Pacific Coast Society of Orthodontists Bulletin Summer 2017 - 70

Presentation Summary

Early Detection and Management
of Reduced Airway
Dr. Dawn Pruzansky
PCSO Bulletin Contributing Editor

Presented by Dr. Juan-Carlos Quintero at the PCSO
Spring Training, March 4, 2017.
Dr. Quintero discussed recently developed
technologies and how these advances allow for
visualization of the airway and evaluation of any
changes that may result from orthodontic treatment. He uses the i-CAT FLX because of its validated low exposure to the patient.1 He suggests
that airway should be added to the diagnostic
list of findings. A quick review of airway anatomy
reveals the following:

Dr. Juan-Carlos Quintero
South Miami, FL

1. Support - Vertebra, maxilla, mandible, hyoid
bone
2. Valves - Soft palate, tongue, epiglottis
3. Encroachments - Tonsils, adenoids, tumors,
turbinates
Obstructive sleep apnea (OSA) comprises 40%
of all sleep-disordered breathing, and can only
be diagnosed by a physician. The average life
expectancy for an adult, overweight, untreated
patient with severe OSA is 10 years, and the many
comorbidities include increased risk of auto accidents due to fatigue. One in five adults has a mild
form of OSA; 1 in 15 has moderate OSA.
The three main areas of obstruction are the nose,
back of the throat, and base of the tongue. When
analyzing these areas, look for the minimum
cross section (MCA), which varies in location
based on the individual. A general rule of thumb
for MCA is that a value of 50/100/150 mm2 represents high/moderate/low risk of OSA. The shape
of the MCA is also important: a wide MCA is
more favorable.
There is a correlation between the jaws, teeth, and
airway. A Class II, convex phenotype has the worst
airway, and Class III, concave shows the best airway. A small jaw generally means a small airway.

Dr. Quintero's lecture was
sponsored by I-CAT.

Dr. Quintero discussed the methods for obtaining
the best mandible and airway, including orthognathic surgery, orthopedics, and natural growth.
Transverse development is important, as is
condylar health, because the condyles drive
mandibular growth.

Treatment of adult OSA can involve the following:
* Weight loss
* Oral appliances - 85% get unwanted tooth
movement, and some can exhibit enlargement of TMJ spaces
* Continuous positive airway pressure (CPAP)
therapy - gold standard, but only 40% to 50%
can tolerate it
* Uvulopalatopharyngoplasty (UPPP)
* Orthognathic surgery (maxillomandibular
advancement [MMA]) - 100% success rate,
but invasive surgery
Dr. Quintero argues that we need to intervene
during development of the maxilla and mandible
in order to circumvent the need for MMA. We
need to look at normative data regarding growth
and development and aging in order to predict
what type of early intervention may be required.
According to Schendel,2 airway size and length
peaks at 20 years of age, growing at approximately 10 mm2 per year. Between the ages of 20
to 50, the airway decreases; over the age of 50,
the airway decreases more rapidly. Using this
data, the orthodontist can measure the size of
the airway, compare to the normative value, and
treat or refer accordingly.
The last note that Dr. Quintero discussed was on
the topic of standardized records. When taking
a CBCT to assess airway, natural head position,
centric relation, and upward/forward tongue
position are all needed in order to minimize
the effect on MCA. 
References
1. Ludlow JB, Walker C. Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography. Am J Orthod Dentofacial Orthop
2013;144:802-817.
2. Schendel SA, Jacobson R, Khalessi S. Airway growth
and development: a computerized 3-dimensional analysis. J Oral Maxillofac Surg 2012;70:2174-2183.

Suggested Reading
Kim KB. How has our interest in the airway changed
over 100 years? Am J Orthod Dentofacial Orthop
2015;148:740-747.

PCSO Bulletin  Summer 2017

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Summer 2017