of existing facial
and dental morphology.

55

Adenoid faces



Associated with long history of mouth breathing.
C/F:
–
–
–
–
–
–
–
–
–

Open mouth posture.
Flattened nose.
Pinched nostrils.
Short upper lip.
Voluminous and pouting lower lip.
Vacant facial expression.
Proclined upper incisors.
V-shape upper jaw – high palatal vault.
Skeletal Class II relationship.

56

Adenoid faces


57

Effects on the dentition& facial skeleton
of a change from mouth to nose
breathing-Linder Aronson
1973


58

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


59

Method:
Children examined 1 and 5 yrs post op


60

Results
Upper incisal
inclination
- Relatively greater
increase in upper incisor
inclination.
- Normalization of upper
incisor inclination to SNduring the five year
postop period
.

61

Results
Inclination of the lower
incisors






Greater change during
first year post-op
Next 4yrs no significant
change
Normalization of lower
incisors inclination occur
during the 1st year post-op


62

Results
Changes in arch
width


1st year greatest change 0.
9mm – statistically
significant.



Normalization of arch
width took place
following adenoidectomy

63

Results
Effect on the
nasopharynx
Normalization of the
depth of nasopharynx
occurs during the 1st yr
post-op


64

Results
Effect on
maxillomandibular
angle




1st yr post-op – 0.4° not significant
Next 5 yrs - greater
change
ML/MN angle ↓ after
change from mouth to
nose breathing.

65

Mechanisms of change in dentition &
facial morphology


66

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


67


68

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


69

Results:
 Significant differences
in the size of SN/Vert
angle before
adenoidectomy.
 No difference after
adenoidectomy b/n
two groups


70

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


71

Pierre Robin syndrome


72

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


73

Prevalence


Upper resp infection – peaked – 1 & 6 years and
significantly ↓ thereafter.



Hypertrophy of tonsils and adenoids – more common in
boys – under 6 yrs

.


Hypertrophy tonsils –twice in adult female.



Otitis media – 2nd common disease in childhood.
All these conditions - ↓ - after 6 yrs.




74

Urgent indications for surgery:
-Alveolar hypoventilation
-Tonsil enlargement – difficulty in swalowing.

Tonsillectomy –– foll conditions
1) Recurrent tonsillitis
2) Chronic tonsillitis

Adenoidectomy indicated in –
persistent nasal obstruction
recurrent otitis media with effusion.


75

Factors influencing the degree of
obstruction






Degree of obstruction is primarily related to the
size of the tonsils and adenoids relative to their
surr compartment.
Recurrent chronic inflammation – ↑ the degree of
obstruction.
Acute rhinitis – moderately obstructing adenoids marked ↓ in nasal airflow.
Body position –
Recumbency in general – ↑ upper airway
obstruction

76

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


77

Methods of assessing degree of
respiratory obstruction


Thorough history & physical examination –
Sleeping habits
Snoring
Mouth breathing
Distortion of speech
Hypersomnia
Headaches
Lethargy
Weight gain
Nightmares
Difficulty in awakening

Physical examination – head neck, chest & abdomen areas

78

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


79

Classification
1 ± tonsils not visible behind the ant pillar
2 ± tonsils visible just beyond the pillar
3 ± tonsils are almost touching
4 ± tonsils meet in the midline
Radiographic films – lateral,
posterioanterior & submento vertex
views

80

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


81

Results
Experimental group – initially – steeper MP
angles, longer lower face heights
 5 yrs postoperative – more horizontal
growth pattern



82

Association of lip posture & the dimensions of tonsils
and sagittal air way with facial morphology
- Trotman et al – Angle Orthod 1997


Method: clinical & ceph data – 207 children
(adenoid or tonsil problems)



Conclusions:
–

More open lip posture - backwardly rotated
face & ↑ lower face height.

– Reduced airway size – backward relocation of
max & mand.
.

83

Effects of maxillary protraction on craniofacial
structures and upper airway dimensions –
Shigetoshi et al – Angle Orthod 2002
Aim: To examine the effect of max. protraction
appliance on upper airway dimensions.
 Material: - 25 pts – mean age 9.8yrs
Class III malocclusion
Method:
Lateral cephalogram evaluation
Conclusions:
The max growth had significant positive effect
on the superior airway dimension.
84


Conclusions
1.
2.
3.

↑ in max growth
Inhibition of mand growth
Clockwise rotation of mandible.


85

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

86

Results
Respiratory area ↑
 Nasal cavity width & max. width - ↑
 Decrease in nasal airway resistance
 MP suture seperated - ↑ in the internasal
volume
 Nasal resistance decreased & respiratory
area ↑ after RME



87

Comparison of nasopharyngeal endoscopy & lateral
cephalometric radiography in diagnosis of
nasopharyngeal airway obstruction –
Daniel Filho – AJO 2001

Aim:
2 methods of diagnosing nasopharyngeal
airway obstruction were compared
 Material:
30 orthodontic pts – 7-12 yrs
Mouth breathers
 Method : Nasopharyngeal endoscopy &
radiographic examination – same day



88



Conclusions

Lateral cephalometric radiography – sufficiently
reproducible for diagnosing hypertrophy of the middle
and inferior turbinates

.


Lateral cephalometric radiography – overestimates
turbinate hypertrophy – false positive findings.



Nasopharyngeal videoendoscopy – more suitable in
diagnosing obstruction of nasopharyngeal origin.
Nasal septal deviations
Hypertrophy of the inferior & middle turbinates

89

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


90

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


91

Comparison of the sizes of adenoidal tissues
and upper airways of subjects with and
without CLCP - Imawaru
Shigetoshi
AJO Aug 2002
Sample
 1. 90 juvenile with CLP(CLP/J)
90 controls – control/J
2. 40 adolescents with CLP – CLP/A
40 controls – control/A



92

 Method – measurements using Lat. Ceph
 Results – Adenoid tissue

significantly larger in CLP/J than in
control/J
no significant difference betn CLP/A &
control/A
adenoids smaller in CLP/A than in CLP/J

93

Upper Airway
Significantly smaller in CLP/J than in
control/J
 Significantly smaller in CLP/A than in
control/A
 CLP/A- increased airway than CLP/J
 Control/A larger than control/J
 Larger adenoids in CLP/J group decreased
to a smaller size with aging



94

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


95

Etiology
Loss of muscle tone
 Obstruction of nasal passages
 Large tonsils
 Large tongue
 Retrognathic mandible
 Obesity
 Alcohol
 Sedative medications



96

Classification
1. Central
 2. Obstructive
 3. Mixed



97

Pathogenesis
Occlusion at the level of oropharynx
 Progressive asphyxia – brief arousal from
sleep – airway restored – sleep.
 400-500 times per night
 Critical subatmospheric pressure
 Sleep – reduces the activity of upper airway
muscles
 Alcohol – imp. Cofactor

depressant action



98

Anatomic disturbances – adenotonsillar
hypertrophy

retrognathia

macroglossia
 Obesity
 Snoring



99

Clinical features
Behavioral disturbances
 Fragmentation of sleep
 Nocturnal cerebral hypoxia
 Excessive day time sleepiness
 Intellectual impairment
 Memory loss
 Impotence – in men



100

manifestations
Bradycardia – during apnea
 Tachycardia – 90 – 120 beats/min



101

Prevalence
Increases with age
 More prevalent in women
 Moderate obesity
 Mild to moderate hypertension



102

Diagnosis


Definitive investigations
–
–
–

Poly somnography
Arterial O2 saturation
Heart rate


103

Treatment


104


105


106

herbst


107


108


109

Modified functional appliance for
treatment of sleep apnea
Sleep apnea – sleep with mouth open
 Reduced tonicity of genioglossal mucsletongue sucked back
 Diagnosis - best by pulmonologist



110

New appliance – NAPA
Nocturnal airway patency appliance
 Mechanism –


– Posturing the tongue more anteriorly
– Inhibiting wide jaw opening
– Assuring adequate air intake when nasal
obstruction exists


111

Construction


Constructed using wire and acrylic


112

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


113

summary
Mandible was protruded to advance the
tongue to the posterior pharyngeal wall
 Genioglossus originates from the inner
surface of the mandibular symphysis
 ¾ distance b/w centric occlusion and full
protrusion was selected
 5-7 mm of protrusion
 Oral breathing beak – ptns with nasal
congestion



114



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


115

Removable Herbst appliance for
treatment OSA – Ernest A.Rider
16 SA ptns
 Plunger mechanism
 Sustained pharyngeal patency
 Advancement


– Edge to edge position


116

Results


70 – 100 % improvement – 12 ptns


117

Therapeutic efficacy of an oral
appliance in the treatment of OSA –
2 yr follow up


Purpose – the long term efficacy of
Karwetzky activator


118

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119

Naso respiratory function and growth sleep apnea /certified fixed orthodontic courses by Indian dental academy

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