|Sleep Apnea from an Anatomical and Developmental Perspective|
Researcher and presenter: Brian Palmer, D.D.S. (June 4, 2004)
This presentation is for the serious researcher or individual who is interested in the cause and possible prevention of snoring, obstructive sleep apnea (OSA) and sleep disordered breathing (SDB). This presentation has a total of 264 slides / illustrations. This commentary is approximately 17 pages long. You can copy & paste this commentary or just print it off. It will take some time to download the four sections of the presentation onto your computer (if you want to) because of size. Section A is 4.2MB, B is 2MB, C is 2.8MB and D is 1.3MB. All are in Adobe Acrobat (PDF) format. Please download the free Adobe Acrobat Reader to open the files.
A condensed version of this presentation was given at the 14th Annual Academy of Dental Sleep Medicine (ADSM) conference in Philadelphia on June 4, 2004. The ADSM is an association of dentist, physicians and researchers from around the world who are interested in the issues associated with snoring, OSA and SDB.
WARNING: This presentation does have human fetus and adult cadaver dissections and one surgery that may not be suitable for viewing by all individuals. It is believed that the dissections are necessary for the presentation because of the specificity of the topic.
Information on the presentation given at the ADSM Conference
Objectives of presentation: This course will illustrate the many anatomical structures that can contribute to OSA/SDB. Using illustrations of both fetus and adult cadaver dissections, it will be demonstrated how and why the human airway is so uniquely different from all other mammals that doing any OSA research on animals and trying to compare results to humans is invalid before the research even begins. By comparing the features in skulls of prehistoric man to the oral characteristics of ‘modern’ humans, the course will cover why one can hypothesize that prehistoric man may not have suffered from OSA/SDB. The importance of breastfeeding as a possible way to reduce the risk of OSA/SDB will be discussed as well as how bottle-feeding and infant habits are major contributing factors to the collapse of the oral cavity and airway. A review of the scientific principals involved in OSA/SDB will also be discussed.
Biosketch of Dr. Palmer: Dr. Palmer graduated from UMKC dental school in 1970. After a one-year hospital residency in Pittsburgh, PA, he returned to Kansas City where he established a full time family dental practice. Since about 1975 he has been doing self-funded research trying to determine the reasons for the collapse of the oral cavity and airway. He has walked down many paths, has taken thousands of impressions for study models and has taken thousands of pictures for documentation. He has also taken extensive post-graduate courses including the Pete Dawson Seminar series and attending the Pankey Institute. He trained under Dan Garliner at the Institute for Myofunctional Therapy in the mid 70s and did twin-wire orthodontics for 7 years. As a former physical education major and professional football player, he has always been interested in health and fitness. He developed dissecting skills as a human anatomy lab assistant in the mid 60s and has taken very interesting and unique illustrations of both fetus and adult airway dissections. He has evaluated 600 prehistoric skulls, including many at the Smithsonian. He has done extensive research on the importance of breastfeeding as it relates to total health and has given presentations on breastfeeding issues for the International Lactation Consultant Association and La Leche League International. He will be a keynote speaker at the International Breastfeeding Conference in Hobart, Australia in September of 2005 (Information on that conference can be obtained at: http://www.cdesign.com.au/aba2005.)
Click here to download presentation Section A (5MB – 66 slides)
Anatomical features of OSA
Click here to download presentation Section B (3.9MB – 53 slides)
Click here to download presentation Section C (3.1MB – 89 slides))
Basics of breastfeeding
Click here to download presentation Section D (2.1MB – 56 slides)
Scientific principles of
Commentary: Section A (3+ pages, 66 slides)
Slide # Comments
A2 – Some pictures may not be suitable viewing for some people. There is a “warning” note on the illustration prior to dissection or surgery illustrations.
A4 – I believe this is one of the most important formulas in the medical field today. I also believe very few health-care providers know about the formula. I believe it is important because it has a predictive value to help determine who is at risk for OSA/SDB – which I also believe is a very common denominator in many of the health problems people have today. The ability to breathe and sleep well are critical for good health. The research may be difficult to reproduce because measurements in the mouth can be difficult and/or subjective – but the basic “common sense’ of the formula is very scientific. I believed in the concept long before I even learned about the formula. I hope this presentation will help one understand the validity of the formula.
A7 – This demonstrates where the cuspids and molars should line up to be in a correct Class I occlusion. The mesial buccal cusp of the maxillary first molar should rest over the buccal grove of the mandibular first molar, and the cusp tip of the upper canine should be positioned just behind the lower cuspid.
A8 – Demonstrates a Class II, division 1 malocclusion. Dr. Alan Lowe stated (2003 ADSM conference) that about 85% of the sleep apnea cases treated at the University of British Columbia were of this malocclusion. Note the retrognathia (pushed back jaw) – the lower jaw is pushed back the distance between the upper and lower arrows. This means the tongue is also distalized (pushed back) by this amount – since the tongue is attached to the inside of the lower jaw (see next slide).
A10 – A Herbst appliance like this can be used to advance the jaw of a sleep apneic patient. It is only worn while the person is sleeping.
A11 – A bonded and fixed Herbst appliance in a child 11-1/2 years old. The appliance is cemented in the mouth and worn 24 hours a day to help stimulate forward jaw growth.
A14 & 15 – An example of an ‘overjet’.
A17 – Palatal surgery on this person was contra-indicated at this time because of risk factors.
A18 – A massive tongue contributed to his sleep apnea problem.
A19 – This appliance was unsuccessful because the person was unable to keep his mouth closed while sleeping, despite wearing a chin strap and elastics.
A22 – A key illustration. ‘A’ represents a normal healthy mouth: wide palate, good nasal space, and teeth in proper alignment (upper teeth overlap outside the lower teeth by half a tooth). ‘B’ represents someone who is at risk of having sleep apnea: high palate infringes on nasal space and narrow upper arch infringes on tongue space. Note also how the roof of the mouth (palate) is also the floor of the nasal chamber. This helps illustrate why doing nasal surgery on someone with a high palate may not always have great results – the surgeon just does not have very much room to work with. This illustration also demonstrates how a cross bite can be created.
A23 – An example of ‘B’ above.
A26 – Note that first bicuspids were extracted. This makes for a very narrow arch and high palate.
A28 – An ideal arch should be ‘U’ shaped. This allows more room around the perimeter of the arch for the proper alignment of the teeth. A ‘V’ shaped arch infringes on space for teeth and also infringes on tongue space (and a place were the tongue wants to rest). Note that first bicuspids were extracted and arch collapsed - resulting in a very poor post-orthodontic result.
A29 – A rapid palatal expander (RPE) – or – rapid maxillary expander (RME). By expanding the palate/arch the arch can be changed from a ‘V’ shape to a ‘U’ shape, thus allowing for more room for the teeth to erupt into a better alignment. RPE / RME can only be done BEFORE the mid-palatal suture line fuses (late teens?) (before age 16 would be best). Only way to expand the maxillary arch after fusion is by surgically fracturing the maxilla – but this does not expand the Pterygoid plates – critical for developing a large beginning of the soft airway ‘tube’. (Illustrated later)
A30 – Dr. Cistulli and his researchers had good results treating OSA by RME but needed surgical help to get expansion on the older patients. Surgical expansion does not have the benefit of expanding the Pterygoid plates, as does RME BEFORE the fusion of the mid-palatal suture line (discussed more later).
A31 – Don Timms from the United Kingdom also reported good results from RME – reducing airway resistance by 37% in 1987, and resolving nocturnal enuresis (bedwetting) in 1990. Bedwetting can also be a result of OSA in children (and adults).
A32 – Dr. Robertson, out of New Zealand, also resolved bedwetting of a 12-year-old by using an appliance to advance the mandible – a treatment for OSA.
A34 & A35 – Some studies are looking for genetic markers that cause abnormal tongue activity. Some factors like macroglossia (large tongue), ankyloglossia (tongue-tie) and Central Nervous System (CNS) challenges are genetically linked and can cause abnormal tongue activity (I generically refer to this type of abnormal tongue activity as ‘tongue thrusting’), but MOST abnormal tongue activity (tongue thrusting) is due to infant habits (demonstrated later and discussed in more detail in other presentations on this website).
A36 to A39 – This high palate, narrow arch, overjet, open bite and tongue thrust are the result of being bottle-fed and excessive thumb sucking.
A40 – It is very obvious how this elongated soft palate could obstruct the airway, as could the elongated uvula in A41.
A42 & A43 - This 12 year-old was falling asleep in class, getting poor grades and was disruptive in class. His pediatrician would not recommend the removal of the tonsils because the youngster did not meet the insurance companies criteria for removal of having 3 Strep infections in one year. Parents then took him to an ENT who recognized that he had a breathing/sleeping problem. His tonsils were removed which resulted in a dramatic positive improvement in the boy’s well being.
A44 – Research that supports the need to remove tonsils and adenoids –IF NEEDED.
A45 to A51 – Person with severe sleep apnea. Must sleep with CPAP. His UPPP surgery (part of soft palate removed) did not resolve his problem. Has massive tongue with lateral indentations. Person was also tongue-tied which resulted in abnormal tongue activity (tongue thrusting). The large tongue and tight frenum (ligament under the tongue) in A49 is somewhat similar to what a Down’s Syndrome patient had who was referred to me for the treatment of his OSA. I referred him to an oral surgeon to have a frenectomy done (there are 2 presentations on this website to explain a need for this procedure). The frenectomy freed up his tongue - which allowed him to extend his tongue out of this mouth better. I then fabricated a tongue-retaining device (TRD) to hold his tongue forward and out of his mouth more while he slept – with very good results. A50 shows tongue thrusting between teeth during a swallow. A51 demonstrates open spaces between teeth that are due to the tongue thrusting.
A52 to A56 – Person who had palatal surgery (UPPP). Too much tissue was removed which resulted in food and fluids coming out the person’s nose during swallowing. An obturator had to be fabricated to resolve the problem. Person’s massive tongue was a major contributor to her sleep apnea – but was never recognized by others as a contributing cause of her problem. A tongue-retaining appliance (a Snor-X) successfully resolved her problem.
A56 - WARNING – Next 5 illustrations are of a surgical procedure to reduce the size of the tongue.
A57 to A61 – One example of tongue reduction surgery.
A62 – These large bony benign growths are called tori. They take up tongue space and can also contribute to OSA.
A63 – A high narrow nose like this is prone to collapse and contribute to nasal airway resistance. A nose like this is quite common on individuals with long face syndrome (covered later in this presentation).
A64 to A66 – A four-bicuspid extraction orthodontic case – with poor results. Note posterior edge-to-edge bite, recession and abfractions (discussed more in 2 articles in ‘Article Section’ of this website). ‘V’ shaped arch was not expanded. Removal of 4 bicuspids for orthodontic reasons can be potentially deadly if OSA develops. Expansion while this individual was still young would have been the BEST way to treat this crowded dentition. Appliance stopped snoring first night person wore appliance.
B1 – There are 4640 different species of mammals. It is amazing that all mammals, other creatures and plants of the world are so intricately and delicately designed with such specific systems and functions.
Why is the human mouth so susceptible to malocclusions, human teeth so prone to decay and human airways so susceptible to collapse? The other 4639 species of mammals do not seem to have these same challenges. Why? Are humans so inferior to all the other species of mammals that only humans have these challenges, or are humans responsible for their own breakdown? I believe the challenges we humans have are the direct result of our own habits and lifestyles. I am hoping this presentation can help demonstrate why I believe human habits and lifestyle can be major contributing factors to our poor health.
B3 to B5 – In the 1930s, Dr. Weston Price traveled all over the world visiting ‘uncivilized tribes’ (I would prefer to call them non-industrialized cultures) trying to determine why Americans had so much decay in their teeth and people from these cultures did not. He discovered that the people had minimal decay, had beautiful dentition, nice occlusions, nice facial forms, and could breathe well. He attributed his findings to good nutrition and non-processed foods. Another thing that was common to all – infants all had to be breastfed and no bottle-feeding or pacifiers were available.
B6 to B18 – Prehistoric skulls (approximately 600) that I have evaluated (Smithsonian and KU) demonstrated minimal decay, nice ‘U’ shaped Class I occlusion, good palates, wide arches and no retrognathia. Main observation was that teeth were quite flat due to coarse diets. Due to wide palates, skulls also exhibited large posterior nasal apertures or Choanae (exit passage from the nose)(B10). B17 – Note mid palatal suture line – this is the suture line that can separate during rapid palatal expansion.
B19 to B21 – Younger skulls at the Smithsonian (1930s & 40s) demonstrated crowded dentition, periodontal disease, narrow arches, high palates and smaller posterior nasal apertures.
B22 – Key illustration comparing large posterior nasal aperture of a prehistoric skull to a smaller posterior aperture of a more modern (1940s) skull. Since the posterior nasal aperture is at the beginning of the soft tissue part of the airway, the larger the aperture the less the risk of airway collapse. The skull on the right is much closer to the camera, so the aperture seems larger than it is. The aperture is significantly smaller than on the prehistoric skull.
B23 – “The Connection” – I have been investigating the reasons for the collapse of the oral cavity and airway and the importance of breastfeeding for 30 years. I have discovered that the malocclusions created by bottle-feeding, excessive infant habits, pacifiers, etc. are the same malocclusions that are the risk factors for obstructive sleep apnea (OSA).
B24 – This slide is very significant when one realizes that pre-historic skulls and non-industrialized societies had/have very little non-pathological malocclusions or decay. Probably the 89% represents the snorers in our society, and the 16% represents those with serious OSA.
B25 – It is not by coincidence that the 89% in slide B24 (1996) is close to the 85% in slide B25 (1997). There is definitely a negative link between pacifier use, malocclusions and sleep apnea.
B26 to 28 – This evidence shows there is a high risk of malocclusions in infancy and if we are ever going to reduce the risk of sleep apnea in our society, we need to treat these malocclusions as early as possible.
B29 – If one accepts the correlation between malocclusions and sleep apnea, then we MUST treat children before their craniofacial development is complete – and the earlier the better.
B30 – A must read article. This article introduced me to Dr. Crelin and his research on the relationship between the soft palate and epiglottis, and the naturally advanced position of the tongue during early infancy.
B32 to B35 – Note the relationship between the soft palate and epiglottis and the advanced position of the tongue in these illustrations.
WARNING: 6 of the next 10 illustrations are of fetus and adult cadaver dissections.
B36 – Note slight separation of the lips.
B37 – Close up of the lips illustrating the advanced position of the tongue.
B38 – Full head view to illustrate the position of the mouth.
B39 – Close up of mouth illustrating the natural close relationship of the soft palate to the epiglottis and the naturally advanced anterior (forward) position of the tongue. If we are designed with so much perfection, what is the significance of these relationships? 1) The elevated position of the epiglottis forms a separation or wall between the airway and the tongue. It helps prevent the tongue from falling back and blocking off the airway. Since the fetus did not have to breathe in the womb, it is not really prepared to immediately breathe in the outside world. This ‘protection’ allows the infant time to develop a more complex breathing pattern over time. 2) The forward position of the tongue prepares the newborn to immediately breastfeed when born. This will be covered more in the next section.
B40 – Cr. Crelin’s illustration illustrating the soft palate and epiglottis touching during quiet respiration.
B41 – Cr. Crelin’s illustration demonstrating the elevation of the epiglottis during the act of breastfeeding. Lines illustrate how a newborn can both breathe and swallow at the same time – something adult humans cannot do – but all other young and adult mammals can do.
B42 – Illustrates how the breastmilk passes around the interlock of the soft palate and epiglottis and through the faucium channels.
B43 – Key Point: The natural descent of the epiglottis only occurs in humans – making humans totally unique from all other mammals. This allows humans to speak. During this time, infants start experimenting with making different sounds. I believe an infant would be at risk for SIDS during this descent period.
WARNING – Next 2 slides are of cadaver dissections.
B44 - Illustrates how as the epiglottis descends down, the tongue is pulled back into the mouth to attain its natural adult resting position inside the mouth.
B45 – Adult dissection illustrating the separation that takes place between the soft palate and epiglottis in humans only. This separation allows humans to speak, but it complicates the swallowing and breathing process. The posterior 1/3 of the tongue now becomes the anterior wall of the oropharynx which can allow the tongue to possibly fall back and obstruct the airway.
B46 – This is the oropharynx (throat) of a very healthy 90-year-old gentleman. Only medication he was on was a small pill for stomach problems. This slide also illustrates one of the main functions of the uvula – to funnel fluids down the middle of the throat. A healthy open throat like this is only possible if one has a large posterior nasal aperture as illustrated in slide B47.
B48 to B53 – Cr. Crelin’s illustrations demonstrating why animals are obligate nose breathers (because the soft palate and epiglottis interlock) and that their airways are uniquely different from adult humans (but are similar to human newborns).
C1 – When a human infant is born its tongue is in a naturally advanced / forward position. This forward position adapts the infant for breastfeeding immediately. The forward position of the tongue and the elevated position of the epiglottis allow a newborn to both breathe and swallow at the same time (Sometimes called Obligate nose breathing).
WARNING: Next illustration is a fetus cadaver dissection. It may not be suitable for viewing by all.
C2 – Illustration demonstrating the natural forward position of the tongue of a newborn. This forward position of the tongue immediately prepares the newborn to breastfeed. This forward position is critical for proper breastfeeding.
C3 & C4 - Illustrations by Escott and Woolridge demonstrate the forward position of the tongue during breastfeeding and also the peristaltic motion of tongue during breastfeeding. Key Points: The tip of the tongue stays in the same forward position (over and past the gum pad) throughout the act of breastfeeding. It is the peristaltic or rocker motion from within the tongue that moves the breastmilk (along with some help from the mother’s ‘let down’ process). The tongue constantly protects the breast from the hard gum pad during the act of breastfeeding.
Another key point about
breastfeeding is that all the peri-oral musculature gets involved. Breastfeeding
is a complex process needing coordinated efforts by all the muscles of the mouth
and jaw. Infants have to work all the muscles of mastication during
breastfeeding. This is not true during bottle-feeding.
C5 – The tongue motion learned during breastfeeding / bottle-feeding / pacifier sucking is continued into adult life. The action of the tongue during swallowing is critical to the proper development of the oral cavity, airway shape, and facial form. During a correct adult swallow, the tip of the tongue should stay forward and rest just behind the upper front teeth during the entire swallow. The rest of the tongue should go up to the roof of the mouth only and not exert any force on any teeth in any direction. Test yourself: Close your eyes and feel where your tongue goes when you swallow. It should start on the roof of your mouth just behind the upper front teeth and should stay up on the roof of your mouth during the entire swallow. It should not go forward or sideways and should not exert any pressure on any of your teeth. If it does exert force on any teeth, there is a strong possibility those teeth will be out of proper alignment or exhibit wear or sensitivity (Read articles on this site on ‘abfractions’).
C6 – Atlas illustration demonstrating teeth that have erupted into a ‘neutral’ position. There are no abnormal forces placed on the teeth by the tongue or cheeks. Teeth want to erupt into this ‘neutral’ area. The eruption or position of teeth in the mouth can be very much influenced by muscles forces. Abnormal muscles forces cause teeth to position themselves in abnormal positions. Muscles always win out in a battle with bone when it comes to determining where teeth will erupt.
C7 – Drawing trying to demonstrate same thing as C6.
C8 – During breastfeeding, the ‘breast’, which includes some of the areolar tissue and the nipple, gets drawn into the mouth and is stretched and extends to about the proximity of the junction of the hard and soft palate (Dr. John Neil – Australia). The breast adapts to the shape of the mouth. The palate is pliable (moldable) during infancy and the peristaltic motion of the tongue helps determine the shape of the palate (See ALCA and JHL articles elsewhere on this website).
C10 – Key Illustration: This illustration demonstrates the negatives that can occur during bottle feeding, pacifier use, noxious / excessive infant habits, etc. The object (bottle/thumb/pacifier, etc.) can act as a fulcrum driving back (or preventing the forward growth of) the mandible while advancing the maxilla up and out. The tongue could get traumatized/crushed if it advanced forward under the object so it learns to stay back behind the lower teeth/gum pad – this results into an abnormal swallowing pattern or tongue thrust. Since the tongue is driven back, there could be a premature separation of the soft palate and epiglottis – which can impact breathing. The distal position of the tongue could also drive the soft palate up into the area of the Eustachian tubes – resulting in congestion and possibly otitis media.
C11 – The laws of nature state there is an opposite and equal force whenever an action takes place. The vacuum and collapse of the bottle created by sucking on this bottle also creates the same vacuum and collapse inside the mouth. Note the inward force or collapse on the cheeks and in the throat area in this illustration.
C12 – This illustration demonstrates the forces that are occurring inside the mouth with an object other than the breast. The bottle nipple, which is usually firmer than the breast, can put an upward force on the palate as well as a downward pressure on the tongue. The cheeks have an inward force on the upper teeth, and the displacement of the tongue can be laterally – expanding the lower teeth outward. The tongue, separated from the palate by the firm object, cannot have the positive influence on the shaping of the palate (See ALCA and JHL articles). The vacuum created by a very strong suction could put enough force on both the maxilla and mandible that both upper and lower arches could be narrowed.
C13 – A diagrammatic of the forces that can occur. “A” is normal development. “B” shows how a high palate can decrease nasal volume (which makes it difficult for surgeons to improve the airflow). It also illustrates how an inward movement of the upper teeth and the lateral movement on the lower teeth can create a cross bite.
C14 – Models demonstrating C13.
C15 – Close-up of the cross bite.
C16 – Models showing severe cross bite and malocclusion of a lady with severe obstructive sleep apnea (OSA).
C17 – She also had a large tongue. A tongue-retaining appliance was fabricated for her with outstanding results.
C18 & C19 – The reason I knew a tongue-retaining appliance would be successful was because she had fabricated her own tongue-retaining appliance. This is a shampoo bottle top that she had cut a hole in big enough to accommodate the tip of her tongue, and little air holes on the front side of the top. She wore this appliance in her mouth while sleep – with some success. Her sleep apnea was so bad that sometimes she had a difficult time getting up in the morning, and fell asleep at inappropriate times during the day if she had a quiet time. Thankfully she never fell asleep while driving. The new appliance dramatically improved the quality of her life.
C20 to C28 – Various techniques and vessels that were used to feed infants in the past. The precursor of the ‘modern’ bottle was invented in the 1780s.
C31 – Thumb sucking is even learned in-utero. Thumb sucking should not be discouraged in the early years as long as it does not become excessive. BUT, what is excessive? Excessive is whenever damage results from the act – and you usually do not know that until it is too late. Judgment has to come into play here.
C32 – Excessive thumb sucking (and other habits) can have consequences as described in C10 with bottle feeding, but consequences can possibly be more severe – again depending on excessiveness.
C33 to C50 – Consequences that can result have habits - malocclusions and abnormal tongue activity (tongue thrusting).
C51 – Rapid palatal expander used on arm sucker – an excellent way to widen a narrow arch.
C52 – Orthodontics was required to align her teeth – a costly expense for ‘just’ sucking on her arm.
C53 – A very positive note – she was fortunate enough to have a Kansas University ‘Jayhawk’ in her retainer.
C54 – Amount and extent of damage by any habit is based on the excessiveness of the habit.
C55 to C60 – Documentation by others.
C62 to C64 – Test your own swallow again as you did at C5. Make a nasally sounding ‘N’ (like the ‘n’ in the word ‘noise’). This should put the tip of your tongue in a position just behind your upper front teeth. C63 is the position the tongue should start at, and stay during the swallow – just behind the upper front teeth. C64 shows the peristaltic or rocking motion of the tongue during the swallow. Note how in ‘D’ and ‘E’, near the end of the swallow, the Tensor palatini and Levator palatini muscles fire to tense and elevate the soft palate to prevent food or fluids from escaping back out through the nose. (The Tensor palatini muscle opens the Eustachian tube when you swallow – clearing your ears when you swallow while taking off or landing in an airplane.)
C65 to C71 – Examples and consequences of anterior tongue thrusts. Note how the action of the tongue determines the position of the teeth.
C72 & C73 – A two-bicuspid extraction post-ortho case with poor results because the orthodontist did not remedy the tongue thrust. Person was a snorer.
C74 to C76 – Key case – This is the individual that inspired me to start my research close to 30 years ago. She is still a patient in my practice today. She first presented with an odd open bite. I encouraged her to see a speech therapist trained in myofunctional therapy (or oral facial myology) to address her tongue thrust. She did not think my recommendations were valid, so went to another dentist. He recommended, and she accepted his recommendations – full orthodontics and fracturing her face to fully align her teeth. Her teeth were placed in fully contact. After her bite opened up again, she returned to my practice. We discussed the various options. She chose not to have speech therapy and did not want to close her bite. We chose to maintain and observe. She was the first person I had ever seen in my practice who was a posterior, bilateral tongue thruster. I do not even know how the tongue can go out to both sides at the same time during the swallow, but her tongue does. Models and illustration of the swallow demonstrate what happens. Her teeth have never changed position again. Her posterior teeth have never super-erupted and never will! The action of her tongue has determined, and will continue to determine, the position of her teeth in the dental arch.
C77 – Recent article (Sept 2003) that demonstrated that swallowing dysfunction (what I generically call tongue thrusting) was seven times more frequent among patients with snoring and sleep apnea as it was among controls.
C79 – The ‘Divine’ or ‘Golden Proportion’ is used in many fields as a technique of achieving pleasant eye symmetry. The ratio is 1.618/1.0. In esthetic dentistry it is used to determine the best height and width of teeth for the prettiest smile line.
C80 – This breastfed child, at age 2 and 3 1/3 years, exhibits this nice natural proportion of the facial contour.
C81 – This adult, who was breastfed exclusively as a child, has a similar, naturally pretty symmetry. C82 is a close-up of her smile, ‘U’ shaped arch and beautiful teeth.
C83 – Lip contour of a 4-month and 4 ½ year old boy who was breastfed.
C84 – Demonstrates how a strong vacuum created by excessive sucking can collapse the mouth and throat and have a direct impact on the shape of the face. Note collapsing of cheeks and throat.
C85 to C88 – At age 4 months this infant was already an excessive thumb sucker. It was difficult to remove his thumb to take a picture of his lips at age 4 months. I informed his mother at that time that I feared he would have challenges with oral cavity and facial form later in life. Note natural open mouth posture and forward position of tongue. He was also a mouth breather. C87 – Note long face and open mouth at age 7 years. C88 – Note open bite/ tongue thrust posturing and compromised oropharynx. He was diagnosed as sleep deprived, developed dark circles around his eyes, had tonsils removed and is now in orthodontics. I can state with confidence that many of his problems are/were the direct result of his excessive thumb sucking! He is now 11 years old and I am still monitoring this case.
C89 – A diagrammatic of how forces can impact facial form.
D1 – Long face syndrome (Longer than normal height of face plus narrower than normal width of face) can be a genetic link, but it can also be due to an obstructed airway. This narrowness of the face (and dental arches) places the individual at risk for OSA.
D2- Article by Guilleminault et al. stating that craniofacial features can be a strong indicator of risk for the development of OSAS.
D3 – Test yourself - Try holding your nose and see what happens. In a short period of time you will be forced to open your mouth in order to breathe. When your airway is chronically blocked and your mouth is open all the time, your face can just naturally get ‘longer and narrower’. Since the orofacial characteristics are 90% developed by age 12 (see B29), it is critical to understand this concept early in an infant’s life to prevent this potential risk factor for OSA from developing. Anything that blocks the airway can contribute to the condition. Enlarged tonsils and adenoids are probably the biggest cause.
D4 & D5 – Massive tonsils in 12-year-old easily obstructs airway. Once his tonsils were removed he could breathe and sleep much better, with significant improvement in his abilities and attitude.
D6 – D8 – Examples of large tonsils – various ages.
D9 to D11 – Example of young individual with a long face syndrome. His lips are slightly parted in D9. He is a chronic mouth breather – which has a tendency to dry the mouth - which can make a person at a higher risk for periodontal disease and decay. D10 illustrates his congested oropharynx. D11 – The open spaces between his teeth were due to his tongue thrust apparent in D12.
D13 – Another youngster with long face syndrome and open mouth due to mouth breathing. D14 – Note open-bite malocclusion due to his tongue thrust apparent in D15.
D16 – Adult with long face syndrome and significant sleep apnea. She also had a large tongue (D17) and elongated soft palate (D18). D19 illustrates a typical lateral view of a person with long face syndrome – forward angulation of the head – similar to how one pulls the chin forward during CPR so the individual can breathe better – can also lead to head and neck aches because the head is suppose to be in alignment over the spine. Most have a larger than normal nose (to accommodate more air since the oropharynx in more obstructed) and the face comes more to a point as illustrated by the arrows. An oral appliance significantly reduced the consequences of her OSA.
D20 – Article by Bosma discussing impact of long face on posture. Also brings attention to the unique relationship of the epiglottis and uvula of a newborn.
D21 & D22 – Contributing factors that can enlarge tonsils & adenoids and cause the swelling of tissue lining the airway are infections and inflammation. These challenges are caused by illnesses and allergies that results from various factors – even if an infant is breastfed. This is why even breastfed babies are at risk for obstructed airways – BUT - breastfed babies are at LESS RISK for illness, allergies and disease because they normally receive immunological and nutritional benefits from breastmilk (IF the mother is healthy!) that are not available in formula.
D24 – During the creation of a vacuum during a sucking action, there is an equal force of collapse in both the bottle and in the mouth / throat.
D25 & D26 – Gravity is a big contributor to snoring and sleep apnea when and individual sleeps on his/her back.
D28 – Venturi Principle - The smaller the tube, the faster the air must flow – which in turn can create a ‘wind tunnel’.
D29 to D31 – Bernoulli Principle is used in the atomizer to ‘suck’ up perfume from the bottle and then spay it out the tip. The rapid passage of air coming from the left ‘sucks’ up the perfume through the bottom tube. The rapid passage of air coming from the left creates an inward collapsing effect on the walls inside the tubes.
D32 – The tube coming from the bottle has been changed to a different position and labeled a ‘nose’. The ‘bulb’ of the atomizer has been labeled the ‘mouth’. Now the area between the two ‘wind tunnels’ is called the palate, with the uvula extending from the tip. The uvula is now stuck between two wind tunnels; somewhat similar to a flag standing outstretched in a high wind. The faster the air moves past both sides of the uvula the more likely the uvula could be stretched as in D33. The more inflamed or constricted the two air tubes, the greater the speed of the air passing through them.
D34 & D35 – The larger the posterior nasal aperture an individual has, the less risk the airway will collapse. The nylon represents the airway. (Low budget research!)
D36 & D37 – The opposite is true for a small posterior nasal aperture. The smaller the posterior nasal aperture, the smaller the beginning of the soft portion of the airway, the greater the risk of airway collapse.
D38 – Demonstrates the path of the Tensor palatini muscle around the Pterytgoid hamulus. This is much like the fan belt in a car. The belt must be tight in order to be efficient. If the pulleys on the car are not tightened enough, the belt can become loose, slip and malfunction. If a person has a narrow palate, this ‘pulley’ effect could come into play regarding the ‘sagginess’ of the soft palate and the risk it has of being elongated in the ‘wind tunnels’.
D39 –During rapid palatal expansion (RPE) – which has to be done prior to the fusion of the mid-palatal suture line – the Pterygoid plates expand with the expansion of the hard palate. After fusion, the expansion of the Pterygoid plates does not occur. During adult expansion, the maxilla must be sectioned and repositioned. The Pterygoid plates are NOT affected during surgical expansion. Negative result – palatal muscles are not affected either – i.e. – not tightened.
D40 – Demonstrates the path of the Tensor palatini muscle on a skull that has a wide palate. This also means the Pterytgoid plates (Butterfly / pillar-like bone structures on both sides of the posterior nasal aperture) are at the proper width for the muscle – i.e. – holds the palate muscles in a firm position. If the Pterygoid plates are narrow – as can be found on a skull with a narrow, high palate, the muscles are not pulled tight by the pulley (Pterygoid hamulus) then the palate muscles could be loose and flabby. These ‘loose’ muscles can then vibrate during passage of air and cause the noise of snoring. The muscles could also be pulled and elongated, which in turn could put an individual at risk for sleep apnea.
WARNING – The next two illustrations are of an adult cadaver dissection demonstrating the position and path of the Tensor palatini and Levator palatini.
D41 & D42 – Dissection from behind demonstrating the position and path of the Tensor palatini and Levator palatini muscles. D42 illustrates the pulley like effect the Pterygoid hamulus has on the Tensor palatini muscle.
D44 – There are several reasons for the collapse of the oral cavity and airway. One must be aware of all – and there may be more reasons than listed here.
D45 – Article commenting on the importance of prevention.
D46– Breathing is the key to life and well-being. Humans need oxygen to live and be healthy. Death is but a few minutes away if one cannot breathe! We all need to enjoy the present moment! Your degree of health is directly related to your ability to breathe AND sleep well.
D47 – Even in an emergency medical situation the rescuer addresses the victim’s ability to breathe first – because if he/she cannot get the victim to breathe, there is no chance the victim will live.
D48 – Because prehistoric man did not have the morphometric features of high palates, narrow dental arches or overjets, I believe OSA and SDB are ‘modern’ illnesses which are the direct result of our habits and lifestyle.
D49 – Hypothesis about breastfeeding. My strong commitment to the importance of breastfeeding is based solely on my self-funded research.
Opinion on obesity. Obesity is the number one contributing risk factor for OSA. Many researchers are looking for genetic factors that might cause obesity, but in simple truth, if intake is greater than output, one is going to gain weight. I also believe the key to understanding obesity is in the mother’s breastmilk. Breastmilk has a variable fat content in it, and somehow the infant (and the mother’s hormonal input) determines when the infant has had enough food to meet the infant’s needs. During breastfeeding, once the infant’s nutritional needs are met he/she stops feeding. Bottle-fed infants usually get a measured dose of formula and are ‘forced’ to drink the whole amount – if it meets its nutritional needs or not. That infant is being ‘programmed’ to eat whatever is placed in front of it. Of the other 4639 breastfeeding mammals, how many have the obesity problems of people in developed countries –and in particular, those in the USA?
D52 – Don’t let what happened to my brother, happen to you or your loved ones! You MUST understand sleep apnea and be willing to do something about it – NOW!
D53 – My Dream:
1) Have others accept my research as being sound and continue researching using more scientific controls to better prove what I have stated is valid.
2) Challenge my research and try to prove it unscientific. I know my research will withstand the test of time. These people will end up being the strongest supporters of my research.
3) Prevention is the key. I recently underwent two months of radiation therapy at a cost of $105,000 (March-April 2004). I wish someone had told me how to PREVENT the cancer – I would have done anything. I know many of the sleep apnea patients I have treated and talked with, would have also done anything to prevent their condition. I strongly believe obstructive sleep apnea and sleep disordered breathing are major underlining conditions of many health problems. This presentation will not help the adults who currently suffer from OSA/SDB, but the information in this presentation can help reduce the risk of OSA/SDB in YOUR children and YOUR grandchildren.
Encouraging mothers to breastfeed their children and also educating them why it is important to breastfeed, is the best way to help lower the health care costs in our society – and make for happier and healthier family units.
I have done the best that I can. I just do not have the funding or manpower to take this research to a higher level. It is now up to others to carry on the research.
If you can make it, please come to the international breastfeeding conference in Hobart, Tasmania, Australia, September 28-30, 2005. I will be one of the keynote speakers at that conference. I have heard it is a beautiful country with beautiful people. It will be the spring season in Australia at that time. I am really looking forward to presenting at that conference and meeting everyone. Information on that conference can be obtained at: http://www.cdesign.com.au/aba2005.
Until then, HAVE A GREAT DAY!
Brian Palmer, DDS June, 2004.
I hope my research is of interest to others who may have the funding and manpower to continue the research. If anyone would review my total website and then read the following list of publication that have most influenced my research, I know you will arrive at similar conclusion as I have.
1 - Daniel Garliner, Myofunctional Therapy, 1976. W. B. Saunders, ISBN: 0-7216-4055-9
2 - Daniel Garliner, Swallow Right - Or Else, 1979. Warren H. Green, Inc. ISBN: 87527-1952-2.
3 - Daniel Garliner, Myofunctional Therapy in Dental Practice, Abnormal Swallowing Habits: Diagnosis-Treatment, 1974 2nd Ed. Bartel Dental Book Co.
4 - Weston A. Price, Nutrition and Physical Degeneration, 1997 6th Ed. Keats. ISBN: 0-87983-816-7
5 - Laurence I. Barsh, The Origin of Pharyngeal Obstruction during Sleep, Sleep and Breathing 1999; 3(1)17-22. ISSN: 1520-9512
6 - Clete A. Kushida, Bradley Efron, Christian Guilleminault, A Predictive Morphometric Model for the Obstructive Sleep Apnea Syndrome, Annals of Internal Medicine 1997;127:581-587. This paper is also available at http://www.acponline.org/journals/annals/15oct97/morphom.htm
7 - Edmund S. Crelin, The Human Vocal Tract - Anatomy, Function, Development, and Evolution 1987. Vantage Press, ISBN: 0-533-06967-X
8 - Edmund S. Crelin, Development of the Upper Respiratory System 1976; CIBA Pharmaceuticals; 28(3).
9 - James F. Garry, Environmental and Iatrogenic Influences on Oro-Facial Development Leading to Musculoskeletal Dysfunction of the Head and Neck (TMJ Disorders) 1988. (Booklet) TMData Resources (800-533-5121).
10 - James F. Garry, Upper Airway Compromise and Musculo-Skeletal Dysfunction of the Head and Neck (MSD) 1997. (Booklet) TMData Resources (800-533-5121).
11 - Peter Dawson, Evaluation, Diagnosis, and Treatment of Occlusal Problems 1989, Mosby, 2nd Ed. ISBN 0-8016-2788-5.
For Better Health!
Brian Palmer, DDS