A series of lectures by Dr. Barry Raphael on Airway-focused orthodontics. Chapter 4: How the basic assumption of Maxillary Dysplasia affects diagnosis and treatment planning in Airway-focused orthodontics.

1. Airway Orthodontics
A lecture series prepared by
Dr. Barry Raphael
Of the
Raphael Center for Integrative Orthodontics
Clifton, NJ.
www.alignmine.com
www.myobracenj.com
“Skeletal Treatment” - 2013
1Thursday, June 6, 13

2. •Animations are not included in this archive and may
affect the meaning or intent of the slide
•As the information in these presentations is
constantly evolving, please consider the date of creation
when reviewing the material.
2Thursday, June 6, 13

3. Skeletal Relationships
Based on Bell, Profit, and White, Surgical Correction of Dentofacial Deformities, 1980
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4. Skeletal Relationships
Cranium
Naso-maxillary
complex
Max dentition
Mand dentition
Mandible
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5. Skeletal Relationships
Ideal, Class I
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6. Skeletal Relationships
Maxillary Dental Protrusion
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7. Skeletal Relationships
Class II, Mandibular Retrusion
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8. Skeletal Relationships
Skeletal Open Bite
Maxillary Protrusion with Mandibular Auto-rotation
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9. Skeletal Relationships
What’s This?
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10. The Tropic Premise
Maxillary Growth is supported by Tongue Posture on the Palate
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11. The Tropic Premise
But if the tongue is chronically held away from the palate…
…the maxilla collapses in all three dimensions.
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12. Then the Mandible Adapts
If the mandible stay with maxilla: Class I Crowded
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13. Then the Mandible Adapts
Mouthbreathing and/or tongue thrust hinders growth : Class II
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14. Then the Mandible Adapts
Low Tongue keeps mandible growing forward: Class III
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15. Nasion Perpendicular
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16. Bolton Standards
15yo
The Maxilla is
Down and Back
The Mandible is
Retrognathic
Nasal Cartilage
Collapse
Insufficient Facial
Support
Bi-maxillary Retrusion
16Thursday, June 6, 13

17. 17Thursday, June 6, 13

18. The relationship
between retruded chins
and airway obstruction!
Both infants and
adults die from
obstructed airways!
(Grant’s Atlas of Anatomy, Fifth Edition, 1962, Williams & Wilkins)
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19. Kevin Boyd
Must treat early!
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20. Predictive factors that puts an
individual at risk for OSA include:
• Large body mass index (obese)
• Large neck size
• High palate
• Narrow dental arches
• Overjet (jaw back - retrognathic)
IF the individual does not have a large neck and/or body
mass, then the predictive value for being at risk for OSA is
based on a high palate, narrow dental arches and overjet.
From Kushia and Guilleminault, 1997
20Thursday, June 6, 13

21. Pharyngeal Airspace
Three-dimensional assessment of pharyngeal airway
in nasal- and mouth-breathing children
Alves, M, et.al., Int J Ped ORL 75 (2011) 1195–1199
Cone Beam and Airway analysis tool
21Thursday, June 6, 13

22. Pharyngeal Airspace
•Exam for Mouthbreathing
•the habitual posture of the lips
•size and shape of the nostrils
•control reflex of the Alar Nasalis
•Glatzel mirror test
•Rhinoscopy
•Adenoid hypertrophy
25 Nasal breathers, 25 mouth breathers,
Avg 8-9 y/o
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23. Pharyngeal Airspace
Mouthbreathers have significantly
smaller airway space.
(measurements PAS-OccL, PAS-UP, airway volume, area and minimum axial area)
Mouth breather Nasal breather
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24. Which is easier to breath through?
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25. Which would you trust most?
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26. Which would you rather have?
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27. Big Problem!
… except for
bimaxillary advancement surgery,
conventional orthodontics has
no workable protocols for
correcting this type of malocclusion
in the late mixed or permanent dentitions.
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28. Treatment
The one common feature of posture-related malocclusion is
Maxillary Collapse
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29. Treatment
What is the appropriate treatment for a Collapsed Maxilla?
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30. Treatment
Headgear?
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31. Treatment
Extractions ?
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32. Treatment
Class II Elastics?
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33. Treatment
Mandibular Advancment Appliance?
(Herbst,Twin Block,MARA with reciprocal anchorage)
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34. Bimax
retrusion
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35. Successful
dental result
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36. Failed Profile Result
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37. Bimax
retrusion
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38. Successful
dental result
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39. Failed Profile Result
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40. Treatment
The appropriate treatment for a Collapsed Maxilla…
Moves the Maxilla up and forward…
AND the Mandible rotates and moves forward
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