DOI: 10.1051/odfen/2010305 J Dentofacial Anom Orthod 2010;13:254-272 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, 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 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 , 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 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 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. fective and appropriately swift, it is - Obstacles in the rhino-pharyn- often necessary for the otolaryngolo- geal area gist to perform a . Sometimes X-ray films show ser- Numerous post-operative cephalo- iously enlarged adenoidal tissue that metric films demonstrate the re-estab- appears to constitute a blockage of lishment of correct backward nasal breathing and, accordingly, movement of the tongue and an to prevent the tongue from assuming upright positioning of its posterior an elevated position.

J Dentofacial Anom Orthod 2010;13:254-272 257 J. GILLES ABEN-MOHA, BRUNO BONNET

In cases of severe anterior and lateral well as an anterior vertical deficiency, open bite caused by hyperdivergence an is the logical and with a posterior vertical deficiency as indispensable first step.

3 – THE ROLE OF THE OTOLARYNGOLOGIST (DR. ABEN MOHA)

Otolaryngologists acquire in their passages, which are often associated training and in their routine daily prac- with each other, make mouth breathers tice only an incomplete knowledge of out of the children who suffer from cranio-facial growth and of orthodontic them and also oblige them to carry their procedures: but this understanding will tongues in a low, anterior position. By develop as their collaboration with their thus diminishing tongue action on the orthodontic colleagues develops. In maxilla, they are also responsible for a this presentation I shall outline some contraction of the upper arch that of the problems posed by our joint prevents it from articulating properly endeavors. with the lower arch, a relationship that provokes an excess of vertical devel- opment of the face. 3 – 1 – When should This combination of altered nasal an orthodontist ask breathing and a preponderance of for an ENT evaluation? mouth breathing that prevents some orthodontic patients from thrusting Orthodontists refer patients for an their tongues against their otolaryngological assessment, in my may explain their reluctance, even experience, after they have noted outright refusal, to wear appliances nasal obstructions, mouth breathing, like night guards. In sum, airway low tongue position, an anatomic obstructions and their consequences obstruction on an X-ray film, or simply may degrade the quality or the because the orthodontic problem is stability of an orthodontic treatment severe and the need for a complete result. work-up becomes evident. Additional reasons impelling orthodontists to seek ENT opinions include failure of any of the gamut of myofunctional 3 – 1 – 2 – Macroglossia training, courses, a patient’s inability Macroglossia, involving the free to wear a nocturnal orthodontic appli- portion of the tongue, its base, or ance, an unsatisfactory orthodontic auxiliary parts, associated in varying treatment outcome, an unstable re- degrees with a short frenum and sult, and, the beginning of relapse. hypertrophied tonsillar tissue can force the tongue into an anterior 3 – 1 – 1 – Obstruction of the position. Its forward thrust during primary swallowing can lead to upper nasal and rhino- anterior open bite, an increase in pharyngeal airways anterior and vertical growth of the Obstructions in the upper nasal air- mandible, and a tendency toward ways and in rhino-pharyngeal prognathism.

258 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

3 – 1 – 3 – A raising and thrusting surgical intervention should be post- of the upper lip under poned. a projecting anterior nasal spine 3 – 2 – What questions to ask, A raising and thrusting of the upper and things to look for, lip under a projecting anterior nasal in the intake interview spine also encourages lip incompe- tence that rapidly establishes a vicious circle of functional mouth breathing, 3 – 2 – 1 – Breathing even when no airway blockage is • During the day: present, and thus provokes excess - is nasal obstruction unilateral or vertical growth of the lower third of bilateral? the face. - is it symmetrical or alternating - is mouth breathing permanent or 3 – 1 – 4 – Lack of muscular temporary? Is it initiated by circum- equilibrium stance or position, lying down, for example, by time of year, a visit to Similarly, a lack of balance between the countryside, or by exposure to the tongue musculature and the labial allergens? and cheek musculature prevents facial - is it possible for the patient to growth from unfolding harmoniously. breathe through his nose? Or is it Noxious habits like sucking of impossible? Does patient use thumbs and pacifiers can provoke mouth breathing exclusively? anterior or lateral open bites whose - when respiration is primarily by symmetry or asymmetry depends on mouth, is nasal breathing uncom- the choice of which fingers to suck fortable? patients make and the intensity with which they suck them. They can also - can patient maintain nasal breath- lead to under-development of the ing? for how long? while playing maxilla if, for example, a thumb is sports? does patient suffer from kept lodged against the hard palate, or episodes of dyspnea? cause an upper alveolar protrusion - is respiration noisy? accompanied by a retrusion of the • At night: the examiner should ask lower alveolar processes or even a the same questions with the addition retrusion of the mandible itself. of these: - is the mouth kept open? Is it dry? 3 – 1 – 5 – Doubt of blockage - is saliva left on the pillow by morning? Sometimes the onset of orthodontic treatment helps some patients who - does patient wake up at night to get had been mouth breathers to close a drink of water? is the mouth dry in their lips correctly and begin nasal the morning? respiration. For them, especially when - are there episodes of apnea? with there is doubt about the presence of a snoring? and/or with pauses in frank airway blockage, a proposed breathing?

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• Other questions: body tonus and an active participant - rhinolalia: does patient speak with a in sports? nasal tone owing to excessive - Is patient able to concentrate and closure or openness of a nasal do well academically or does he passage, have learning difficulties? - does patient suck thumb or a - Does patient have any memory pacifier? lapses? - Is he irritable, nervous, apathetic? 3 – 2 – 2 – Difficulty in sleeping - Does patient have a history of - does patient have trouble falling cranio-facial trauma? asleep? - is his sleep disturbed by agitation, 3 – 2 – 4 – Presence nightmares, shouting, somnambu- of inflammation and lism? infection - does patient snore or breathe noi- Examiners should look for or check: sily? - Rhinitis or pharyngitis, snoring, - are there periods of apnea or tonsillitis, distal rejection of phlegm pauses during sleep? indicated, perhaps, by sniffling during - does patient wake with a start or swallowing, hemmage, sinus pain. get up for a drink? Is she a bed - Posterior hypopharyngeal and lar- wetter? yngo-tracheo-bronchial reflux, di- - does patient suffer from night gestion problems. sweats? - Inflammation and extensive reflux: - is her morning awakening difficult? asthma, renal problems, cardiac - does patient awaken from a night’s murmurs, arthralgia sleep feeling refreshed? - Otological condition; tympanic con- dition, tubular catarrhs, hearing pro- blems (an audiogram may be 3 – 2 – 3 – General health status indicated). Repercussions - Any known allergies, vaso-motor - Does patient show any signs of the signs, any impairment of sense of sleep apnea syndrome? Examiners taste or smell, nasal itching. An will find the Epworth index of day- assessment of allergies, skin, and time sleepiness most useful. When blood condition is best made in the Epworth index suspicion scale patients more than seven years old is over 10 in older children and when allergens can be effectively adolescents, a sleep polygraph will discerned. be helpful. - Does patient suffer from somno- lence or headaches? 3 – 2 – 5 – Presence of accessory - Can patient be described as suffer- problems ing from asthenia, or generalized - Some questions to ask. Does patient weakness, or is she alert with good suck thumb, finger, or pacifier? If so,

260 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

with what intensity and frequency? muscles contract at the menton tuft With which fingers, of which hand? when patients try to close their Or has patient recently stopped the lips? habit? The presence of such a habit - Status and position of lips. Is the may explain why an anterior open upper lip short or does it project? bite is more marked on one side than Does patient have a gummy smile? the other or why it is centered - Is the tongue readily visible? Does around a digit placed against the patient thrust it between teeth in hard palate. the initial phase of deglutition? Are - Does the patient have any swallow- the tongue’s borders notched? ing problems? Does the tongue seem large and - Does she eat ‘‘nervously’’ or noisily, in constant movement, with quiver- jump up from her seat frequently, ing at what should be a stable rest chew her food badly and swallow it position? quickly, and have trouble synchro- - Does patient have any congenital nizing breathing with deglutition? malformations, or jaw retrusion? - Does her ingested food sometimes - Is there any evidence of malforma- take wrong turns with nasal regur- tion of the nasal pyramid or the gitation? facial profile that are possible se- - Is there any reflux, vomiting, or quellae of trauma or of fractures of nausea? facial bones. Is there a puffed-up Has a physician previously exam- area below the menton, often a ined or treated the child for: sign of mouth breathing? - appetite problems, anorexia? - Physicians can assess symmetry of nasal breathing by placing a dental - speech problems with pronuncia- mirror under each nostril to see tion difficulties? which clouds it up. They should - posture problems: are any positions check to see to see if nasal breathing painful? Does patient have neck or improves after instillations of vaso- back pain? Are there signs of constricting nose drops that may scoliosis? stimulate patients to close their lips. - The old notion that ‘‘adenoidal 3 – 3 – The examination facies’’ cause children to breathe exclusively through their mouths has been abandoned for many 3 – 3 – 1 – The initial inspection years. • The facial exam: what the practi- • What the physician should look tioner looks for for in a global inspection - Facial symmetry. A uni-lateral nasal - What is patient’s global posture, obstruction can aggravate asymme- inclination of the head, and inclina- try. tion of the neck? - Growth, vertical excess of the face, - At what level are the patient’s eyes lip incompetence, mouth held open and shoulders? Are they symme- from time to time or at rest. Do trical?

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- Are the patient’s cervical muscles spontaneously by closing their contracted? mouths; - Is there any sign of tirage, an - status of inflammation. A pale or inspiratory recession of the chest lilac color of the mucosa indicates wall that would indicate an obstruc- an allergy provoked inflammation; tion of the larynx? - presence or absence of polyps or - Are there any regions of general- pus at the sinus meatuses; ized hypertrophy? Is the patient’s - status of the senses of smell and appetite good or are there indica- taste; tions of anorexia? - status of the interior of the sinus - What is the patient’s weight and cavities, if the ostia are open; general tonus? - the patency of the choanae, the - Does the patient show any signs of posterior nasal passages; the vo- psychological distress? lume of the cavum and the volume of the adenoidal vegetations that may have grown in it; closing of the soft 3 – 3 – 2 – The physical exam palate during phonation. To test this • Nasal fossas and the cavum the physician may ask patients to Physicians make a rhinoscopic ex- hold the pronunciation of the letter amination of the anterior and posterior ‘‘A’’ while they speak and during fossas and, after anesthetizing nasal swallowing. soft tissues and atomizing them with a Contraction of extruded tissue vasoconstricting solution, perform an known as Passavent’s ridge, when endoscopy that allows them to study present, constitutes a transverse bar- the: rier that aids in closing entry to the - nasal septum and its possible high cavum. deviations that could cause pain, • The oral cavity headaches, problems of the sinus The physician should look for and and of olfaction, and be and be at make assessments of: the root of respiratory difficulties. As a general rule patients prefer to - The patient’s orthodontic and den- sleep on the side of the septal tal status noting presence or ab- deviation because the interference sence of diastemas or temporary with venous blood flow on this teeth. homolateral side in patients who - Evidence of bruxism, presence of are lying down is aggravated even worn areas on teeth, status of more. They unconsciously protect dental articulation. Discoloration of the better functioning nostril by anterior teeth may be a sign of placing it in the uppermost position; mouth breathing. Physicians should - volume of the turbinates. Their also check the constriction of the possible retraction after application masseter muscles and the status of of vasoconstrictors may ameliorate the temperomandibular articulation. respiration sometimes causing pa- -Athick labial frenum interposed tients to indicate this improvement between an upper anterior diastema

262 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

and its possible interference with of a cleft palate. Palpation may detect the orthodontic appliance. the presence of an osseous cleft in - Mobility of the tongue. Does its themaxillaaboveit. bulk suggest macroglossia with its - The oropharynx, which may be borders notched from imprints of thickened and show traces of in- teeth? Is the tongue held in an flammation due, as a rule, to anterior position? In the first stage esophageal reflux. of swallowing does it thrust itself - the diameter of the hypopharynx, between an anterior open bite or a with the Muller maneuver. To do diastema from a low position? this, after asking patients to make a -Doesthelingual frenum,whichmay forced expiration, the physician be short, thick, and bifurcated near the asks them to inspire while holding Wharton ducts, prevent the tongue their mouths and nostrils closed from being raised? If it is tightly and then uses a fibroscope to attached to the base of the tongue, obtain the results. the frenum may impede the tip of the - The size of the base of the tongue tongue from advancing, which makes and the lingual tonsils with their pronunciation of certain sounds diffi- crypts. cult and, on rare occasions, because • Additional examinations of its lack of propulsive power may send boluses of food on a false route - Otological to see if nasopharyngeal backwards. obstructions have affected the ears. -Anarrow palate with a retruded - Broncho-pulmonary. maxilla prevents the mandible from • Para-clinical examinations being enveloped by the upper jaw Depending on results of the clinical and reduces nasal breathing and review, physicians may decide they may also be a sign of excessive need the additional information that thumb sucking. can be provided by: - Status of the cheek mucosa. Find- - A profile radiological view of the ings might include slightly moist cavum and the sinuses. appearance, evidence of bite marks - An audiogram. or lichen planus, or of cheek sucking. - A sleep polygraph using the Ep- - Position and size of the tonsils worth Index to evaluate the possi- whose poles may be set in the soft ble presence of the sleep apnea palate in relationship with the columns syndrome. and may descend steeply toward the - Functional breathing tests. base of the tongue where they can be exposed to infection, crypts, and caseum. 3 – 4 – Non-surgical treatment - The soft palate and the tonsillar columns, which may be long, 3 – 4 – 1 – Medical thick, and hypertrophied. • This is often required because the -Theuvula, which may be long and fragile tissues of the region are bifurcated, imitating the appearance highly susceptible to repeated

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bouts of infection that can become patients how to adopt proper tongue chronic. Patients need to be ad- posture and how to make sounds vised on how to take precautions using the correct pronunciation tools and how to maintain good preven- and organs, not to speak nasally or to tive health behaviors. Physicians make other dysphonic sounds. use sonic aerosols, antibiotics, and Visits to therapists should produce corticoids to treat pain, sinusitis, at least partial results in 10 to 15 and tonsillitis and to stimulate im- appointments. If they do not, physi- mune responses. cians should look for a possible • Physicians deal with esophageal mechanical cause of the problem. reflux by advising patients on prop- er eating behavior and, in extreme cases, with surgery. 3 – 5 – Surgical treatment • Thermal cures are employed for infectious and allergic problems. 3 – 5 – 1 – Surgical procedures • In their treatment of allergies and • On the nasal septum asthma, physicians may prescribe: The surgeon performs an endo- - corticoids for short term benefit, scopic septoplasty (figs. 1 to 3) under - anti-histamines in the form of anti- general anesthesia, sometimes on allergic nose drops. Corticoids with quite young children when there is a vasomotor effects can be substi- major near total or total obstruction, tuted for purely vaso-constricting usually as a result of trauma, even noses drops, but only for patients though it is understood that growth older than 15 as a trial treatment. and orthopedic expansion of the max- • Physicians will eventually deliver illa may provoke a new deviation that more definitive allergic and later spe- will have to be re-evaluated and may cific immune-desensitivity treatment. require another surgical procedure. Surgeons therefore prudently limit 3 – 4 –2 – Various recommendations their early interventions to severe and re-training programs deviations and scrupulously avoid any adjustment of posterior and superior - Patients have to be taught how to portions of the nose. This procedure stop sucking thumbs, fingers, or may be carried out in conjunction with pacifiers. At first they are allowed to an endoscopy of large size and swol- fall asleep with the desired object in len middle turbinate bones thought to place, knowing that it will be be causing pain, headaches, chronic removed when they are sleeping sinusitis from faulty aeration, or olfac- and that they should not replace it. tion problem. - Patients can be asked to voluntarily • Operations on the inferior turbi- try to close their mouths and nates (fig. 4) breathe through their noses. It is often advisable for surgeons to - Re-training: reduce the size of the inferior turbi- Speech therapists and physical nates, under local or general anesthe- therapists can help by showing sia, but never to remove them

264 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

Figure 1 Figure 2 A deviated septum. A separated septum.

Figure 3 A septal deviation and the inferior turbinate bone.

entirely. The amount of osseous tis- - by electrocoagulation with a bipolar sue removed depends upon the age pliers under general anesthesia of the patient and the size of bones. (fig. 5); This operation often eliminates the - by luxation with aid of a Kilian necessity of correcting a mildly de- speculum (figs. 6 and 7), a proce- viated septum. dure that may also be associated Surgeons accomplish this proce- with electrocoagulation; dure either: -orbyapartial turbinectomy (fig. 8) - by thermal cauterization or by radio that reduces the bone’s height and, frequency ablation in endoscopy or usually, leaves the base mostly with a laser under fibroscopy; unaffected to lower the risk of

J Dentofacial Anom Orthod 2010;13:254-272 265 J. GILLES ABEN-MOHA, BRUNO BONNET

Figure 4 Figure 5 Hypertrophied lower left turbinate. Electrocoagulation of the lower left turbi- nate with interposition of a silicone plate.

hemorrhage. A portion of the oss- geal approach would not reach eous skeleton of the turbinate may them. be resected, possibly asymmetri- For older children and adolescents, cally. physicians should regard the adenoi- After completing procedures on the dal tissue of their patients with inferior turbinates under general an- vigilance conducting frequent esthesia, surgeons usually interpose a anatamo-pathological examinations silicone plaque between them and the as a matter of principal, because this septum for 15 days to make certain no tissue can disappear spontaneously or adhesions develop between these relapse into its former state as a result two structures. of esophageal reflux. Whenever a child is placed under • Adenoidal vegetation (figs. 9 and general anesthesia for another surgi- 10) cal procedure, surgeons usually take Surgeons can remove these either advantage of the opportunity to by: remove any residual adenoidal tissue - a traditional adenoidectomy passing even if only a small amount of it is left. through the mouth under the soft • Frenums palate, if the adenoidal tissue is to - The lingual frenum (figs 11 to 15) be found in the cavum, its usual A surgeon performs a lingual fre- position, nectomy by resecting the hypertro- - or under control of endoscopy phied portion on the tongue’s ventral through a combined oral and nasal surface being careful not to impinge approach if the adenoidal tissues upon the nearby Wharton submandib- had invaded the posterior choanae ular ducts. The surgeon frees the of the nose where a rhino-pharyn- lateral borders and places an inverted

266 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

Figure 6 Figure 7 Luxation of the lower left turbinate. After luxation of lower left turbinate, hypertrophied adenoidal tissue and transverse suture in a forcible effort to middle cornet can be seen. prevent relapse, always bearing in mind the possibility of provoking growth of taut scar tissue that would • (Figs 16 to 18) mimic the original condition. A tongue Always bilateral even in patients carried in a low position and chronic displaying size asymmetry, hypertro- mouth breathing encourage this phied tonsils are removed by dissec- undesirable outcome. tion under general anesthesia with - Sectioning of upper and lower surgeons maintaining effective hemos- labial frenums is far less fre- tasis and carefully avoiding cutting into quently indicated

Figure 8 Figure 9 Partial lower left turbinectomy. Hypertrophied adenoidal tissue.

J Dentofacial Anom Orthod 2010;13:254-272 267 J. GILLES ABEN-MOHA, BRUNO BONNET

often accompany respiratory insuffi- ciency problems caused by ana- tomic and organic obstructions.

3 – 5 – 2 – Indications for surgery It is imperative for practitioners to evaluate every possible surgical inter- vention with extreme care, in terms of the risk/benefit ratio, evaluating all relevant information particularly about the possibility of complications, even though they are extremely rare. But when they do occur, they may Figure 10 pose serious health threats, even life After an adenoidectomy and clearing of the posterior threatening ones, like hemorrhage. choanae, a compress has been placed in the cavum to They may require surgical re-interven- plug it up. tion that could be of an urgent nature. Before undertaking any operative pro- cedure surgeons should carefully ex- plain its goals, its probable results, and the pillars especially in young children its potential benefits, as well as its to protect against the potential risk risks, to patients and parents in order such a misstep would pose of deform- to obtain their informed consent and ing the soft palate with accompanying cooperation. disturbance of phonation and installa- Surgeons make their final deci- tion of open rhinolalia. Such a deformity sion to operate only after: would also impair the digestive process by causing false alimentary routes and - a period of alternative medical nasal regurgitations if the posterior treatment has convinced reluctant pillars were pulled forward. Even worse patients how beneficial a proposed would be a shortening of the soft palate operation would be. Surgery should that might occur if a removal of over- be postponed if any alternative abundant adenoidal tissue were at- medical treatment would improve tempted at the same time. conditions. Then if this alternative • Partial anterior are approach fails or provides insuffi- performed only in cases of enor- cient improvement, surgery can be mous hypertrophy of lingual tissue. undertaken; • Surgeons may also be called upon to - orthodontic treatment of facial undertake certain associated oto- deformities has accomplished as logical interventions,creating much as it can and surgical interven- trans-tympanic aerators, for exam- tion is needed to complete treatment ple, and to perform endoscopic or stabilize it; examination of sinuses, as well, - the prospective patient has because disturbances in this region reached the age and stature

268 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

Figure 11 Figure 12 A simple section of the lingual frenum. Suture placed in the lingual frenum.

Figure 13 Figure 14 A bifurcated lingual frenum, Wharton Section of the two parts of a lingual duct, and bite block. frenum.

considered desirable for the inter- tongue posture have not yet vention; but the presence of major achieved their objectives in spite problems may persuade surgeons of of the patient’s good cooperation or the necessity of operating on very if orthodontic therapy had not fully young children; attained the desired results; - it has become clear that myofunc- tional therapy for respiration and

J Dentofacial Anom Orthod 2010;13:254-272 269 J. GILLES ABEN-MOHA, BRUNO BONNET

Figure 15 Figure 17 Simple suture in lingual frenum. Patient prepared for operation.

Figure 16 Hypertrophied tonsillar tissue. Figure 18 After the tonsillectomy.

- pathological processes, polyposis, appetite, weight loss, and problems for example, are affecting the oto- in growth and in school. logical tubes or the sinuses; In order for orthodontic treatment to - all of the above factors may be conclude with a satisfactory outcome added, in varying degrees, to patients and parents must offer ortho- breathing problems, infections, dontic therapists their whole-hearted poor general health status, includ- cooperation. But older and more phy- ing poor sleeping with its repercus- sically mature patients may become sions on waking behavior, loss of impatient with the apparent slowness of traditional orthodontic treatment

270 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

and favor the ‘‘more aggressive’’ orthodontic, growth, and emotional approach that surgery promises. points of view. • Finally, with very young patients especially, surgeons making deci- 3 – 5 – 3 – Over all, contra- sions based on widely discordant indications for surgery data might be well advised to adopt depend upon: a posture of watchful waiting to • The results of a careful assessment gain time for more rigorous obser- of the risk/benefit ratio with regard vations, further testing, and, per- to: haps, to allow orthodontic/ orthopedic treatment to begin and - the presence of a deficiency in perhaps ameliorate conditions and blood clotting; justify a re-evaluation of the surgical - the possibility of causing a malfor- prospects. mation, especially one in the vas- • Non-cooperation, even defiance cular system; from some families, constitutes, - the possibility of soft palate func- within the highly litigious frame- tioning becoming overloaded if all work of our present society, more the airways were to be fully liber- than enough reason for surgeons to ated by clearing of obstacles due to postpone, more or less definitively, vegetations, tonsillar and adenoidal any intervention. hypertrophy, and blockage in the • Post-operative vigilance, designed turbinates. In the face of such an to avoid or at least limit complica- eventuality, even though the formal tions, like nasal adhesions is crucial. indications for surgery are positive During this period, re-training pa- for a variety of reasons, the surgeon tients in proper nasal breathing, may decide to divide the interven- affected by the palate and the tion into two stages, separated by tubules, may be indicated. an appropriate period of time, so that the patient can progressively In any case, after an initial evalua- adapt to the new conditions, per- tion for possible surgery, surgeons haps assisted by myo-functional should see all patients for at least and speech therapy. Surgeons one more visit, with the possible may even decide to postpone inter- exception of those whose first assess- vention indefinitely until patients ment ruled out any surgery at any are fully prepared for it, from time.

4 – CONCLUSION

We have reviewed some of the ably as treatment proceeds. In many unfavorable organic and functional cases, otolaryngologists are called conditions that orthodontists find in upon to review the status of their patients at the outset of their such patients and to establish a treatment and that develop unfavor- well-reasoned risk/benefit ratio for a

J Dentofacial Anom Orthod 2010;13:254-272 271 J. GILLES ABEN-MOHA, BRUNO BONNET

possible surgical procedure. When that might accompany an operation the inter-disciplinary team decides to designed to help optimize the ortho- postpone a surgical intervention, the dontic/orthopedic result, one that ENT specialist will later re-evaluate would not, in any case, rule out the the situation taking into account all possibility of orthognathic surgery at the contra-indications and dangers a later date.

272 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