Studies on Airway Orthodontics and Facial Development. Compiled by Dr. Barry Raphael.

1. Research Studies Evidence

2. Anatomy of SDB

3. 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.
• 134 Japanese Males
• PSG and various measures
• Risk Factors for Increase AHI (Apnea-Hypopnea Index)
• Age
• BMI
• Position of Hyoid Bone
• Size of Airway (and resistance to flow)
• Neck Circumference

4. Which is easier to breath through?

5. Which would you trust most?

6. Which would you rather have?

7. 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
•Apnea occurs due to craniofacial morphology and obesity,
each with their contributions
•The single most important cephalometric variable in predicting
AHI severity was the horizontal dimension of the
maxilla (ie, porion vertical to supradentale [PV-A] distance).
•SDB ncreased fivefold to sevenfold in nonobese
subjects and threefold in obese subjects

8. Anatomic Determinants of SleepDisordered Breathing Across the
Spectrum of Clinical and Nonclinical Male Subjects*
•It is the maxilla that determines the effective
horizontal dimension of the pharynx, and in
particular the upper pharynx.
•A constricted maxilla places the upper pharynx
(pharyngeal isthmus) at increased risk of collapse
with loss of muscle tone.
•According to present findings, individual differences in
upper airway skeletal morphology may well explain
these differences in individual susceptibility of AHI
to weight gain

9. Chronic Mouth Breathing
And Forward Head Position
Okuro, R.T., et.al., J Bras Pneumol. 2011;37(4):471-479

10. Pharyngeal Airspace
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

11. •Exam for Mouthbreathing
•the habitual posture of the lips
•size and shape of the nostrils
•control reflex of the Alar Nasalis
•Glatzel mirror test
•Rhinoscopy
•Adenoid hypertrophy
25 Nasal breathers, 25 mouth breathers,
Avg 8-9 y/o

12. Pharyngeal Airspace
Mouth breather
Nasal breather
Mouthbreathers have significantly
smaller airway space.
(measurements PAS-OccL, PAS-UP, airway volume, area and minimum axial area)

13. Morphology and SDB
in children
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752
“Abnormal craniofacial morphology, but
not excess body fat, is associated with an
increased risk of having SDB in
6–8-year-old children.”

14. Morphology and SDB
in 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

15. Morphology and SDB
in children
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752
Risk Factor
Incidence
Obesity
0
Tonsilar Hypertrophy
3.7x
Crossbite
3.3x
Convex Facial Profile
2.6x

16. Morphology and SDB
in children
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752

17. Morphology and SDB
in children
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752
“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.”

18. 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
• 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

19. OSAS and swollen Tonsils
• The most common cause of airway collapse in
children is adenotonsillar hypertrophy
• There is a “significant positive relation between
tonsillar enlargement and OSAS”
• T-P Ratio =
• T-P ratio is better predictor than visual inspection

20. T-P Ratio
• Compares the size of the tonsil to the size of the
pharyngeal compartment
• T = maximum horizontal width of tonsilar tissue
• P = depth of the pharyngeal space
• T/P ratio.
•

21. Signs of OSA
frequency

22. • 140 children with OSA
• Avg 4.5yo
• AHI ~ 17
• Low pO2 ~ 80%

23. Airway Stenosis
• Normal: A&T hypertrophy peaks at age 5-6
• In OSA, hypertropy at all ages
•Airway stenosis caused by
• A&T Hypertropy
• Skeletal Abnormality
• Hypertrophy > Stenosis > Mouth Breathing > Skeletal
abnormatility > OSA

24. • On the other hand, they say:
•“ In addition to soft tissue factors, skeletal
abnormality should be considered a cause of upper
airway stenosis”
So which is it? Does a blocked airway cause poor
growth, or does poor growth block the airway?

25. James McNamara
Angle Orthodontist - 1981

26. 49.3% retrusive

27. James McNamara
v

28. 69.6% Vertical Excess

29. Associations between sleepdisordered breathing symptoms
and facial and dental morphometry,
assessed with screening examinations
Hyunh, et.al., AJODO, 2011, 140:762-70
SDB associated with:
Dolicofacial shape
High mandibular plane angle
Narrow palate
Severe crowding
Swollen Tonsils and Adenoids
Long and narrow face
Allergies
Frequent Colds and Infections
Habitual Mouth Breathing

30. Nighttime symptoms of SDB in kids
•Abnormal sleeping position
•Chronic, heavy snoring
•Delayed sleep onset
•Difficulty breathing
•Difficulty waking up in AM
•Drooling
•Enuresis
•Frequent awakenings
•Insomnia
•Mouth breathing
•Nocturnal migraine
•Nocturnal sweating
•Periodic Limb movement
•Restless sleep
•Sleep talking
•Sleep terror
•Sleep walking
•Witnessed apnea

31. 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

32. Of the 600 orthodontic patients...
16% had long facial form
86% had convex profiles (mandible set back from maxilla)
Over 50% had daytime mouth open posture

33. 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
Abrupt sleep associated death in seven children
with good pre-mortem history

34. Findings in all 7 cases
chronic indicators of abnormal sleep
1.enlargement of upper airway soft tissues
2.a narrow, small nasomaxillary complex,
with or without mandibular retroposition

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

36. Dental Arch Morphology
in Children with SDB
K.Pirilä-Parkkinen,et.al.,European Journal of Orthodontics 31 (2009) 160–167
Finland,
41 children with OSA
41 children with snoring
41 chilren with no obstruction
Ortho exam and 13 study cast measurements

37. OSA children have...
• Significantly more:
• Increased Overjet
• Decreased Overbite
• Narrow Maxillary Arches
• Shorter Mandibular Arches
•Somewhat more:
• Assymetric Arches (Cl II subdivision)
• Mandibular Crowding
• Anterior Open Bite
“...can be explained by long-term changes in the
position of the head, mandible, and tongue in order
to maintain airway adequacy during sleep.”

38. t factors such as nasal obstruction
and mouth breathing, for example, may affect morphology
even if subjects exhibit good overall health.
If any factor interferes with their craniofacial
development, the consequences could have an impact over
the course of the child’s lifetime.
Early
treatment could alleviate symptoms easily and effectively,
which may benefit not only normal growth of the craniofacial
structures but also reduce the risk of SDB in the future

39. The Original Report
Sleep Apnea in Eight Children
Christian Guilleminault, M.D., Frederic L. Eldridge, M.D., F. Blair
Simmons, M.D., and
William C. Dement, M.D.
Pediatrics 1976;58;23
Paper on Mac “Guilleminault OSA in children”

40. The Great Leap Forward
Terrence M. Davidson
Department of Otolaryngology – Head and Neck Surgery, University of California, San Diego and the VA San Diego Health Care System, San Diego, CA, USA
Received 19 June 2002; received in revised form 23 October 2002; accepted 30 October 2002
The natural selection pressure for speech and language
was so strong that the undesired consequence of OSA was
carried forward to modern man. Based on this reasoning,
obstructive sleep apnea is an anatomic illness

41. Craniofacial and upper airway morphology in
pediatric sleep-disordered breathing:
Systematic review and meta-analysis
Vandana Katyal,et.al, AJODO, 2013 Jan;143(1):20-30
Metanalysis of published and unpublished, moderately strong evidence
“There is strong support for reduced
upper airway width* in children with
obstructive sleep apnea.”
* A-P on ceph

42. Nasal breathing helps the maxilla
grow
Effects of Airway Problems on Maxillary Growth: A Review
Ahmet Yalcin Gungora and Hakan Turkkahramanb Eur J Dent. 2009 July; 3(3): 250–254.
E-mail: aygungor@hotmail.com
The volume of air passing through the nose and
nasopharynx is limited by its shape and diameter.
1.Continuous airflow through the nasal passage during
breathing induces a constant stimulus for the lateral growth of
maxilla and for lowering of the palatal vault.

43. Airway problems Change the Maxilla
•shorter maxillary length
•more proclined maxillary incisors
•thicker and longer soft palate
•narrower maxillary arch
• higher palatal vault.
Ahmet Yalcin Gungora and Hakan Turkkahramanb Eur J Dent. 2009 July; 3(3): 250–254.
E-mail: aygungor@hotmail.com

44. Origins of Dental Crowding
and Malocclusion
J. Rose and R. Roblee, Compendium, 2009, 30:5, 292-300
• Looked at 94 ancient Egyptian skulls
• Reviewed Begg’s Attrition Hypothesis and Carlson’s Masticatory
Hypothesis.
• Crowding is due to lack of alveolar development.
• Alveolar development depends on masticatory effort.
• Treatment should expand the arches and increase alveolar bone
volume.
• Best done early in life while bone if forming (ie. Before the
eruption of permanent teeth.

45. The Masticatory Function
Hypothesis
Carlson and Van Gerven, Am J Phys Antropol, 1977,46(3), 495-506,
•Human skull changes from Mesolithic to Christian Era
•10k year span, coinciding with transition to agricultural
society and food processing technology
•Maxilla and Mandible
•Moved posteriorly
•Rotating underneath the forehead
•Less robust
•Mandibular dentition more distal, creating the “chin”
• Changes due to less chewing stress on developing jaws
• (show figure 11)
•Corroborated by Robert Corruccini, and Weston Price

46. Ankyloglossia
Ann Otol Rhinol Laryngol Suppl. 1991 May;153:3-20.
Ankyloglossia with deviation of the epiglottis and larynx.
Mukai S, Mukai C, Asaoka K.
Source
Mukai Clinic and Research Institute of Biology, Kanagawa, Japan.
Abstract
We observed ankyloglossia to be usually accompanied by displacement of the epiglottis and larynx. Infants with this disease developed dyspnea and
skin and hair abnormalities. In addition, they had other symptoms, such as a dark forehead, a frowning expression, a dark color around the lips, scanty
eyebrows, swelling around the palpebrae, harsh respiratory sounds, hard crying, snoring, and frequent yawning. In spite of these abnormalities, they
had been considered to be healthy by their pediatricians. Arterial oxygen percent saturation (SaO2) was measured while the infants were asleep,
suckling, and awake. The results revealed that their SaO2 was unstable and slightly low. The symptoms and signs of this disease were very similar to
those observed in victims of sudden infant death syndrome before their death. Correction of the ankyloglossia and deviation of the epiglottis and larynx
resulted in great improvement of these signs as well as a stabilization and increase of SaO2.

47. Diagnostics

48. OSA Questionnaire
A Diagnostic Approach to Suspected Obstructive Sleep Apnea in Children
Brouilette, R, et.al. J.Pediatr 1984,105:10,10-14.
Used a questionnaire to determine:
1. Negative: Normal needing no further treatment.
2. Positive: Definitive OSA requiring T&A
3. Possible: Symptomatic requiring further study, PSG

49. Topics for the 57 questions
1. Signs of sleep-related upper airway obstruction
2. Sleep Habits
3. Parentally observed problems in behavior,
learning or development
4. Past History of ear, nose, or throat disease
5. Family history (breathing, SDB, T&A)
Rating: never, occasionally, frequently

50. Significant Factors
1. Signs of sleep-related upper airway obstruction
1.Snoring
2.Difficulty Breathing
3.Sweating
4.Restlessness
5.Observed Apnea
2. Sleep Habits
1.Less nighttime sleep
2.More daytime sleepiness
3. Parentally observed problems in behavior, learning or development
1.(none)
4. Past History of ear, nose, or throat disease
1.Chronic rhinorrhea
2.Recurrent middle ear infections
3.Hearing problems
4.Mouth breathing
5.Frequent URI infections
5. Family history (breathing, SDB, T&A)
1.(none)

51. Effects of OSA/SDB

52. 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
“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.”

53. Sleep-Disordered Breathing in a Population-Based
Cohort: Behavioral Outcomes at 4 and 7 Years
“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.”

54. Sleep-Disordered Breathing in a Population-Based
Cohort: Behavioral Outcomes at 4 and 7 Years
Karen Bonuck
Dr Raanan Arens
Dr John Bent
Dr Sanjay Parikh
(Montefiore Medical Center/Albert Einstein College of Medicine),

55. 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
•Childhood OSA is associated with
•Deficits of IQ
•Deficit of executive function
•Possible neuronal injury in the
hippocampus and frontal cortex.
•
“...untreated childhood OSA could permanently alter a
developing child’s cognitive potential.”

56. Snoring and Soft Tissue Dysfunction
Dentomaxillofacial Radiology, 2003,32:311-316
• 52% of snoring patients have swallowing dysfunction no
matter how severe the AHI.
• Chronic snoring stretches and injures the tissues of the soft
palate, uvula, and throat leading to more obstruction.

57. Snoring in Preschoolers

58. Airway in OSA
Methods
• Physical Exam
• Nasal Exam
• Upper airway collapsibility tests
• Acoustic Reflection
• Cephalometry
• CT
• MRI
• Family History

59. Both obese, one w OSA

60. One in Ten 6 To 8-Year-Olds Has Sleep-Disordered Breathing, Finnish Study Finds
Dec. 14, 2012, Pubished in European Journal of Pediatrics.
Symptoms on spectrum from snoring to OSA
Daytime Symptoms
• Daytime Hyperactivity
• Behavior difficulties
• Learning difficulties
• Compromised somatic growth
Risk factors
• Swollen Tonsils and Adenoids
• Crossbite (Narrow Palate)
• Convex facial profile

61. "If a child has symptoms of sleep-disordered
breathing, his or her craniofacial status and
dental occlusion need to be examined.
On the other hand, children with tonsillar
hypertrophy, crossbite and convex facial
profile should be examined to assess the
quality of their sleep,"
Recognising the risk for sleep-disordered breathing
at an early age allows an early intervention to
prevent the progression of the disease.

62. the risk of 6-8 year old children for having sleep-disordered breathing is associated with certain craniofacial morphology traits, but not
with excess body fat.
some of those at risk for obstructive sleep apnea syndrome as adults could be identified already in childhood

63. 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]

73. We’re Dying Younger
January 9, 2013
die earlier and live in poorer health

74. SDB linked to Maladaptive Behavior
Perfect,M.M., etal, Sleep 2013, 36(4):517-525
Risk of behavioral and adaptive functioning difficulties in youth with
previous and current sleep disordered breathing
Youth with current Sleep Disordered Breathing exhibited:
1.Hyperactivity
2.Attention Problems
3.Aggressivity
4.Lower Social Competency
5.Poorer Communication
6.Diminished Adaptive Skills
1.negotiate social situations
2.engage in self-care
3.to meet his or her own needs
4.apply skills learned in school

75. ADHD: Real or Hype
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76. Use of Meds on the Rise
Sales of stimulants to treat A.D.H.D. have
more than doubled to $9 billion in 2012 from
$4 billion in 2007, according to the health
care information company IMS Health.
“Criteria for the proper diagnosis of A.D.H.D... have
been changed specifically to allow more adolescents
and adults to qualify for a diagnosis…”

77. 20% of Boys with ADHD?

78. Snoring and OSA in children
Snoring and obstructive sleep apnoea in children: Why should we treat?
David Gozal , Louise M. O'Brie
Paediatric Respiratory Reviews
Volume 5, Supplement 1, January 2004, Pages S371-S376
In recent years, it has become apparent that OSA and snoring are
•not as innocuous as previously thought.
•Indeed, epidemiological and pre-post treatment analyses have identified substantial morbidities that primarily affect
cardiovascular and neurobehavioural systems, namely
• pulmonary hypertension,
•systemic elevation of arterial blood pressure,
•nocturnal enuresis,
•reduced somatic growth,
•behavioural problems that resemble attention deficit-hyperactivity disorder,
•learning and cognitive deficits.
•These problems are associated with marked increases in healthcare-related costs. More importantly, if timely diagnosis
and intervention are not implemented, some of these morbid complications may not be completely reversible, leading to
long-lasting residual consequences.

79. Disk Displacement and Mandibular
Growth
Temporomandibular joint disk displacement and subsequent adverse mandibular growth
Fredrik Bryndahl
UMEÅ UNIVERSITY ODONTOLOGICAL DISSERTATIONS
New series No. 103, ISSN 0345-7532, ISBN 978-91-7264-523-3
In rabbits, the disc was artificially pulled out of place,
Creating bilateral disc derangement without reduction...
bilateral nonreducing TMJ disk displacement caused
bilateral impairment of mandibular growth (19%),
resulting in a retrognathic growth pattern.
It caused destructive changes in the condylar cartilage

80. Implications for treatment
“...early treatment implying normalization of disk position
should be considered, and in doing this
the need for future corrective therapy might be reduced.”
If the disc reduces, then pull-forward treatment that reduces the
disc can be beneficial to future growth.
But if the disc does not reduce, then pull-forward treatment may
aggravate the joint and lead to condylar degeneration.
Therefore, must study the joint before treatment

81. Occlusal Wear
Tooth Wear in the Mixed Dentition: A Comparative Study
between Children Born in the 1950s and the 1990s
Andrea Marinellia, et.al., Angle Orthodontist,Vol 75, No 3, 2005, 340-343.
• Occlusal Wear (attrition) is a NORMAL part of physiology in
ancient and indigenous skulls
• There is less wear now (90’s) than even the recent past
(1950’s)
• Less wear associated with
• Processed, easy to chew, food
• Increased open mouth posture
• Increase incidence of malocclusion

82. studies19,20 on the secular trend of malocclusions in recent years advocated that the
change in dietary habits that occurred in the past decades appears to be linked to the
increased prevalence of occlusal disorders. The decrease in masticatory activity as a
consequence of the increased use of processed food could also be responsible of
inadequate wear of deciduous teeth along with underdeveloped jaws. Dental interferences
and forced guidance of mandible to an incorrect position in both the sagittal or transverse
planes result from lack of physiological changes in the dental arches.22,23 On the contrary,
the use of hard and fibrous foods is associated with a greater diameter of the dental arches,
with an increased wear of occlusal surfaces,13 and with a smaller probability of occurrence
of anomalous occlusal patterns.
Mouth breathing, as a consequence of the increased prevalence of allergies,28 has also been
reported as a significant cause for the amplified prevalence of malocclusions in the past
years.19

83. Treatment SDB

84. 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
•A statistically significant increase in the pharyngeal airway
volume occurred systematically.
•The average percentage of increase was:
• 69.8% with MMA
• 78.3% with Mandibular Advancement
• 37.7% with Maxillary Advancement

85. Mandibular Protrusion Device
helps Pediatric OSA
Randomized Controlled Study of an Oral JawPositioning Appliance for the Treatment of
Obstructive Sleep Apnea in Children with
Malocclusion
MARIA P. VILLA, EDOARDO BERNKOPF, JACOPO PAGANI, VANNA BROIA, MARILISA MONTESANO,
and ROBERTO RONCHETTI
1
American Journal of Respiratory and Critical Care Medicine, Vol. 165, No. 1(2002), pp. 123-127.
Do this…..

86. 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.”

87. OSA TX and Brain Function
treatment of OSA in children normalizes brain metabolites in
portions of the neuronal network responsible for attention and
executive function," concluded Halbower. "We speculate that if
OSA is treated earlier, there may be a more brisk improvement in
the hippocampus, a relay station for executive function, learning,
and memory."
Ann Halbower, MD, associate professor at the Children's Hospital
Sleep Center and University of Colorado Denver
presented at the ATS 2012 International Conference in San Francisco

88. •11 kids with OSA
•Treated with T&A, CPAP, and nasal treatments
•children with OSA before treatment
• significantly decreased N-acetyl aspartate to choline ratios (NAA/
•
Cho) in the left hippocampus and left frontal cortex,
•along with significant decreases in the executive functions of
verbal memory and attention.

89. Trainer
Influence of Pre-Orthodontic Trainer treatment on the perioral and
masticatory muscles in patients with Class II division 1 malocclusion
1.
Tancan Uysal*,**, Ahmet Yagci*, Sadik Kara*** and Sukru Okkesim***
European Journal of Orthodontics ,2011, Volume 34, Issue 1 Pp. 96-101
“...POT appliance
showed a positive
influence on the
masticatory and perioral
musculature.”

90. Oral Myofunctional Therapy Applied on Two Cases of
Severe Obstructive Sleep Apnea Syndrome
Danielle Barreto e Silva Pitta, et.al, Intl. Arch. Otorhinolaryngol.,São Paulo, v.11, n.3, p. 350-354, 2007.
“The results show an:
•extreme regression of the syndrome,
•a decrease in the apnea/hipopnea index,
•the diurnal sleepiness symptoms and
snoring,
•as well as an improvement in oxygen
saturation”

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

92. Diagnosis and Management of Childhood
Obstructive Sleep Apnea Syndrome
-Clinical Guidelines-Technical Report-
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
Stephen Sheldon, DO (Sleep Medicine, General
Pediatrician; Liaison, National Sleep Foundation;
No financial conflicts; Affiliated with Children’s
SUBCOMMITTEE ON
Memorial Hosp, Chicago; Published research
OBSTRUCTIVE SLEEP APNEA SYNDROME
related to OSAS)
American Academy of Pediatrics
http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1672

93. 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.

94. Symptoms and Signs of OSAS
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

95. 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)

96. 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.

97. 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.”

98. Increasing the Airway
Cranio April 2007, (25:2)
• 53 patients, avg 12 years old
• Biobloc treatment for avg 20 months
• Posterior airway measured on ceph
•31% Increase in nasopharynx area
•23% Increase in oropharynx area
•9% Increase in hypopharynx area

99. Oral Myology helps OSA
Effects of Oropharyngeal Exercises on Patients with
Moderate Obstructive Sleep Apnea Syndrome
1.
Kátia C. Guimarães1, Luciano F. Drager1, Pedro R. Genta1,Bianca F. Marcondes1 and Geraldo Lorenzi-Filho1
Am. J. Respir. Crit. Care Med.May 15, 2009 vol. 179 no. 10962-966
•N = 30 subjects with moderate OSA,
•BMI = 30 avg, Waist = 40 inch avg
• 15 did exercises involving the tongue, soft palate, and lateral
pharyngeal wall.
• 30 minutes/day for 3 months
• 15 did sham exercises
•Decreased snoring (freq and intensity)
•Decreased sleepiness (Epworth)
•Improved sleep quality
•Decreased AHI (from 22 to 13 on average)
•No change in weight but neck size decreased

100. Include Ortho in SDB Tx
Sleep Breath 2012, 16:971-976
Literature review
“...orthodontic therapy {maxillary expansion and mandibular
advancement} should be encouraged in pediatric OSAS…
...an early approach may permanently modify nasal breathing
and respiration, thereby preventing obstruction of the upper
airway.”

101. Ortho and Ped OSA
Rose and Schessel, JOrofacial Orthopedics, 2006,67:58-67
Report of two cases
Case 1
• 8yo girl
• T&A did not relieve OSA
• RME and Frankel II gave total relief.
• No further treatment needed
Case 2
• 6.5yo boy w muscular dystrophy
• Long face, mouthbreathing
• FR II reduced all apneas, though some hypopneas remained

102. Ortho and Ped OSA
“Orthodontic therapeutic
measures should be considered as
a causal treatment option in
children with OSAS and
craniofacial anomalies restricting
the upper airway”

103. Ortho and Ped OSA
Chad M. Ruoff & Christian Guilleminault
Sleep Breath, 2011, pub online, May 11
Surgical treatment of the maxilla and mandible offers a more
definitive therapy for OSA...but has risks.
The “environment plays an important role in the
development of SDB. Therefore, manipulation of
environmental actors 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.”

104. Ortho and Ped OSA
Chad M. Ruoff & Christian Guilleminault
Sleep Breath, 2011, pub online, May 11
“Although dentists and orthodontia recognize
the importance of evaluating and treating
OSA, they have yet to realize how wellpositioned they are for the prevention of
sleep-disordered breathing (SDB).”

105. Ortho and Ped OSA
Chad M. Ruoff & Christian Guilleminault
Sleep Breath, 2011, pub online, May 11
1. Clearing Nasopharyngeal Airway
1.Reduction of Tonsillar Enlargement
1. Anti-leukotrienes (Singulair)
2. Reduction of micro-trauma from mouth-breathing
3. Surgical removal
2. Nasal Cleaning
3. Nasal Surgery
2. Palatal Expansion and Advancement
1.Orthodontically
2. Distraction Osteogenesis
3. Orthognathic Surgery
3. Muscle Training
1. Oral myofuntional therapy

106. Mandibular Advancement
Sleep Breath (2012) 16:971–976
“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.”
Yesss!!!

107. Orthodontic treatment in children to prevent
sleep-disordered breathing in adulthood
Sleep and Breathing
Published online: 17 November 2005©
10.1007/s11325-005-0028-8
Review
Makoto Kikuchi
“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.”

108. Comparison case
Older sister: Extract two upper premolars. Airway 14 to 10mm
Younger sister: Non-extraction. Airway from 14-17mm

109. Comparison case
The result of the treatment looks almost the same
from the appearance; however, there were big
differences between the sisters inside the face that
was the most important structure for human beings:
the size of the airway.

110. 3yo Tx with Frankel
Case Report: Schessel,et.al.
Respiration 2008:76,112-116
•3 yo boy, normal occlusion in primary dentition
•Significant OSA due to collapse of sides epiglottis (aryepiglottal
folds)
•Significant desaturations...80%
•No Adenotonsilar hypertrophy
•Treated with Frankel II appliance
• Mandibular advancement
•Nighttime wear only
•Significant improvements in
•Snoring
•Apnea
•Arousals
•Only occasional desats of 88%
•Daytime behavior

111. Trainers
Angle Ortho, 2004, 74:605-609
20 cases, Class II div 1, avg 9yo
After 13 months trainer wear
Significant reduction of overjet due to dento-alveolar
compensation

112. Trainers
i
JAPANESE JOURNAL OF CLINICAL DENTISTRY FOR CHILDREN 2009 APRIL (Vol.14 No.4)

113. Phase I doesn’t matter
Am J Orthod Dentofacial Orthop. 2004 Jun;125(6):657-67.
Outcomes in a 2-phase randomized clinical trial of early Class II treatment.
Tulloch JF, Proffit WR, Phillips C.
• Prospective Randomized Control Trial
• Class II severe overjet (>7)mm
• Early treatment with Headgear or Bionator
• Improvements show in Phase I
• Improvements disappeared after braces put on

114. Setback at your Peril
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”
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
American Journal of Orthodontics & Dentofacial Orthopedics
Volume 131, Issue 3 , Pages 372-377, March 2007
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

115. Best time to modify the palate
Three-dimensional longitudinal evaluation of palatal vault changes in
growing subjects
The Angle Orthodontist: July 2012, Vol. 82, No. 4, pp. 632-636.
Jasmina Primozˇicˇ a; Giuseppe Perinettib; Stephen Richmondc; Maja Ovsenikd
http://www.angle.org/doi/pdf/10.2319/070111-426.1
CONCLUSIONS
1. Palatal growth modifications were detected during
primary dentition through early and intermediate
mixed dentition stages.
2. Orthopedic treatment in the upper jaw should be
performed during this period to enhance treatment
efficiency.

116. Early expansion helps palatal volume
II. Three-dimensional assessment of palatal change in a controlled study
of unilateral posterior crossbite correction in the primary dentition.
Primozic J. Baccetti T. Franchi L. Richmond S. Farcnik F. Ovsenik M.
European Journal of Orthodontics. 35(2):199-204, 2013 Apr.
[Journal Article. Research Support, Non-U.S. Gov't]
UI: 23524586
Authors Full Name
Primozic, Jasmina. Baccetti, Tiziano. Franchi, Lorenzo. Richmond,
Stephen. Farcnik, Franc. Ovsenik, Maja.
ABSTRACT The aim of this study was to quantify the palatal change in three
groups of children: children with a unilateral posterior crossbite
(TCB) who were treated, children with untreated unilateral posterior
crossbite (UCB), and children without a crossbite (NCB). Study casts
of 60 Caucasian children in the primary dentition (20 TCB, 20 UCB, and
20 NCB), aged 5.4 +/- 0.7 years, were collected at baseline (T1) and
at 1-year follow-up (T2). Both TCB and UCB groups had unilateral
posterior crossbite and midline deviation. The TCB group was treated
using a cemented acrylic splint expander in the upper arch. The study
casts were scanned using a laser scanner and palatal surface area,
palatal volume, and symmetry of the palatal vault were evaluated and
compared between the three groups. At T1, the palatal volume of TCB
(2698 mm(3)) and UCB (2585 mm(3)) was significantly smaller than that
of NCB (3006 mm(3); P < 0.05, analysis of variance test). After
treatment, the palatal volume of the TCB group (3087 mm(3)) increased
and did not differ from the NCB group (3208 mm(3)), whereas the UCB
(2644 mm(3)) had a significantly smaller palatal volume than the NCB
or TCB groups (P < 0.05). The increase of palatal volume in the TCB
group (389 mm(3)) was significantly greater than in the UCB (59 mm(3))
and NCB (202 mm(3)) groups. The symmetry of the palatal vault was
greater than 90 per cent in all three groups at T1 and at T2.
Treatment of unilateral posterior crossbite in the primary dentition
has a significant effect, particularly on the palatal volume increase.
Boyd commentThe primary causal component of posterior crossbite in kids (with LTS) is compensatory functional shift of the mandible in response to unbalanced occlusion due to moderate/severe maxillary (transverse) skeletal/palatal
constriction; however, most children with moderate/severe maxillary (transverse) skeletal/palatal constriction do not actually go into a compensatory functional shift of the mandible because they can adequately
intercuspate with the mandibular dentition. It's a good thing that most pedos and RO's no longer dispute that posterior crossbites are best treated in kids with LTS....so why neglect to treat, those kids who have equal or more
maxillary constriction merely because they don't exhibit posterior crossbite...makes no sense!

117. Buteyko

118. Control Pause
1975, researchers Stanley et al noted that breath holding
was a simple test to determine respiratory chemosensitivity
and concluded that "the breath hold time/partial pressure of
carbon dioxide relationship provides a useful index of
respiratory chemosensitivity which is not influenced by
airways obstruction."
Evaluation of breath holding in hypercapnia as a simple
clinical test of respiratory chemosensitivity.
Stanley,N.N.,Cunningham,E.L.,Altose,M.D.,Kelsen,S.G.,Levi
nson,R.S.,and Cherniack,N.S.(1975).Thorax,30,337-343.

119. Control Pause
Nishino acknowledged breath holding as one of the most powerful methods to
induce the sensation of breathlessness, and the breath hold test "gives us
much information on the onset and endurance of dyspnea (breathlessness)."
The paper noted two different breath hold tests as providing useful feedback on
breathlessness. The first breath hold test is the length of time until the first
urges to breathe. This easy breath hold provides information of how soon first
sensations of breathlessness take place, and was noted to be a very useful tool
for the evaluation of dyspnea. The second measurement is the total length of
breath hold time. This provides feedback of the upper limit of toleration of
breathlessness and is influenced by behavioural characteristics such as
willpower and determination. As the first test is not influenced by training effect
or behavioural characteristics, it can be deduced that it is a more objective
measurement.
Respir Physiol Neurobiol. 2009 May 30;167(1):20-5. Epub 2008 Nov 25.
Pathophysiology of dyspnea evaluated by breath-holding test: studies of
furosemide treatment. Nishino T.

120. Control Pause and exercise
tolerance
Eighteen patients with varying stages of cystic fibrosis were studied to
determine the value of the breath hold time as an index of exercise tolerance.
The breath hold times of all patients were measured. Oxygen uptake (Vo2)
and carbon dioxide elimination was measured breath by breath as the
patients exercised. The researchers found a significant correlation between
breath hold time and VO2 (oxygen uptake), concluding "that the voluntary
breath-hold time might be a useful index for prediction of the exercise
tolerance of CF patients."
Eur J Appl Physiol. 2005 Oct;95(2-3):172-8. Epub 2005 Jul 9 Relationship
between breath-hold time and physical performance in patients with cystic
fibrosis.
Barnai M, Laki I, Gyurkovits K, Angyan L, Horvath G.

121. Breath Hold and breathlessness
Results from a study of 13 patients with acute asthma,
concluded that the magnitude of breathlessness, breathing
frequency and breath hold time correlated with severity of
airflow obstruction and secondly breath hold time varies
inversely with dyspnea magnitude when it is present at rest.
Rev Invest Clin. 1989 Jul-Sep;41(3):209-13. Rating of
breathlessness at rest during acute asthma: correlation with
spirometry and usefulness of breath-holding time.
Perez-Padilla R, Cervantes D, Chapela R, Selman M.

122. Roger Price on Control Pause
“the breath-hold or control pause is a measurement of the point at which the body
initiates breathing. If it is used at the start of a period of reduced breathing it will
provide a baseline indication of trigger response.
If the period of reduced breathing has been effective a control pause should indicate
that the response time has lengthened - and that is the goal.
It is a similar concept to going on a diet. The bathroom scale is the indicator of the
starting point, the reduced eating is the key and the scale indicates the level of
success. The scale has NOTHING to do with the diet. It can be any colour and can
even be a couple of kilograms under or over - this will have no bearing on the
success of the reduced eating program.
The simple fact is that some people simply cannot do a control pause or breath hold for whatever reason - and this causes them not to get the benefit from the reduced
breathing exercises as they feel that they have failed.”
From Weblog, 2012

123. BIBH survey of practitioners
Buteyko Institue of Breathing and Health, Australia
1. Based on over 11,000 clients, estimates from the 2010 BIBH survey suggest that breathing
retraining using the BIM show significant improvement in sleep for >95 percent of clients
with sleep apnoea who undertook BIM courses.
2. Estimates from the 2010 survey also suggest that approximately 80 percent of clients were
able to cease using their CPAP machine.
3. Sleep medicine research suggests that breathing pattern disorder, i.e. intermittent or chronic
hyperventilation, is common in people with sleep apnoea.
4. Independent clinical trials in the medical literature indicate that the Buteyko method of
breathing retraining is successful in improving disordered breathing patterns and reducing
hyperventilation.17
5. Although not explored in association with breathing retraining, research in the medical
literature appears to support the Buteyko hypothesis on sleep apnoea.
6. Increasing numbers of people are currently being diagnosed with sleep apnoea and
increasing numbers of people with sleep apnoea are attending Buteyko Institute courses.
Therefore it is necessary to ascertain scientifically how effective the BIM is for sleep apnoea.
7. Currently, limited treatment options are available for many people with sleep apnoea. If
validated scientifically, the Buteyko Institute method of breathing retraining would provide a
further treatment option for people who cannot tolerate CPAP or oral appliances.
8. Sleep apnoea is a condition with serious co-morbidities, therefore further effective treatment
options are urgently required, in light of significant non-adherence with currently available
treatments.
9. Compared with existing treatments for sleep apnoea, the cost of the Buteyko Institute
Method of breathing retraining is very economical. Buteyko Institute Method of breathing
retraining course fees are estimated at approximately 25 percent of the cost of CPAP or oral
appliances. In addition, there are no ongoing expenses in relation to the upkeep and
maintenance of equipment or appliances.

124. Oral Myology

125. Creating objective measure of
something immeasurable
Validity of the ‘protocol of oro-facial myofunctional
evaluation with scores’ for young and adult subjects
C. M. DE FELI´CIO*, A. P. M. MEDEIROS* & M. DE OLIVEIRA
MELCHIOR
Journal of Oral Rehabilitation 2012 39; 744–753

126. OM helps OSA
Effects of Oropharyngeal Exercises on Patients with
Moderate Obstructive Sleep Apnea Syndrome
Ka´tia C. Guimara˜es, et al
AM J OF RESP AND CRITIC CARE MED VOL 179 2009, p962-966
• RCT, n=16 adults
• 3 months of exercise training reduced
the severity of OSAS
by 39% (by AHI and lowest O2 sat)
• a reduction in snoring, daytime sleepiness, and quality of
sleep score
• significant reduction in neck circumference
• muscle training while awake will reduce upper airway
collapsibility during sleep in patients with OSAS.
• improvements in several subjective sleep scales

127. •Patients with OSAS typically had
•elongated and floppy soft palate and uvula,
•enlarged tongue
•inferior displacement of the hyoid bone

129. SLEEP 2012: Associated Professional Sleep Societies 26th Annual Meeting. Abstract #1050. Presented June 12, 2012.