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DOI: 10.1051/odfen/2010305 J Dentofacial Anom Orthod 2010;13:254-272 Ó RODF / EDP Sciences The role of, and the control of, obstruction of the upper airways and of congenital and other ENT anomalies in excess vertical growth of the face that impede orthodontic treatment J. Gilles ABEN-MOHA (ENT), Bruno BONNET (Orthodontist) ABSTRACT The objective of this article is to demonstrate the effectiveness of good cooperation between orthodontists and Ear, Nose, and Throat specialists because of the importance of freeing the upper airways from obstruction in order to achieve a good orthodontic result as well as the other side of the coin, the beneficial effect orthodontic treatment can have in stimulating a functional liberation of those airways when no mechanical blockage is present. The article will emphasize how important it is for orthodontists to understand and to be alert to the signs and symptoms that would indicate the need for an ENT evaluation. KEYWORDS Mechanical and functional obstacles to respiration ENT examination Upper airway problems Sleep apnea syndrome Orthodontic treatment ENT surgery. Address for correspondence: J. G. ABEN MOHA 48 rue de Tocqueville 75017 Paris, France [email protected] 254 Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2010305 THE ROLE OF, AND THE CONTROL OF, OBSTRUCTION OF THE UPPER AIRWAYS AND OF CONGENITAL AND OTHER ENT ANOMALIES IN EXCESS VERTICAL GROWTH OF THE FACE THAT IMPEDE ORTHODONTIC TREATMENT 1 – INTRODUCTION This article is the fruit of a longtime encounter in the daily practice of our collaboration between two specialists, respective specialties. From the con- one in orthodontics and the other in frontation that our extensive collabora- otolaryngology. In it we attempt to tion has forced each of us to make present an appreciation of the pro- with the special cares and limitations blems our patients endure and we are of the other, we have both been called upon to treat, each of us with a granted a golden opportunity to gain specific training and experience in our a better understanding of the thera- own fields that color our comprehen- peutic indications of our shared sion of situations we do not routinely enterprise. 2 – THE ORTHODONTIC POINT OF VIEW (DR. B. BONNET) When, and after noting what signs, by clearing the upper airways of should we ask our patients to seek an obstructions as a secondary benefit evaluation from an otolaryngologist? of their treatment of ‘‘facial insuffi- And at what age? And with respect to ciency.’’ The adequate and reasoned what rational protocol? intervention of each of the participating In some cases the failure to obtain specialists can operate effectively only what would have been a critical and on the foundation of a shared under- redemptive otolaryngological opinion standing of the formal indications for can condemn our orthodontic and and feasibility of treatment for growth orthopedic efforts to treat growth problems of children. problems, tongue maturation and All of our appliances designed to faulty position difficulties to ineffec- re-stimulate facial growth aim at en- tiveness and sometimes even harmful couraging the critical support of an outcomes. The ENT specialist, in such active tongue propelling itself verti- instances, can contribute enormously cally toward the palate but their effec- to the success of orthodontic treat- tiveness may be compromised or ment of ‘‘facial insufficiency,’’ completely negated by obstacles, And to an equal extent, ‘‘morpho- some of which are otolaryngological genetically aware’’ otolaryngologists in origin, that prevent this upright should be motivated by the same type positioning from occurring. of reasoning to evaluate the indications for their therapeutic interventions to act as aids in assisting orthodontists to 2 – 1 – Tongue activity confined achieve their treatment objectives. In to a low position: thrust effect, it is essential for all care givers against the cheeks who participate in the effort to correct or the lips, or to the chin the growth problems children suffer symphasis from to understand the capability of orthodontic/orthopedic mechanisms Orthodontists should never overlook to prevent or eliminate sleep apnea or deprecate the possibility in their J Dentofacial Anom Orthod 2010;13:254-272 255 J. GILLES ABEN-MOHA, BRUNO BONNET clinical assessments that patients may will stimulate the tongue to achieve an maintain their tongues in a low position upright position spontaneously. A zone purely out of habit. And, in fact, in our of fibrous tissue often fills the incision opinion this behavioral source is the and continues to restrict the tongue’s basic reason for adoption of this pos- free movement. We have found it ture in the immense majority of cases. advisable before surgery to provide In all of these cases the tongue is not patients with a suitable orthodontic held high, not placed vertically but device, such as a tongue envelope or remains stubbornly ‘‘hooked,’’ ‘‘mag- a Herbst appliance to help them keep netized,’’ ‘‘seduced’’ by the cheeks the tongue elevated so that repair (Class I, II, or II division 2), by the lips tissues forming in the incision will not (Class I or II division 1) symmetrically, or lock it in its habitual low position. attempting to embrace the chin sym- It is important to note that using phasis. It sometimes happens that the the occasion of the general anesthesia ENT consultation has for its objective employed for an ENT operation on the not to deprecate this tongue behavioral nasal fossas as an opportunity to add a problem as being the cause of certain lingual frenectomy gratuitously may malformations but, rather, to ascribe to well produce a scar tissue locked it, with all delicacy, the full weight of its tongue owing, doubtlessly, to the importance. In fact, the elimination of temporary post-operative nasal ob- breathing as a vital etiological factor or struction forcing patients to breath pointing to the small contribution it is through their mouths, thus leaving making are sometimes necessary for their tongues in a low posture. setting in motion a simultaneous psy- chomotor or psychotherapeutic and, if 2 – 3 – Tongue kept in low possible familial, support system. The ENT evaluation can help patients and position when patients families to reach an understanding that are forced into mouth a successful treatment outcome de- breathing pends largely on the patient’s repeated We should be careful to differenti- daily response to suggested tongue ate between the various factors that behavior changes. force patients into mouth breathing such as a growth problem in what is 2 – 2 – Tongue kept in low called facial insufficiency, from ana- position because tomic airway obstructions, because of of anatomic factors: inflammation, or owing to allergies. a short, tight lingual frenum 2 – 3 – 1 – The need to breathe through the mouth A short, tight lingual frenum physi- because of insufficient cally prevents the desired posture of tongue elevated, mandible depressed. facial growth But in every case orthodontists should All the types of insufficient facial guard against the simplistic expecta- growth can cause constriction of the tion that a simple lingual frenectomy upper airways. This is well known and 256 Aben-Moha J.G., Bonnet B. The role of, and the control of, obstruction of the upper airways and of congenital and other ENT anomalies in excess vertical growth of the face that impede orthodontic treatment THE ROLE OF, AND THE CONTROL OF, OBSTRUCTION OF THE UPPER AIRWAYS AND OF CONGENITAL AND OTHER ENT ANOMALIES IN EXCESS VERTICAL GROWTH OF THE FACE THAT IMPEDE ORTHODONTIC TREATMENT it is frequently suggested that expan- elements that would not have been sion of the upper arch is a means to possible without surgical removal of overcome this problem. But the pos- the hypertrophied tonsillar tissue that sibility of a simultaneous vertical as was formerly inducing a nausea reflex. well as transverse bi-maxillary course • Tongue blocked into a low of therapeutic action according to the position by obstacles to nasal lines of procedure we recommend in breathing. this article is often under-estimated - Obstacles in the region of the and even misunderstood. Its descrip- nasal fossas tion can be found on line on the www.revue-odf.org site as published Sometimes a clinical examination in the 2010 issue 4 under the title suggests that an obstacle is impeding A Combined Orthodontic and Otolar- nasal breathing and accordingly yngological approach to ‘‘facial insuffi- preventing the tongue from assuming ciency’’ and hyperdivergence. an upright position. Many clinical signs, like pinched nostrils or clouding of the mouth 2–3–2–Deviations in tongue mirror that we use throughout our posture caused dental examination, together with in- by ‘‘anatomic formation gleaned from the intake oto-laryngological interview, as well as views of nasal obstacles’’ fossas congested by hypertrophy of the inferior turbinates with or without • Tongue blocked in a forward septal deviations all suggest the advi- position by a large mass of sability of an ENT assessment. Some- enlarged adenoidal tissue times we evaluate the assessment of Sometimes, enormously enlarged the malformations as grave when, for adenoids appear on an X-ray film, example, there is a tendency to seeming to force the tongue into a anterior vertical deficiency and lip forward position. In such cases, at- incompetence and excessive labial tempts by practitioners to upright the inclination of incisor teeth. At other tongue’s posture and to move it instances we consider ENT interven- backward, are, at best, impeded, and tion less urgent when patients exhibit in the worst case, totally blocked by mixed nasal and mouth breathing the mass of adenoid tissue. during the day as well as at night In order to make the indicated even after functional orthopedic orthopedic and functional therapy ef- expansion therapy.

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