Analysis of the upper airway through low dose 3D Orthodontic Imaging By Juan-Carlos Quintero, DMD, MS

The ability of orthodontists to understand, visualize and measure the upper airways on our patients is becoming increasingly relevant due to the accumulating scientific research strongly correlating facial shapes with airway character. The human upper airway is readily viewable and measurable through CBCT (Figure 1a, 1b). This article will explore the ability to analyze the human airway through the use of low dose CBCT.

Figure 1a

Figure 1a

Figure 1b

Figure 1b

Cone beam computed tomography (CBCT) was developed in the 1990’s and is increasingly becoming the imaging modality of choice in just about every specialty in dentistry. With the introduction of newer CBCT machines (such as the i-CAT FLXTM) which are actually less radiation than a traditional 2D panorex13, CBCT is quickly becoming THE standard of care in clinical Orthodontics14. It now becomes the obligation for, and the responsibility of, every orthodontist to not only consider upper airway measurement and risk for OSA in every orthodontic case, but to actually treatment plan the case for the best supportive airways (Figure 2).

Figure 2

Figure 2

CBCT is already the imaging technique of choice in orthodontic academia and orthodontic research. This is mainly due to significantly lower effective dose, reduced costs, reduced acquisition time, and greater market availability compared to conventional medical grade CT scanners known as multidetector or multislice CT (MDCT or MSCT)8.

In the next article posted on this blog, we will be reviewing the scientific research linking facial types, to upper airway measurements, to obstructive sleep apnea (OSA). This relationship has driven an increased interest in the ability to use craniofacial imaging techniques such as CBCT to screen for patients at risk for OSA and treatment plan orthodontic treatments relative to airways. It has also fueled a slew of recent studies providing insight into the effects of various treatments and their effects on airways, and thus OSA.

According to the medical literature, we now know that airway evaluation can be performed accurately with magnetic resonance imaging (MRI)1,2,3. Although medical grade CT scans are superior to CBCT in discerning between different soft-tissue structures of the craniofacial region, they do so at the expense of greater biological and financial costs (i.e. money and radiation). Evaluation of the upper airway, using CBCT imaging has been scientifically studied, validated and documented to be as accurate as medical grade CT.4, 5, 6, 7, 8, 9, 10, 11, 12.

Because of its easy access, reduced cost and lower radiation compared with medical CT’s and especially its ability to distinguish the boundaries between soft tissue and airspace such as the sinuses and the pharyngeal airway accurately, “CBCT has become an unprecedented diagnostic method to analyze the airway three dimensionally”, according to researcher Dr. R. Guijarro-Martinez8 (Figure 3).

Figure 3

Figure 3

As a result, the number of publications related to upper airway evaluation with CBCT has increased significantly during the last few years8. CBCT technology has emerged as the standard of care for obtaining a thorough 3D assessment of the upper airway in orthodontics14. Other major benefits of CBCT include the ability to see the 3rd dimension, the width of gum’s & bone, the TMJ’s, the sinuses, forecasting the eruption of future teeth in children, assessment of third molars, screening for potential pathology and many more (Figure 4).

Figure 4

Figure 4

Of course from an orthodontic treatment planning perspective the sky is the limit with advanced virtual treatment planning allowing the orthodontist to simulate various treatment plans and their potential effect on airways (Figure 5).

Figure 5

Figure 5

This airway screening approach, and this airway-based orthodontic treatment, could very well be the key to preventing OSA in children and in their future adulthood as in Dr. Quintero’s own son (Figure 6, 7)15.

Figure 6

Figure 6

Figure 7

Figure 7

The following training video demonstrates the ease of identifying, segmenting, and measuring the upper airway using software called Invivodental from Anatomage Corporation (www.anatomage.com):


References

  • Abbott MB, Donnelly LF, Dardzinski BJ, Poe SA, Chini BA, Amin RS. Obstructive sleep apnea:MR imaging volume segmentation analysis. Radiology 2004: 232: 889–895.
  • Arens R, McDonough JM, Corbin AM, Rubin NK, Carroll ME, Pack AI, Liu J, Udupa JK. Upper airway size analysis by magnetic resonance imaging of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2003: 167: 65–70.
  • Arens R, McDonough JM, Costarino AT, Mahboubi S, Tayag-Kier CE, Maislin G, Schwab RJ, Pack AI. Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2001: 164: 698–703.
  • Ghoneima A, Kula K. Accuracy and reliability of cone-beam computed tomography for airway volume analysis. Eur J Orthod. 2011 Aug 10.
  • McCrillis JM, Haskell J, Haskell BS, Brammer M, Chenin D, Scarfe WC, Farman AG. Obstructive sleep apnea and the use of cone beam computed tomography in airway imaging: a review. Semin Orthod. 2009;15:63–69.
  • Ogawa T, Enciso R, Memon A, Mah JK, Clark GT. Evaluation of 3D airway imaging of obstructive sleep apnea with cone-beam computed tomography. Stud Health Technol Inform. 2005;111:365–368.
  • Ogawa T, Enciso R, Shintaku WH, Clark GT. Evaluation of cross-section airway configuration of obstructive sleep apnea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103:102–108.
  • Guijarro-Martinez R, Swennen GR. Cone-beam computerized tomography imaging and analysis of the upper airway: a systematic review of the literature. Int J Oral Maxillofac Surg. 2011;40:1227–1237.
  • Lohse AK, ScarfeWC, Shaib F, Farman AG. Obstructive sleep apnea-hypopnea syndrome: clinical applications of cone beam CT. Australasian Dental Practice. 2009;20:122–132.
  • Abramson Z, Susarla S, August M, Troulis M, Kaban L. Three-dimensional computed tomographic analysis of airway anatomy in patients with obstructive sleep apnea. J Oral Maxillofac Surg. 2010;68:354–362.
  • Cameron Aboudara, Ib Nielsen, John C. Huang, Koutaro Maki, Arthur J. Miller, and David Hatcher. Comparison of airway space with conventional lateral headfilms and 3-dimensional reconstruction from cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2009;135:468-79)
  • Lenza MG, Lenza MM, Dalstra M, Melsen B, Cattaneo PM. An analysis of different approaches to the assessment of upper airway morphology: a CBCT study. Orthod Craniofac Res 2010: 13: 96–105.
  • John B. Ludlow and Cameron Walker Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography Am J Orthod Dentofacial Orthop 2013;144:802-17
  • Quintero, JC. New Study May Change the Face of Orthodonitcs. Orthodontic Practice US. January/February 2014- Volume 5, N0 1. Page 41-43
  • Quintero, JC. (Case Report) Unlocking King Airway, TMJ and Growth with CBCT as the key. OrthoTown, September 2011, Page 70.

About Dr. Juan-Carlos Quintero

Dr. Juan-Carlos Quintero (AKA Dr. “Q”) received his Dental Degree from the University of Pittsburgh in Pennsylvania and Degree in Orthodontics from the University of California at San Francisco (UCSF). During this time he also received a Master’s of Science Degree in Oral Biology. This optional degree requires an extra year of formal education and research. Before moving to Florida, Dr. Quintero was in private practice in San Diego, California for one year, where he practiced with, and mentored under world-renown orthodontist Dr. Ron Roncone.

Dr. Quintero has served as National President of the American Association for Dental Research- SRG, won numerous National research competitions, published over 14 articles in peer reviewed scientific journals and currently lectures extensively both nationally and internationally. Dr. Quintero is a faculty member at the prestigious The L.D. Pankey Institute and an attending professor at Miami Children’s Hospital, Department of Pediatric Dentistry.

Dr. Quintero is immediate past-president of the South Florida Academy of Orthodontists (SFAO). He has also been featured on several television news shows, including the Discovery Channel. He is in private practice and took over the orthodontic practice of the late Dr. Lindsey Pankey, Jr. in South Miami, Fl. His academic interests include technology in orthodontics and 3D craniofacial imaging.

5 thoughts on “Analysis of the upper airway through low dose 3D Orthodontic Imaging By Juan-Carlos Quintero, DMD, MS

  1. What a wonderful resource to have available to us! This is truly taking orthodontics to the next level with comprehensively approaching airway obstructions issues for patients of all ages. As a dental hygienist, it is empowering to be aware of these great advances. If we don’t know it, we won’t share it! What a disservice this would be for our patients/clients. Being a former Quintero Orthodontics patient-mom, I have been aware of CBCT for quite some time; my now adult son and daughter are former patients and I can categorically state CBCT made a world of difference in my daughter’s impacted lower right premolar and her treatment. In my capacity of executive coach for general practices, I feel it is my responsibility to spread the word about the link of air way development issues with the dental practices I have the honor to coach. Thank you Dr. Q for challenging us to keep raising the bar in advocacy for our patients’ total health!

  2. Nice article and information. I do alot of early treatment as you did for your son with expansion and positioning of the anterior dentition. I often have an issue with referrals to the ENT docs for evaluation of airway and possible T&A procedures. While I see very enlarged tonsil and adenoid tissues and subsequent mouthbreathing they often want to take a watch and see approach. I have no evidence but it appears this is more the case with HMO type insurances as opposed to more the fee for service docs who likely lean toward surgery- go figure. Without the proper airway my treatment results are more limited. I do not currently have 3-D imaging so I cannot present much evidence other than visual to the ENTs.

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