AIRWAY - BREATHING - HABITS AIRWAY - BREATHING - HABITS - PowerPoint PPT Presentation

AIRWAY - BREATHING - HABITS AIRWAY - BREATHING - HABITS & & MYOFUNCTIONAL CONSIDERATIONS MYOFUNCTIONAL CONSIDERATIONS in in ORTHODONTICS ORTHODONTICS Jules E. Lemay III d.d.s., cert. ortho., F.R.C.D. (C) Diplomate, American Board of Orthodontics

ORAL HABITS ORAL HABITS Most prevalent habit ✓ in children (50%)  TONGUE THRUSTING TONGUE THRUSTING   DIGIT SUCKING DIGIT SUCKING   TONGUE SUCKING TONGUE SUCKING   NAIL & LIP BITING NAIL & LIP BITING   foreign objects foreign objects  2

Infantile (Visceral) Swallow • Tongue thrust • Pursed lips • Peri-oral sphincter action • Mand. thrust • Tongue: ♦ away from palate ♦ narrow, elongated ♦ depressed central furrow • Peri-oral sphincter action • Separated gum pads 3..

Mature (Somatic) Swallow Mature (Somatic) Swallow • Tongue: • Peri-oral sphincter action ♦ humped up • No mand. thrust ♦ approximates palate • Momentary inc. contact ♦ shallow central furrow ♦ peristaltic action ♦ border between teeth 4

ADULT SWALLOW  SYNONYMS: SYNONYMS:   NORMAL, NORMAL, MATURE, SOMATIC SWALLOW MATURE, SOMATIC SWALLOW   FACTS: FACTS:   MAY APPEAR AS EARLY AS AGE 3 MAY APPEAR AS EARLY AS AGE 3   CONSIDERED CONSIDERED NORMAL NORMAL BY BY AGE 4-5 AGE 4-5   ACHIEVED BY ACHIEVED BY 50% 50% AT AT AGE 6 AGE 6  FREQUENCY & DURATION:  FREQUENCY & DURATION:  … …   5

ADULT SWALLOW FREQUENCY & DURATION FREQUENCY & DURATION    FREQUENCY: Estimates = 1200-2400x / day  Swallowing: 1x / min. x 1 sec. duration x 60 min. x 24hr = 1400 sec. / day  DURATION ≈ 1400 sec. / day = 23-25 min.  Variable (Sleep = 4-8 x / hr)  Reality: 800-1000 sec. / day = 13-16 min.

TONGUE THRUSTING (terminology )  “ “RETAINED RETAINED” ” INFANTILE SWALLOW INFANTILE SWALLOW   MISNOMER: THRUSTING MISNOMER: THRUSTING vs vs FORCE FORCE   “ “HABIT HABIT” ” vs vs ABNORMALITY ABNORMALITY  ✓  DELAYED LEARNING DELAYED LEARNING  7

INCIDENCE OF TONGUE THRUSTING INCIDENCE OF TONGUE THRUSTING AGE INCIDENCE AGE INCIDENCE REFERENCE REFERENCE newborn 97.0% newborn 97.0% LEWIS et AL (1965) LEWIS et AL (1965) 1 1 50-70% 50-70% DAVIDSON (1967) DAVIDSON (1967) 4 4 most have stopped most have stopped ” ” ” ” 4.9 4.9 58-86% 58-86% HANSON HANSON 5 5 82.0% 82.0% BELL et AL BELL et AL 6 6 52.3% 52.3% FLETCHER et AL (1961) FLETCHER et AL (1961) 35-71% 35-71% HANSON HANSON 50% 50% 8 38.0% 8 38.0% FLETCHER et AL (1961) FLETCHER et AL (1961) 9 41.9% ” ” ” ” 9 41.9% ” 10 34.0% ” ” ” 10 34.0% 16 23.5% ” ” ” ” 16 23.5% 18 24.5% ” ” ” 18 24.5% ” • 10-15 • 10-15 10-15 % % NEVER NEVER ACHIEVE ACHIEVE ADULT ADULT SWALLOW ADULT SWALLOW 10-15 % % NEVER NEVER ACHIEVE ACHIEVE ADULT SWALLOW SWALLOW 8..

Prevalence vs Age Prevalence vs Age 60 60 Tongue-thrusters (White) Female Thumbsuckers Male Thumbsuckers 50 50 Black Children Open Bite N N White Children > 2mm O O 40 40 I I T T A A L L U U P P 30 30 O O P P % % 20 20 10x 10x 10 10 6 6 10 10 14 14 18 18 AGE AGE Fletcher et al. 1961 9.

ROLE of the TONGUE in MALOCCLUSION ROLE of the TONGUE in MALOCCLUSION  DURATION DURATION   INTENSITY INTENSITY   LIGHT LIGHT vs vs HEAVY PRESSURE HEAVY PRESSURE   OPEN BITES: 2 X normal tongue pressure OPEN BITES: 2 X normal tongue pressure   PROTRUDING INC.: less pressure against incisors PROTRUDING INC.: less pressure against incisors   FREQUENCY FREQUENCY   T. THRUSTERS SWALLOW LESS OFTEN T. THRUSTERS SWALLOW LESS OFTEN  ✓ ✓  RESTING POSTURE RESTING POSTURE  10

TONGUE THRUSTING vs MALOCCLUSION ... SOME CONCLUSIONS  T.T. & T.T. & maloccl maloccl. relationship is . relationship is unclear unclear  (WHITE, 1979 ) (WHITE, 1979 )  Chronic / persistent T.T. Chronic / persistent T.T.   may prevent spontaneous self-correction of a may prevent spontaneous self-correction of a  maloccl. or exacerbate it. . or exacerbate it. (AAO, 1991) maloccl (AAO, 1991)  Direct Direct cause-and-effect relationship is cause-and-effect relationship is  questionable (AAO, 1991) questionable (AAO, 1991)  T.T. = T.T. = Contributing Contributing factor factor  in the development of malocclusions in the development of malocclusions ✓ Multifactorial Etiology 11.

GLOSSECTOMY EXPERIMENT CONCLUSIONS HARVOLD et AL, 1968  TONGUE FUNCTION & TONGUE FUNCTION & POSTURE POSTURE  - greater influence on the mand mand. arch (stability) . arch (stability) - greater influence on the  OCCL. & INTERDIGITATION of TEETH OCCL. & INTERDIGITATION of TEETH  - minor influence on arch form - minor influence on arch form  SHAPE OF THE TONGUE SHAPE OF THE TONGUE  - adapts to its surroundings - adapts to its surroundings 12

Resting Pressure: Tongue vs vs Lips Lips Resting Pressure: Tongue PDL metabolic activity Balanced Forces Balanced Forces Equal Forces Equal Forces < 5 gm < 5 gm 5 gm 5 gm Tongue 10 gm 10 gm 5 gm 5 gm JHL JJ JHL JJ 13…

Soft Tissue Paradigm « Goals Goals and and Limitations Limitations of of « Orthodontic and Orthognatic Orthodontic and Orthognatic treatments are are determined determined by by treatments the soft tissues soft tissues of of the mouth the mouth the and face face and and not by not by the teeth the teeth and and bones » » and bones W. Proffit Proffit 2004 2004 W.

MOUTH BREATHING FACTS MOUTH BREATHING FACTS  RESPIRATORY NEEDS RESPIRATORY NEEDS   = Primary determinant of jaw = Primary determinant of jaw  & tongue posture tongue posture & (CAN ALTER JAW & TONGUE POSITION) POSITION) (CAN ALTER JAW & TONGUE  Newborns = Newborns = Obligatory nasal breathers Obligatory nasal breathers   HUMANS = HUMANS = Nasal breathers primarily Nasal breathers primarily   TOTAL TOTAL NASAL NASAL OBSTRUCTION OBSTRUCTION   Very rare in humans Very rare in humans   TERMINOLOGY: TERMINOLOGY: “ “ ORONASAL ORONASAL ” ” RESPIRATION RESPIRATION  Proffit Proffit, , 1986 , Proffit Proffit , 1986 1986 1986 15

MOUTH BREATHING: Possible Etiologies MOUTH BREATHING: Possible Etiologies MOUTH BREATHING: Possible Etiologies  ENLARGED ENLARGED T & A T & A   STRUCTURAL STRUCTURAL NASAL DEFECTS NASAL DEFECTS   NASAL POLYPS NASAL POLYPS   CHRONIC CHRONIC ALLERGIES ALLERGIES   INFECTIONS INFECTIONS   ASTHMA ASTHMA   FOREIGN BODIES FOREIGN BODIES   UNREDUCED FRACTURES UNREDUCED FRACTURES   AGGRESSIVE SURGICAL AGGRESSIVE SURGICAL TX TX  (cleft palate) (cleft palate) Anything causing obstruction may lead to mouth breathing Anything causing obstruction may lead to mouth breathing 16

Effects of M. Breathing Caused by Nasal Obstruction Effects of M. Breathing Caused by Nasal Obstruction (Rhesus monkey experiment - Harvold Harvold et AL., 1973) et AL., 1973) (Rhesus monkey experiment - CONCLUSIONS CONCLUSIONS  CHANGED MODE OF BREATHING CHANGED MODE OF BREATHING  ORAL GRADUAL: NASAL GRADUAL: NASAL ORAL (individual variation) DIFFERENT ADAPTATIONS  DIFFERENT ADAPTATIONS (individual variation)   VARIOUS MALOCCLUSIONS DEVELOPED: VARIOUS MALOCCLUSIONS DEVELOPED:  CL II-III, OPB, ANT. XB, SPACING, 2-BITES CL II-III, OPB, ANT. XB, SPACING, 2-BITES  = ADAPTATIONS / COMPENSATIONS = ADAPTATIONS / COMPENSATIONS   PARTIALLY REVERSIBLE PARTIALLY REVERSIBLE  17

ROLE of TONSILS & ADENOIDS ROLE of TONSILS & ADENOIDS  IMMUNOLOGY: IMMUNOLOGY: autovaccination autovaccination   lymphocytes, antibodies lymphocytes, antibodies   “ “GATE - KEEPERS GATE - KEEPERS” ”: :   strategic locations strategic locations   EARLY EARLY PROTECTION: PROTECTION:   1st few weeks of life 1st few weeks of life   Tonsils vs Adenoids Tonsils vs Adenoids  18.

CHILDREN WITH ENLARGED ADENOIDS CHILDREN WITH ENLARGED ADENOIDS & OBSTRUCTION & OBSTRUCTION (Linder-Aronson et AL, 1970) (Linder-Aronson et AL, 1970)  REDUCED NASAL AIRFLOW REDUCED NASAL AIRFLOW   STEEPER MAND. PLANE ANGLE STEEPER MAND. PLANE ANGLE   MORE RETROGNATHIC MANDIBLES MORE RETROGNATHIC MANDIBLES   LONGER ANT. FACIAL HEIGHT LONGER ANT. FACIAL HEIGHT   MAX. CONSTRICTION TENDENCY MAX. CONSTRICTION TENDENCY  PROFFIT, 1986: PROFFIT, 1986:  MAX. CONSTRICTION TENDENCY MAX. CONSTRICTION TENDENCY   MORE UPRIGHT INCISORS MORE UPRIGHT INCISORS  19 19