Craniofacial, Oral and Dental Manifestations of Oral Breathing

DOI: 10.18606/2318-1419/amazonia.sci.health.v6n1p34-42 ARTIGO DE REVISÃO << Recebido: 14 de março de 2017. Aceito: 07 de maio de 2018. >>

CRANIOFACIAL, ORAL AND DENTAL MANIFESTATIONS OF ORAL BREATHING

MANIFESTAÇÕES ORAIS, DENTÁRIAS E CRANIOFACIAIS DA RESPIRAÇÃO BUCAL

Omar Franklin Molina1, Angra Silva Mendes2, Isabella Rodrigues da Silveira3, Karin Ferretto Collier4, Zeila Coelho Santos5, Vanessa Bastos Penoni6, Karla Regina Gama7.

1 Dentistry. Lecturer at the RESUMO ABSTRACT Dentistry Course of UnirG University Center. Introdução: A respiração bucal é um distúrbio Introdução: Mouth breathing is a pathological Postdoctoral degree from respiratório patológico que afeta muitas estruturas respiratory pathological disorder affecting many Harvard University, USA. orais, dentais e craniofaciais. oral, dental and craniofacial structures. Master in Pediatric Dentistry, Objetivo: Avaliar as manifestações clinicas da Objectives: Evaluate the clinical manifestations Federal University of Santa respiração bucal e explorar os mecanismos que of mouth breathing and explore the mechanisms Catarina, UFSC. provocam alterações dentárias, craniofaciais e causing oral breathing, craniofacial, oral and E-mail: omar-nyorker- orais em crianças. dental alterations in children. Metodologia: As palavras chaves ou termos Methodology: Using the key words mouth [email protected] respiração bucal e frequência, respiração bucal e breathing, frequency; mouth breathing etiology; etiologia, respiração bucal e sinais e sintomas, mouth breathing signs and symptoms, mouth respiração bucal e mecanismos, respiração bucal breathing pathophysiology; mouth breathing MAILING ADDRESS: e diagnóstico e respiração bucal e tratamento signs and symptoms, mouth breathing diagnosis Dentistry Clinic of UnirG foram usadas na procura de artigos científicos no and mouth breathing treatment, we entered these University Center, Pará Google Schoolar. key words in the Google Schollar. Resultados e discussão: A pesquisa obteve 25 Results and discussion: We retrieved 25 Avenue, 1544 - St. Central, artigos científicos escritos em inglês no período papers written in English in the period 200-2016 Gurupi - TO, 77403-010, 2000-2016 e 4 artigos publicados na mesma and four papers written in the same language and Phone: (63) 3612-7579. língua e no período1981-1997. Os artigos published in the period 1981-1997. All these mencionados tinham material escrito o suficiente papers had sufficient oral breathing associated para explorar os diversos aspectos da respiração content in order to prepare the current study. bucal. Final considerations: Clinical manifestations of Considerações finais: As manifestações clínicas mouth breathing associated with craniofacial da respiração bucal relacionada com alterações alterations in children include dental changes, craniofaciais em crianças e adolescentes incluem craniofacial alterations, postural abnormalities, alterações dentárias, posturais, anormalidades musculoskeletal disorders, anatomical musculares-esqueléticas, anatômicas, oclusais, alterations, occlusal, oral and neuromuscular orais e neuromusculares. Os mecanismos da disorders. Mechanisms of mouth breathing respiração bucal que provocam distúrbios causing pathological disorders in children include patológicos incluem fatores obstrutivos, posturais, obstructive, postural, reduction of vertical effect diminuição do efeito vertical dos músculos sobre on muscles, anterior tongue thrusting anatomical, os dentes posteriores, posicionamento lingual disruption of muscle forces exerted by the anterior, alteração das forças musculares tongue, increased expenditure of energy during exercidas pela língua, aumento do gasto de sleep, smaller oral cavity, retruded maxilla and energia, uma cavidade bucal menor, maxila e mandible and increased nasal airway resistance. mandíbula retruídas, e resistência aumentada do nariz na passagem do ar. Descriptors: Mouth breathing. Clinical manifestations. Pathophysiology. Mechanisms. Descritores: Respiração bucal. Manifestações Signs and Symptoms. clínicas. Patofisiologia. Mecanismos. Sinais e sintomas.

INTRODUCTION adequate permeability of the nasal route, establishing itself as the main function of the body. Respiration is one of the body´s vital functions The nasal cavity has a fundamental role in the and under physiological conditions, breathing takes physiology of respiration as it promotes filtering, 2 place in the nose. The mouth breathing syndrome heating and humidification of the inhaled air . Nasal (MBS) is when a child has mixed breathing i.e., nose breathing is the primary mode of air intake for breathing is supplemented by the mouth1. Breathing humans, and is essential for a supply of properly is a vital function and is strongly dependent on the cleansed, moistened and warmed air for the lungs. If the primary airway is blocked, mouth breathing

34 10.18606/2318-1419/amazonia.sci.health.v6n1p34-42 Revista Amazônia Science & Health. Molina OF, Mendes AS, Silveira IR, Collier KF, Santos ZC, Penoni 2018 Jan/Mar VB, Gama KR. Craniofacial, Oral and Dental Manifestations of Oral Breathing.

becomes the only airway available to get air into the DEVELOPMENT 3 lungs . Nasal breathing is the correct mode of breathing in order to attain correct growth and Mouth Breathing 4 development of the craniofacial complex . Because of nasal airway inadequacy or habit, in some Mouth breathing is a respiratory disorder that individuals the oral cavity becomes the established affect children, adolescents and even adults in a and predominant route for the passage of respiratory large percentage of the general population and is airflow. responsible for local and systemic pathological 5 According to the Moss theory or theory of the effects in the short and long-term. functional matrix, only nasal breathing allows proper Many domains of the general health of a child, growth of the dentofacial complex. Moss theory is adolescent and adult may be affected when mouth based on the principle that normal nasal respiratory breathing is present. Mouth breathing syndrome is activity influences the development of craniofacial defined as a set of signs and symptoms that may be structures, favoring a balanced growth pattern by completely or incompletely present in subjects who, adequately interacting with chewing and for several reasons replace the correct pattern of 6 swallowing . nose breathing by an oral or mixed pattern present The association between respiratory disorders for more than six months2. The mouth – breathing and oral, craniofacial and dental disorders has been syndrome is when a child has mixed breathing i.e., investigated using a number of approaches. There is during breathing the function of the nose is a potential or actual interaction between respiratory supplemented by the function of the mouth1. 7 function and craniofacial growth pattern . Mouth breathing usually occurs as a vicious habit out of the Frequency need to adapt due to partial nasopharyngeal 8 obstructions . Mouth breathing brings adverse Mouth breathing is a respiratory dysfunction 9 effects on one´s oral health . that affects approximately 10-15% of child Because it is not known to what extent nasal population10. Mouth breathing has a frequency of resistance or mouth breathing influences dental and 14% among children with dental and maxillary craniofacial complex, and the relevance of airway abnormalities, girls (55.8%) being more affected obstruction and mechanisms implicated in than boys and occurs very frequently in children alterations in facial growth and development, have living in urban areas (79%)11. In children, mouth not been fully determined, this study was designed breathing was found to be the second most common to: 1 - Evaluate the clinical manifestations of mouth oral habit after tongue thrust12. breathing in children; 2 - Assess the mechanisms One investigation11, evaluated a sample of causing oral breathing, craniofacial, oral and dental 307 children and adolescents aged 5-16 years and alterations in children. reported an incidence of 40.2% mouth breathing. The frequency of this disorder was almost equally METHODOLOGY distributed in girls and boys. When researchers11 analyzed the frequency of mouth breathing by age, We used the Key Words Mouth breathing they reported a higher frequency (62.8%) in 10-12 etiology; Mouth breathing pathophysiology; Mouth years-old children as compared to children and breathing frequency; Mouth breathing diagnosis and adolescents in other age groups. Mouth Breathing Treatment to collect papers in order to prepare this study. Etiology Inclusion criteria: Only papers written in English, papers with clinical cases, case reports and The most common cause of nasal obstruction published between 1999 and 2016 were accepted to in children is hypertrophy of the adenoids, which is carry out the current investigation. the nasopharyngeal pad of lymphoid tissue. Children Different key words were used to collect and adolescents usually present the so called papers in order to discuss different subjects in the “Adenoid Facies”. The features of “adenoid facies” literature review. The electronic site are listed below: 1.Pinched nostrils, short upper lip; scholar.google.com was the only one from which all 2.Open mouth posture and elongated face; scientific papers were retrieved. Exclusion criteria 3.Increased lower, steep angle of mandible; were the following: Papers published before 1999, 4.Mandibularretrognathism, vacant expression; papers written in Portuguese, Spanish, French and 5.Prominent upper teeth, narrow upper alveolus, hypoplastic maxilla, anterior tongue position, other languages and papers with insufficient content 13 to discuss different subjects in the review of the retroclined mandibular incisors . literature. It has been established that enlarged adenoids are mainly responsible for obstructive mouth breathing. However, some children continue

35 2 10.18606/2318-1419/amazonia.sci.health.v6n1p34-42 Revista Amazônia Science & Health. Molina OF, Mendes AS, Silveira IR, Collier KF, Santos ZC, Penoni 2018 Jan/Mar VB, Gama KR. Craniofacial, Oral and Dental Manifestations of Oral Breathing.

to breaththrough their mouth even after surgical Pathophysiology or mechanisms in mouth removal of their adenoids. This could be due to breathing habitual mouth breathiness and laziness in using the nose despite having an adequate nasal airway3. It Decreased incidence of competent upper lip may be that in many children there are some in mouth breathing children is attributed to high mechanical obstacles other than adenoids nasal resistance, hence, an open mouth posture preventing the child from nasal breathing3. In fact, it allows for adequate air intake through the mouth3. It seems that a combination of upper airway and nose may be that because the muscles around the nose anatomic disorders are more likely to cause a shift are not physiologically used, some atrophy also from nose to mouth breathing. Mechanical barriers occurs in the upper lip, thus leading to hypotony. that may contribute to the blockage of the nasal air Sinusitis is a common finding in mouth breathing passage and cause the child to shift to a pattern of children, adolescents and adults. mouth breathing include anatomical variations The reasons for a higher incidence of sinusitis present in the nasal cavity and the paranasal region in mouth breathing children can be explained as during development in the turbinate and concha follows: Inflammatory sinus disease offers a bullosa regions, as well as inflammatory sinus and mechanical obstacle against the airflow through the nasal changes such as recurrent chronic sinusitis nasal passage. Additionally, sinusitis is usually and hypertrophy of the inferior nasal concha3. associated with blockage of the osteomeatal unit, One study3 evaluated a sample of 67 children which poses a second barrier facing the airflow. It with ages ranging from 10 to 15 years. They were has been established by the newly developed grouped in those with and without mouth breathing. unified airway concept that the respiratory system In mouth breathers researchers reported a functions as an integrated unit and that diffuse frequency of 87% hypertrophied adenoids, 77% of inflammation often affects the mucosal surfaces of maxillary sinusitis, 55% had a deviated nasal the nose, sinuses, middle ear and tracheobronchial septum, 55% had hypertrophied inferior concha, tree simultaneously3. 45% had ethmoid sinusitis and 23% showed frontal Mouth breathing usually develops as a sinusitis. Such changes were significantly less consequence of nasal resistance4. In one study16, prevalent in non mouth breather children. Mouth nasal obstruction was induced in experimental breathing is often associated with obstruction or animals. Obstruction resulted in mouth breathing, congestion of the upper respiratory tract3. maxillary narrowing, increased lower facial height, Regarding factors associated with upper malocclusion and dental anomalies.Retruded maxilla airway obstruction, they include developmental and mandible in patients with oral breathing and disorders, macroglossia, anatomical constriction of obstructive sleep apneia, leads to a smaller oral airway, enlarged tonsils/adenoids, nasal polyps, and cavity, diminished functional space for the tongue, allergic rhinitis, but enlarged adenoids and tonsils which will occupy a more posterior position, thus are consideredas major contributing factors14. favoring, obstruction of the upper airway during In one investigation3, mouth breathing children sleep15. Lymphoid tissue hypertrophy plays an showed a significantly higher incidence of septal important role in the pathophysiology of both oral deviation as compared with nose breathing breathing and sleep apneia in children. Maintaining children.It was found that the overall incidence of nose breathing during childhoodis important for sinusitis was generally higher in mouth breathers preventing abnormalities of the facial skeleton15. than in nose breathers. Habitual mouth breathing is often One study3 evaluated the frequency and accompanied by habitual anterior tongue posture, etiology of mouth breathing in children and reported instead of alip closure, in order to create the anterior a frequency of inflammatory changes and adenoid seal necessary for the initiation of physiological hypertrophy in 87.1% in mouth breathers as deglutition17. Anterior tongue thrusting during compared to only 31% in non mouth breathers. The swallowing exerts pressure forces on teeth that higher frequency of adenoid hypertrophy typically counteract the orthodontic forces that are emphasizes the leading role of adenoid as etiologic applied for a closure of an open bite17. Anterior factor in mouth breathing3.Cuc and Cuc11, evaluated forward head posture in mouth breathing children a sample of 307 children aged 5-16 years and and adolescents acts with the purpose of facilitating reported a frequency of 43/307=14% of mouth air entry through the mouth, resulting in postural breathing. The most common causes of this disorder changes that determine the worsening of pulmonary were habitual mouth breathing (12%), enlarged function creating a feedback mechanism that adenoids (60%) and deviated septum (28%). It has generates progressive respiratory and been reported that the nasopharyngeal air space is musculoskeletal disorders2. markedly reduced in mouth breathing children and in Postural changes areone mechanism that is apneic patients15. related with the clinical manifestations of mouth breathing. In one experimental stud in monkeys18,

36 10.18606/2318-1419/amazonia.sci.health.v6n1p34-42 Revista Amazônia Science & Health. Molina OF, Mendes AS, Silveira IR, Collier KF, Santos ZC, Penoni 2018 Jan/Mar VB, Gama KR. Craniofacial, Oral and Dental Manifestations of Oral Breathing.

the nasal openings were closed with latex plugs so breathing20. Intraorally, there is usually a narrow as to inhibit nose breathing. The sudden change maxillary arch, a high palatal vault, a shorter left and from nasal to oral respiration caused severe right molars distance, a posterior cross bite and a alterations in the function of the chewing muscles. class II dental maloclussion20. The ultimate facial and dental abnormalities One investigation5, evaluated children depended on three forms of respiration adopted by presenting with mouth breathing that were compared animals. Some monkeys that rhythmically lowered with a control group of non mouth breathing children. and raised their mandibles in each breath developed Researchers reported that 11/44=25% of the mouth a class I open bite; animals that rotated their breathing group presented with a unilateral posterior mandibles in a posterior and inferior direction cross-bite and 5/44=11.4% with a bilateral posterior developed a class II malocclusion, and animals that cross bite. Mouth breathing children also presented maintained their mandibles in an anterior position a smaller palatal surface and volume as compared developed a class III malocclusion and a skeletal to the control group. Mouth breathing in children class III profile18. leads to hypotrophy of the maxillary complex, resulting in narrowing of both intermolar and Signs and symptoms intercanine widths5.It has been reported19 that mouth breathing is associated with snoring at night, waking Sign and symptoms of oral breathing include up during the night, dry mouth and sleepiness during a long face, dark circles around the eyes, postural the day. The most commonly described speech position with open mouth, flattened cheek bones, disorders in mouth breathers include anterior short and incompetent upper lip, small and position of the tongue during production of lingual hypotonic nostrils, low-lingual posture, a posterior dental phonemes, inaccuracy of bilabial phonemes rotation of the mandible, a tendency to open bite, in Portuguese and frontal/lateral lips21. hyperextension and rotation of the head, extrusion of the posterior teeth, posterior cross-bite, constricted Craniofacial manifestations maxilla, lingual positioning of posterior upper teeth and arched palate10. Additional signs and symptoms Using mouth breathing on a regular basis,can in mouth breathing children and adolescents include cause many serious problems, mainly inadequate daytime sleepiness, headache, agitation and facial growth and bone development3. One clinical nocturnal enuresis, frequent fatigue, poor appetite, investigation7 reviewed some aspects of growth bruxism, school problems, learning deficits and pattern in children and reported that there is an behavioral disorders, irritability during the day, association between mouth breathing patterns, snoring, sleeping with mouth open, restless sleep, increased lower anterior facial height and deep nasal obstruction2. antigonial notches. A mandibular antigonial notch is Other signs and symptoms include lack of lip associated with the mandibular growth direction. seal, V-shape and/or arched palate, class II One investigation7 assessed an association between malocclusion, unilateral or bilateral cross-bite, open breathing pattern and mandibular morphology and bite, sleep apnea, facial rotation of the lower lip, reported that deep mandibular antigonial notch and retracted upper lip, generalized facial hypotonia, vertically directed growth pattern were more postural changes, dark circles, elongated face, prominent in mouth breathers than in non mouth lowered mandible, dental alterations, abnormal breathers7. speech, abnormal tongue position and mentual There is sufficient information indicating that muscle hyperfunction during lip-closure2. Attention mouth breathing reduces anterior maxillomandibular deficit hyperactivity disorder or ADHD is commonly development, such that these structures are more found among mouth breathing children. It is known retrudedin relation to the skull base15. Among the that both mouth breathing and ADHD may trigger consequences of mouth breathing are alterations of sleep disorder breathing. Both ADHD and mouth craniofacial growth, abnormal body posture, breathing can trigger sleep disorder breathing19. abnormal muscle tone, flaccid jaw elevator muscles, anterior head posture and maxillary atresia20. The Oral and dental manifestations amount of dentoalveolar and skeletal deformation in mouth breathers is related to the frequency, Mouth breathing causes malocclusion, duration, direction and intensity of certain habits and abnormal dental alignment, dryness of the oral should be assessed by the dentist and physician. tissues, compromising gingival health and leading to Changes that may occur to the dental caries and oral malodour3. Mouth breathing is dentoalveolarstructures include anterior or posterior often associated with the long face syndrome and open bite, interference of normal tooth position and adenoid facies. Patient with this syndrome usually eruption, alteration of bone growth and development present increased facial height, lip apart posture, and cross bites22. narrow alar base and frequently self reported mouth

37 10.18606/2318-1419/amazonia.sci.health.v6n1p34-42 Revista Amazônia Science & Health. Molina OF, Mendes AS, Silveira IR, Collier KF, Santos ZC, Penoni 2018 Jan/Mar VB, Gama KR. Craniofacial, Oral and Dental Manifestations of Oral Breathing.

Diagnosis recommended in non growing patients. Studies20 have demonstrated that this treatment leads to To identify enlarged adenoids, a lateral balanced vertical height proportions, improved lip cephalometric radiograph of the nasopharynx contact at rest and improved facial aesthetics. It has provides a valuable method in the evaluation of been suggested that when evaluation and proper children with upper airway obstruction for assessing diagnosis is carried out at an earlier age including adenoid size. We emphasize that a cephalometric diagnosis of nasal obstruction, appropriate radiograph only shows a bidimensional anatomy of a orthodontic intervention using maxillary expansion structure which is tridimensional anatomically may resolve the vertical facial growth pattern at an speaking. Thus, CBTC may be required to assess earlier age with the advantages of improving volume and proper anatomy of enlarged adenoids13. aesthetic, function, facial morphology and perioral Early diagnosis in collaboration with the pediatrician muscle function20. is mandatory in order to design proper interceptive Surgically assisted maxillary expansion may treatment. Early diagnosis is the first step in the be carried out in adults presenting with severe diagnosis and treatment dyad. In this way, is malocclusion and is considered a relatively safe possible to prevent several conditions including technique. Planned bilateral sagittal split surgery frequent infections, a pathological chewing pattern, advances the mandible, widens the airway and the development of a malocclusion, incorrect relieves the symptoms of upper airway obstruction13. swallowing, inadequate speech and body posture A mandibular advancement splint is a very useful abnormalities10. technique in elder patients who have sleep apnea due to narrowing of the pharyngeal airway space. Treatment This device is thought to place the mandible in an anterior position thus, increasing pharyngeal airway Treatment of enlarged adenoid tissue includes space enabling the passage of increased air volume. a course of antibiotic (Clindamycin or augmentin) Maxillary expansion improves nasal volume which acts again beta-lactamase producing and flow and alleviates the symptoms of upper pathologic organisms. Surgical intervention airway obstruction13. One clinical investigation24 includesadenoidectomy with or without tested the efficacy of speech therapy to achieve tonsillectomy, conservative septal surgery in nasal breathing awareness and automation in growing patients, and radiofrequency inferior conjunction with intranasal beclomethasone turbinate reduction which is performed with a dipropionate in children presenting with mouth specially designed probe with a needle at the end, breathing, asthma and allergic rhinitis. placed into the submucosalstroma of the inferior Researchers reported that speech therapy turbinate and controlled radiofrequency energy is and beclomethasone improved significantly delivered for tissue ablation13. One follow up respiratory capacity as compared to the use of investigation23 evaluated facial growth in children medication alone. Speech therapy and eclo with severe nasopharyngeal obstruction and mouth methasone dipropionato had a positive impact on breathing. Researchers compared the treatment functional and clinical management of both asthma using adenoidectomy and the outcome was and allergic rhinitis in mouth breathing children. compared with the growth direction in normal control children. Researchers reported that the sample RESULTS AND DISCUSSION treated with adenoidectomy initially showed lower face heights and five years following surgery, Etiology of mouth breathing children showed a more horizontal lower jaw growth direction, but this difference was significant only for Hypertrophy of the adenoids and palatine girls. tonsils is the second most common cause of upper Orthodontic treatment includes maxillary respiratory obstruction and consequently, of mouth expansion using a quad-helix appliance or a rapid breathing in children25. One investigation26 asserts maxillary expansion with a hyrax screw or palatal that the etiology of mouth breathing is multifactorial distractor. Mandibular advance devices may also be and includes other factors likeasthma, allergies and 13 used to enlarge the upper airway . In one review of enlarged glandular tissues. Cuc and Cuc´s 3 the literature , researchers found that upper airway investigation11 indicates that mouth breathing has relief, most commonly, by performing obstructive anatomic causes including tonsils or adenoidectomy, can lead to a normalization of adenoid hypertrophy, nasal septum deviation and or occlusion in children who were obligate mouth allergic rhinitis which may occur singly or in breathers. Regarding treatment of a class II combination. malocclusion, posterior cross bite and a narrow Other factors causing nasal obstruction and maxillary arch together with mouth breathing, a thus a shift to mouth breathing are chronic allergic combination of orthodontics and surgery may be rhinitis, nasal traumas resulting in minor anatomic

38 10.18606/2318-1419/amazonia.sci.health.v6n1p34-42 Revista Amazônia Science & Health. Molina OF, Mendes AS, Silveira IR, Collier KF, Santos ZC, Penoni 2018 Jan/Mar VB, Gama KR. Craniofacial, Oral and Dental Manifestations of Oral Breathing.

deformities, congenital nasal deformities, foreign of mouth breathing children. Open bite or reduced bodies, polyps, and tumors4. overbite of less than 1mm was found in 68% of One study5 evaluated children presenting with mouth breathing children, posterior cross bite mouth breathing that were compared with control coexisting with class II malocclusion was observed non breathing children. Researchers reported that in 65.7% of the sample and maxillary crowding was 44% of mouth breathing children presented with found in the 64.6%. Children with abnormal palatal and or pharyngeal tonsil hypertrophy and craniofacial patterns show a predisposition towards 100% of these children presented with chronic some type of respiratory sleep disorder as do allergic rhinitis. Thus, it seems apparent that the children with tonsillar and adenoid hypertrophy15. etiology of mouth breathing is multifactorial. Mouth breathing patients have a low oxygen concentration in their blood than those who have Clinical manifestations of mouth breathing in nasal respiration. Low oxygen concentration in the children blood has been associated with high blood pressure and cardiac failures27. Mouth breathing irritates the Mouth breathing in children and adolescents upper airway mucosa, and children often have is usually associated with increased lower facial swollen tonsils and adenoid, one of the major height, lip apart posture, narrow alar base, narrow causes of upper airway obstruction, sleep disorders, maxillary arch, high palatal vault, posterior cross bite and sleep apnea27. and a class II dental malocclusion. This is so as the faces of mouth breathing children and adolescents Mechanism of craniofacial, dental and oral develop aberrantly as a result of chronic airway alterations in children obstruction25. One investigation25, evaluated 20 mouth Prolonged mouth breathing leads to muscular breathing children with enlarged adenoids, 20 mouth postural alterations which, in turn, cause breathing children with nasal obstruction and 10 dentoskeletal changes. One study25, points out that nose breathing individuals (control group). mouth breathing is in fact a neuromuscular disorder Researchers reported a significant increase in IMPA, that secondarily causes or even increases the interlabial gap, and facial convexity in both mouth severity of a malocclusion.The interposition of the breathing with enlarged adenoids and in the group hypertonic lower lip between mandibular and with mouth breathing and nasal obstruction as maxillary incisors, cause labioversion of the upper compared with the group of ten normal children. The incisors and linguoversion of the mandibular incisors upper incisor proclinationand facial convexities were in relation to the mandibular plane in patients with higher in mouth breathing children with adenoid adenoid hypertrophy25. Adenoid hypertrophy is the hypertrophy as compared with the group with nasal cause of proclined mandibular incisors in mouth obstruction and with the control group. breathing children and this disorder is not observed The review of the literature25 has shown that in mouth breathing children without hypertrophied maxillary incisors are protruded in mouth breathers adenoids25. and this disorder is caused by the interposition of an Based on the outcome of a clinical hypertonic lower lip between maxillary and investigation7, researchers concluded that growth mandibular incisors causing labioversion of maxillary directions and craniofacial changes in form, occurs incisors. One investigation25 comparing mouth in subjects with a mouth breathing pattern due to breathers with controls non mouth breathers mandibular growth rotations, increased gonial angle demonstrated that two different groups of mouth or increased Y-axis and the mandibularantigonial breathers (hypertrophied adenoids and nasal notch may be deeper, due to mandibular flexion in obstruction group), demonstrated a higher degree of the antigonial notch region by a masseter muscle lip separation as compared with the control group. A imbalance.When children switch from nasal to previous study9demonstrated that mouth breathing mouth breathing, the position of the lips, tongue, and patients complain of dry mouth and throat discomfort the mandible should change to provide an airway due to a reduction in the quantity and quality of through the mouth , thus, improving breathing saliva especially during sleep and or during ability. Thus, while breathing through the mouth, all awakening.Mouth breathing children usually chewing motions must be stopped and/ or impeded9. presenta dolicofacial appearance, a narrow maxillary Egarding one mechanism causing malocclusion, one arch, increase in anterior facial height, and greater clinical investigation9 in mouth and nasal breathing inclination of the mandibular plane angle9. subjects, reported that mouth breathing reduces the One study4 evaluated 67 children presenting vertical effect on the posterior teeth, which can affect with mouth breathing habits. All patients were the vertical position of posterior teeth negatively, referred for orthodontic examination and analysis. leading to malocclusion. Researchers reported a frequency of 78% of class Anterior tongue thrusting during swallowing II skeletal relation, overjet of 4mm or more, in 89.4% exerts pressure forces on teeth that typically

39 10.18606/2318-1419/amazonia.sci.health.v6n1p34-42 Revista Amazônia Science & Health. Molina OF, Mendes AS, Silveira IR, Collier KF, Santos ZC, Penoni 2018 Jan/Mar VB, Gama KR. Craniofacial, Oral and Dental Manifestations of Oral Breathing.

counteract the orthodontic forces that are applied for Lymphoid tissue hypertrophy plays an a closure of open bites17. It may be that enlarged important role in the pathophsyiology of both mouth adenoids aggravate and or obstruct normal nasal breathing and sleep apneia in children and breathing, thus, this breathing pattern disrupts those adolescents and maintaining nose breathing during muscle forces exerted by the tongue, cheeks and childhood is important for preventing abnormalities lips upon the maxillary arch and these alterations in of the facial skeleton15. Mouth breathing children normal oral function can lead to anomalies affecting extend their heads forward and downward to the maxillary and mandibular arch, resulting in improve their respiratory pattern, thus increasing dental and skeletal abnormalities including cervical kyphosis15. One comparative research5 malocclusion4. evaluated mouth and nose breathing children and One investigation4 carried out in 67 children concluded that nasal airway resistance is one with a mean age of 9.3 years found a correlation mechanism associated with nasal deformities and between nasopharyngeal airway obstruction, mouth maxillary growth deficiencies. breathing habits and the development of various skeletal and dental abnormalities. Some researchers Diagnosis claim that the mechanism of abnormal head posture in oral breathing children and adolescent is one in Complete visualization of adenoid tissue using which abnormal functions such as mouth breathing, endoscopic examination provides direct and tongue thrusting, can lead to forward head posture tridimensional image of nasopharynx and associated and the development of malocclusion28. adjacent structures25. Mouth breathing, low tongue According to one review of the literature15, posture and elongation of the lower anterior facial facial growth abnormalities, hyperactivity, antisocial height are apparent at 3 years of age, but are more behavior, depression, cognitive difficulties and motor commonly detected after age five but the deleterious dysfunction are observed among mouth breathing impact of decrease naso-respiratory function is children and the mechanism of such disorders is virtually complete by puberty, thus the effects of increased expenditure of energy during sleep. mouth breathing may be diagnosed between five Tonsillar and adenoid hypertrophy favors the and twelve years of age25. development of mouth breathing. Mouth breathing In order to correct mouth breathing in children, during the growth phase is responsible for triggering the pediatric dentist and or orthodontist, must be a chain of events resulting in growth changes and able to make a correct diagnosis to treat the abnormalities of cranial and maxillomandibular dysfunction as early as possible and to prevent the development15. onset of cascade mechanisms10. The key aspect One mechanism of dental malocclusion is which may be used as a guide in the diagnosis to mouth breathing. Mouth breathing leads to anterior identify a mouth breather is the “adenoid facies”. facial height, a narrow and deep palate, increased Cephalometry is useful as a screening test for lower facial height, open bite and a tendency to anatomical abnormalities among patients with cross bite along with the occurrence of hearing obstructive sleep apneia syndrome. The loss15.Retruded maxilla and mandible in mouth anteroposterior position of the maxilla and mandible, breathing and apneic patients, leads to a smaller inclination of the mandibular and occlusal planes, oral cavity, with diminished functional space for the position of the anterior teeth, dimensions of the tongue, which will occupy a more posterior position, nasopharyngeal and posterior air spaces are thus favoring obstruction of the upper airway during commonly associated with mouth breathing and sleep15. obstructive sleep disorders and should be evaluated Nasal obstruction caused by tonsillar and to obtain a proper diagnosis15. adenoid hypertrophy impairs normal nose breathing. General and pediatric dentists may be in the Patients then will have to adapt their respiration by best position to screen and treat patients who suffer moving over to mouth breathing through postural from upper airway obstruction and mouth breathing. changes of the head, maxillae, tongue, and labial Dentists and pediatricians often see patients on a musculature, thereby altering the muscle pressure regular basis and swollen tonsils can be easily balance in the maxillae and teeth and modifying detected by examining the back of a patient´s craniofacial growth and development15. Greater throat27. inclination of upper incisors in mouth breathing children and adolescents may be explained by the Treatment pressure that the tongue exerts on the palatine side of these teeth and this mechanism is caused by a The protocol of intervention to manage mouth retruded maxilla and mandible, which in turn, breathing in children include the use of a maxillary reduces the functional space for the tongue. The rapid expander to correct the transverse tongue also exerts pressure on the lower apical discrepancy, increase the amplitude of the upper base, causing retroinclination of the lower incisors15. respiratory airway and to reduce nasal resistance in

40 10.18606/2318-1419/amazonia.sci.health.v6n1p34-42 Revista Amazônia Science & Health. Molina OF, Mendes AS, Silveira IR, Collier KF, Santos ZC, Penoni 2018 Jan/Mar VB, Gama KR. Craniofacial, Oral and Dental Manifestations of Oral Breathing.

association with the use of functional devices changes ( dry mouth, xerostomia, throat discomfort, including a nasal and oral obturators to allow the low oxygen concentration, irritation of the upper reconstruction of a physiological balance between airway mucosa) and neuromuscular disorders. the perioral muscles and tongue, to obtain nasal and Mechanisms of mouth breathing causing lips competence and to reduce overjet10. dental and craniofacial alterations is children include Denotti and colleagues10 evaluated a sample obstructive anatomical mechanisms in the upper of 20 patients between six and ten years of age airway and nose, forward and downward head presenting with a mouth breathing pattern. The posture, mandibular rotation and flexion, hypertonic protocol of early treatment they used included a lower lip, reduction of vertical effect of muscles on rapid palatal expander, bonded on the deciduous the posterior teeth, anterior tongue thrusting during molars, in association with the use of silicone swallowing, disruption of muscle forces exerted by myofunctional devices such as the nasal stimulator the tongue, increased expenditure of energy during and the oral obturator that speeds and increases the sleep, smaller oral cavity, retruded maxilla and effectiveness and stability of treatment to obtain a mandible and increased nasal airway resistance. physiological balance between the perioral muscle sand the tongue, to improve overjet and to obtain lips and nose muscle competence. REFERENCES Following a one-year follow up, researchers reported strengthening of the perioral musculature, 1. Abreu RR, Rocha RL, Lamounier JA, Guerra AF. lips competence and a gradual transition from oral to Etiology, clinical manifestations and concurrent nasal breathing. features of mouth breathing children. J Pediatr 29 In experimental studies in humans , it has (Rio J) 2008; 84: 529-35. been found that mouth breathing decreases considerably when patients are put on nasal CPAP, 2. Veron HL, Antunes AG, Milanesi JD, Corrêa EC. however, mouth breathing patients may still have Implications of mouth breathing on the pulmonary more mouth breathing on CPAP as compared to function and respiratory muscles. Rev CEFAC nose breathers. Regarding treatment, there are 2016; 18: 242-51. reasons to believe that a combination of speech therapy and beclomethasone used in mouth 3. Farid MM, Metwalli N. Computed Tomographic breathing children with, asthma and allergic rhinitis evaluation of mouth breathers among pediatric may be effective. patients. Dentomaxillofac Radiol 2010; 39: 1-10. 24 Researchers reported that both modes of treatment improved respiratory pattern and 4. Elmomani BR, Tarawneh AM, Bashdan HA, functional and clinical management of asthma and Shuqran KK. Orthodontic alterations associated allergic rhinitis in mouth breathers children and with mouth breathing habit. Pakistan Oral & 24 adolescents . Surgical removal of swollen tonsils Dental J 2015; 35: 234-37. and adenoids is highly recommended when such structures negatively affect sleep by obstructing 5. Lione R, Franchi L, Ghislanzone LTH, Promozic 27 upper airway . J, Buongiorno M, Cozza P. Palatal surface and volume in mouth-breathing subjects evaluated with three-dimensional analysis of digital dental FINAL CONSIDERATIONS casts: a controlled study. Eur J Orthod 2014; 1- 4. Based on the literature review to perform this study, it is concluded that: clinical manifestations of 6. Moss ML. The functional matrix hypothesis mouth breathing associated with craniofacial revisited: The role of mechanotransduction. Am J alterations in children include dental changes Orthodont Dentofac Orthop 1997; 112: 410-17. (greater forward inclination of upper incisors, open bite, maxillary crowding), craniofacial alterations 7. Ferreira FC, Corotti K, Lopes PD, Junqueira TH, (increased lower facial height, greater inclination of Stocco JR. Association between respiratory the mandibular plane), postural (lip apart posture, pattern and mandibular morphology. Rev forward head posture, rotation and/or displacement Odontol. Universidade Cidade de São Paulo of the mandible), musculoskeletal (class II 2009; 21: 18-23. malocclusion, open bite, class III malocclusion), anatomical (narrow alar base, narrow maxillary arch, 8. Fratu A. Orthodontie, diagnostic, clinical, high palatal vault, interlabial gap, hypertrophy of the treatment, Editora Vasiliana, Iasi, 2002. lower lip, hypotrophy and hypotonicity of the upper lip, greater overjet); oclussal alterations (posterior 9. Choi JE, Waddell JN, Lyons KM, Kieser JA. cross bite, open bite, class II malocclusion); oral Intraoral pH and temperature during sleep with

41 10.18606/2318-1419/amazonia.sci.health.v6n1p34-42 Revista Amazônia Science & Health. Molina OF, Mendes AS, Silveira IR, Collier KF, Santos ZC, Penoni 2018 Jan/Mar VB, Gama KR. Craniofacial, Oral and Dental Manifestations of Oral Breathing.

and without mouth breathing. J Oral Rehab 2016; 21. Hitos SF, Arakaki R, Solé D, Weckx LLM. Oral 43: 356-63. breathing and speech disorders in children. J Pediatr 2013; 89: 361-65. 10. Denotti G, Ventura S, Arena O, Fortini A. Oral breathing: new early treatment protocol. Journal 22. Amer Acad Pediatric Dent. Policy on Oral Habits of Pediatric and Neonatal Individualized Medicine 2006; 30: 51-52. 2014; 3: 1-7. 23. Linder-Aronson S, Woodside DG, Lundstrom A. 11. Cuc A, Cuc O. Mouth breathing: An etiological Mandibular growth direction following factor of dental and maxillary abnormalities. adenoidectomy. Am J Orthod 1986; 89: 274-84. Analele Universitatii Din Oradea 2013; 12: 185- 92. 24. Campanha SMA, Fontes MJF, Camargos PAM, Freire LMS. The impact of speech therapy on 12. Karbanda OP, Sidhu SS, Sundaran KR, Shukla asthma and allergic rhinitis control in mouth DK. Oral habits in school going children of Delhi: breathing children and adolescents. J Pediatr A prevalence study. J Indian Soc Pedo Prev 2010; 86: 203-8. Dent 2003; 21; 120-24. 25. Basheer B, Hegde KS, Bhat SS, Umar D, 13. Agarwal L, Tandon R, Kulshrestha r, Gupta A. Baroudi K. Influence of mouth breathing on the Adenoid faciais and its management: An dentofacial growth of children: Cephalometric orthodontic perspective. Indian J Orthodontics study. JIOH 2014; 6: 50-55. and Dentofacial Research 2016; 2: 50-5. 26. Nwhator SO, Ayanbadejo PO. Uncommon 14. Coelho AR, Tanaka O, Ribeiro JS, Machado MA, causes of gingivitis. J Dent Oral Hygiene 2011; 3: Camargo ES. Transverse craniofacial dimensions 65-68. in Angle Class II division I malocclusion according to breathing mode. Braz Oral 27. Jefferson Y. Mouth breathing: Adverse effects on Res2010; 24: 70-5. facial growth, academics, and behavior. General Dent 2010; Jan/Feb: 18-25. 15. Juliano ML, Machado MA, de Carvalho LB, do Prado L, Do Prado GF. Mouth breathing children 28. Nowak AJ, Warren JJ. Infant oral health and oral have cephalometric patterns similar to those of habits. Pediatr Clin North Am 2000; 47: 1043-66. adult patients with obstructive sleep apnea syndrome. Arq Neuropsiquiatr 2009; 67: 860-65. 29. Bashour A, Maasilta P. Mouth breathing compromises adherence to nasal continuous 16. Harvold EP, Vargervik K, Chierici G. Primate positive airway pressure therapy. Chest 2004; experiments on oral respiration. Am J Orthod 1981; 79: 359-73. 126: 1248-54.

17. Knösel M, Klein S, Bleckman A, Engelke W. Coordination of tongue activity during swallowing in mouth-breathing children. Dysphagia 2012; 27: 401-407.

18. McNamara JA Jr, Brudon WL. Orthodontics and Dentofacial Orthopedics, Third Edition, Ann Arbor, Michigan: Needham Press; 2004: 123-25.

19. Pacheco MC, Casagrande CF, Teixeira LP, Finck NS, De Araújo MT. Guidelines proposal for clinical recognition of mouth breathing children. Dental Press J Orthod 2015; 20: 39-44.

20. Vig KWL. Nasal obstruction and facial growth: The strength of evidence for clinical assumptions. Am J Orthod Dentofac Orthop 1998; 113: 603-11.