Treating in the primary dentition

► Prevention of
crowding/malocclusion.
► Improving the airway in
children who aren’t
sleeping well.
► Working with the natural
growth of the jaw to
guide the forward
development of the jaws
in addition to widening.
Why Treat in
the Primary
dentition?
Craniofacial development by age

2 years old: 55% developed

4 years old: (male) 73.33%

(female) 77.68%

12 years old: (male) 89.43%

(female) 94.36%
 What to look for in a
potential airway patient

Primary dentition ages 2-6

 Open mouth
posture

► Limited tongue
space
► Headed towards
crowding
► Airway
deficiency
Open bite
► Thumb sucking (A
compensation to
open the airway)
► Tongue thrust (a
abnormal swallow
pattern to get the
tongue out of the
airway space)
Narrow
Palate/V-shaped
maxilla

► Limited tongue
space/open
mouth posture
► Crowding
Gummy smile
► Excess vertical
growth pattern
► Locked in mandible
Enlarged
Tonsils
► Mouth breathing
► Airway
restriction
► Referral to ENT
 Down and
backward
growth pattern
► Restricted airway
space
► Elongated facial
shape
► Leads to open
mouth posture and
oral breathing
Underdeveloped/inset jaws

► Excessive crowding
► High nose lip angle
► Thin upper lip
Dental wear

► Grinding and clenching

Causes:
► A reflex for the body to
attempt to open the airway
and get more oxygen
► Malocclusion

Flattened canines
Mentalis
Strain
► Open mouth
posture
► Snoring
► Vertical growth
pattern
Overbite

► Lingually inclined
teeth
► Locked in lower
jaw
 No
space/crowding
in primary
dentition
► Headed towards
severe crowding
► Small mouth and
compromised
airway
► Mouth breathing
measurements for ages 1-5

► The indicator Line- Developed by Professor Dr. John mew in

The 1970’s to measure facial lengthening and vertical growth
Which relates to malocclusions and facial balance.

► The ideal Indicator line measurement in children is age+21

*A greater number
indicates a Downward
direction of growth*
 Measuring intermolar width ages 3-5
The (Bogue index) is used for patients that don’t yet have 6 year molars.
Measure from gingival margin to gingival margin on the primary E’s .

*If the BI measurement in under 28mm expansion should be considered*

Before primary E’s erupt

► There is not a
measurement guide for
proper width.
Look for:
► Crowding
► Scalloping on the
tongue
► Lack of space between
teeth
► Mouth breathing
► Tongue between teeth
at rest
Evaluating a tongue tie

► Measure the max opening and

the max opening while doing a
tongue suction and hold.
► If the measurement while
doing tongue suction and hold
is under ½ of the max opening
a tongue tie release should be
considered. (referral to a
myofunctional therapist to
evaluate)
► If the measurement is ½- 2/3
of max opening a release might
be a consideration.
► From www.Fairest.org
 Pediatric
Diagnostic tools
► Pediatric sleep
questionnaire
► Fairest 6
► Sleep evaluation
► Ecco airflow
measurement
 Pediatric sleep
questionnaire

If a parent answers yes to 8 or

more questions may indicate a
problem with sleep disordered
breathing.

► This is a very helpful screening tool

that can easily be integrated into new
patient paperwork or exams.

► This questionnaire gives you talking

points for parents to address a sleep
disorder they may be unaware of.
Pediatric sleep questionnaire
Pediatric sleep questionnaire
 Fairest 6

►Scoring for risk of sleep

disordered breathing

►2 –mild risk

►4- moderate risk

►6- severe risk

A helpful screening tool that
is easily integrated into
patient exams.
www.fairest.org
 Sleep evaluation

At home sleep study

evaluates:
► Sleep quality
► Sleep duration
► NREM/ REM sleep
cycles
► Phenotype OSA vs.
CSA
Sleep image -pediatric sleep ring
(ages 2+)
This system collects signals
controlled by the automatic nervous system
during sleep to measure:
• Wake VS. Sleep
• Sleep States REM vs. NREM
• Sleep stages
• Objective sleep quality using the FDA-cleared sleep quality index
(SQI)
• Respiration
• Blood oxygen
• Movement

PROS: minimally invasive, convenient, price

LIMITATIONS: It does not track body position or brainwaves

Sleep Cycles

► Stable Sleep: Effective deep sleep, Non-Rapid-Eye-Movement (NREM). During deep

stages of NREM sleep, the body repairs/regrows tissues, builds bone and muscle,
strengthens the immune system, nervous, metabolic, cardiovascular, and other
systems.
► Unstable Sleep: Ineffective deep sleep; fragmentation causes unstable sleep and has
the exact opposite features when compared to stable sleep. Unstable sleep can be
responsible for poor behavior and poor cognitive development. Restricting periods of
this state of sleep has consequences similar to those of total sleep deprivation,
including sleepiness and metabolic dysregulation.
► REM: Rapid Eye Movement sleep; skeletal muscular paralysis, a motionless state
except for eye movement. REM stimulates the areas of the brain that help with
learning and is associated with increased production of proteins. Dreaming occurs in
this state.
 Sleep cycles

Ideal Sleep Cycle:

•4-5 cycles of deep and REM sleep with no disruptions within the cycle.

Disrupted Sleep cycle:

•Lots of Fragmentation within the REM cycle.
Young Child with upper Airway
resistance syndrome
Indicated by the
red arrows you can
see that each time
the oxygen dips
there is a sleep
disturbance
because the heart
rate spikes.

This happens to arouse this person enough to get the tongue

out of the back of the throat, so they can breathe well again.
This young healthy person’s adrenals are working well so they
can arouse quickly without the prolonged drop in oxygen, but
they are still suffering from many breathing related sleep
disturbances throughout the night.
Airway related sleep disturbances

AHI (Apnea Hypopnea Index)

• This is number of times an hour breathing disturbances/pause occurs for
longer than 10 seconds, measured at both 3% and 4% desaturation levels.
REI (respiratory event index)
• This is a term often used in at home sleep tests that means the number of
apneas or hypopneas recorded during the sleep study per hour.

sRDI (Respiratory disturbance index)

• Number of times per hour there is a disturbance in breathing, these are not
considered an apnea event because there is a less the 3% desaturation or they
last less than 10 seconds, but they are still events that effect the cycles of
sleep and overall sleep quality.
Sleep quality expected values
No Sleep Apnea Mild Sleep Apnea Moderate Sleep Apnea Severe Sleep
Apnea
Adults AHI/REI < 5.0 AHI/REI > 5.0 to < 15.0 AHI/REI > 15.0 to < 30.0 AHI/REI > 30.0

Children AHI < 1.0 AHI > 1.0 to < 5.0 AHI > 5.0 to < 10.0 AHI > 10.0

Expected Values Adults Children

Sleep Quality Index > 55 > 70

Sleep Apnea Indicator (SAI) Mild/Moderate/Severe threshold markers > 5 / > 15 / > 30 > 1 / > 5 / > 10

Apnea Hypopnea Index (sAHI) Mild/Moderate/Severe threshold markers > 5 / > 15 / > 30 > 1 / > 5 / > 10

Respiratory Disturbances Index (sRDI) Mild/Moderate/Severe threshold > 5 / > 15 / > 30 > 1 / > 5 / > 10
markers
Ecco Pharyngometer
(ages 5+)

► The Ecco vision machine uses acoustic

reflection technology to map out the
size, structure and collapsibility of the
oral and nasal airway.
► The Ecco is a great diagnostic tool to
examine the health of an airway
throughout treatment, as well as how
the airway changes in response to
mandibular advancement.
Airway Consults Ages 2-6

Taking a full orthodontic photo series

Pediatric sleep questionnaire

Sleep Evaluation

Fairest 6 airway evaluation

Full ortho evaluation

Ecco Pharyngometer

Presenting findings and a treatment plan

How to Take full Orthodontic photo
series
Supplies
needed:
► Cheek retractors
► Intraoral occlusal
photograph mirror
► Hot water bath (To keep
mirror fogging to a
minimum
► Smart phone or camera
with a flash
► A plain background /
white backdrop
Patient facial photographs

Camera setting:
Set the camera to portrait mode

► Have patient Stand against a plain background

► Have patient remove glasses and put hair back or behind ears and back
► Make sure to capture the shoulders to have a record of patient posture
► Alignment is important for profile photographs. Have the patient stand to the
side with feet in line and look straight ahead.
 Facial photographs
Facial Facial
Front front
smiling

Facial Facial
profile Profile
smiling
intraoral
photographs

► Adjusting camera settings is

important for the best result, the
following settings should be used:
• Aperture or f/stop: Set in manual
mode (from f/8 to f/14).
• Shutter speed: Set in manual mode.
• ISO: Set to 100 to maximize image
quality and clarity.
• Magnification: Set in manual mode.
• White balance: Set to “flash.”
► Blurred images occur when the
subject is in motion. Increasing the
shutter speed or stabilizing the
camera and patient can reduce
motion blur.
Place mirror over
hot water

This keeps the mirror from

fogging during intraoral
photographs.
Positioning of
the patient

► Have the Patient sit in

Dental or another chair
► When capturing
anterior, buccal, and
occlusal images, keep
the patient’s head level
with the Frankfort
horizontal plane.
Patient’s head should
be perpendicular to the
floor.
• The occlusal plane
leveled.
• The position of the
teeth is parallel to the
tabletop.
 Intraoral photographs
Lower Occlusal
Upper Occlusal

Intraoral right Intraoral left

Intraoral center
Intra oral scans

This is the easiest and fastest way to get records to the lab
for fabrication
Intraoral scans are much more tolerable and accurate for
young patients

For fabrication of the appliances we will need:

► Upper scan
► Lower scan
► Bite scan
Capturing a good quality scan

► 5mm of gum tissue on the buccal and lingual all the way around the arch.
► The entire palate
► The entire back molar and gum tissue behind back molar.

>5mm
 Orthodontic photo series-Talk through and point out visual findings.

Indicator line measurement-can be used to determine excess vertical

growth

Pediatric sleep questionnaire- Talk over the list of the symptoms

Presenting marked and how they could correlate to an airway disruption.

findings Fairest 6- What risk is the patient at based on this screening and how
these factors contribute to an increased risk of a compromised airway.

Sleep evaluation- What is the patient’s quality of sleep and airway

health.

Ecco Pharyngometer- How is the health of the nasal and oral airway/
how it could be improved by mandibular advancement.
 Outline the goals
of treatment
What are the goals of treatment and
symptoms that we are looking to
improve through treatment
- Sleep
- Airway restriction
- Crowding
- Sleep walking
- Mouth breathing
- Behavior
- Frequent illness
- Energy
Creating a treatment plan

Based on the indicator line and the intermolar width determine how much
growth is needed to get to ideal jaw development.

Appliance expansion:
Each appliance expands 8 mm approximately 48 turns.
If turned 2x/week appliance will be worn for 6 months.

Treatment time:
Most patients use 2 upper appliances and 1-2 lower appliances.
Appliance treatment time is typically 6-12 months (depending on the compliance of the
patient)
Finishing up records and
starting an airway
patient.
In depth orthodontic evaluation
The Airway Center orthodontic clinical examination is a comprehensive
evaluation that includes:

► Doctor and patient concerns

► Dental assessment
► Esthetic assessment
► Extra/intraoral assessment
► Muscle evaluation
► Airway assessment
► TMD Assessment
► Myofunctional Assessment
Initial measurements

► Indicator line
► Bogue index (Ages 2-6 with no permanent molars erupted)
► Intermolar width (After permanent molars are erupted)
► Overjet
► Overbite
► Max. retrusive
► Max. Protrusive

► These measurements are taken at every recall appointment to track the

growth and progress of treatment.
Overjet

►Measure From the facial

surface of the lower
central incisor to the
facial surface of the upper
central incisor when in a
normal bite.
Maximum Protrusive

►With the lower jaw as far

forward as possible.
Measure from facial
surface of upper central
incisor to facial surface of
lower central incisor.
Max retrusive

►With the lower jaw moved

back as far as possible
measure from the facial
surface of lower incisors
to facial surface on upper
incisors.
Indicator line

►The Distance from the incisal

edge of the upper central
incisal edge to the front point
of the nose.
Bogue Index
(before the 6 year molars erupt)
The (Bogue index) is used for
patients that don’t yet have 6 year
molars.
Measure from gingival margin to
gingival margin on the primary E’s .
Intermolar width

►Measure the distance

between the upper
permanent first molars at
the mesial lingual gingival
margin.
Airway center
laboratory
Records needed to submit a case:

► Full orthodontic photo series

and one of the options below:
► STL scan files of upper, lower
and bite
► Stone models of upper/lower
with blue bite
► Polyvinyl impressions with blue
bite
Setting up your DDX account

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Go to Select login Choose Enter login Drop down Click the “+” Partner Search in:
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right corner drop down where it •By: State
menu says: Go To •State:
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