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Unlocking Airway, TMJ and Growth with CBCT as the Key Juan-Carlos Quintero, DMD, MS

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How one scan changed the life of one of Dr. Quintero's “most special” patients

The male patient was seven years old. He arrived at the office because he was snoring, mouth breathing and grinding his teeth at night. He had also become plagued with frequent sinus and ear infections. After seeing numerous doctors, including an allergist and pediatrician without receiving a definitive diagnosis, it was decided an orthodontist's opinion would be beneficial. CBCT scanning with i-CAT technology was the central clue in solving the mystery. When the child's permanent teeth began to erupt, the parents noticed he had some crowding, so I performed a routine orthodontic work up using a 4.8-second Quick Scan and an Anatomodel from Anatomage (Fig. 1).

This 4.8-second scan is approximately half the dose of the i-CAT 8.9 scan – 74μSv, 2007 tissue weight – and is roughly equivalent to a traditional 2D X-ray series with rectangular collimation, or a pan/ceph/bitewings combination.1,2 To my surprise, the scan showed a very narrow trachea and airway with adenoid hyperplasia that caused a significant airway obstruction (Fig. 2). The view of his airway obtained through 3D imaging explained his snoring, mouth breathing and frequent illnesses. Mouth breathers can have suboptimal mandibular growth, and this information helped us to understand some of the orthodontic problems, including why the mandible was not growing as favorably as it should have been at his age.

An appointment was quickly set up with the ENT to deliver a directive to remove the adenoids. Sometimes, to get the ENT to address this type of problem, a parent has to be a bit forceful about the necessity to perform this procedure. Some ENTs opine, "Most kids outgrow these problems," and while this is true, it is also a fact, as orthodontists are aware, there is a critical window of facial growth during that period.

After viewing the i-CAT scan and seeing the anatomy in three-dimensions, a treatment plan was developed and set in motion that included adenoidectomy, coblation of turbinates and orthodontic palatal expansion (Fig. 3). The results were dramatic. The child progressed from being an obligatory mouth breather to a predominant nose breather. He instantly slept better, tasted his food better, ate better, breathed better and even had a better quality of life (Fig. 4, 5). Two years later, a follow-up included another 4.8-second Quick Scan, to measure the results over time (Fig. 6).

Personally, I was glad to be sitting down, because the results floored me. I could hardly believe my eyes. The airway almost tripled in volume from 8cc to 23cc, and the smallest cross-sectional area (the bottleneck) went from 23mm² to 168mm² (Fig. 7, 8). The obstruction was removed. The palatal shelf, being the floor of the nose, was expanded through Phase I orthodontic therapy. The mandible was unlocked from its transverse discrepancy, and the vector of mandibular growth was improved though nose breathing. The TMJs probably received less stress and grew better as well, which is consistent with a recent study showing an increased incidence of TMJ osteoarthrosis on patients with environmental allergies.³

The child's everyday life has also improved. Now, there is room for the teeth to erupt, and the profile looks better. The color of his skin is improved, and his smile looks great. He has improved alertness during the day, and is more rested from more consistent sleep patterns. Eating better; sleeping better; living better – What more can we ask for?

Not only did this one scan change this boy's life, but it also completely changed my outlook on cases and my practice focus. There is a sensible reason why orthodontists concentrate so much on head and neck anatomy in school. And, there is also a very good reason to use CBCT to view this head and neck anatomy from all sides in three dimensions. CBCT allows orthodontists to not just look at teeth but at the greater craniofacial complex, with airways, bone, sinus and TMJ health – all part of an integrated system. Although this vital anatomy has always been taken into account, now with the capability for 3D, diagnosis and treatment planning takes on a whole new dimension because of our ability to view all of this vital anatomy and not make mistakes or miss clues to unusual dental conditions.

While to the patient it might seem that orthodontics is just focused on the appearance of the teeth, I know that achieving results entails much more than that. Now when I treatment plan, I look at airways and sinuses first, then TMJs, then skeletal relationships, then alveolar housing, and lastly, the teeth. Then, I can truly understand all of the underlying problems and better know how to fix them rather than just guessing, and having the child suffer the consequences later.

Having a CBCT scan to review during my treatment planning sessions is like having the patient right in front of me. I can expand or rotate the volume to any angle or view any axial slice, or completely dissect them if I want to, in order to really get to know the anatomy inside and out.

With all of the time spent on this young man's case, I had to overcome my guilt of not having caught this problem and alleviated this child's suffering earlier. After all, I should have known better, since the boy is, in fact, my own son. But, CBCT imaging helped me to improve his life, and in the long run, improve the lives of many other parents' sons and daughters because of all of the data I obtain with this precise imaging method.


Fig. 1: Anatomodel from Anatomage used to create a comprehensive diagnostic and forecast tool.


Fig. 2a-2b: Initial scan showing constricted airway.


Fig. 3: Phase I treatment plan


Fig. 4a-4b: Pre- and post-treatment of adenoidectomy, coblation of turbinates and Phase I expansion. Fig. 5a-5b: Dentition pre- and post-treatment of adenoidectomy, coblation of turbinates and
Phase I expansion.


Fig. 6a-6b: Pre- and post-treatment scans showing results of adenoidectomy.


Fig. 8a-8b: Pre- and post-treatment comparison of facial growth over time relative to improved airway.


Fig. 7a-7b: Pre- and post-treatment scans show changes in segmented airway volumes.

References:
  1. Ludlow, John, et al., Comparative Dosimetry of Dental CBCT Devices and 64-Slice CT for Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Path Oral Radiol Endod 2008; 106:106-14.
  2. Ludlow, et al. Patient Risk Related to Common Radiographic Examinations. JADA, Vol. 139,, September 2008, http://jada.ada.org, (Accessed: Nov. 15, 2010).
  3. Masato Nishiokaa, et al., TMJ Osteoarthritis/Osteoarthrosis and Immune System Factors in a Japanese Sample. Angle Orthodontist, Vol. 78, No. 5, 2008.
Author’s Bio
Dr. Juan-Carlos Quintero received his dental degree from the University of Pittsburgh in Pennsylvania and degree in orthodontics from the University of California at San Francisco (UCSF). He also holds a Master's of Science Degree in Oral Biology. He has served as national president of the American Association for Dental Research – SRG, is a faculty member at the L. D. Pankey Institute and an attending professor at Miami Children's Hospital, Department of Pediatric Dentistry, as well as immediate past-president of the South Florida Academy of Orthodontists (SFAO). He currently practices in South Miami, Florida.
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