According to the guidelines of the AAO (American association of orthodontists) it is advisable to submit each child to an orthodontic examination within 6 years to evaluate any breathing difficulties, to evaluate any anomalies in the dentition, to assess that swallowing takes place correctly and that the both skeletal and dental growth is harmonious.
In the dialogue between pediatrician and O.R.L. specialist, in the treatment of adeno-tonsillar hypertrophy of the child, the dentist is rarely asked for the diagnostic and therapeutic contribution that is instead in his / her possibilities to add.
In reality, in recent years, we have very often observed, since the beginning of an adequate orthognathic therapy, a clear improvement of these oropharyngeal pictures, and above all of the respiratory hepatologies which are connected to the obstructive hypertrophy of the Waldeyer ring.
We have therefore attempted to frame the orthognathic aspects that can intervene in the determinism and aggravation of obstructive syndromes. The most important connecting element is oral breathing. It is customary to frame the problem of oral breathing as the effect of adeno-tonsillar hypertrophy. On the other hand, it is our belief that some disorthodontic pictures can in many cases induce the establishment of oral breathing, and that the latter secondarily ends up favoring adeno-tonsillar hypertrophy.
When the child breathes with the mouth, in fact, a considerable amount of inhaled air jumps the physiological filter constituted by the ciliated nasal epithelium and invests, not preheated in the nasal cavities and sinuses, the adeno-tonsillar tissue. The hypertrophy of the latter, which follows, will end up aggravating the non-use of the nasal route to the point of excluding it, thus establishing a vicious circle.
The decreased respiratory flow will generate a pulmonary hypoventilation, with decreased gas exchange and a tendential reduction of the alkaline reserve.
Hypo-oxygenation can also interfere with the child’s intellectual development, it can make him apathetic and unable to concentrate and memory.
Even sleep is often agitated, with snoring breathing, interrupted by fits of coughing, up to dangerous episodes of apnea.
It should also be stressed that this is a “two-way” problem. In fact, if, as we will see, various types of malocclusion favor the onset of oral breathing and obstructive syndromes, on the other hand many respiratory problems can influence the type of growth and development of the mouth and skull which, in addition to giving the little patient the typical “Facies adenoidea”. it also ends up orienting dental occlusion towards some disorthodontic pictures. It is therefore a vicious circle that must be broken by implementing an appropriate orthognathic, physiotherapy and speech therapy therapy suitable for individual clinical pictures, regardless of whether the malocclusion is primary or secondary in the context of obstructive pathology, otherwise the failure of the medical therapy and the risk of surgical overtreatment.
The therapy, which we will call structural, is aimed at correcting dental malocclusion with appropriate orthodontic equipment, with speech therapy treatments for labial and lingual dysfunctions and altered breathing patterns, and with physiotherapy and chiropractic treatments for muscular tensions and posture defects. It is important to note that the orthodontist, in addition to being able to intervene on the open bite and thus fight oral breathing, has enormous possibilities to improve the patency of the nasal passages: in fact, by acting with rapid disjunctors on the median palatine suture, he can also enlarge 10-12 mm the base of the nose and, correcting the palatine ogive.
It will remove the invasion of the overlying nasal passages. The correction of deviated or retruded bites, in addition to returning to the tongue the endooral space that it needs for its functionality, in itself sufficient in many cases to restore nasal breathing, will correct the perverse orientation of the development in deviation of the nasal septum.
The mandibular repositioning, when indicated, is very often decisive and decisive also for various pictures of muscle-tension headache, recurrent otitis and vertigo. The speech therapist will take care of correcting atypical swallowing, incorrect attitudes of the perioral muscles and changing the thoracic-clavicular breathing pattern in favor of the diaphragmatic one.
The physiotherapist and the chiropractor will be called to solve postural problems, to detect any concomitant ascending causes, and above all to modify the muscle patterns that favor the establishment of the various dysorthodontic pictures: in deep bites, for example, it will be necessary to release the levator muscles of the mandible, while in open bites it will be very important to induce a elongation of the above and below hyoidi.
With this diagnostic and therapeutic approach it is possible to intercept and radically resolve cases of respiratory diseases in which the pathogenetic role supported by dental malocclusion is evident. In doubtful cases it will not be useless to start with a minimal orthodontic treatment, substantially free of contraindications and an effective biological price, resorting to the surgeon in cases of failure. In cases where surgical treatment appears unavoidable, the contextual structural treatment will constitute a valid collateral therapy. In any case, it is good to keep in mind that, if the malocclusion is present, it will have to be treated sooner or later, and therefore rather than indications for orthodontic therapy it is actually more correct to speak of indications for anticipating a therapy that would in any case be earlier. or then put in place: also for this reason we can be sure that the structural treatment of obstructive respiratory diseases is, in addition to being a source of great satisfaction for the doctor and the patient, substantially without an effective biological price.
MALOCCLUSIONS AND OSTRUCTIVE RESPIRATORY PATHOLOGIES
RIS – Italian Journal of Stomatology – number 10-October 1994
E. Bernkopf *, V. Broia **, A. Bertarini ***