Airway centric(™)2
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MAY LEAD TO OSA, TMD, SPEECH
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AIRWAY CENTRIC
Airway , Breathing and Sleep
A Collaborative Approach
AAPMD.ORG
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HIGH, NARROW PALATE IS ONE SIGN OF OSA (KUSHIDA, EFRON, GUILLEMINAULT, 1997)
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LOW TONGUE REST POSTURE MAY LEAD TO A HIGH
NARROW PALATE
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RESTRICTED TONGUE
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MYOFUNCTIONAL THERAPY AND
TONGUE-TIE RELEASE DR BILL HANG
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LASER RELEASE
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BRAZILIAN PROTOCOL (IRENE MARCHESAN)
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LINGUAL FRENULUM DR IRENE MARCHESAN
• Normal
• Anterior
• Short
• Short and Anterior
• Ankyloglossia
AIRWAY CENTRIC
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ENLARGED TONSILS
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FRIEDMAN AIRWAY CLASSIFICATION
AIRWAY CENTRIC
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FRIEDMAN AIRWAY CLASSIFICATION
AIRWAY CENTRIC
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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
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BULLDOG EVOLUTION NY TIMES NOV 22 2011
AIRWAY CENTRIC
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MODERN BULLDOG IDEAL BULLDOG
AIRWAY CENTRIC
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THE MODERN BULLDOG
AIRWAY CENTRIC
•Thick neck
•Snores
•Collapsed airway
•Malaligned jaw
•Elongated soft
palate
•OSA Heart
disease
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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
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AIRWAY CENTRIC
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SLEEP STAGES
AIRWAY CENTRIC
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AIRWAY CENTRIC
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AIRWAY CENTRIC
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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
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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
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ANATOMIC RISK FACTORS SDB
• Macroglossia
• Tight Frenums
• Nasal obstruction
• Craniofacial anomalies
• High Mallampati
• Allergies
• Obesity
AIRWAY CENTRIC
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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
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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
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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
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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
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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
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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
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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
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MOUTHBREATHING-SNORING>27% OF KIDS
AIRWAY CENTRIC
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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
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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
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BREASTFEEDING 2-5 MONTHS PROTECTS AGAINST
SDB
AIRWAY CENTRIC
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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
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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
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David Gozal, M.D.
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