|Anatomy of the Nasal Airway with computerized imaging
of airway space.|
What we are really seeing in the literature is a merging of medicine and dental; perhaps something that is less common than it should be but nonetheless this sharing of data is now helping educate providers and push for better patient care and more successful outcomes. From my practice, experience shows that by the time a patient sees the Orthodontist by General Dental referral, much of the damage is already done. That is because most dentists gauge the need for braces by the crowding of the teeth and they tend to want to wait until most or all baby teeth are lost (which is entirely too late for more severe problems). In these now adolescent cases, we use traditional braces (with or without expansion/removal of permanent teeth/surgical repositioning) to undo what we can and work to establish a new arch form with alignment of teeth while providing the best esthetics and function possible.
“… experience shows that by the time a patient sees the Orthodontist by General Dental referral, much of the damage is already done.”
This adolescent was referred only after once all permanent teeth erupted; patient had a history of breathing problems and chronic airway obstruction that went untreated.
Following extensive Orthodontic treatment including Rapid Palatal (Maxillary) Expansion and removal of the upper right 2nd bicuspid; although the teeth are corrected and arches restored, stability will never be possible without long-term nightly retainer wear; following treatment, the patient was referred to an ENT for removal of excessive soft tissue for added stability.
Correcting a narrow maxilla or a smaller (retrusive) lower jaw due to an airway issue can be time consuming and expensive to correct later in life; stability is sometimes based not only on early intervention and good dental correction but also on alleviating any airway construction before or after the orthodontic correction. Patients and parents of patients should understand that the development of the dental arches are usually only a reflection of the forces in the mouth; whatever causes a severe malocclusion will still be affecting the teeth following the correction. Therefore it is important to consider the airways when determining if a correction can be maintained without long-term appliances/retainers.
At 7 years old, this young patient was identified as having large tonsils and an obstructed airway with under-developed upper jaw and retrusive lower jaw.
Following expansion of her upper jaw, you can see the lower jaw has come forward; patient reports improved breathing and parents report correction of snoring.
At this point, patient is referred to an ENT for possible removal of tonsils and will be monitor as we await the remaining permanent teeth.
In a Februrary 2013 study published in the Journal of the American Association of Orthodontics (AJODO) (http://dx.doi.org/10.1016/j.ajodo.2012.09.014 ) entitled Tongue posture improvement and pharyngeal airway enlargement as secondary effects of rapid maxillary expansion: A cone-beam computed tomography study, investigators using computer tomography imaging on patients treated with palatal expansion measured the before and after airways and tongue posturing known to affect development and contribute to sleep apnea.
In this study, researchers pointed out that “Rapid maxillary expansion (RME) is known to improve nasal airway ventilation. Recent evidence suggests that RME is an effective treatment for obstructive sleep apnea in children with maxillary constriction.”
Yellow arrows show the nasal airway space in four patients each with varying
amounts of resistance from soft tissue.