A series of lectures by Dr. Barry Raphael on Airway-focused orthodontics from 2013. Chapter 5: The Goals of Airway Orthodontics and some of the approaches to preventing deficiencies in facial growth in young children.

1. 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
“Goals and Prevention” - 2013
1Thursday, June 6, 13

2. •Animations are not included in this archive and may
affect the meaning or intent of the slide
•As the information in these presentations is
constantly evolving, please consider the date of creation
when reviewing the material.
2Thursday, June 6, 13

3. Airway-focused Orthodontics
for the Orthodontist
Part 2:The Solution
• Goals of Treatment
• Diagnostics
• Prevention
• Intervening Form
• Intervening Function
• Interdisciplinary Treatment
• Cases
3Thursday, June 6, 13

4. Airway-focused Orthodontics
for the Orthodontist
Dr. Barry Raphael
drbarry@alignmine.com
www.alignmine.com
Part 2:The Solution
Goals of Treatment
4Thursday, June 6, 13

5. The Goals of Treatment
1. Long Term Stability :The Holy Grail of Orthodontics
2. Neutral tooth positioning without interferences
3. Balanced jaw mechanics
4. Balanced facial and jaw shape, size and position
5. Balanced, unstrained, muscular function
6.Tongue on the palate at rest (Neutral Posture)
7. Lips together in repose
8. Nasal Breathing
In order to have Happiness… you need _________
5Thursday, June 6, 13

6. The Priorities of Airway-Centered
Myofunctional Orthodontics
1. Breathing through the nose
2. Lips together at rest
3. Correct tongue position
4. No facial muscles moving on swallowing
5. Optimal facial development
6. Balanced Jaws
7. Straight teeth
8. Better Stability long term
6Thursday, June 6, 13

7. Strategies for
Airway-focused Orthodontics
1. Thorough Diagnosis
2. Prevention before intervention
3. Intervene the Form
4. Intervene the Function
7Thursday, June 6, 13

8. Airway-focused Orthodontics
for the Orthodontist
May 31, 2013
Dr. Barry Raphael
drbarry@alignmine.com
www.alignmine.com
Part 2:The Solution
Prevention
8Thursday, June 6, 13

9. Pre-natal care
9Thursday, June 6, 13

10. Lingual Frenectomy
10Thursday, June 6, 13

11. Attachment
Length
The Frenum attachment
•The most distal point on the
ventrum of the tongue to which
the frenum attaches.
•This serves as a tether-point
for movement of the tongue.
•It determines the most vertical
extension of the tongue.
•Measured from the tip of the
tongue.
11Thursday, June 6, 13

12. Normal Frenum
• Full extension of tongue allowed
• Can reach out past lower lip
• Can touch upper incisal edges on wide open
• Can rest against palate
• Dorsum seals palate on swallow.
tongue
Frenum
12Thursday, June 6, 13

13. N-Point and N-Angle
The tongue folds
Normal
N-1
N-2
N-3
N-4
13Thursday, June 6, 13

14. N-4 Frenum
• attached to the tip of the tongue
• Show a “Heart-Shape”
• often affects speech.
• Ironically,the shortest frenums don’t cause the
greatest harm
to the dentition.
• don’t always create tongue thrust because the tongue tip is tied
down and thus cannot push the upper teeth up and out.
14Thursday, June 6, 13

15. N-3 Frenum
• shorter and stronger than an N-2,
• creates sufficient force to distort the whole tongue
• forming a pronounced “U” or “V” shape at the tip
(Fig. 8).
15Thursday, June 6, 13

16. N-2 Frenum
• short lingual frenum,
• Stronger than an N-1 and usually thick.
• pulls on the tongue with sufficient force to form a sulcus at
the tip or on the underside of the tongue
16Thursday, June 6, 13

17. N-1 Frenum
• constrains the normal mobility
• limits ability to reach the upper incisors
• does not distort the shape of the tongue
• Strong enough to hold down the dorsum of
the tongue
• preventing it from rising to shape
the palate.
• narrow palate creates a short arch
perimeter,
• crowding and rotations, crossbite, open bite,
and anterior or lateral tongue thrust
17Thursday, June 6, 13

18. Internal Frenum
•The most undiagnosed form of ankylosis
•Keeps the dorsum of the tongue down
•Can be “created” by incomplete anterior frenotomies
18Thursday, June 6, 13

19. Short Frenum can lead to
• Difficulty nursing
• Choking or gagging on food
• Gingival recession
• Diastema
• Tooth rotation
• Bone loss
• Limitation of tongue mobility
• Speech impairment (?)
• Poor scaffolding for the growing maxilla
19Thursday, June 6, 13

20. Lingual frenum and maxillary growth
hypothesis
1. Muscle determines the shape of bone
2. Food is swallowed by vacuum force in the mouth
3. To create the vacuum, the tongue seals the palate,
creating pressure on the palate
4. The palate takes its shape from this pressure
5. If the tongue does not reach the palate, the palate will
grow narrow and tall.
6. This is a LEADING CAUSE of non-skeletal
malocclusion
20Thursday, June 6, 13

21. Lingual frenum and
Dental Development hypothesis
1. The tongue can raise to the point of the frenum
attachment.
2. If locked, the tongue swings forward to create the oral
vacuum
3. The facial musculature must activate to finish the seal
4. This places pressure on the anterior teeth
5. Results in anterior open bite or crowding
6. This is a LEADING Cause of dental relapse after
orthodontics.
21Thursday, June 6, 13

22. Frenectomy
From Paula Fabbie, COM
22Thursday, June 6, 13

23. Frenx for Openbite
From Paula Fabbie, COM
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24. Internal Frenectomy
From Paula Fabbie, COM
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25. Internal Frenectomy
25Thursday, June 6, 13

26. MUST DO P.T.
PRE- AND POST-operative Mobility Exercises
• Clucks
• Caves
• Palate Wipes
•Waggle Spots and Waggle Flaps
From Paula Fabbie, COM
26Thursday, June 6, 13

27. Infant Frenectomy
From Larry Kotlow, DDS
27Thursday, June 6, 13

28. Breast-feeding
28Thursday, June 6, 13

29. Difficulty Breast Feeding
Infant Factors to consider
A. No latch
B. Un-sustained latch
C. Slides off nipple
D. Prolonged feeds
E. Unsatisfied after prolonged feeds
F. Falls asleep on the breast
G. Gumming or chewing on the nipple
H. Poor weight gain or Failure to thrive
I .Unable to hold pacifier
29Thursday, June 6, 13

30. Difficulty Breast Feeding
Maternal Factors to consider
A. Creased or blanched nipples after feeding: flattened
B. Cracked, bruised or blistered nipples
C. Bleeding nipples
D. Severe pain with latch
E. Incomplete breast drainage
F. Infected nipples
G. Plugged ducts
H. Mastitis & nipple thrush
30Thursday, June 6, 13

31. ADHD/Breastfeeding/Malocclusion/
dental trauma/SDB
Understanding the relationships between
breastfeeding, malocclusion, ADHD, sleep-disordered
breathing and traumatic dental injuries.
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]
31Thursday, June 6, 13

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33. 33Thursday, June 6, 13

34. 34Thursday, June 6, 13

35. 35Thursday, June 6, 13

36. 36Thursday, June 6, 13

37. 37Thursday, June 6, 13

38. 38Thursday, June 6, 13

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40. 40Thursday, June 6, 13

41. Source
Child and Adolescent Psychiatry, School of Medicine, Marmara University, Dept. Child and Adolescent Psychiatry, Istanbul, Turkey. Electronic address:
sabuncuoglu2004@yahoo.com.
Abstract
Attention-deficit/hyperactivity disorder (ADHD), one of the most common neuropsychiatric disorders that present at young age, may occasionally be
associated with physical problems and disorders. Among them exists a group of oral-pharyngeal conditions with considerable clinical morbidity. Previous
research that identified absence or short duration of breastfeeding in ADHD children has been reviewed. Essential nutritional factors in breast milk can
affect brain development and regulate the manifestation of ADHD symptoms. Low ferritin levels caused by insufficient breastfeeding may contribute to
ADHD susceptibility because of the role of iron in dopaminergic activity. Insufficient breast feeding and subsequently excessive bottle-feeding may lead to
increased rates of non-nutritive sucking habits, such as pacifier use and thumb-sucking, all of which are associated with the risk of development of
malocclusions. Malocclusion refers to an unacceptable deviation from the ideal relationship of the upper and lower teeth and necessitates orthodontic
treatment. Sleep-disordered breathing in children may present with neurocognitive symptoms that resemble ADHD and abnormal craniofacial
developments, as well as malocclusions, have been cited as part of the syndrome. Obesity, which is an outcome of insufficient breastfeeding, is a shared
comorbidity of ADHD and sleep-disordered breathing. The risk of traumatic dental injury is higher in children with ADHD and presence of malocclusions
further increases the likelihood of dental injuries. In this review, certain oral-pharyngeal conditions relating to ADHD have been reviewed and links among
them have been highlighted in a tentative explanatory model. More research that will provide increased awareness and clinical implications is needed.
Copyright © 2012 Elsevier Ltd. All rights reserved.
41Thursday, June 6, 13

42. Nutrition
•Soft Processed and Pre-cooked foods
•Limit muscular exercise and development
•Fail to stimulate osseous development
•Fail to develop muscular coordination
42Thursday, June 6, 13

43. Hardening the Diet
• start with fiber crackers
• then fruits, fresh and dried
• then vegetables
• then small, cooked meat
• progressively over 4 to 12 months, depending on child
43Thursday, June 6, 13

44. Baby Led Weaning
•Starting at 6mo
•Give baby real food
•Let them explore
and choose
•Establish Chewing
skills naturally
44Thursday, June 6, 13

45. Chewing Gum
1. Xylitol gum (gluten and sugar free)
2.10 chews on one side
3.10 chews on the other side
4.Repeat 5 times
5.THROW AWAY THE GUM
45Thursday, June 6, 13

46. Myomunchie
Soft, chewable, durable
Squeeze for a count of 10, relax, repeat 10 times
46Thursday, June 6, 13

47. Thera-bite Wafers
Lancer Orthodontics
47Thursday, June 6, 13

48. Habit Control
48Thursday, June 6, 13

49. Oral Functions
Oral functions
•Incision
•Mastication
•Digestion
•Airway
•Communication
speech
facial expression
sexual interaction
•Proprioception
taste
tactility
pleasure/endorphin
•Defense
biting
immune systems
•Parafunction
• Occlusal wear patterns
From eccentric movements
From interferences
From repetitive movements (bruxism)
From protective posturing
• Clenching
hypertrophic musculature
• Soft Tissue Dysfunction
mouth open posture
anterior tongue thrust (tongue cushioning)
lateral tongue thrust
tongue scalloping
cheek biting
lip biting
limited tongue movement (ankyloglossia)
• Sucking
Digit
thumb
finger
object
blanket
sleeve
pacifier
• Gum chewing
• Atypical movements of mandible
•Parafunction
49Thursday, June 6, 13

50. Parafunctions have a function
When there is a mechanical flaw in a body system, the rest
of the body will adapt to cope with it.
Adaptations to a Flaw
1) Pain and parasthesias
2) Parafunctions
3) Anatomic distortions
“All parafunctions, even when destructive, are serving a purpose for
adaptation. Every pattern of wear tells a story. Every malocclusion tells a
story. Our job is to understand what it is. We are the Sherlock Holmes of the
mouth. “ - Gavin James
50Thursday, June 6, 13

51. Oral Habits
•Thumb Sucking
• Pacifiers
• Nail Biting
•Tongue Sucking
• Object Mouthing
• Lip Biting
• Chin-Leaning
•Trichotillomania
51Thursday, June 6, 13

52. Thumb sucking
For
pleasure
and
comfort...
To prop
open the
airway
To relieve a
cranial
strain
Each type needs a different approach
52Thursday, June 6, 13

53. Pacifiers
•Sucking habits are on the rise internationally
• Pacifiers are recommended by AAP(?) to prevent
SIDS for up to 6 months
•By then, habits are started
•Many will convert to thumb
53Thursday, June 6, 13

54. Don’t Let It Fester
• Habits that continue past 12 months will start to
affect structure.
• Damage from a pacifier starts after 2yo
• Damage from a thumb after 3yo
From Shari Green, COM
54Thursday, June 6, 13

55. Give the Child Control
•They must be ready.
• Give them choices.
• Use positive reinforcement.
• Use “Reminders”
• Include OMT.
55Thursday, June 6, 13

56. Bruxism
•Types of Bruxism
•Daytime
•Nighttime
•Signs of Bruxism
•Dental attrition
•Muscle hypertrophy
•Muscle tenderness
•Etiology
•Stress
•Airway Obstruction
56Thursday, June 6, 13

57. Bruxism and SDB
•Apnea leads to...
➡Hypoxia
➡heart rate increase
➡Autonomic activation
➡Arousal
➡Muscle activation and bruxing
➡Pharangeal muscle flexion
➡airway opening.
57Thursday, June 6, 13

58. Jeff Rouse
•Prosthodontist,
•Bruxism is relief for airway problems.
•Treat biology first, then do mechanics
Bruxism and occlusal wear are airway issues
58Thursday, June 6, 13

59. Adenectomy
59Thursday, June 6, 13

60. Carole L. Marcus, MBBCh, Lee J. Brooks, MD, Sally Davidson Ward, MD,Kari A.
Draper, MD, David Gozal, MD, Ann C. Halbower, MD, Jacqueline Jones, MD,
Christopher Lehmann, MD, Michael S. Schechter, MD, MPH,Stephen Sheldon, MD,
Richard N. Shiffman, MD, MCIS, and Karen Spruyt, PhD
American Academy of Pediatrics
SUBCOMMITTEE ON
OBSTRUCTIVE SLEEP APNEA SYNDROME
Diagnosis and Management of Childhood
Obstructive Sleep Apnea Syndrome
-Clinical Guidelines-
-Technical Report-
http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1672
60Thursday, June 6, 13

61. Diagnosis and Management of Childhood
Obstructive Sleep Apnea Syndrome
•Review of 350 relevant articles
•The prevalence of OSAS ranged from 0% to 5.7%,
•obesity being an independent risk factor.
•OSAS was associated with
• Cardiovascular
•Growth deficits
•Neurobehavioral abnormalities
•Possibly inflammation.
•Most diagnostic screening tests had low sensitivity and
specificity.
•Treatment of OSAS resulted in improvements in behavior and
attention and likely improvement in cognitive abilities.
61Thursday, June 6, 13

62. History
•Frequent snoring (≥3 nights/wk)
•Labored breathing during sleep
•Gasps/snorting noises/observed
episodes of apnea
•Sleep enuresis (especially
secondary enuresis)a
•Sleeping in a seated position or with
the neck hyperextended
•Cyanosis
•Headaches on awakening
•Daytime sleepiness
•Attention-deficit/hyperactivity
disorder
•Learning problems
Physical examination
•Underweight or overweight
•Tonsillar hypertrophy
•Adenoidal facies
•Micrognathia/retrognathia
•High-arched palate
•Failure to thrive
•Hypertension
Symptoms and Signs of OSAS
“There is no such thing as
ADHD...only ADHSyndrome and it’s
secondary to a poor night’s sleep”
- Dr. Stephen Sheldon
62Thursday, June 6, 13

63. The 8 KEY ACTION
STATEMENTS
1.Screening for OSAS
•As part of routine health maintenance visits, clinicians should inquire whether the child or adolescent
snores
2. Referral and Testing
•Regular snoring or S&S should be referred for PSG, ENT eval, SM eval, or other tests (video, home study)
•sensitivity and specificity of the history and physical examination are poor
3. Tonsiloadenectomy
• Has OSAS AND hypertrophy, the T&A is “first line of treatment.”
4.High Risk T&A
•Monitor Postoperatively
5.Revaluation
•Further treatment is necessary in approx 21% (in obese, 73%)
6.CPAP
•If T&A can’t be done or didn’t work
•Compliance is a problem
7.Weight Loss
•If needed, with everything else
8.Nasal Sprays
•intranasal corticosteroids for children with mild OSAS (pre- or post T&A)
63Thursday, June 6, 13

64. Rapid Maxillary Expansion
Two case studies without controls (level IV)
•Study 1
•31 patients
•4 months after RME, all patients had normalized AHI
•Pirelli P, Saponara M, Guilleminault C., Rapid maxillary expansion in children with
obstructive sleep apnea syndrome. Sleep. 2004;27(4):761–766
• Study 2
•14 eligible sleep center patients
•a significant improvement in signs and symptoms of OSAS
as well as polysomnographic parameters
•Villa MP, Malagola C, Pagani J, et al. Rapid maxillary expansion in children with
obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007;8(2):128–
134
Data were insufficient to recommend rapid maxillary expansion.
64Thursday, June 6, 13

65. Rapid Maxillary Expansion
Conclusions
•“an orthodontic technique that holds
promise as an alternative treatment of
OSAS in children”
•“maxillary expansion may be effective
in specially selected patients”
•“data are insufficient to recommend its
use at this time.”
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66. Planas Direct Tracks
Maximum Intercuspation Therapeutic Position
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67. Dr. German Ramirez
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68. Shut your mouth and
save your life!
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69. George Catlin
• Lawyer, artist, amateur anthropologist
•Documented native populations in North and
South America
•1870
•“Shut Your Mouth and Save Your Life”
• Book recommended by Edward Angle in 1925
69Thursday, June 6, 13

70. George Catlin - 1870
•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.
70Thursday, June 6, 13

71. George Catlin - 1870
On mouth breathing at night:
“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.”
71Thursday, June 6, 13