MAY LEAD TO OSA, TMD, SPEECH

AIRWAY CENTRIC

Airway , Breathing and Sleep

A Collaborative Approach

AAPMD.ORG

HIGH, NARROW PALATE IS ONE SIGN OF OSA (KUSHIDA, EFRON, GUILLEMINAULT, 1997)

LOW TONGUE REST POSTURE MAY LEAD TO A HIGH

NARROW PALATE

RESTRICTED TONGUE

MYOFUNCTIONAL THERAPY AND

TONGUE-TIE RELEASE DR BILL HANG

LASER RELEASE

BRAZILIAN PROTOCOL (IRENE MARCHESAN)

LINGUAL FRENULUM DR IRENE MARCHESAN

• Normal

• Anterior

• Short

• Short and Anterior

• Ankyloglossia

AIRWAY CENTRIC

ENLARGED TONSILS

FRIEDMAN AIRWAY CLASSIFICATION

AIRWAY CENTRIC

FRIEDMAN AIRWAY CLASSIFICATION

AIRWAY CENTRIC

MODERN BULLDOG NY TIMES NOV 22 2011

AIRWAY CENTRIC

•Protrusion of

tissue in the

main airway

•Elongated soft

palate

•Dry nose

•Pinched nostrils

•Tongue and

Palate

Compressed

•Abnormal

number of

teeth

•Abnormal

tooth

Placement

•Congenital

heart disease

•Short Face

BULLDOG EVOLUTION NY TIMES NOV 22 2011

AIRWAY CENTRIC

MODERN BULLDOG IDEAL BULLDOG

AIRWAY CENTRIC

THE MODERN BULLDOG

AIRWAY CENTRIC

•Thick neck

•Snores

•Collapsed airway

•Malaligned jaw

•Elongated soft

palate

•OSA Heart

disease

AIRWAY CENTRIC

GELB 4/71. The first parallel is drawn at the top of the

fossa

2. The second parallel is drawn at the bottom

of the fossa

3. The third parallel is formed by dividing the

distance between the top and bottom of

the fossa

4. The first perpendicular extend from the top

edge of the fossa.

5. Trace the second perpendicular from the

intersection of the slope of the fossa and

AIRWAY CENTRIC

SLEEP STAGES

AIRWAY CENTRIC

AIRWAY CENTRIC

AIRWAY CENTRIC

ANATOMIC RISK FACTORS SDBDEATH,NASOMAXILLARY COMPLEX AND SLEEP IN YOUNG CHILDREN EUR J PED

2012

Facial Features are present at Birth

• High and Narrow hard Palate

• Mandibular Retrusion

• Enlarged Tonsils

• Enlarged Adenoids

• Deviated nasal Septum

• Small Upper Airway

• Insufficiency of Bony NasoMaxillary Complex

AIRWAY CENTRIC

NIGHTTIME DAYTIME

• Mouthbreathing

• Habitual Snoring

• Witnessed Pauses

• Restless Sleep

• Frequent Awakenings

• Sleep Bruxism, PLM

• Sleeptalk, walk, terrors

• Confused arousal

• Nocturnal Migraine

• Drooling

• Abnormal Sleep Pos

• Morning headache

• Mouthbreathing

• Excessive thirst AM

• EDS and Fatigue

• Shy, Withdrawn, Depressed, Irritable

• ADHD, Aggressiveness

• Poor Concentration

• Learning Difficulty

• Memory Impairment

• Poor Academic Perform

J CranioMand Function Vol 3 Autumn 2011

AIRWAY CENTRIC

ANATOMIC RISK FACTORS SDB

• Macroglossia

• Tight Frenums

• Nasal obstruction

• Craniofacial anomalies

• High Mallampati

• Allergies

• Obesity

AIRWAY CENTRIC

OBSTRUCTED NASAL BREATHING

SINHA AND GUILLEMINAULT 2010

• Large adenoids and tonsils

• Chronic Mouth breathing

• Changes in facial growth

• High arched palate

• Poor maxillary growth

• Narrow nasal passages

• Narrow dental arches

• Long face

• Retrognathic mandible

AIRWAY CENTRIC

PEDIATRIC OBSTRUCTIVE SLEEP APNEA AND

THE CRITICAL ROLE OF ORAL-

FACIALGROWTH:EVIDENCES

• T and A (Guille 2004) only 51% full resolution

• Not curative in 40-70% of cases

• Due to large tongue , small mandible, dev nasal septum – nasomaxillary complex and

narrowing behind the tongue

AIRWAY CENTRIC

LESSONS FROM ORTHODONTICS

• Abnormal nasal resistance induced by high narrow palate and enlarged t and a assoc w

mouth breathing led to craniofacial changes

• Blockade of nasal passage led to narrowing , dec max arch length , anterior x bite, max oj

and incr anter face height

• Inc nasal resis halted maxillary growth

• Narrowing of the cranial skeleton

• Reversible in the developmental phase

AIRWAY CENTRIC

HUANG AND GUILLEMINAULT 2013

• 82% of studied infants high narrow palate

• Enlarged T and A came later after mouth breathing

• Bottle feeding led to abnormal palate at 6 mo

AIRWAY CENTRIC

ORAL-FACIAL MUSCLE HYPOTONIA

• Abnormal nasal resistance early in life leads to mouth breathing associated with abnormal

muscle tone , oral-facial hypotonia and secondary changes in max-mand growth

• Myofacial hypotonia led to recurrence of SDB after T and A and orthodontics

AIRWAY CENTRIC

LOCAL AND SYSTEMIC INFLAMMATION

• Increased nasal resistance and allergy

• Tonsils and adenoids

• Edema and inflamm cell infiltrate

• Increased CRP

• Episodic hypoxia and arousal

• Endothelial Dysfunction

• Systemic Inflammation

• Increased BP

• Increased insulin resistance

AIRWAY CENTRIC

SUMMARY

• Premature infants have high narrow palates, oral-facial hypotonia , abnormal tongue position,

and mouth breathing

• Retraining of the muscles with exercises and myofunctional therapy restored nasomaxillary

complex and mandible , repositioning of the tongue and normalization of breathing

AIRWAY CENTRIC

MOUTHBREATHING-SNORING>27% OF KIDS

AIRWAY CENTRIC

SDB –NEUROLOGIC EFFECTS MAY BE IRREVERSIBLE BONUCK ET AL J PEDIATRICS APRIL 2012

• Peaks 2-8 yrs of age

• Critical Period of Brain Development

• Peak period of Adeno-Tonsillar

hypertrophy

• 10-21% snoring at 6-81 mo

• Symptoms peak 30 mo

• 40-100 % increase in neurobehav

morbidity at age 7

AIRWAY CENTRIC

SDB- OSA, MOUTHBREATHE, SNORE

BONUCK 2012

• Behavioral Difficulties

• Inattention/Hyperact

• Anxiety/depression

• Peer Problems

• Conduct Aggress/Rule breaking

• Impaired Exec Function

• Age 4 20-60%

• Age 7 40-100%

• 200% inc hyperactivity

AIRWAY CENTRIC

BREASTFEEDING 2-5 MONTHS PROTECTS AGAINST

SDB

AIRWAY CENTRIC

ADHD LD SPECIAL ED BONUCK ET AL J PEDIATRICS OCT 2012

• If Child has ADHD then 8X incidence of LD

• 8X incidence of Anxiety

• 3X incidence low social competence

• 40-80 % of 3 million kids in Special Ed for

dev disability also have ADHD

AIRWAY CENTRIC

Breathing

Defensive

Response

Sleep Disturbance

David Gozal, M.D.

ApoE e4 allele CRP and

Neurocognitiv

T and A

Metanalysis

Low O2 Levels

Genes

DNA Methylation

PEDIATRIC

SLEEP

DISORDERS

ED and

Neurodeficits

David Gozal, M.D.