FEATURE This article has been peer reviewed.

Compromised Airway and Atypical Facial Growth in The Adult Patient: A Case Study in the Redirection of Facial Growth

By Catherine M. Sherry, DDS

Abstract: Abstract: This case history is an adult patient with a compromised upper airway, soft tissue dysfunction, and atypical facial growth. The nasal deviation and enlarged turbinates resulted in mouth-breathing and soft tissue dysfunction. Atypical growth occurs when the biological balance between bone remodeling and positional displacement is disrupted. Following septoplasty and turbinate reduction to reestablish nasal respiration and myofunctional therapy to retrain the muscles, the atypical growth was redirected to normal. The final result was an overall improvement in general health, esthetics, and well-being. Keywords: Atypical facial growth, deviated septum, adult compromised airway,myofunctional therapy, soft tissue dysfunction, redirection of facial growth.

ntroduction preventive care for children as young as 1-2 years of age, as well “Dentists are the gatekeepers of the airway.” I first as continuing care for the adult population who suffer from a heard this statement in the early 1980s from Dr. compromised airway. By forming a support community which Waldemar Brehm. I began to better understand includes a wide diversity of health care providers, treatment my responsibility for the patient’s general health as the number can be expedited, and patients will experience the best possible of my patients I diagnosed with airway issues continued to outcome. rise over the next 30 years. I saw how the asymmetry and Enlow2 described the “function of the airway as the imbalance of the muscles and soft tissue affected facial structure. keystone of the face.” The keystone of the face is that part of I observed the health issues related to poorly directed growth the arch if of proper shape and size, stabilizes the positions of and development. It was rewarding to witness improvements the remaining parts of the arch. There are many “arches” in the in health, appearance, and self-esteem. For me, this has been face. The arches of the orbits, the sinuses, the zygomatic arches, the most important and challenging part of dentistry. I feel the palates, etc. are all subject to the airway configuration, size, certain that without this early focus in my career, the patient and integrity. The airway is strategically pivotal to all of them. in this case could have been dismissed in a few minutes after a The influence of the lips and cheeks as well as the position of routine retainer check had I not learned to be a “gatekeeper of the tongue modifies the arches and the fact that almost every the airway.” offers some noticeable manifestation of the I definitely agree that “…the vast majority of health care function of the soft tissues was reported as long ago as 1907 by professionals are unaware of the negative impact of upper Angle.3 compromised airway () on normal facial growth and physiologic health. Children whose mouth breathing is Normal Breathing untreated may develop long, narrow faces, narrow mouths, Breathing is a primal function necessary for survival and high palatal vaults, dental malocclusion, gummy smiles, and thus a reflex function that prevails over all regulatory brain many other unattractive facial features, such as skeletal Class II activity. Humans are obligate nasal breathers and use their or Class III facial profiles. The compromised airways in these mouths as a backup.4 Ideally, one should breathe through the children cause a lack of sleep which can adversely affect their nose 8-12 times/minute, with the tongue resting on the palate. growth and academic performance. Many of these children The nose controls the volume of the air and is designed to filter, are misdiagnosed with attention deficit disorder (ADD) warm, and humidify the air. It’s been estimated that 75% of the and hyperactivity. It is important for the entire health care bacteria entering the nose are deposited in the mucus blanket community (including general and pediatric dentists) to screen and are thus eliminated.5 Nasal respiration reduces the number and diagnose for mouth breathing in adults and in children of upper respiratory infections common in mouth breathing as young as 5 years of age. If mouth breathing is treated early, patients. its negative effect on facial and dental development and the medical and social problems associated with it can be reduced or Soft Tissue Dysfunction averted.”1 Soft tissue dysfunction is defined as any alteration in the My objective is to help raise awareness and improve normal muscular activity of the masticatory muscles as well education so that health professionals will be able to offer as the muscles of the tongue, lips, and cheeks.3 Soft tissue

IJO  VOL. 27  NO. 2  SUMMER 2016 61 dysfunction is often the first observable sign of a compromised facial growth are the airway and the manner in which the tongue airway. The resulting facial disharmony is noticeably functions. unattractive. Lips should be together at rest. Ramirez3 describes how Compromised Upper Airway equilibrium is reached between the forces of the tongue and Upper airway compromise can be defined as a restriction of lips. The main structure of the lips are the upper and lower nasal breathing caused by one or many factors: heredity, growth orbicularis oris muscles and when at rest with a lip seal, there and development, trauma, environment, and many others13 that is no activity in either muscle. The mentalis muscle activity is alter the free flow of air through the nose, over the turbinates, negligible. The incisors are maintained since the tongue delivers and in and out of the lungs. A proper sequence of ventilation is a higher but non-continuous force on the lingual surface of the necessary for normal growth.11 incisors, whereas a lower but continuous force is delivered by the The signs and symptoms of a compromised airway are lips on the buccal surface of the anterior teeth. mouth breathing, tongue thrust, grinding of teeth during When a patient has no lip seal or incompetent lips, there sleep, restless sleep, allergies, hyperactivity, limited attention is greater muscular activity of both the orbicularis oris and the span, crowded teeth, crossbites, dull appearance of the eyes, mentalis muscle. The appearance of the overactive mentalis dark circles under eyes, stoop shoulder posture, neck extended muscle is often referred to as a “golf ball chin,” which is with mouth open, small nostril size, speech hyponasality, noticeable clinically. nasal secretions, and hearing difficulties.11 Additional facial During the subconscious swallow, the teeth should be in characteristics are inactive lips lacking tonicity, short upper or near contact, and there should be no movement of the facial lip, maxillary incisors visible, and a low degree of facial muscles. One swallows 1,000-2,000/day, and ideally the tongue animation.4 Increasing awareness of these symptoms among is resting on the roof of the mouth.6 When the muscles of the vast professional health community, including parents mastication are out of balance, there is often a compensation of and schoolteachers will help patients receive medical attention the facial muscles. sooner. Many of these isolated signs are also completely ignored, misunderstood, or dismissed. As a group, these symptoms Facial Growth have several relationships that when grouped together can help Enlow2 states that facial growth operates by a distinction diagnosis the underlying cause. Too often these children may between the two basic kinds of growth movement: remodeling have an odd appearance or behavior and may fall into the group and displacement. Each category of movement involves that typically gets “picked on and picked last” or bullied by virtually all developing hard and soft tissues. Facial growth their classmates. Some of these children are simply ignored and and development is a strictly controlled and ongoing biological without treatment, they will not reach their full potential. process. Bone growth is not predetermined within the bone A change from a nasal to a mouth breathing pattern induces itself but relies on growth-regulating signals derived from the functional adaptations that have –for at least a century – been functions of the surrounding soft tissue. Facial growth is directed associated with a deviant craniofacial growth pattern. The by the signals that lie in the muscles, tongue, lips, cheeks, typical morphological characteristics associated with nasal integument, mucosa, connective tissue, nerves, blood vessels, impairment can be summarized as follows: an increase in total airway, pharynx, tonsils, adenoids, and other organ masses.7 anterior facial height which is mostly contributed to by a more Forward growth of the face is driven by the tongue, which is vertical development of the lower anterior face. Also an increase gram for gram, the strongest muscle in the body. It is capable of in the mandibular plane and gonial angles and a tipping of exerting forces as high as 500 gms. on the lower anterior teeth.7 the palate can be found. Facial is reported to be Proffit8 has stated that one of the primary factors in maintaining decreased.14 dental equilibrium is the resting pressure of the tongue. In 1970-80s, a series of students by Linder-Aronsen11 A mouth breather lowers the tongue position to facilitate consistently supported the relationship between nasal the flow of air in to the expanding lungs. The resultant effect is obstruction and dental and facial development. His studies maldevelopment of the jaw in particular and deformity of the included a group of patients of post-adenoidectomy patients face in general.9 Mouth breathing and low tongue posture are who returned to nasal respiration and showed a significant shift associated with a forward head posture. Ricketts10 maintained back toward horizontal mandibular growth. that in order to compensate for nasal obstruction, the functional In the famous Harvold12 monkey research, rhesus monkeys answer was to extend the head posture to facilitate breathing were forced to breathe through their mouths by placing latex through the mouth. This leads to habitual poor posture and its nasal plugs. All these monkeys developed craniofacial changes further complications. and crooked teeth. Other facial deformities developed included: Enlow11 notes, “Everything that develops, develops around a lowering of the chin, a steeper mandibular plane angle, and the airway, the airway is the central hub of development, any an increase in the gonial angle as compared with the control event that alters the free flow of air passing over the airway animals. The sudden change from nasal to oral respiration causes dysplasia.” McNamara12 found that “mouth breathing is caused changes in the muscles of mastication, and the monkeys an inevitable result of obstruction of the nasal airway, and when developed long faces. it becomes predominant, it frequently leads to malocclusion As reported by Champagne, 12 others such as Bresolin, et and atypical facial growth.” Whereas, Galella4 added that the al., found that mouth breathers had longer faces with narrower two major factors that generally influence the delicate balance of maxilla and retrognathic jaws, and Trask, et al found that allergic

62 IJO  VOL. 27  NO. 2  SUMMER 2016 children also had longer faces and more retrusive jaws than the interaction with the environment. In contemporary Western control group. society, there is a widespread growing interest for facial esthetics. Compromised upper airway is also important in the study The most common reason for seeking and surgical of how it relates to sleep disordered breathing (SDB) and the treatment is the desire to improve facial esthetics.18 Beauty relation to anxiety disorders. Sleep disordered breathing (SDB) means social power and success and has a positive influence and sleep apnea are becoming more prevalent in society. There in all areas of civilized society.19 Individuals who are blessed are profound effects on the health and well-being of not only with attractive features are treated differently in our society. the ones who suffer from SDB but also the ones who live with “Attractive people do better: in school, where they receive more them. In a theoretical review, apnea/hypoapnea that occurs help, better grades and less punishment; at work, where they during SDB serves as the chronic physical stress which causes are rewarded with higher pay, more prestigious jobs and faster the symptoms of anxiety disorders as manifestations of a chronic promotions; in finding mates, where they tend to be in control allostatic challenge.17 Further studies such as this may help in of the relationship and make most of the decisions; and among the diagnosis and treatment of a variety of disorders relating to strangers, who assume them to be more interesting, honest, anxiety and SDB. virtuous and successful.”20 The direct target for clinical intervention must be the The ancient Egyptians (5,000BC) were possibly among control process which regulates the biology of facial growth, the first to deal with harmonious proportions of the face and which is the influence of the soft tissue and the neuro- body. The ideals of beauty and harmony are reflected in the musculature.6 This paper is limited to examination of the monuments of that time (King Mycerinus, Queen Nefertiti).19 deviated septum and enlarged turbinates. Today it is accepted that “A good-looking face is determined by a strong, sturdy chin, developed jaws, high cheekbones, good lips, correct nose size, and straight teeth. When a face develops Nasal Septum correctly, it follows that the teeth will be straight. Straight The nasal septum is the structure that divides the nasal teeth do not create a good-looking face, but a good-looking passages into the right and left sides. A deviated septum refers face will create straight teeth.”21 Mouth breathing is considered to a septum that is crooked and often results in a compromised unattractive. Nasal breathing in public is considered to be airway. Septal deviation is common in up to 75% of the U.S. socially acceptable and more attractive than mouth breathing.5 population, and septoplasty ranks as the third most common People determine personal attractiveness from the frontal head and neck operation. It has a 71% success rate of achieving view18 since this is the view that most people have during at least a 50% reduction in nasal symptoms. The first attempts the usual mode of communication. Many clinicians have at reconstruction date back to ancient Egypt in treatment of stressed the importance of virtual soft tissue assessment for broken noses. The most modern approaches being improved by facial esthetics. But every lay person knows inherently what is the use of endoscopy in which vastly improved visualization.15 beautiful to the eye.20 A study was done to evaluate the effects of The turbinates are structures on the side wall of the inside vertical dimension on frontal facial attractiveness and perception of the nose that project into the nasal passages as ridges of of lower facial height (LFH) changes by lay people. It was found tissue. The turbinates help warm and moisturize air as it flows that the LFH did influence lay people’s perception of facial through the nose. They are made of bone and soft tissue, and attractiveness and the amount of change in the (LFH) where the either the bone or the soft tissue can become enlarged. Most subjects would seek treatment. More than 80% of lay people commonly, the soft tissue part of the turbinate enlarges, touches were able to detect a difference of 1mm in LFH in silhouettes of the nasal septum, and airflow is blocked.16 Medications can both male and females.18 help reduce the size of the turbinates in some patients and help Ricketts20 attributes this ability to appreciate faces and other improve nasal obstruction. In many cases, turbinate surgery and forms of ideal proportion to the sub-conscious or primitive septoplasty are performed at the same time as was done in this portion of the brain. Every living organism is genetically case. encoded to visually appreciate forms, including the human face, Galella4 describes how “when proper neuromuscular that are in ideal proportions. This ability to appreciate ideal function is achieved, the soft tissue signals create an environment shapes and forms is universal and transcends race, sex, and age. where the ramus is able to upright through remodeling. The These certain rigid dimensions are often called divine proportion remodeling combined with the improved nasal respiration, or golden proportion. increased lip seal, and improved swallow pattern reverses the Ricketts20 reports that esthetic appreciation of shapes and vertical growth and shortens the face. It advances the mandible forms was first described by Phidias, a Greek sculptor. This from the retruded position. With the return to nasal breathing, relation is named Phi (ϕ = 1.618) and goes back to the famous the facial bones are stimulated to return to normal by the Greek sculptor Phidias, who used it in his architecture (the muscles of mastication, thus setting off a plethora of facial temple of Parthenon). He noticed an ordered relationship growth changes. Retraining the swallow patterns moves the of spatially-related parts in nature, later defined as divine or tongue to a more ideal position which again stimulates growth golden proportion, that are instinctively appreciated as being changes in the nasomaxillary complex and the mandible.” beautiful.20 Bonacci, a scholar in 1202, published his findings that the multiplication rates of rabbits eventually reaches a Facial Appearance point where each new addition grew at precisely 1.618 times the Facial appearance is fundamental for communication and previous number, and this ratio of added population increases

IJO  VOL. 27  NO. 2  SUMMER 2016 63 on into infinity. The knowledge of divine proportion was well known to Leonardo Da Vinci and the best example of this is in his famous drawing, Human Figure in a Circle, Illustrating Proportions, 1485-9019 (Figure 1). Phi is present in the patterns and proportions of physical design in many living creatures, flowers, and insects. The most notable appearance is in the human form. Key features of the human face can embody many golden ratios, leading to our perceptions of beauty (Figure 2). Figure 1: Leonardo Da Vinci Phi also appears in the body temperatures, and even in the Human figure in a Circle. dimensions of our DNA. Many forms of architecture and art comply with the proportions of the divine proportion.19 When living organisms reach their maximum genetic potential and “divine proportions” are met, they are at their peak biological efficiency and health. Faces that are in ideal proportions do in turn tend to have less physiologic problems such as a compromised airway, TMD, migraine headaches, head- neck-shoulder and back pains, posture problems, sleep apnea, and a multitude of other problems. Ideally proportional faces are also visually considered to be beautiful.20

Case Report A 27 year-old white, female patient presented for Invisalign® treatment to correct minor lower anterior crowding (Figures 3-4). The orthodontic treatment was completed and retainers were placed and the patient did not return for 4 Figure 2: Facial Golden Proportions. years. In childhood, the patient had several airway issues: ear infections, numerous infections of tonsillitis, hayfever, and dust allergy. Ear tubes were placed, and the tonsils and adenoids were removed at age 10. She received orthodontic treatment at age 12 for minor crowding. Her wisdom teeth were extracted at age 14, at which time her facial features were symmetrical and attractive (Figure 13).

Examination Figure 3: Patient age 27, The patient returned for a routine retainer check 4 years Pre-Invisalign. later, and her was stable. The retainers fit well, and she wore them nightly. She had the general appearance of ill health. Her facial features had changed remarkably since her last visit. The patient had a doliocephalic face with increased lower facial height and angular features with a more pointed chin. The nose was displaced to the left side, which was the side of the deviation. The left nares was smaller than the right. There was a lack of lip seal and asymmetry of the lips. The upper lip was flaccid and asymmetrical in the bow area. The pupils of the eyes were asymmetrical and uneven with excess sclera showing (Figure 5). She reported an increase in headaches, poor sleep, and mild anxiety. The patient had not noticed the facial changes in the past few years but was aware of her mouth breathing and nasal congestion. She had a facial accident three years previously where she received a blow on the bridge of the nose. No diagnosis, x-rays or treatment followed the accident.

Diagnosis The patient suffered from a compromised upper airway. She exhibited signs of soft tissue dysfunction and atypical facial growth. She was a habitual mouth breather, experienced mild anxiety and poor sleep. She also reported an ear problem in the right ear and was referred to an ENT for evaluation (Figure 6). Figure 4: Patient age 27, Pre-Invisalign composite.

64 IJO  VOL. 27  NO. 2  SUMMER 2016 to rest in the palate. See Figure 7 for a 4-week post-op facial photo.

Myofunctional Therapy Myofunctional therapy, also known as oral myology, is the neuromuscular re-education or re-patterning of the oral and facial muscles. The training involves eliminating negative oral habits through behavior modification.22 The goals of oral myology are: 1. Promoting a lip seal 2. Promoting palatal tongue rest position 3. Facilitating nasal breathing Figure 5: Patient age 31, Figure 6: Patient at age 33, 4. Promoting a posterior, tooth together swallow Following facial injury and Pre-op septoplasty, reflects 5. Facilitating bilateral chewing and correct drinking resulting atypical growth. additional facial atypical 6. Keeping hands and objects away from the face growth and asymmetry. 7. Developing a harmonious peri-oral muscle pattern 8. Correcting dysfunctional habit patterns22 The first three are usually recognized as the main goals: Lips together, breathing through the nose, with the tongue in the “N”spot. Patients are instructed to say the letter “N” so they can identify where the tongue should rest on the palate, behind the top front teeth.

Myofunctional therapy used: • Lip trainer®was used 5 min 2x day • Lip pop exercises (myofunctional therapy) • Tic Tac® on palate exercise • Mouth tape by Buteyko® ® Figure 7: Patient 4 week • Breathe Right nasal strips post-op septoplasty and The Lip Trainer® is a myofunctional appliance which turbinate reduction. is placed between the lips and then pulled with a strap. The objective was to increase strength of the orbicularis oris, facilitate a lip seal, and to stretch the lower lip muscles to reduce over- activity during swallowing. It was used for 5 minutes twice daily (Figure 8). The lip pop exercise is a myofunctional exercise to increase Figure 8: Lip Trainer used 5 lip strength and effect a lip seal. The lips are tucked in with none minutes twice daily. of the lip visible and then forcibly “popped” out. It was done 30 times twice daily in front of a mirror. The TicTac® exercise was used to keep the tongue in the “N” spot by having the patient place a TicTac® in the mouth on Treatment Objectives the “N” spot until it melted. This was done 4-5 times daily. The treatment objectives were to restore nasal breathing, Mouth tape by Buteyko® was used to seal the lips and promote lip seal, and a palatal tongue resting position. The facilitate nasal respiration without conscious effort on the part of causative factors needed to be resolved, the compliance was the patient during sleep. essential, and the treatment needed to be stable with minimal- BreatheRight® strips were used to improve nasal respiration to-no relapse. during sleep.23

Treatment Results The ENT specialist diagnosed a deviated septum and The patient returned 18 months later for a check-up, and hypertrophy of the turbinates. There was cerumen impaction photos were taken (Figure 9). The occlusion was stable. There in the right ear. She was scheduled for a simple septoplasty, were many facial changes. The pupils of the eyes were in good turbinate reduction, and the removal of a small mole above the alignment. The nose was straight and no longer bent to the left. upper lip. The lower third of the face was symmetrical, and the angularity The surgeon’s treatment objective of restoring nasal of the mandible had remodeled to a pleasing and gentle curve of respiration was achieved. Following surgery, myofunctional the lower jaws. therapy was added to improve and establish good nasal The lips comprise the key esthetic feature of the lower third respiration, strengthen the orbicularis oris, and train the tongue of the face, with the upper lip having an especially significant

IJO  VOL. 27  NO. 2  SUMMER 2016 65 effect on the esthetic judgment of the face.24 The patient’s upper lip had a more defined bow, and the overall symmetry improved which is consistent with the current trend toward fuller lips being considered more beautiful. Models in the last century have had a gradual increase in lip prominence, making lip augmentation more popular. No augmentation was done in this case (Figure 10). Templates from Phi Matrix® were superimposed on the facial photos to reflect changes in facial features according to the Golden Proportion measurements (Figures 11-12). The health changes noted by the patient were an improvement in the quality of sleep, an increased ability to Figure 9: Patient concentrate, and a decrease in anxiety. Her mouth breathing age 34, completed decreased as the muscle tone of the lips improved. Her treatment. level of energy and confidence increased, and she reported an improvement in her quality of life. She acquired new employment as an actress and screen writer. Her appearance mirrored her facial features of 20 years earlier (Figure 13).

Conclusions The objectives of the surgery and the myofunctional treatment were met. The patient re-established nasal Figure 10: Competent lips following respiration and lip seal. The change from mouth breathing to myofunctional therapy. nasal breathing promoted a normalization of the craniofacial dimensions of growth. Her general health improved as well as her facial appearance. The limitations of the findings of this case study are inherently limited by the data being only clinical examination, non-clinical photographic images, and subjective reports of the patient. Champagne12 stated that the half-life of scientific knowledge is approximately 7 years, which implies that half of everything we know must be updated every 7 years in order to keep our knowledge current. Prospective studies are necessary using cone beam and other technology for a more objective analysis of the mode of respiration and its influence on facial growth as well as the improvements in the overall health and well-being of the patient. An interdisciplinary approach to patient care is the best way to ensure good health. We must communicate effectively with other specialities including, but not limited to, dentists Figure 11: Surgical Pre- Figure 12: Completed of all specialities, pediatricians, primary care physicians, op age 32 (phi matrix treatment. Final age 34 (phi allergists, plastic surgeons, otorhinolaryngologists, chiropractors, template). matrix template). speech therapists, lactation specialists, physical therapists and myofunctional therapists.

References 1. Jefferson Y. Mouthbreathing: Adverse effects on facial growth, health, academics and behavior, Gen Dent 2010 Jan-Feb;58(1) 18-25. 2. Enlow DH, Hans, MG. Essentials of Facial Growth. New York: W.B.Saunders Co., p12-13 3. Ramirez-Yanez G, Farrell C. Soft Tissue Dysfunction: a Missing clue when treating , International Journal of Jaw Functional Orthopedics 2005:1(4):351-9. 4. Galella S, Chow D, Jones E, Enlow D, Masters A. Guiding atypical facial growth back to normal, Part 2: Causative factors, patient assessment and Figure 13: Patient age treatment planning, International Journal of Orthodontics 2012; 23(1):21- 14. Facial Symmetry 30. present before airway 5. McKeown P. Close Your Mouth, 2004, Galway: Loughwell,Moycul, 30-32. was compromised by 6. Flutter J. The key to facial beauty and optimal patient health – Part accident. 1,Australasian Dental Practice, July/August 2009, 146-150.

66 IJO  VOL. 27  NO. 2  SUMMER 2016 7. Galella S, Chow D, Jones E, Enlow D, Masters A. Guiding atypical growth 22. Moeller J. Orofacial myofunctional therapy: The critical missing element back to normal Part 1: Understanding facial growth, International Journal to complete patient care. Dentaltown Magazine, August 2010:1-5. Of Orthodontics 2011; 22(4):47-54. 23. Page DC. Your jaws your life, 2003.,Baltimore, MD: Smile Page 8. Takahashi S, Kuribayashi G, Ono T, Ishiwata Y, Kuroda T., Modulation Publishing, p. 109. of masticatory muscle activity by tongue position. Angle Orthodontist 24. Bisson M, Grobbelaar A.The esthetic properties of lips: A comparison of 2005,75(1)35-39. models and nonmodels, Angle Orthodontist,2004;74(2)162-166. 9. Deb U, Bandyopadhyay SN., Care of nasal airway to prevent orthodontic problems in children, Journal Indian Med Association,2007 Products Nov;105(11):640,642. ® 10. Cuccia AM, Lotti M & Caradonna,D., Oral breathing and head posture, Phi Matrix - PhiPoint Solutions, LLC, PhiMatrix.com ® Angle Orthodontics 2008,78(1)77-82. LIP TRAINER - Myofunctional Research Co., 9267 Charles 11. Tipton WP. Beautiful balanced faces The first 9 years: The most critical Smith Ave., Cucamonga, Ca.91730 time!,International Journal for Orthodontics, 2006;17 (3):13-22. TICTAC® - Ferrero USA, Inc., 600 Cottontail Lane, Somerset, NJ 12. Champagne M. Upper airway compromise (UAC) and the long face 08873 syndrome. Journal General Orthodontics 1991;2:18-25.iddmdm BUTEYKO® - Buteyko Asthma Education USA, 2507 Brewster 13. McNamara JA, Bradon WI. Orthodontic and Dentofacial Orthopedics, 3rd Rd., Indianapolis IN 46268 Ed. 2004; Ann Arbor,MI: Needham Press, p. 123-125. ® 14. Tourne, LPM. The long face syndrome and impairment of the lower BREATHE RIGHT - GSK 5 Crescent Drive, Philadelphia, PA anterior face, 1990 60(3) 167-76. 19112 15. Aaronson NL, Vining E Correction of the deviated septum: from ancient INVISALIGN - Align Technology, Inc., 2560 Orchard Parkway, Egypt to the endoscopic era. Int.Forum Allergy Rhinol.2014;4(11):931-936. San Jose, CA 95131 16. American Rhinologic Society. Available at http://care.american-rhinologic. org/septoplasty_turbinates#sthash.JuXIZy3C.dpuf, Accessed 03/20/2016 17. Gold AR.Functional somatic syndromes, anxiety disorders and the upper airway:A matter of paradigms, 2011; Sleep Medicine Reviews 15: 390-401. Dr. Catherine M. Sherry, is a graduate of the 18. Varlik SK, Demirbas E, Orha M. Influence of lower facial height changes University of Oklahoma College of on frontal facial attractiveness and perception of treatment need by lay Dentistry and has been in practice in Yukon, people, Angle Orthodontist 2010, 80(6)1159-1164. Oklahoma for over 30 years. She has presented 19. Matoula S, Pancherz H, Skeletofacial morphology of attractive and numerous presentations on myofunctional therapy nonattractive faces, Angle Orthodontist 2006,76(2) 204-210. and interceptive orthodontics as well as methods of 20. Jefferson Y. Skeletal types: key to unraveling the mystery of creating community among professionals. Dr. Sherry facial beauty and its biological significance.Journal of General Orthodontics,1996,7(2):7-25. is an active member of the ADA, ODA, IAO and 21. McKeown P. Buteyko Meets Dr.Mew, 2010, Buteyko Clinic.com the AACO. Dr. Sherry is an IAO Senior Instructor Loughwell, Moycullen, Co Galway. and can be reached at [email protected].

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