Airway Mini-residency: Intro to Airway Orthodontics

!
dr. barry raphael
the raphael center for integrative education
!
www.learnairwayortho.com
drbarry@learnairwayortho.com
Airway-focused Dentistry Mini-Residency
Introduction to Airway Orthodontics

Can you
hear me
now?
Let’s turn off ringers...

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]

RO since1983 (31 years...yikes)
Bucknell University 1974
University of Pennsylvania DMD1978
(Three Years in General Practice)
Fairleigh-Dickenson University Ortho 1983

Functional Orthodontics
Frankel
Bionator
Twin Block
MARA
Herbst

2008
Soft Tissue Dysfunction
is THE cause of
malocclusion

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 Orthotropics
BBO Mini-residency
Bill Hang
Agora Hills
2012-13
BBO Intensive
Drs. John and Mike Mew
LSFO
2013

Breathing and Sleep
Buteyko 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

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
Orthodontics
Airway-focused
Pathology
Airway Orthodontics

Chronic
Diseases of
Lifestyle
Soft Tissue
Dysfunction
Malocclusion
and
Orthodontics
Airway-focused
Pathology
Airway and
Breathing
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 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.”

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
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
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
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
Airway and
Breathing
Dysfunction
Malocclusion
and
Orthodontics
Airway-focused
Pathology
Soft Tissue
Dysfunction
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

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.

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

Craniofacial Dystrophy
Maxilla is

Down and Back
The Mandible is
Retrognathic
Nasal Cartilage
Collapse
Insufﬁcient Mid-Facial
Support

is THE cause of
malocclusion
The Maxilla and Upper Dentition
take the Shape of the Muscles
and Muscular Functions that
Surround them.
is THE cause of
malocclusion
“Bone sets the tone but tissue is the issue”
- Mark Cruz

Open Mouth Posture !
is the most common and signiﬁcant
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 Posture
Birth 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
Airway and
Breathing
Dysfunction
Soft Tissue
Dysfunction
Malocclusion
and
Orthodontics
Airway-focused
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

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 5MFour 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
Airway and
Breathing
Dysfunction
Soft Tissue
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” 1907
Edward 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 rate
V. 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…”

18 Months
26 Months
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?

What is the appropriate treatment for a Collapsed Maxilla?
Treatment

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

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©

Retraction affects the airway

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

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
Airway and
Breathing
Dysfunction
Soft Tissue
Dysfunction
Malocclusion
and
Orthodontics
Airway-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)

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
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...
Stuck with Retractive Orthodontics

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

• 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, Surg
Where’s the best
place to start
treatment? Here?
OrHere?
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
Airway and
Breathing
Dysfunction
Soft Tissue
Dysfunction
Malocclusion
and
Orthodontics
Airway-focused
Orthodontics
Airway Orthodontics
Address!
Stress
Airway and
Breathing
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

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Airway Mini-residency: Intro to Airway Orthodontics