"Upper Airway Growth and Orthodontic Intervention" Goli Parsi, DDS, DScD (01/11/2023)

February 03, 2023

ID9439

To CiteDCA Citation Guide

00:00Let's welcome everyone pleased to be
00:03able to introduce garlic parsley from
00:06Boston University School of Medicine,
00:08School of Dental Medicine.
00:11Who's going to give us our talk today?
00:12She's a she's actually a a special
00:15asset to our Sleep Medicine program.
00:18And we're fortunate to have her there.
00:21She's, she's a clinical assistant professor,
00:24associate professor of in in
00:26the School of Dental Medicine.
00:29She recently got her.
00:31Doctorate of Dental Science in
00:342006 from the University Pacific
00:36Arthur Dugoni School of Dentistry.
00:39She then came to Boston University
00:41Goldman School of Dental Medicine.
00:43She completed her training in Orthodontics,
00:47Orthodontics, and Dentofacial Orthopedics.
00:50She went on,
00:52also got her doctorate in science
00:54of dental medicine,
00:56and also has a certificate of
01:00Advanced graduate Science.
01:02In north and orthodontics.
01:05I think I've got it all and she's gone on.
01:08She's been particularly interested
01:09in upper airway development and
01:11also it's been interesting in
01:12relationship to sleep apnea.
01:14And with all of that I'm very
01:15pleased to introduce her.
01:18Thank you so much, Doctor Orbach.
01:20Thank you to the host of
01:23this wonderful meeting.
01:24I'm pleased to have been invited
01:26and I hope I that you'll find my.
01:29Presentation useful.
01:30I know that I'm probably speaking to
01:33most of you in the medical field,
01:35so I'm coming from the dental side of things.
01:38So I hope that some of it will be new
01:40and I apologize if if a bunch of it is
01:43redundant where the overlap is between,
01:46I guess our fields.
01:47So without further ado,
01:49I believe I need to show this.
01:52Uh, Sammy,
01:53disclosure and accreditation for
01:55the numbers that you may need
01:59and I do not have any conflict
02:02financial interest in any of the.
02:04Portions of the lecture that
02:06I will be giving.
02:07So the outline today,
02:08I would like to go over a little bit
02:10for you all about how craniofacial
02:12growth may be associated with sleep
02:14disorder breathing and particularly
02:16in children and as they grow
02:18into adolescence and adulthood.
02:20And how we as dentists and
02:23orthodontists use our screening
02:25tools and other clinical diagnosis
02:27and imaging techniques to understand
02:30what treatment we can offer
02:32and when to refer to you guys.
02:35And went to or which specialty we
02:36need to make appropriate referrals to
02:38and then ultimately what treatment
02:40modalities we can offer because at
02:42the end of the day we're all the
02:45team addressing a multifactorial
02:47problem in these children.
02:50So let's talk a little bit about
02:52craniofacial growth and that's
02:54the part that I'm hoping that may
02:56have some new notes for you all.
02:58You know as an orthodontist that I
03:00work with patients at an age where a
03:03lot about their faces, their bites,
03:04their teeth is going to change.
03:06I do see how the growth and
03:08development of the heart tissue and
03:10the soft tissue structures that
03:12surround the airway that starts
03:14from the nerves to the epiglottis
03:16and can affect the airway.
03:17So in a sense we have.
03:20The development of the softened
03:22heart tissues and that are happening
03:24as the child is growing and that's
03:27having an impact on the airway.
03:29And then the growth of the airway
03:31or any sort of impairment in the
03:33growth of the airway can in turn
03:35affect how the skeletal tissues
03:36and the soft tissues around it in
03:39the craniofacial region are going
03:40to respond and grow in the end.
03:43So we consider it as airway
03:45functioning as a keystone for the
03:47face and how the blueprint of the of
03:49the growth of the skeletal structures.
03:51And the and the bones of the jaws,
03:53the upper jaw and the lower
03:55jaw really is not in the bone,
03:56but it's in the structures around it,
03:58including the muscles, the,
04:01the, you know, the tongue,
04:02the,
04:03the facial structures and the airway itself.
04:06So it all goes into a two way St.
04:09in a way one affects the other very closely.
04:12So it takes about 16 to 18 years for you
04:16know, to fully develop from
04:18a newborn to an adult face.
04:19And during this process there's many
04:22environmental variables that are
04:24acting on what could have genetically
04:26been programmed for face to turn
04:28into with what the child inherits
04:30from their parents and in a sense
04:32for the nasal maxillary complex.
04:35And that's really the area that
04:37you know as an orthodontist I I can
04:40have any control over and that's.
04:42Really the area that grows out
04:44from down and under of the cranial
04:46base and it is pushed from the
04:48cranial base and the growth of
04:50the cranial base around here,
04:52the anterior portion is about
04:53done by the age of 6-7.
04:55So we have a short,
04:57I guess window of opportunity to maybe
04:59have any any impact in that area early on.
05:02And a lot of times I don't even
05:04get to see a lot of the children
05:07during that time to to do much work
05:09and then there's a ton of growth
05:10still left and continuing on.
05:12So.
05:14With that said,
05:15and what what we really sort of
05:18bank on a lot of our treatment is
05:22a very old hypothesis that came
05:25about by Doctor Melvin Moss and
05:28that basically introduced the idea
05:29that the bone growth is under the
05:31influence of the surrounding structures.
05:33So the skeletal structures are
05:36under mostly epigenetic control.
05:38So the stimulus is coming really from
05:40the tissues around the bone basically
05:42to determine their final size.
05:44Shape and there's strong evidence
05:48that the the dental structures is
05:50as much as the Bony structures
05:52are really affected by this,
05:54by the external stimuli,
05:56even the nutrition,
05:57even having a softer diet versus
06:00a harder diet that maybe are
06:03our ancestors were more used to.
06:05So a little bit about the cranial base.
06:08You know,
06:08it connects the skull with the
06:10vertebral column and the mandible.
06:12It influences the craniofacial morphology.
06:15And there's really 2 main ones
06:17that I want to point out here.
06:20That's the inner sphenoidal suture here.
06:23And then there's the spheno
06:26occipital suture right here.
06:28And those are the two that,
06:31you know,
06:31sort of their growth affects the anterior.
06:35Out of the cranial basin because
06:37again as you saw the nasal maxillary
06:39complex is right underneath that any
06:41growth in the cranial base effects how long,
06:43how wide and you know how the size of
06:47the the nasal maxillary complex for us.
06:50So the inner entrance interest
06:52Sphenoidal synchondrosis that's
06:53that that junction usually for the
06:551st 12 months it's it's active
06:57with this phenoxy Capital One.
06:58The more posterior one it tends to
07:01stay active for for a bit longer
07:03and really it's active even.
07:05Well into, you know, the teen years,
07:07and it has been evidence that it
07:09may not even fully fuse up until,
07:12you know, maybe 1820 years of age,
07:14but that's more posteriorly.
07:15The anterior part of the cranial
07:17based generally is done.
07:18You know,
07:19we can sort of count on it being
07:21done by 6-7 years old.
07:22But it's flexure as I as I was
07:24explaining how it affects the
07:26the nasal maxillary complex,
07:28it's interesting because as
07:29the basic cranial flexes it,
07:32the cranial base tends to shorten and
07:34widen and then the Volt increases in
07:36height and the cranial base angle closes.
07:38So as you can see here where
07:40we have a the slightly flexed
07:44cranial base that's in red it,
07:46it tends to translate into a much
07:50narrower and longer maxillary.
07:52Arch and that's sort of the
07:54upper arch of the teeth.
07:55And then when we have the the green one
07:58where the cranial base is more flexed,
08:00it tends to end up sort of
08:02correlate again with a much wider
08:04and shorter maxillary arch.
08:05So you can see how how they are all
08:07are are going hand in hand and these
08:09patients tend to have longer faces
08:11than these ones with shorter faces.
08:13So that the shape of the palette and
08:15the arch form is actually sort of all
08:17in a pattern with with how the face
08:19looks too and the height of it and then how,
08:22how maybe a lot.
08:23Face that's long then the the the child
08:25has a hard time bringing their lips
08:27together and then they end up maybe
08:29having more of a mouth breathing pattern.
08:31So.
08:33Um, the airway configuration in general,
08:35and its size would affect
08:37the arch form of the orbits.
08:39The nasal and oral sides of the
08:41palate are affected by it because
08:42the the nasal side of it is
08:44obviously the nasal cavity.
08:45The oral side would be
08:46the would be the mouse,
08:47the maxillary arch,
08:49the sinuses right above it,
08:51and the zygomatic arches are all subject
08:53to it because as you can see here,
08:55the way that the growth is happening
08:57within that we have the Bony
08:59walls of the of the nose that are
09:01all sort of resorptive surfaces.
09:03Is the child that's growing,
09:04there's resorption of the bone on
09:06these lateral walls the the the nose
09:08is becoming wider at the same time
09:09the sinuses are growing in size.
09:11But the medial wall of it,
09:13there is opposition of the bone
09:14sort of in in response to having the
09:17resorption on the lateral walls of the nose.
09:19And then it sort of grows laterally
09:21and and becomes wider.
09:23Similarly we have opposition of the
09:25bone and the sort of in the orbits there.
09:27So,
09:28so this whole segment between the floor
09:30of the eye and the and the mouth.
09:33It just lengthens significantly between
09:35because we have opposition right and
09:37inferiorly here and then superiorly there.
09:39And this height just increases
09:42significantly between the the child
09:44sort of growing into adulthood
09:45and that's making the whole array
09:47again longer and then wider here.
09:49And then we have the palatal side
09:51of the the whole structure sort
09:53of acquisition there.
09:54So in a way again we have facial
09:57areas and exceedingly significant
09:59component that's involved in
10:01normal versus abnormal facial
10:04morphogenesis. Now mouth breathing and
10:06how how that correlates to all this is
10:09that we're where we tend to see a lot
10:11of the mouth readers would then have
10:14smaller nasal cavities if for whatever
10:16reason they're I mean whatever would
10:19be the the etiologic factor for it
10:21that aside they tend to show smaller
10:23nasal cavities and that they're now
10:26they're they're mid faces are smaller
10:28again all the the the blueprint being
10:30in the in the soft tissue and the
10:33structures around the skeleton.
10:35Then the and the airway they they
10:37never got the in a way the the
10:39motive to to grow more around the
10:41mid face so they they it tends to be
10:44smaller and then ultimately the their
10:46maximas are going to be narrower.
10:48Their arches if you look in these
10:50patients mouth they tend to have
10:52much much narrower upper jaws,
10:53the pallets the the roof of the
10:55mouth is is much higher deeper
10:57in a way but but much narrower.
11:00So what we call this these sort
11:02of all of these significant.
11:05The findings together they kind of
11:07compile into what we call a long
11:09face syndrome that would go hand in
11:12hand with chronic mouth breathers
11:14that have that's implicated in the
11:16dental facial deformities they have.
11:18They tend to have extended head,
11:20the craniocervical posture they're,
11:22they're sort of forwardly inclined
11:24as they try to increase their.
11:27The air flow there they have
11:29excessive anterior facial height.
11:31They the especially the lower part of
11:34the face tends to be become much longer
11:37and their lips therefore is not competent.
11:40A lot of times there as they try to
11:42bring their lips together you see
11:43dimpling on the on the chin there's
11:45mentalis strain going on and but at
11:47rest every time you look at them their
11:50their lips are not comfortably together.
11:52And Umm,
11:53there's a flared external Canaries
11:54and what we call the steep mandibular
11:57plane is if you look here on the
11:59on the lateral cephalogram,
12:00you could see that too that this
12:02mandibular plane is very stable.
12:03Normally the the angle should be much,
12:05much flatter this way.
12:06So and I'll explain in a little
12:09bit why all of this happens in
12:11response to being a mouth breather
12:13and not you know having the normal
12:15growth pattern that we expect.
12:17Now intraorally you know they
12:19tend to have large over over jets
12:21here they tend to have again.
12:23Very narrow upper arches even narrower
12:26in this I can show you pictures.
12:29Much narrower than that you can tell,
12:31and the palatal volts tends
12:33to be pretty deep.
12:38Now, Umm, there's an experimental,
12:41I guess a paper out there that actually
12:43shows that when where there is an
12:46instant nasal blockage automatically and
12:48almost instantly there's five degree
12:50change in the cranial vertebral angle.
12:53So for mouth breathers,
12:55this this can be sort of, again,
12:57they're not necessarily 100% mouth breathers.
12:59There may also always be some
13:01percentage of nasal breathing going on.
13:03But with with with the effect of
13:05mouth breathing, what the what
13:06these patients are trying to do,
13:07they're lowering their mandibles.
13:09Of tongues and they're extending their
13:11heads forward and the posterior teeth
13:13then are sort of coming apart from each
13:15other as the as the mouth is sort of
13:18held open and the mandible is is held down.
13:20Now there is really nothing stopping the
13:22back teeth from necessarily erupting more
13:24and that's what we call the Super eruption.
13:26So as these back teeth are now
13:28erupting more because the jaws
13:30weren't really held together,
13:31that's sort of the vicious cycle
13:33there now their teeth that are
13:35erupted more and therefore even
13:37if the the job wants to rotate.
13:39Close. It can't.
13:40It's in the way.
13:41So the mandible itself is rotated
13:43down and back and.
13:45The opening the bite would then
13:47translate into an upfront where the
13:48back that's come down together up
13:50front you can see that maybe the front
13:52teeth will not be touching and then
13:54they'll have an increased overjet.
13:55And there there has to be then more
13:58stretching more pressure coming from
13:59the from the cheeks and the lips
14:02to just just bring them together.
14:03And a lot of times if you could if
14:05you could imagine that you know a
14:07child that may be sucking on their
14:10thumb habitually then just this
14:12sucking pattern and and the way
14:14that the that the cheeks are.
14:16Sort of going through these contractions,
14:18that tends to again affect
14:21the the position or the,
14:23I guess the the way that the
14:25upper jaw is shaped and that way
14:27especially at the corners,
14:28it tends to just never grow wide enough.
14:30And again that sort of continues
14:32on with the with the pattern that
14:35I was just explaining.
14:37Here too,
14:37and these kids go from thumbsucking
14:39to just being mouth breathers and
14:40then their tongue is going to
14:42be sitting in that space too.
14:43So it all,
14:44it all affects their long term
14:46how how their face is going to
14:48grow into looking a certain way.
14:51So if you can look at it and
14:52how they affect each other,
14:53if you could think of it as the
14:55obstruction of the airway happens first,
14:57maybe for whatever reason,
15:00then there is enormous muscular
15:02feedback that causes the postural
15:04change of the mandible sort of
15:06rotating down the head flexing.
15:08Uh,
15:08forward tilting.
15:09And then there is the differential
15:11forces on the skeleton because
15:12of that as this stretches on the
15:14on the cheeks and the tissues
15:15around it is happening.
15:16And that really is what causes
15:19the morphological change
15:20because we believe in the hypothesis
15:22of the functional matrix theory
15:24where the information is coming,
15:26the blueprint is coming from
15:27the soft tissues around.
15:28So if that's really true,
15:29which we do see all the time,
15:31then that sort of goes hand in hand
15:32with then affecting the obstruction of
15:34the airway because now the tissue is
15:36not growing as much as it should be.
15:38That the mandible that's rotated
15:40down and back,
15:41it's narrowing the airway in the back here.
15:43So again this this cycle just
15:45keeps continuing on and on.
15:48Um, so in a newborn and the pharynx is
15:51very similar to other primates and mammals.
15:54The uvula and epiglottis are very much in
15:57close proximity around 18 months of age.
15:59The with the development of the larynx,
16:01it's sort of descends down to the C5
16:04level and that's really because of the
16:06role of the pharynx information and in
16:09humans and this lengthening right there,
16:11I'm sure you you know more about it
16:13than I would and how how it's now
16:15more susceptible to obstruction and.
16:17All the problems that we're going
16:20to discuss today,
16:21but then anatomically the regions
16:23that are that are going to cause these
16:25blockages in a child versus the adults,
16:27it's it's very different.
16:28And again I'm sure you all would
16:30know this more than I would.
16:32Where we do tend to see in younger
16:34children the obstruction being more
16:36in the higher nasopharyngeal area,
16:39maybe higher oropharyngeal area
16:40with the where the adenoids and
16:42tonsils would be the culprits.
16:44And then while in adults it would
16:46be maybe lower oropharyngeal area,
16:48retro glossal area.
16:50Would be probably more often encountered.
16:55So the narrowing as you can see here
16:57is just an example of enlargement of
16:59the tonsils and adenoids there versus
17:01an adult where it would be the blockage
17:03and little bit lower in the airway.
17:06So what do we do I guess is orthodontist
17:09and we go by the recommendations of
17:12the American Association of PD Atrics
17:14where you know that they recommend
17:16that all children or adolescent
17:18who snow regularly be screened for
17:21obstructive sleep apnea and because
17:23we think that at least being in.
17:25The dental field and seeing children
17:27maybe every six months for their
17:29checkups as a pediatric dentist,
17:31as an orthodontist and we get referred
17:33to when they when they do see something
17:35maybe off going on about their,
17:37their dentition sort of growth
17:39or even their facial development,
17:41we get to see them.
17:42And the recommendation really force
17:44adonic screening is by the American
17:46Association of Orthodontics is
17:48sometime between age of seven.
17:50We would like to see every child just
17:51to make sure that even if they're
17:54really not that many permanent teeth.
17:55Maybe come in again,
17:56maybe mainly baby teeth are still
17:58in their mouths.
17:58We still would like to see to maybe
18:00be able to intervene sooner.
18:02So what we do routinely in our practices
18:05is that at least at the dental school,
18:08what we have implemented is that we
18:10screened for obstructive sleep apnea
18:11by really virtue of history taking
18:13their question is that I'm going
18:15to show you in a bit and clinical
18:17examination and then if we see red
18:20flags that we think that there
18:22needs to be a sort of more.
18:26You know, figuring out really what it is,
18:28we make a referral for polysomnography
18:30by you all or Umm,
18:31you know,
18:32again having you involved in it and
18:34figuring out what's best for the patient.
18:36And then alternate testing
18:38this day and age with probably
18:40sonography being very difficult to sign up
18:42our patients for financially or otherwise,
18:45then maybe in a home sleep test and such.
18:48So we start out as part of our medical
18:51history taking for our patients every
18:53new patients that we get, you know,
18:56probably under the age of 18.
18:58We use the Bears questionnaire that I'm
19:00sure you're all familiar with to go over
19:03any bedtime problems that they may have any.
19:05So here's the here's the breakdown
19:08of the questions right there.
19:10But again, we have the toddler preschoolers,
19:12their parents are answering those questions
19:14if they have any bedtime problems,
19:15any excessive daytime sleepiness
19:17awakening during the night.
19:19Or any irregularity during sleep
19:21and of course snoring.
19:23And then we have the same set of questions
19:25that the child or the parent for some of
19:27them can answer between the ages of 16
19:29and 12 and for adolescence of 13 to 18.
19:32The child tends to answer all of those
19:34questions except for the question
19:35for the snoring that we would expect
19:37the parent to know,
19:38hopefully be able to hear and let us know.
19:40And then if there are any yeses to that,
19:43to that on their medical history,
19:45we then sort of give them the
19:47pediatric Sleep Questionnaire that
19:48I'm sure you're all familiar with.
19:50It's high validity and you
19:54know specificity and.
19:56Sensitivity that was sort
19:58of validated against PSG.
20:00So we used that again routinely for
20:01anyone who has answered yes to any of
20:04the of the Bears questionnaires and then
20:06we'll go from there for any further question.
20:08I'm not going to go over
20:10each segments of these.
20:11I'm sure you've seen them,
20:12but again that's Doctor Shervin.
20:15But paper there,
20:17the next step for us is to clinically
20:20examine these patients and being you
20:24know working in the in the mouth,
20:26it's very easy for us to
20:28check out their tonsils.
20:29So we look for tonsillar hypertrophy
20:32and understanding that we're working
20:34with children at an age where
20:36you know there is some shrinkage
20:38expected to happen as they get older.
20:41But then also do we want to make
20:44sure that it's not you know again?
20:46Putting all of it together with
20:47their answers to the questioner
20:49and what we see clinically,
20:50then we make the we would like to be
20:52able to make the appropriate referrals,
20:54so then we go by them.
20:56By the scale of the bronsky scale
20:58here where I'm sure again you know
21:01all the way from grade one to four
21:03with the kissing tonsils and then
21:05three and four where is where really
21:08we're more worried and we added to
21:10all of our other findings and make
21:13the referrals and then we'll do the
21:16Mallampati Friedman sort of scaling
21:18too just to see how much again orphan
21:20jail crowding we have and for the child
21:23and you know how that's all affect how,
21:26how.
21:26That really translates into what
21:28we're seeing from their questionnaires
21:30and their chief complaints.
21:32And Umm, we do hear a lot of bruxism,
21:34actually complaints from the patients
21:36and a lot more from children.
21:39We we tend to see it obviously in a
21:42higher prevalence than in the in the
21:44children and how sort of as they grow
21:46into adolescence and then adulthood,
21:48at least the nighttime bruxism,
21:50the sleep bruxism tends to become
21:52less prevalent as opposed to the wake
21:55time bruxism that is lower in the in
21:58the childhood ages and then it sort
22:00of increases in the adulthood, so.
22:02We do ask for that.
22:04We do see that.
22:05We do look for signs of any wear
22:07and attrition on the teeth that
22:10could be caused by bruxism.
22:12Any white coating on the tongue
22:14where the popular overgrown and you
22:17could see the projections there.
22:19And we do look for their tongues.
22:20There is some evidence of you
22:23know having an ankyloglossia,
22:25the the short lingual frenum.
22:27There's really no robust evidence
22:28on that and how that affects sleep,
22:31disordered breathing, but.
22:32There has been here and there
22:34some articles that show that maybe
22:36doing some treatment for for that
22:38and releasing it can help with
22:40the tongue movement and hence with
22:43with snoring or sleep apnea.
22:45But again,
22:45because we see a lot of this and in the
22:48Brexiters and we see a lot of this,
22:49these coating of the tongue
22:51in the mouth breathing again,
22:53we we tend to again have have
22:54a way of looking for it.
22:56And then we have the comparison of
22:58having a very narrow arch where again
23:00there's crowded space for for the tongue.
23:03And the argument is that if the tongue
23:05doesn't have much space to sit in,
23:07then it tends to sort of fall backwards
23:10posteriorly towards the oropharyngeal
23:11area and sort of narrow the airway
23:14there as opposed to having the.
23:16Wider arch here and having ample
23:18room for the for the time.
23:20But then again I just want to point
23:22out here too that there's only so
23:23far that we can push the teeth out.
23:25So just just widening the arch
23:27and pushing the teeth out is not
23:28the answer for everyone because
23:30there's only so much bone and we
23:32can't really grow bone out in the
23:33outer side of these teeth.
23:35If we do push them far out and
23:37there's initially there may not
23:38be any symptom any problems but
23:40then over time you you're going to
23:42notice that what we don't see is
23:44that there's thin bone underneath
23:46and fenestrations and sort of.
23:47Again,
23:48holes created in the bone that we do
23:50not see and is covered by by gum,
23:51but as they age and recession happens,
23:54then all these problems sort of arise.
23:56So again pushing the teeth out is
23:58not the answer and you know I'm
24:00going to go over some of the
24:03alternatives that we have to.
24:05And and like I said,
24:06we look for tooth grinding against
24:08sleep related breakfast that
24:09may affect up to 50%
24:10of children. Most of the time we're
24:12telling the parents that do not worry,
24:13it's part of their.
24:16The stage they're in now and they're
24:18going to grow out of it because fifty
24:21turns into 15 into adolescence and Umm,
24:23but the sleep bruxism risk is 4 times
24:25higher in children who have OSA.
24:27So that's why we still pay attention to it,
24:29although the percentage is so high.
24:31But in the context of having all these
24:34other symptoms and all the other,
24:36you know the way that their answer
24:38is that their questionnaires and
24:40what we see clinically then it there
24:42may be something valid to it because
24:44also too what we see as part of the.
24:47The categories that's that the International
24:49Classification of Sleep Disorders has,
24:51has sent out.
24:52We see the sleep related breathing
24:54disorders and sleep bruxism,
24:56they're they're both underneath
24:57the same umbrella.
24:58So again they're very close, they're there.
25:01It's not that which one, if,
25:03if there is any cause and effect,
25:05if if sleep related breathing,
25:07if obstructive sleep apnea is
25:08causing sleep racism or vice versa.
25:10But there's so many commonalities
25:12between the two and so much overlap
25:14that we do tend to see a lot of bruxism.
25:17And um, apneic patients too.
25:19So they both have been associated,
25:23but there's no cause and effect between them.
25:25So the hypothesis is that there's
25:27this rhythmic muscle,
25:28masticatory muscle activities that
25:29may help reinstate the airway patency
25:32following an obstructive event.
25:34Or another is that it's a physiological
25:37motor event that lubricates
25:39the oropharyngeal structures.
25:41So again,
25:42it it happens as there's mouth
25:44breathing going on,
25:45but at the same time they're
25:48both more common when sleeping.
25:50Supine position for both of them,
25:54the masticatory muscle activity
25:56that's happening in the sleep disorder
25:58breathing and apnea event and the
26:00sleep bruxism they both occur during,
26:03it's unclear if the muscle activation in
26:06apnea is resulting in the sleep racism.
26:09So in a way,
26:10is it that the patient stopped
26:12breathing and now as a defensive
26:14mechanism the bruxism is happening?
26:17To wake them up and cause an arousal
26:19so that they can gasp for air or not.
26:22But the arousal for an apnea,
26:25as you know it happens after the
26:28apnea episode but for the sleep
26:30bruxism on the PSG we see that
26:32the the sleep sleep racism,
26:34which is the muscular activity
26:36of the of the chin.
26:38Area that's that's how it would show up.
26:41It would,
26:41it would,
26:42it would occur during the within the
26:44arousal and both of them patients
26:46tend to report headaches and tension
26:48type and migraine headaches have
26:50both been associated with have been
26:52associated with both sleep racism
26:54and sleep disordered breathing and
26:56children with sleep racism report three
26:59times more headaches than children
27:01who don't have bruxism at night.
27:0330 to 50% of the adults that have
27:05sleep bruxism complain of headaches.
27:08And this repetitive rhythmic
27:09contractions of the mass auditory
27:11muscles may be the cause of
27:12these tension type headaches.
27:14But again, there's no robust evidence in the
27:16literature that can confirm that for sure.
27:19And again, sleep disorder
27:20breathing is also to associated
27:22with sleep bruxism and headaches.
27:24Now could it be because of the fragmentation
27:27because of the hypoxemia and hypercapnia?
27:30Or again, as you see they're sort
27:33of all related to each other.
27:34And the way that we would manage
27:36this would be we generally would
27:38give the patient some an occlusal
27:41splint to essentially protect their
27:43teeth from further wear and there's
27:46pharmacotherapy that you would probably
27:48know more about than I do Botox,
27:51you know to some extent can
27:53help and physical therapy.
27:55Hypnotherapy,
27:55cognitive behavioral therapy,
27:57and ultimately, sleep hygiene.
28:01So let's move on to another diagnostic
28:05sort of arsenal that we use as
28:09a lateral cephalogram or a CBCT.
28:12That would really show us
28:14statically in the moment with the
28:17patient actually sitting up,
28:18which really has very little to
28:20do with what they would look
28:21like when they're on their backs.
28:22And while sleeping with the
28:24muscle tonicity very different,
28:26just gives us a general idea of the
28:29size and the shape of the airway.
28:31So there's a position paper by the
28:34American Association of Oral Maxifacial
28:36Radiology back in 2013 that actually
28:39and they came up with the with this,
28:43with this position paper saying that
28:45there despite there is a number of
28:47publications and the use of cold beam CT
28:49and specifically in orthodontics what I do,
28:52but there is no benefit
28:53for airway assessment.
28:54So in a sense we can't really justify or
28:58be able to make a diagnosis based on it.
29:01Ultimately it's the uh,
29:02I guess PSG that we could go by,
29:05but it gives us an idea.
29:06And since we do need these X-rays
29:08anyways a lot of times for our
29:11purposes of moving teeth, moving jaws,
29:13and again it's right there,
29:14we can just take a look and see if
29:17things are adding up in the in the
29:19shape and size of the airway too.
29:22The limitations are are that,
29:24but the problem with these is
29:25that they're very useful for us,
29:27as again as orthodontist,
29:28to see where the where the jaws
29:29need to be moved to where the
29:31teeth need to be moved to,
29:32what are our limitations to how
29:34far we can we can move things.
29:37But there's lack of standardization
29:38of the head and tongue posture as
29:41these are taking and that's what's
29:42really the head being flexed or not.
29:45And the tongue being, you know,
29:47placed on the roof of the mouth
29:48versus in between the teeth.
29:50All of these will affect the airway.
29:51And again, that's why we can't really count.
29:53On the way that the airway looks
29:55on these X-rays and there's a
29:57great intra and inter examiner
29:59reliability for the airway volume
30:01and maximum cross section area.
30:04So there's lack of it I should say.
30:06And then there's the and there is lack
30:08of an established protocol also to
30:10for the standardization of these the
30:12the measurement on the on
30:14the softwares that we use.
30:15So, so when we go to different
30:17softwares depending on the threshold
30:19that we pick for soft tissue
30:21versus heart tissue and airway.
30:23Every software is going to have some,
30:24some level of discrepancy.
30:26Every, every patient's bone thickness
30:28may be different soft tissue.
30:29So there's always a little bit
30:31of an error to really know the
30:33exact volume for for these.
30:35But on average the volume of the
30:37fringer airway has been reported to
30:38be maybe about 20 cubic centimeters
30:40and the mean volume of the superior
30:43component versus the inferior component
30:45being around 9 versus versus 12 there.
30:49So.
30:51Let's move on with police and
30:52don't want to go over because I
30:55haven't gotten to treatment yet.
30:56But polysomnography again ultimately
30:58gold standard that we go by and based
31:01on that and in collaboration with
31:04sleep physicians such as yourselves,
31:06we come up with a treatment plan.
31:07Now the idea is that we we do want to
31:10work as a team because we don't want
31:12to be like these people and touching,
31:15you know,
31:15a certain part of what we are good at.
31:18I don't want to be the orthodontist
31:20that expands every child's.
31:21With the with the sleep disorder
31:23breathing with an expansion and not
31:25really make the correct referral
31:26same as probably you know every
31:28pulmonologist doesn't want to
31:29be the one just giving the CPAP.
31:30Well there may be you know adenoids involved.
31:33So let's go over again adenoidectomy,
31:36I'm not going to go over to you
31:38all know more about it than me.
31:39But the effect of it and how it
31:41affects the growth and development
31:42of the face that I was very early on
31:44in the lecture I was going over it.
31:46It's been shown that Adenoidectomy
31:48now results in a normal airway
31:50now having a normal airway.
31:52Being the blueprint for the growth of
31:55the skeletal craniofacial skeleton then
31:57leads to a less extended posture of the head.
32:00And then there has been and there has been,
32:02it has been shown that the children
32:05who underwent adenotonsillectomy,
32:06they showed an additional 3 millimeters
32:08forward and downward movement of the chin.
32:10So their their jaws are growing
32:12downward and forward more.
32:13And that's significant enough for
32:14for us to see after this procedure.
32:17So that goes to say that if, if,
32:19if, there was no intervention,
32:21if the if the adenoidectomy.
32:23Was not done.
32:24Then these children would
32:25essentially end up with smaller jaws.
32:27Now this would be affected,
32:29affecting their bites.
32:30It would be affecting their, you know,
32:32their profiles, their aesthetic,
32:34look up their faces and then, you know,
32:36later in life maybe that would,
32:37you know,
32:38turn out to be a surgical treatment
32:39if it's significant enough to
32:41the patient or to their function.
32:43And I mean,
32:44obviously you all know better than
32:46me the improvement in cognition,
32:48IQ test and quality of life.
32:50And CPAP again,
32:52very effective treatment for persistent OSA.
32:56It's unfortunately, as you know,
32:58it's not always tolerated in children.
33:01And it's expensive.
33:02Adherence is a problem, anxiety,
33:03sleep disruption and such.
33:05But now the same way that we were
33:07talking about how the soft tissue is
33:09affecting the growth of the skeleton.
33:11If you could imagine having the
33:13CPAP on with where it's placed and
33:16where it's strapped on now in turn,
33:18that the pressure that it that
33:19it has for a sustained amount
33:21of time over the amount of time
33:23that the that the child's in bed.
33:25So let's say a good, I don't know,
33:27four or five, 6810 hours,
33:29the amount of time that the
33:30child can actually.
33:31Tolerated and wear it.
33:33Now this will directly affect further
33:35growth of the of the jaws because it's
33:38sort of holding it by holding the
33:40soft tissue back and hence having an
33:42effect on the on the growth of the skeleton.
33:45So there has been significant
33:47maxillary retrovision.
33:48The upper jaw does not grow
33:49as much as the control screw.
33:51So if you look here, this is the,
33:52this is the control group,
33:53this is normal growth of the maxilla
33:55down and forward and this is after,
33:57you know this is the the child with the CPAP,
34:00there's counterclockwise.
34:01Clipping of the palatal plane so.
34:04Again,
34:04the powerful plane should be
34:06coming down and forward and you
34:07see this tipping down happening.
34:09The backside is coming down in the
34:11front side is sort of held up and
34:13you know dentally to then which may
34:15not be as significant for you all,
34:17but again being an orthodontist
34:19for us there is this flaring or the
34:22torquing of the upper incisors as well.
34:24So what do we do?
34:26A lot of times, again, as an orthodontist,
34:27there are sort of what we look
34:29for is if this is really,
34:31truly a problem within the skeleton,
34:33if the maxilla is really narrow,
34:34and who caused it? It?
34:36Was it the chicken or the egg?
34:38That aside,
34:38now we we use what we call a
34:41rapid maxillary expansion.
34:43Now that what it does is it just
34:45articulates the maxillary and the
34:46palatal bones and it moves them laterally.
34:49Now there's because there's
34:51this pyramidal shaped expansion
34:53that's happening we have.
34:54We have the fulcrum being if you
34:56could imagine that the nasal area
34:57and the the inferior part sort
34:59of comes apart makes it wider.
35:00And then also to if you're looking
35:02at the axial view here the anterior
35:04part tends to widen more and the
35:06back part tends to widen less.
35:08But All in all this will cause a
35:11narrow maxilla to to become wider
35:13in a sense and because right above
35:15it it's the nasal cavity then the
35:17we're increasing the volume of the
35:19of the nose too and I'll show you
35:21some articles on that and and some
35:23of actually the work that we did.
35:24Here so just a quick don't know
35:28if this video will. Works.
35:33Be not. OK, let's say this was just
35:36going to show you how the how the
35:38over superimposition of the bonus,
35:40but I have some static screenshots of it.
35:43So if you look at the green
35:45and here that's the after the
35:47yellow was the before expansion,
35:49so that's where the teeth were,
35:50but did the expansion and that's how
35:52the jaw sort of widened and along with
35:54that the teeth traveled outwardly too.
35:56So you see the red being the most
35:58amount of movement versus the blue
35:59the least amount of movement.
36:01You see how most of the movement
36:03is happening here as opposed to
36:04up there and again the widening.
36:06And the posterior as well.
36:08And because again all of this
36:10is connected to each other,
36:11I would like to show you how the
36:14widening in the upper arch has
36:16actually caused the increase.
36:18As you can see here in the red
36:19here in the even the sinuses and
36:21the oropharyngeal area here right
36:23behind the tank.
36:24So this is,
36:25this is the cross-sectional view of
36:27the airway and you can see just by
36:29widening of the air of the upper arch.
36:31The idea is that now the tank has
36:33more room to sit up above where it
36:35really should be on the roof of the
36:37mouth and that's why we see this increase.
36:40And Umm.
36:40The fragile space there.
36:42Here's some examples of what these
36:45palatal expanders would look like.
36:46And there are many different
36:48designs depending on,
36:49you know,
36:50the teeth that are there depending
36:51on if we need any bone supported or
36:54just tooth support is good and so.
36:56But what they all have in common is
36:58this Jack screw in the middle that
37:00tends to cause significant amount of
37:02force that then and has the ability
37:04to open the sutures and growing children.
37:07Now again we have a limited window of
37:09opportunity now after a certain age.
37:11Because there's so much resistance
37:13and the actually not so much
37:15within the mid palatal suture,
37:16but further back in the terrago maxillary
37:19area and the zygomatic buttress,
37:21then it becomes almost impossible
37:23to use these in adults and be
37:26able to really crack them open.
37:27And that's when we need to
37:29do an additional surgery,
37:30release those sutures and then do the
37:32same type of expansion to widen the the arch.
37:35And that has been shown to that
37:38the nasal cavity and orphans and
37:40can expand about 11% and for each
37:43millimeter of expansion the airway
37:45volume increased about 2.4%.
37:47And this is a very,
37:49Umm,
37:49I thought a very interesting article
37:51that is now you know it's it's
37:53been a while since it came out,
37:55but it the the the good thing about it,
37:57the interesting thing is that
37:58is that it's a very long term
38:00follow-up study on children and Umm,
38:02this is the group with I think
38:04Doctor Gimeno too.
38:05Umm.
38:05Stanford that looked at it on children
38:084 to 8 years old that underwent rapid
38:10maxillary expansion.
38:12The HI decreased from 6 to 4,
38:15the oxygen saturation increased
38:16from 95 to 97 and a 12 year
38:19follow-up study on them showed that
38:22the post rapid mixer expansion
38:24HIV increase decreased 12 to .4,
38:28oxygen saturation increased 78 to 95.
38:31So wrong long term results is
38:33really what we're interested in,
38:35but then also to you.
38:36Would argue that well all these
38:37you know these 12 year follow up
38:39part of it is that the the the the
38:42children are you know growing too
38:43and in essence the you know the
38:46adenoids and tonsils are shrinking
38:48as well but you know they had a
38:50control group to compare this with
38:51and still this is the this is the
38:53results that they're showing so
38:55there is some validity to that
38:56and some it's not for every child
38:58absolutely I'm not saying that but
39:00definitely in the in the for the
39:02wrong right candidate it's effective
39:04and it's it's been shown it also.
39:07Helps improve quality of life.
39:09And the questionnaires that we've done,
39:12this is a study we did here at BU
39:14where we analyzed the nasal airway
39:17symmetry and upper airway changes
39:19after rapid mixer expansion.
39:21So we had two groups.
39:22So we had a group of patients that
39:24we that we that had rapid maxillary
39:26expansion and we were looking at each
39:29segment of the airway separately.
39:30So we had the right and left nasal cavity,
39:32the nasal pharyngeal area,
39:33the oropharyngeal area and
39:35the Hypopharyngeal area.
39:36And what we showed was that both
39:38the control groups this was over 2.
39:40Two years time point on the initial
39:42call beam CT's were taken right
39:43before chronic treatment and two
39:45years later when it was done.
39:47And what we showed was that both
39:49groups that control and the the
39:51rapid mixer expansion group showed
39:53an increase in in all segments.
39:55However,
39:56for the control group the only
39:58significant increase was in the
39:59oropharyngeal region and the screen portion.
40:01But for the for the subject group,
40:04for the,
40:04for the children who had maxillary expansion,
40:07all of these other segments.
40:10To increase significantly.
40:11But what we also found was that
40:14where the rights if if the right
40:17side was the smaller side relative
40:19to the left side before rapid mixer
40:22expansion it tended the discrepancy
40:25between them tends to become less.
40:27So the one that started up smaller became.
40:31I guess it grew more in a way
40:33or it it became larger than the
40:36one that started out larger.
40:38However in the control group.
40:40The side that's started out
40:42smaller states smaller after that.
40:44So it it almost seems like there
40:47would be a balancing effect too
40:49to the to sort of balance out and
40:52equalize the the right and left side
40:54as well with rapid mixer expansion.
40:56This is just some of the tables I
40:59know I'm running out of time so.
41:01Just to show you the significant
41:03increase in each of those segments
41:05that I was talking about and this is
41:07for the control group or the
41:09only significant increase was
41:10in the oropharyngeal region?
41:13And I just went over that.
41:15Another treatment modality is the
41:19functional appliances that are very
41:21similar to what you all may be familiar
41:23with with the oral appliances and
41:25adults to essentially posture the
41:27the mandible forward to increase
41:29the airway volume posteriorly.
41:31And in children,
41:32we do this normally because the idea is
41:35that again by posturing the mandible forward.
41:38We're sending the signal through the
41:41soft tissue around too that there
41:43would be a sort of an increase in
41:45the condylar activity in a sense
41:47helping them grow a larger mandible.
41:49Now there's a lot of debate about
41:52that and it's not that significant.
41:54If we're lucky,
41:55we may be able to get one to two
41:57millimeter of longer mandibles per se.
42:00And a lot of it may be really
42:02borrowing from future.
42:02But in essence,
42:03and this is also what it's doing,
42:06is that it's helping us with
42:08with correcting the occlusion.
42:09Of the of the children with maybe
42:12potentially helping them with a little
42:14bit more growth of the lower jaw and
42:16at the same time opening up their Airways.
42:19And you know there are several
42:20articles on this I can I can leave
42:22these here with you that you know
42:24how they can reduce they may reduce
42:26the risk of OSA later but again
42:28they're not treatment for OSA and
42:29I would not really edge it just to
42:31put it out there for you that these
42:33are sort of some of the treatment
42:35that we do the opposite problem
42:36when the upper jaws that fault and
42:38it's smaller than the lower jaw.
42:40Use what's what we call a face mask
42:43that sort of brings the maxilla
42:45forward and that tends to bring the
42:47maxilla forward and downward and
42:49then it rotates the mandible back.
42:50And again there are studies that show
42:52it's this is sort of what it looks like.
42:55So the upper teeth would be
42:57sort of falling behind here.
42:59It doesn't show that it's
43:00behind because of these.
43:01The the byte block that you
43:02see here it's holding it open.
43:04But a lot of kids would have this
43:06underbite and then we can use this
43:08appliance that holds on to this
43:09contractor we make inside and.
43:11It pulls in and at this age
43:13it actually is able to.
43:15Promote growth at the level
43:17of the sutures right.
43:18Right where I was showing you in
43:19the very first slides where can
43:21still we can we can manipulate it
43:23and and cause activation within
43:24these sutures in the maxilla and
43:26and and effect and have the effect
43:28for it to actually grow downward
43:30and forward more and hence the
43:32airway would be become larger.
43:34So here's,
43:34here's an example of before and after.
43:36You see red is after yellow was
43:39before and how it's come forward
43:41and the mandible has gone down
43:43and back and the airway enlarges.
43:45The one thing that I really
43:47would like to mention
43:48just because there's a lot of talk about you
43:51know orthodontic treatment, taking out teeth,
43:54extraction of teeth and causes sleep apnea.
43:58And there there are a lot of dentists that
44:00actually claim that there's a lot of you
44:03know you know many, many I guess people
44:06in medical profession have heard that.
44:08So I would I would just like to go over
44:10this very quickly that when we take
44:13out a tooth we have reasons for it and.
44:16And like I said earlier too,
44:17one is that, you know,
44:19there's only so much around bone around the
44:21tooth and we don't want to compromise that.
44:24So just to show you here, for instance,
44:26if a tooth is extracted here,
44:27we can, we can use the space
44:29several different ways we can,
44:30we can push everything back from the front.
44:32There could be some movement from
44:33the front teeth and from the back
44:35teeth and then it could be that
44:36all the back teeth come forward.
44:37So again there's so many different
44:39ways we can manipulate, but we,
44:40we if we need to take out
44:42a tooth to make room for a,
44:43for another tooth that's
44:44impacted or when there are.
44:46Indications that actually extraction of the
44:47tooth is needed and if it's not extracted,
44:50it can have, you know, sort of.
44:53Side effects in a way.
44:55Umm, later on in life,
44:56if if not that.
44:57So there are times that it's it's effective.
44:59So for instance,
45:00I just want to show you a case of mine
45:02when I was doing my residency and this is,
45:04this is the mouth of an 18 year old boy
45:07with there's absolutely no room for
45:09these two canine teeth to be placed.
45:11So if if anybody would would tell
45:13me that you need to fit all these
45:14teeth and push these teeth out,
45:16create more room for the tongue.
45:17And because this kid is going
45:19to have sleep apnea,
45:19if you take out teeth that's,
45:21you know that that's the wrong
45:22thing to do because the.
45:23They cannot push these teeth out and not
45:26cause problems for this child who is now 18,
45:28not a child anymore,
45:29but you know by 45 is going to
45:32have recession all along here.
45:33And Umm, you know,
45:34sensitive teeth and all sorts of problems.
45:36So no, we, I took out four teeth,
45:38as we can see is missing.
45:40Now these two teeth are gone here,
45:41and the same thing on the lower 2.
45:43Teeth are gone.
45:45Everything's fit nicely.
45:46And if you look at the side lateral view,
45:48you know there's not a the airway,
45:50at least from this view.
45:51You can't see significant change in it there.
45:54There shouldn't be and it's not.
45:56And this is sort of the superimposition
45:58before and after you see them gone back.
46:00I actually had to push the
46:01top teeth back too,
46:02but essentially there's really.
46:04Not a significant change.
46:05So a lot of times we do have to take
46:07out teeth. But unfortunately there
46:09has been a recent talks of, you know,
46:13over the past few years that orthodontists
46:15are causing sleep apnea because
46:17they're taking out teeth and all that.
46:19Just, you know, just to give you an example,
46:21if I'm sure you will hear it
46:22at one point or the other,
46:24us being accused to, Umm, you know,
46:26adding to your patient population in a way.
46:28So the last thing I want to go
46:31over is the orthognathic surgery.
46:34Interventions that we do a lot to not
46:37during usually we tend to do that for,
46:39you know, when the children are done with
46:41growing but you know sort of bringing
46:43the jaws forward for orthodontic effort,
46:45they're, you know,
46:46sort of their function and their
46:48aesthetics of their faces.
46:49But also too we know how that
46:51would affect their Airways too.
46:52So the idea is that we can still, uh,
46:54when there is mandibular deformities,
46:56when there's efficiency in the
46:57mandible mandible,
46:58we don't have to necessarily
46:59wait for them to,
47:00you know be 2122 to do the
47:03surgery the if there is.
47:04As preoperative rate of growth is can
47:07be maintained after bilateral sagittal
47:10osteotomy or vertical Ramis osteotomy.
47:13If the rate of growth was normal and
47:16the the jaws were just very much they
47:19had a large discrepancy and we do the,
47:21we do the surgery then you know
47:23that it tends to grow at the same
47:25normal rate that it was going.
47:26Now if the rate of growth was deficient
47:28for the mandible prior to surgery then
47:30chances are that it continues the
47:32same way and the and the the child may need.
47:34And a second surgery later on.
47:36But a lot of times there could
47:38be indications that we have to do
47:40the surgery maybe when they're,
47:41you know, 1314.
47:43And then for maxillary deformities,
47:45if there's a very small maxilla now,
47:47now the problem becomes the like
47:49we have to realize that any laford
47:51maxillary osteotomy inhibits
47:52further growth of the maxilla.
47:54So a vertical growth continues
47:56at the presurgical rate.
47:57But because we can't expect much
47:59forward growth in the in the
48:01maxilla after the Lefort osteotomy,
48:03there has to be some overcorrection
48:05plans too.
48:06And the last thing I want to go over
48:08is another another study we did here
48:11at at BU looking at the effect of.
48:13Different types of surgeries and again
48:15different segments of the airway.
48:16Now we have again the nasal area,
48:19the nasopharyngeal area,
48:20oropharynx and hypopharynx and we looked
48:23at the maxillary advancement alone,
48:26mandibular advancement alone and
48:28then bimaxillary advancement.
48:30And I've just highlighted the significant
48:32changes in volume in each of them.
48:33And you can see that the next
48:35three advancement along the only
48:37significant change actually appeared
48:38in the oropharyngeal region with
48:40the mandibular advancement alone,
48:41same thing or financial region.
48:43Increased significantly.
48:44But when you put the two together
48:46and you do an MMA bimaxillary
48:48advancement now there is increase
48:50in nasopharyngeal cavity or pharyngeal
48:52cavity and hypopharyngeal cavity.
48:54Now because by bringing the maxilla
48:56forward now we're giving a chance for
48:59the mandible to be even further brought
49:01forward and in harmony with the upper jaw.
49:04And this is, this is what we're seeing
49:06both in the volume and this is the
49:09minimum cross section area that for all
49:11of them actually increased significantly.
49:14And then we showed that you know if
49:17there is any for every millimeter of
49:20anterior movement that the greater
49:22Palatine frame and that we that we
49:25measured for bimaxillary surgery for
49:27every anterior movement of the maxilla
49:30we we see so much increase in in volume
49:33and same way with the downward with
49:36every millimeter downward movement of
49:39the posterior nasal spine again we're
49:41seeing so much increase in nasopharyngeal.
49:44Gravity.
49:44So just to show you some pictures,
49:48this is an example of a
49:50mandibular advancement.
49:50You see how the mandible is so far back huge
49:53overjet and this is before surgery where
49:56the jaw was and where it's brought forward,
49:59just a single jaw.
50:01Mandibular advancement.
50:02And this is the facial change,
50:05the not sort of occlusion
50:07and then on the airway too.
50:09So this is where the jaw used to be.
50:11The upper is not touched practically
50:13this is where the initial.
50:14Position of the lower jaw,
50:16the final position and the increase
50:18in the in the airway as you can see.
50:21And from another view from the
50:23axial view again this is where you
50:25know the initial position and and
50:27after and how the airway changes
50:29and she's not going to go over the
50:31numbers much with you at this point.
50:33Skeletal class 3,
50:34that's when the maxilla is has not
50:36grown as much in a way it's smaller
50:39and it's not projected as much or the
50:42mandible appears to be to have grown so much.
50:45But really and truly most of the time
50:46really the mandible is is not at fault
50:48and it's the maxilla didn't grow much.
50:50So it's best.
50:51And also to for the airway,
50:53it's best to try and bring the maxilla
50:55forward as opposed to setting back the
50:57mandible and that's what we set up
50:59the patients for and we set them up
51:01and then they go through the surgery.
51:03So this was a double job because we
51:05don't want to do just the demand.
51:07Maxilla forward sometimes may affect
51:09the esthetics of the nose too depending
51:11on how much advancement we need.
51:12So then we sort of titrated not having
51:15to do just the mandible back and
51:18affecting the airway in a negative way.
51:21And then the most common one for sleep
51:23apnea maxillomandibular advancement and
51:25that it enlarges the pharyngeal airway space.
51:27It tightens the upper airway
51:29muscles and tendons and Umm.
51:31But the counterclockwise rotation
51:33especially there's 4547% increase that's
51:36been shown in the financial airway space,
51:39in the soft palate and at the
51:40base of the tongue.
51:41This goes up to 76%
51:44and another superimposition of it showing
51:48the before and after how that changes.
51:51It's a bimaxillary advancement
51:52and most of the changes you see is
51:55happening in the oropharyngeal area.
51:57I'm sorry I went very fast the last
51:59few slides, but that's all I got.
52:00Happy to answer any questions you may have.
52:08Doctor Orbach, I think
52:09you're on mute. You're muted.
52:18Sorry, we can't. I can't hear you.
52:21Alright, ask to mute.
52:27There you go.
52:28OK. Am I off? So thank you so much for
52:33such a wonderful talk, so thorough.
52:35I I wonder if we have a few minutes.
52:37And I think that people can unmute
52:40themselves to ask questions.
52:43If there are any people have any questions,
52:45they'll probably be the easiest way to do it.
52:48All right, let's see.
52:48Let me, I see. Doctor Robert
52:50Thomas has a question in the chat.
52:52So let him unmute himself first,
52:53then we'll go to Doctor Connor Perry.
52:58Yes, the question I had was
53:00the time it takes to remodel
53:02the face, say expansion and
53:05similar techniques months, years.
53:09Ohh sure. So what we do with expansion
53:11is generally it's definitely a month.
53:13So what we do is that the active
53:15portion of it would be probably
53:17weeks and then we sort of hold it
53:19to allow for a bone acquisition
53:21and remodeling to happen somewhere
53:23between four to six months after.
53:25And then we hold the teeth with with some
53:28sort of a retainer or will we go on to
53:30the to with the rest of the treatment.
53:34Already done in adults. I mean you
53:36had a crack in the bone to do that.
53:37But so that's what I was
53:40explaining earlier that the,
53:41the suture itself may not be a problem much,
53:44but there is the sort of the zygomatic
53:46buttress and the terrigal plates
53:48posteriorly that become really most of
53:50the resistance is coming from there.
53:52So that's why if we once we
53:54need to do it in adults,
53:55a lot of times we do need the surgeons
53:57to go in and uh, release those.
53:59So it would it would involve what
54:01we call a surgically assisted
54:03rapid maxillary expansion.
54:05A starpiece,
54:05so that that's sort of the indication here.
54:12Is that major surgery?
54:14It can be an uh in office
54:17surgery actually, but most,
54:18most surgeons that I know prefer,
54:21you know, to do it. But it's not.
54:23I think it's a day surgery not not
54:25keeping the patients overnight.
54:29Doctor Kenneth Perry.
54:30Hi, Doctor Parsi, thanks.
54:32That was such a interesting topic.
54:34I I work in Pediatrics.
54:37So these are issues that we we
54:39think about a lot and actually have
54:41two questions of first of all I I
54:43do wonder if you think there's any
54:44role for myofunctional therapy.
54:46I think you sort of kind of referenced
54:48a lot of the myofunctional therapy
54:50zealots talking about you can never
54:52pull out a tooth or someone's
54:54going to be a terrible airway and
54:56and and and the other question,
54:58but I do think there is some,
55:00there's some interesting.
55:01Stuff in the literature about that.
55:02And the other thing is if you think
55:04that this is something I think
55:05about with my kids when I see them
55:07looking at their phones all the time.
55:09If you think that having people
55:10have their head a lot in sort of an
55:12anterior head carriage is going to
55:14affect their airway adversely as well.
55:16I mean I I think I have the,
55:18I share the same sentiments that you
55:20with them like children on the phone too.
55:23And I can't imagine it wouldn't
55:24because again at the end of the day,
55:26I don't know.
55:27I mean the the tissues don't know what
55:29it is that's holding them in that position.
55:31So the response.
55:31Would be the same.
55:32We just have to hit the threshold.
55:33It just has to be held in that position
55:35long enough for the response to happen.
55:37If these are intermittent short
55:39instances it's fine.
55:40But if it's long instances that it,
55:43it's sort of like the same way
55:45that you were just mentioning the
55:47myofunctional therapies and there's
55:48definitely some some benefit to them.
55:50I'm not very well versed and I don't
55:53think there's really a lot of robust
55:55good peer reviewed literature out
55:57there unfortunately to to set up
55:59protocols for us on my functional
56:00therapy but for sure.
56:02When I see a sort of the anterior
56:04teeth not touching and I see a
56:06tongue that's just sort of sitting
56:08there at all times,
56:09then I know the reason there.
56:10So if that tongue would be trained
56:12not to sit in between those teeth
56:13and sit on the roof of the mouth,
56:15I see the teeth actually self
56:17correct most of the way if not all.
56:19So there is definitely some some
56:22benefit to to to a lot of it but.
56:26But like many other new things
56:27that we just don't know enough
56:29about and there hasn't been a good
56:31studies uh carried out.
56:33It's overused a lot of times with not
56:35having a good base knowledge about it.
56:40Thank you.
56:43All right, doctor Guaruja.
56:47OK, still need it, Sir. See.
56:52Doctor Barsi, absolutely fascinating.
56:54Thought so. Thank you for that.
56:57Thank you. There.
56:58There are some data which suggests
57:00that over the past several centuries,
57:03the human jaws may have shrunk
57:05or maxilla and our mandible.
57:07And that may be related to not
57:11eating some form. Yes. Yes.
57:13And then you suggested that mouth
57:16breathing itself can produce
57:18skeletal abnormalities which
57:20can contribute to sleep apnea.
57:22So do you feel lifestyle changes
57:25like like eating more solid food or
57:28ensuring nasal patency or ensuring
57:31even habitual nose breathing?
57:33Those can prevent sleep disordered
57:35breathing in some children.
57:37I mean, I guess the keyword here
57:39is in some children, as you said,
57:41the ones that would have otherwise,
57:43you know, have this anatomical
57:44contribution to it because, you know,
57:46you know better than me that that this is,
57:48this is a multifactorial animal we're
57:50dealing with that we can't, you know,
57:52just blame the anatomy on all of it.
57:54But you're absolutely right.
57:56I, I don't.
57:56But I don't know to what extent we could,
57:58we could ask a child of this day
58:01and age to be on a hard diet similar
58:04to our ancestors versus, you know,
58:06where things weren't cooked.
58:07You know so so I don't know realistically
58:09if what you're suggesting is doable
58:11so I think unfortunately we're we're
58:13dealing with the beast that we're
58:14dealing with and we have to play the
58:16game and and you know the the jaws
58:18are small but as absolutely I think
58:20nasal patency is huge I mean you
58:22know them not being able to bring
58:24the bring them out the their their
58:26the jaw falling back the the tongue
58:27sort of not sitting on the so imagine
58:30if if the tongue is not sitting on
58:32the palette now the the arch has
58:34it's only under the influence of
58:36the the pressure from the cheeks.
58:38The tongue is not sitting there
58:39to balance it out.
58:40So this this arch is going to grow,
58:42the maxilla is going to grow narrow.
58:43So if if we're able to not allow
58:45for the for the for the lower jaw
58:47to bounce down and back and then the
58:49the the time not to be out sort of
58:52lower and be where it needs to be.
58:54Yes a lot of this would be
58:56preventable absolutely.
58:57Wonderful.
58:57And and another very quick question.
58:59So I don't read a lot of children,
59:01but curious if someone has some
59:04increase in adenoids and has a small
59:07mandible and large tongue, would you
59:10go for adenoidectomy or joy expanders?
59:14I think actually we do.
59:15I think,
59:16I mean that's when I would
59:19really defer to our ENT,
59:22pediatric ENT physicians.
59:23We don't do just I mean if they if they
59:26think that I should be the one doing
59:29the sort of rapid maxillary expansion first.
59:31I get the referral from them.
59:32We tried,
59:32but I've had the opposite to that.
59:34They've had,
59:34they've done the annual tonsillectomy,
59:36it did not.
59:37It was only effective maybe a percentage
59:40and then they're sent to me to do more
59:42work with the expansion or whatnot.
59:45And then, you know,
59:46they may still need even more.
59:47They need to lose another, you know,
59:49100 pounds too or something.
59:50So it's just, uh, you know,
59:52that combination we do, we do,
59:53we sort of try to address all of them,
59:55sure. Yeah. Thank you.
59:59I think we've just about
01:00:00come to the end of our time.
01:00:02I would like to thank you again
01:00:04for such a fascinating talk.
01:00:06I wonder, I wonder if there
01:00:07are any other questions people
01:00:08could just e-mail you directly.
01:00:09Would that be OK?
01:00:10Sure, absolutely. Happy to.
01:00:12Great. And with that, thank you
01:00:15and I wish everybody a good day.
01:00:18Thank you so much for thank you
01:00:21so much everyone. Thank you.