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Dento-maxillary anomalies among children with nasal septum deformations.

Introduction

The disturbance of breath caused by obstruction of a nose and nasopharynx is an issue not only in otolaryngology. The expressed difficulty of nasal breath leads to hypoxia disturbance of oxygen supply to organs and fabrics. Children, badly breathing with nose, develop worse, lag behind peers in mastering of the school program. Long disturbance of nasal breath results in development of a range of troubles, including chronic rhinitis, a pathology of perirhinal bosoms, an acoustical pipe and middle ear, inflammatory diseases of nasopharynx, a throat and the bottom departments of respiratory ways, negatively affects functioning of cardiovascular system, causes the whole complex of neurologic disturbances (Yunusov and Bogomilskiy, 2001; 2003; Khorov and Shamrilo, 2007; Kryukov, Tsarapkin, Turovskiy, and Kirilenko, 2008).

The Dento-maxillary System (DAS) of the child in the course of the growth and development undergoes the difficult anatomic and functional changes in many respects connected with formation, eruption and change such highly-mineralized bodies as teeth. The harmonious course of this physiological process is quite often broken under the influence of external and internal adverse environmental factors leading to formation of dento-maxillary anomalies (Khoroshilkina, 1999; Duchateaux, 2004; Persin, Elizarova and Dyakova, 2006).

Philo- and ontogenetic unity of bones of the top and median part of the face causes their common development. It is known that at the end of the second month of pregnancy there is an anlage of organs of maxillofacial area and at the end of 3 months in cartilaginous skeleton rudiments there are first sites of ossification. This formogenetically difficult period is connected with development of the palate, nasal septum, formation of tongue, rudiments of teeth, glands and other structures (Khoroshilkina, 1999).

Such dento-maxillary anomalies (DMA) are met, according to different researchers, at 33.7-74.0% of surveyed children (Khoroshilkina, 1999; Persin, Elizarova and Dyakova, 2006). Prevalence of DMA is considerably higher among children, suffering other diseases and having bad habits: sucking and biting lips, tongue, cheeks, objects (Navruzov, Makhsudov and Khasanov, 2001; Distel, Suntsov and Vagner, 2001).

Makhsudov (2002) has determined that 61% DMA develop owing to rhinopharyngeal obstructions. The reason for obstruction in 70% of cases is related to nasal septum deviation (DNS). 39.4% have revealed "residual oral breath" after surgical sanitization of the nose and nasopharynx and 35.6% had DMA relapses after orthodontic treatment.

As Bresolin et al. (1983), Smith and Gonzalez (1989) inform frequent reason of dentomaxillary deformations are the pathologies influencing development of nasofrontal gristle of appendage of the top jaw, the front part of molar arches and area of the superior nasal meatuses. They include allergic reaction of a nasopharynx, adenoids, hypertrophy of palatine tonsils, choanal atresia, hypertrophic rhinitis, etc. It is proved that they cause narrowing of the top jaw and teeth protrusion. According to Linder-Aronson (1970), Obraztsov et al., (1986), Makhsudov et al., (1995), there is a correlation between oral breath and anomalies of jaws. Harvold et al. (1981) experimenting with primates, and Makhsudov (2002) with cats have proved that experimental nasal cavity obstruction of and the influenced oral breath causes DMA, since the nasal septum relates to formations of the median zone of the facial skeleton, their development and growth are interconnected.

Thus, the question on influence of the nasal septum curvature on development of a children's organism as a whole and dento-maxillary systems in particular, is still little studied and remains a disputable subject. There is no common opinion about the character of influence of DNS on growth and development of dento-maxillary system and time of occurrence of DMA. Frequency, kinds and pathogenesis of dento-maxillary anomalies, observed among children with DNS remain unstudied. The tactics of otolaryngologist and volume of surgical intervention on nasal septum incases of nasal septum curvature combined with DMA is not studied either.

All the above stated allowed us to determine the main aim of the present research: to investigate frequency and kinds of dento-maxillary anomalies among children with nasal septum deformations. The following research objectives were covered under the study: pathologies accompanying DNS, causing nose and nasopharynx obstruction; character of deformities of cartilaginous and bony sections of the nasal septum; and frequency and kinds of DMA among children suffering Nasal septum deviation hospitalized in ETN clinics

Material and methods of research

194 patients with age ranged from 4 to 15, operated on at the ETN-clinics of Tashkent Pediatric medical University due to nasal septum deformities, were under our supervision.

Distribution of patients according to groups, age and sex is demonstrated in the Table 1. As it may be seen from the Table 1, all the age groups had prevailing number of boys (correlation B/G [approximately equal to] 3:1), With age increasing frequency of nasal septum curvatures gradually increased (correlation of age groups approximately--1:2,1:4,6).

General otolaryngological and stomatologic survey were applied, together with tests for definition of type of breath and degree of disturbance of nasal breath, taking photo of dentoalveolar complex (front and profile), Teleroentgenogram of skulls (under indications), jaw orthopantomography, biometric studying of models of jaws (Makhsudov and Navruzov, 2001).

The results of the survey were entered in a database "Microsoft Access". All the obtained digital material was processed by means of variation statistics.

Results and discussion

In 17 (8.8% cases) out of 194 patients the "pure nasal septum curvature" was registered, i.e. without any other "obstructive" pathologies of nose and nasopharynx. In other 177 (91.2%) cases the DNS was combined with the following accompanied pathologies, taking course with nose and nasopharynx obstruction (Table 2).

Deformation of nasal septum was combined with chronic purulent rhinosinusitis--in 158 cases (81.4%) (Table 2). Chronic purulent ethmoiditis and maxilloethmoiditis were prevailed among chronic rhinosinusitis. Such high frequency of prevalence of sinusitis was not noted by other authors. Therefore, all patients with DNS were recommended to get X-rayed or make a corticotomy of additional bosoms of a nose.

We agree with the thesis that DNS plays a huge role in pathogenesis of chronic rhinosinusitis. Chronic rhinosinusitis, in turn, lead to hypertrophic rhinitis, adenoid growths and a hypertrophy of palatine tonsils that corresponds to the literature data.

Before correcting operations on nasal septum sanitization of additional bosoms of a nose by a method of "irrigation treatments by Proetz" was made and in necessary cases frontal, sphenoid and maxillary sinuses catheterization was carried out. Submucous resection of nasal septum simultaneously with corresponding operative interventions were made in other obstructive pathologies.

According to Khorov, Shamrilo (2007), 82 (73%) children suffering DNS revealed accompanying diseases of ETN-organs. Chronic hypertrophic rhinitis is established among 7 (8.5%) patients, vasomotor rhinitis (allergic or neurovegetative forms)--27 (46%), chronic sinusitis--10 (12%), adenoids--37 (45%), tubo-otitis--42 (37.5%) patients, chronic tonsillitis--4 (4.9%), malocclusion--(4.9%), chronic purulent average otitis--5 (4.1%), deformation of external nose--16 (14.3%). The difference between our results and those obtained by these authors is caused by character considered nosologies. In our data now even chronic otitis is registered very seldom.

Character of curvatures of bony and cartilaginous sections of nasal septum among operated 194 patients is demonstrated in Table 3.

In 30.9% of cases the right-hand crest, in 23.2%--bilateral crest and in 17.5% of cases--a left-hand crest is revealed (Table 3). A crest, being at the reason of deformation of cartilaginous section of the septum can simultaneously be the basic point of development of anomaly of dental arch of the top jaw, i.e. DMA.

Curvature of cartilage of nasal septum (together with combined bony part) was noted in 91 (46.9%) cases. Of them in 29.9% of cases, i.e. very often, "[R]"-shaped thickening on joint place of a cartilage with a perpendicular plate of a trellised bone is revealed. Such curvature in some references is named as "hillock" of nasal septum. Semantic value of this word in our opinion does not correspond to truth. The second place on frequency is occupied by "C"-shaped deviation of a cartilage of the septum. It was almost always accompanied with a right-hand or bilateral crest of bony section of nasal septum in the area of crista nasalis. Other kinds of deformations of a cartilage of nasal septum were revealed rather seldom.

103 (53.1%) out of 194 patients reveal deformation only in bony and at 49 (25.3%) only in cartilaginous sections. 42 (21.6%) reveal curvatures simultaneously in bony and cartilaginous sections. This circumstance indirectly suggests that deformation in bony section is formed first, and, subsequently, cartilaginous section of the nasal septum is involved in the process. Therefore, the insignificant deviation of bony section of nasal septum should alert rhinologists concerning the further development of DMA as complications of DNS. This provision is a basis of the given message.

Referring to the above-stated, it is possible to assert that the curvature of cartilaginous section of the nasal septum is a consequence of deformation of bony section. Therefore, in cases of insignificant curvatures of cartilaginous section resection of the bony section of nasal septum can be sufficient. This provision has received full acknowledgement in our daily work.

194 patients with deformation of nasal septum DMAs are discovered in 172 (88.7%) cases. Table 5 shows kinds and frequency of revealed DMA among children with deformations of nasal septum.

Analyzing the Table 4, it is possible to conclude that in cases of deformation of nasal septum among DMA the most frequent ones were constriction of the top jaw with dense location of front teeth and with increase in depth of a hard palate--in 85 cases (43.8%) (Figures 1, 2, 3).

On the second place was upper prognathism with constriction of the top jaw accompanied by the Gothic form of the palate and dense location of front teeth in 32 cases (16.5%) (Figures 4, 5, 6). Top retrognathism was on the third place in frequency 25 cases (12.9%) stood (Figure 7). Open bite was diagnosed only in 7 (3.6%) patients (Figure 8).

It is revealed that frequency of occurrence of each kind of DMA in age groups is not identical. The highest indicator of DMA was observed among children at the age from 6 to 14 that coincides with the periods of change of a milk teeth and rapid growth of nasomaxillary complex. On the other hand, the pathology of ETN-organs causing difficulty of nasal breath was observed much more often in the given age group (Navrusov et al., 2001).

Thus, children's dentists, orthodontists and doctors of other specialties should pay attention to the above-stated circumstances; DMAs are easily diagnosed since even with naked eye it is possible to define malocclusion or wrong position of teeth. Thus, it is possible to assume presence of obstructions of a nose and nasopharynx (difficultly diagnosed by them) and send such patients to otolaryngologists. This stomascopic way of diagnostics of nasal septum curvature can be used in screening-diagnostics. Our experience shows that, among patients with nasal septum deformity combined with DMA after surgical correction and osteotomy of nasal crest of a palatal shoot of the top jaw, orthodontic disclosing of a palatine suture occurs several times faster and anomaly relapses of dento-maxillary system decrease considerably.

Conclusion

Deformation of nasal septum is more often combined with chronic purulent rhinosinusitis --158 (81.4%) cases, hypertrophy of palatine tonsils--14 (7.2%) cases, adenoid vegetations -9 (4.6%) cases and a hypertrophic rhinitis--6 (3.1%) cases.

Sinusitis often revealed among such children can be understood as consequence of DNS because of difficulty of nasal breath.

High frequency (74.7%) of curvatures of bony section of nasal septum is noted. Of these cases the right-hand crest made 30.9%, bilateral crest--23.2%, and left-hand crest--17.5%. Thorns of bony section of nasal septum fluctuated up to 1.5% of these cases.

Slightly less often (46.9%) a curvature of cartilaginous section of nasal septum was noted, thus in 29.9% of cases "[R]"-shaped thickening on the joint place of cartilage with the perpendicular plate of a trellised bone is revealed. The second place on frequency is occupied by "C"-shaped deviation of a cartilage of the septum. It was almost always accompanied with a right-hand or bilateral crest of bony section of nasal septum in the area of crista nasalis.

The curvature of nasal septum in 88.7% of cases becomes complicated by dento-maxillary anomalies, most frequently by constriction of the top jaw with high hard palate and dense location of front teeth (43.8%), upper prognathism with constriction of the top jaw with high hard palate and dense location of front teeth (16.5%), and upper retrognathism with constriction of the upper dental arch and density of front teeth (apical insufficiency) (12.9%). Anomaly of position of a separate teeth of the top jaw (without change of the form of jaws) 6.2% and an open bite (front, vertical disocclusion) (3.6%) was seldom marked.

DNS forwards formation of DMA, because of anatomo-topographical connections of the nose and dental arch, and also disturbance of harmony in growth of rhinomaxillary complex.

The highest indicator of DMA was observed among children at the age from 6 till 14 that can be explained by change of teeth at this age and rapid growth of nasomaxillary complex.

Integrated work of otolaryngologist and orthodontist will provide normal growth of the median zone of the facial skeleton, including rhinomaxillary complex with the subsequent harmonious formation of all anatomic structures.

References

Bresolin, D., Shapiro, P., Shapiro, G. et al., 1983. "Mouth breathing in allergic children: Its relationship to dentofacial development," Am. J. Orthod., Vol.83(4), pp.334-40

Distel, V., Suntsov, V., Vagner, V., 2001. Dentoalveolar anomalies and deformations: Main reasons of development [Zubochelyustnye anomalii i deformacii: Osnovnye prichiny razvitiya], in Russian, Nizhny Novgorod: NGMA

Duchateaux, C., 2004. "Nasal ventilation and orthodontia," Int J Orthod Milwaukee, Vol.15(1), pp.27-29

Harvold, E., Tomer, B., Vargervik, K., Chierici, G., 1981. "Primate experiments on oral respiration," Am. J. Orthod., Vol.79(4), pp.359-72

Khoroshilkina, F., 1999. Guidance to orthodontics. [Rukovodstvo po ortodontii], in Russian, Moscow: Medisina

Khorov, O., Shamrilo, G., 2007. "A septorhinoplastic technique for correction of nasal septum deformation in children," Bulletin of otorhinolaryngology [Vestnik otorinolaringologii], in Russian, No.5, pp. 48-50

Kryukov, A., Tsarapkin, G.,Turovskiy, A., Kirilenko, E., 2008. "Septal stents-a perspective tamponadeless management of patients after septoplasty," [Septalnye stenty--perspektiva bestamponadnogo vedeniya pacientov, perenesshih septoplastiku], Bulletin of otorhinolaryngology [Vestnik otorinolaringologii], in Russian No.3 pp.45-46

Linder-Aronson, S., 1970. "Adenoids. Their effect on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the denition. A biometric, rhino-manometric and cephalometro-radiographic study on children with and without adenoids," Acta Otolaryngol Suppl., Vol.265(1), pp.1-132

Makhsudov, S., 2001. "Mechanism of deformation middle section of facial skeleton and their consequences to children with obstructive pathology nasopharynx," Central Asian Medical Journal [Centralno-Aziatskiy Medicinskiy Zhurnal], in Russian, No.4, pp.21-25

Makhsudov, S., Navruzov, K., 2001. "Teleroentgenogrammetric analysis for estimation of maxillonasal complex of the middle facial skeleton," J Russ. Rhinology [Rossiyskaya rinologiya], in Russian, No.3, pp. 35-39

Makhsudov, S., 2002. Clinical-biological and radiological indicators of rhinopharyngogenic dentoalveolar anomalies and methods of complex orthodontic treatment of this anomalies [Kliniko-biometricheskie i rentgenologicheskie pokazateli rinofaringogennyh zubochelyustnyh anomaliy i metody kompleksnogo ortodonticheskogo lecheniya etih anomaliy], in Russian, Synopsis of doctoral dissertation, Tashkent

Makhsudov, S., Sagdullaev, Sh., Khasanov, S. et al., 1995. "The influence of nasopharynx airway's obstructive pathology to development of middle facial skeleton," in Uzbek, Abstracts of the Conference of Young Scientists of the Republic of Uzbekistan Problems of emergency, critic condition and mother and baby health protection, Tashkent, pp.71-73

Navrusov, K., Khasanov, S., Babakhanov, G., 2001. "Pathomorphological changes in the nasal septum due to deformation in children," Russ. Rhinology [Rossiyskaya rinologiya], in Russian, No.3, pp.29-32

Navruzov, K., Makhsudov, S., Khasanov, S., 2001. "The study of influence of heavy nasal breathing on the development of dentomaxillofacial system of a child," Russ. Rhinology [Rossiyskaya rinologiya], in Russian, No.1, pp.14-16

Obraztsov, Yu., Larionov, S., Vishniakova, I., 1986. "Interrelation of mouth breathing and maxillodental anomalies in children in the North," Stomatology [Stomatologiya], in Russian, Vol.65(6), pp.52-54

Persin, L., Elizarova, V., Dyakova, S., 2006. Pediatric Dentistry [Stomatologiya detskogo vozrasta], in Russian, Moscow: Medisina

Smith, R., Gonzalez, C., 1989. "The relationship between nasal obstruction and craniofacial growth," Pediatr Clin North Am., Vol.36(6), pp.1423-434

Yunusov, A., Bogomilskiy, M., 2001. Rhinoseptoplastics in early ages and adolescence [Rinoseptoplastika v detskom i podrostkovom vozraste], in Russian, Moscow

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Appendix

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[FIGURE 8 OMITTED] Gulimbay Babakhanov, Saidakram Khasanov, Sunnat Makhsudov, Maqsad Bobokhonov

Tashkent Pediatric Medical University Tashkent, Uzbekistan
TABLE 1. DISTRIBUTION OF PATIENTS ACCORDING TO AGE AND SEX

                                 Age

 4-6 years old     7-9 years old    10-15 years old       Total

 Boys    Girls     Boys    Girls     Boys    Girls     Boys    Girls

  18       6        46       14       84       26      148       46
 9.3%     3.1%    23.7%     7.2%    43.3%    13.4%    76.3%    23.7%

TABLE 2. FREQUENCY OF REVEALED ACCOMPANYING PATHOLOGIES
CAUSING NASAL BREATH DISTURBANCES

Revealed accompanying pathologies          Number of
                                      observations (n=194)

                                       Absol.       %

Chronic purulent rhinosinusitis         158       81.4%
Hypertrophy of the palatine tonsils      14        7.2%
Adenoid vegetation                        9        4.6%
Hypertrophic rhinitis                     6        3.1%
All pathologies                         187       96.4%

TABLE 3. CHARACTER OF DETECTED CURVATURES OF BONY AND CARTILAGINOUS
SECTIONS OF NASAL SEPTUM AMONG 194 CHILDREN

NSC character                                       Number of
                                              observations (n=194)

                                                  ABS        %

Right-hand crest                                   60      30.9%
Right-hand thorn                                    3       1.5%
Bilateral crest                                    45      23.2%
Bilateral thorn                                     1       0.5%
Left-hand crest                                    34      17.5%
Left-hand thorn                                     2       1.0%
Curvature of the bony section                     145      74.7%
  of the nasal septum, total
"[phi]"--shaped curvature                          58      29.9%
"C"--shaped curvature                              21      10.8%
Thorn                                               8       4.1%
counter "C"--shaped curvature                       2       1.0%
"S"--shaped curvature                               1       0.5%
counter "S"--shaped curvature                       1       0.5%
Curvature of the cartilaginous                     91      46.9%
  section of nasal septum, total
Curvature of the bony and cartilaginous           236     121.6%
  sections of nasal septum, total
Curvature only in the bony section                103      53.1%
Curvature only in the cartilaginous section        49      25.3%
Curvature only in both cartilaginous and           42      21.6%
  bony sections
Total number of children with DNS                 194     100.0%

TABLE 4. KINDS AND FREQUENCY OF DMA AMONG
PATIENTS WITH NASAL SEPTUM DEFORMITIES

                   DDA types                             Number of
                                                   observations (n=194)

                                                    Absol        %

Constriction of upper jaw with dense location of      85       43.8%
  front teeth and gothic shape of bony palate
Superior prognathism with constriction of upper       32       16.5%
  jaw and deep palate
Superior retrognathism with constriction of           25       12.9%
  upper dental arch and congestion of front
  teeth (apical insufficiency)
Anomaly of location of separate teeth on the          12        6.2%
  upper jaw (without change in the jaw shape)
Open bite (frontal, vertical disocclusion)             7        3.6%
Other anomalies                                       11        5.7%
DMAs total                                           172       88.7%
DNS without DMA                                       22       11.3%
Total number of patients with DNS                    194      100.0%
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Author:Babakhanov, Gulimbay; Khasanov, Saidakram; Makhsudov, Sunnat; Bobokhonov, Maqsad
Publication:Medical and Health Science Journal
Article Type:Author abstract
Date:Jan 1, 2013
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