March 9, 2017
by Douglas Musseau
As parents, we absolutely want what is best for our children in every way. Many parents are well aware of the specific milestones that our children should reach during the first 18-months of life, however, there are several important growth and development factors that must be evaluated in each child during the first decade of life. Surprisingly, it is your child’s dentist who becomes the guardian of normal facial growth and development. The role of your dentist is more than just taking care of your child’s teeth. The goal of most every dentist is to monitor and guide the growth and development of young children to achieve the following:
1. A pleasing face which equals optimal esthetics
2. A beautiful “full smile”
3. A normal and functional bite
4. An adequate airway allowing optimal oxygenation
5. No TMJ problems
6. A lifetime of oral health
Many parents are unaware that 60 percent of their child’s facial development is completed by age eight and that 90 percent of facial development is completed by age 12. This means that the earlier your child sees a dentist the better the opportunity to detect and correct any growth and development problems that may be present.
Facial growth is the sum of the individual growth of each bone, which comprises the face. There are several influences, which can cause an unequal growth of a child’s face, and this imbalance may affect a child’s health and appearance. A normal balanced face is a result of more than just bone growth. It is the balance of normally functioning muscles, proper nutrition and the ability to breathe normally. Scientific literature and studies have shown that when these delicate balances are altered, changes in health and appearance occur.
One of the most common abnormalities in a child’s facial growth and development is caused by a compromised airway or quite simply stated – the inability to breathe properly through the nose. Children who cannot breathe well through their nose will tend to breathe through their mouth. This sets up a chain of events which may severely impact not only the health of a child but also the way a child’s facial feature develop and ultimately the way a child looks as an adult. The most common causes of altered breathing are:
1. Enlarged adenoids
2. Enlarged tonsils
3. Deviated septum (nasal obstruction)
5. Chronic sinus infections
The effects of a compromised airway on the growth of a child are revealed in many ways. The tongue often positions itself snugly in the lower jaw so that it grows more vertically. This change in growth direction makes the child’s face grow longer. T the same time, since nasal breathing is severely compromised, the upper jaw and midface – the nasal bones, cheek bones, and bones supporting the tissue of the face – fail to develop at a normal rate because the natural growth stimulant of air flow through the nose is absent. This results in a deficiency of growth of the upper jaw and midface, which added to the long facial growth from the lower jaw and directly impacts the facial balance and beauty of a child and later as an adult.
As parents, we often see the signs of airway problems, however, they often go unnoticed. Here are a few common symptoms of airway problems:
1. Mouth breathing – lips apart
2. Chapped lips and soft tissue gingivitis
3. Venous pooling beneath the eyes – dark circles beneath the eyes
4. Change in head posture – posturing the head forward and/or tipping the forehead backwards
5. Tonsil and adenoid problems – chronic sinus problems, throat problems
6. Snoring – children do not usually snore
7. Loud grinding of teeth during sleep
8. Bed wetting
9. Reflux in the Eustachian tube – leads to inner ear infections
Enlarged adenoids and tonsils are by far the most common causes of airway compromise. Adenoids are tonsil-like glands located at the back of the nose. The most currently literature indicates that tonsils and adenoids serve to bolster the immune system during the first two years of life. After that, there seems to be no obvious function and a child can live normally without them.
Children are born with adenoids, which are quite small. As a child grows, so do the adenoids, reaching their maximum size when the child is 10 to 12 years old. From that point on, normal adenoid tissues start to shrink on their own. It is during the growth phase that adenoids can cause problems. Enlarged or “hypertrophied” adenoids can block a child’s nasal passages and result in nasal congestion, mouth breathing and increased snoring. In severe cases where the adenoid block the nasal passage completely, they can cause sleep disturbances, like sleep apnea where breathing is stopped altogether. A child may be tired all the time as a result of interrupted sleep related to the nasal blockage, which typically worsens at night.
Of course, enlarged adenoids are not the only cause of persistent nasal congestion in children. Aside from the history of symptoms, the best way to access the size of the adenoids is for the dentist to take a 3D CBCT image or a cephalometric X-ray of the head and neck region. The adenoids are hidden behind the nose and cannot be seen by direct physical examination, therefore, these X-rays show several very important details:
1. Whether the adenoids and tonsils are enlarged and to what degree they block the nasal passage
2. If changes of growth of the facial bones have occurred and to what degree
3. If congestion of the various sinuses is present
4. What stage of growth and development the child is undergoing and to what degree can the growth changes be corrected by intervention
The ideal treatment for chronically enlarged obstructing adenoids and tonsils is to surgically remove them.
We also know that chronic nasal blockage can contribute to increased rates of ear infections and persistence of fluid in the middle ear area. For the child with recurrent ear infections, removal of enlarged and obstructing adenoids may help reduce the number of ear infections.
The child’s dentist working closely with an Otolaryngologist (ear, nose and throat specialist), can help to assess and eliminate the causative factors of facial growth abnormalities. When corrected early in a child’s life, the facial growth is encouraged to return to a harmonious growth and development. In those cases, where facial growth changes are significant and facial harmony is disrupted, the dentist may intervene and guide the child’s growth back to normal. Using growth guidance appliances, the dentist can actually modify the abnormal growth pattern and restore the balance of growth that nature intended. Taking your child to the dentist as early as possible, even at age three, is very important. Here are four advantages of early examination, diagnosis and treatment:
1. Removes harmful factors influencing growth
2. Excellent ages for growth guidance and restoring normal growth
3. Assists in improving the psychological well-being of the child
4. Saves some patients from future jaw surgery
It is important to bear in mind that no matter what your child’s rate of development and growth, a loving and supportive environment are crucial to his or her happiness and self-esteem. If you have a concern about your child’s ability to breathe, or rate of growth or development, discuss it with your dentist. OH
Please feel free to contact Dr. Douglas Musseau with any questions or comments. I wish you and your family good health, balanced faces and beautiful smiles.
This article may be used with permission by Dr. Douglas Musseau and is Copyrighted 2016 with all rights reserved.
1. Cara F Dosman, MD FRCPC FAAP, Debbi Andrews, MD FRCPC, and Keith J Goulden, MD DPH FRCPC. Evidence-based milestone ages as a framework for developmental surveillance, Pediatric Child Health. 2012 Dec; 17(10): 561–568.
2. Toga AW, Thompson PM, Sowell ER; Thompson; Sowell. Mapping brain maturation. Trends Neuroscience. 2006 29 (3): 148–59.CS1 maint: Multiple names: authors list (link)
3. Kail, Robert V. Children and Their Development (6th Edition) (Mydevelopmentlab Series). 2011Englewood Cliffs, N.J: Prentice Hall.
4. Rogol AD, Clark PA, Roemmich JN. Growth and pubertal development in children and adolescents: effects of diet and physical activity. Am J Clin Nutr. 2000; 72(2): 521S-528S.
5. Enlow DH,Hans MG. Essentials of Facial Growth. Philadelphia, PA: WB Saunders; 1996.
6. Enlow DH,Hans MG. Essentials of Facial Growth, 2nd ed. Ann Arbor, MI; Needham Press, Inc.; 2008.
7. Rubin RM. Effects of nasal airway obstruction on facial growth. Ear, Nose & Throat Journal 1987; 66: 212-219.
8. Enlow DH, Bang S. Growth and remodeling of the human maxilla. Am J Orthod 1965; 51:446.
9. Enlow DH, Moyers RE: Growth and architecture of the face. JADA 1971; 82:763.
10. Enlow DH: Normal and abnormal patterns of craniofacial growth. In: Scientific Foundations and Surgical Treatment of Craniosynostosis. Ed. By J. A. Persing, M. T. Edgerton, and J. Jane. Baltimore; Williams and Wilkins, 1989.
11. Frost HM. Skeletal structural adaptations to mechanical usage (SATMU). Redefining Wolff’s law: The bone modeling problem. Anat Rec 1990; 226:403-413.
12. Frost HM. A 2003 update of bone physiology and Wolff’s Law for clinicians. Angle Orthodontist 2004; 74(1):3-15.
13. Katsavrias EG. Changes in articular eminence inclination during the craniofacial growth period. Angle Orthodontist 2002; 72(3): 258-264.
14. Shaw RB, Katzel EB, Koltz PF, Kahn DM, Girotto JA, & Langstein HN. Aging of the mandible and its aesthetic implications. Plast Reconstr 2010; 125: 332-342.
15. Linder-Aronson S. Adenoids: Their effect on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the dentition. A biometric, rhino-manometric and cephalometro-radiographic study on children with and without adenoids [thesis]. Acta Otolaryngol Suppl. 1970;1-132.
16. Linder-Aronson S. Effects of adenoidectomy on the dentition and facial skeleton over a period of five years. In: Cook JT (ed). Transactions of the Third International Orthodontic Congress. London: Crosby Lockwood Staples, 1975:85-100.
17. Behlfelt K. enlarged tonsils and the effect of tonsillectomy. Characteristics of the dentition and facial skeleton. Posture of the head, hyoid bone and tongue. Mode of breathing. Swed Zdent J Suppl. 1990;72:1-35.
18. Galella SA, et al. 29. Guiding atypical facial growth back to normal Part 1: Understanding facial growth. International Journal of Orthodontics 2011;22:4:49-56.
19. Galella SA, et al. Guiding atypical facial growth back to normal Part 2: Causative Factors, Patient Assessment, and Treatment Planning. International Journal of Orthodontics 2011;22:5:23-32.
20. Harari 2. D, Redlich M, Miri S, Hamud T, Gross M. The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. Laryngoscope.2010:120(10):2089-93.
21. D’Ascanio 3. L, Lancione C, Pompa G, Rebuffini E, Mansi N, Manzini M. Craniofacial growth in children with nasal septum deviation: A cephalometric comparative study. Int J Pediatr Otorhinolaryngol. 2010;74(10):1180-3.
22. Solow B, Sonnesen L. Head posture and malocclusions. 4. European Journal of Orthodontics 1998; 20:685-693.
23. van der Beek M5. C, Hoeksma JB, Prahl-Andersen B. Vertical facial growth: a longitudinal study from 7 to 14 years of age. Eur J Orthod. 1991;13(3):202-8
24. Zettergren-Wijk 47. L, Forsberg CM, Linder-Aronson S. Changes in dentofacial morphology after adeno-/tonsillectomy in young children with obstructive sleep apnoea–a 5-year follow-up study. Eur J Orthod. 2006;28(4):319-26.
25. Mattar S32. E, Valera FC, Faria G, Matsumoto MA, Anselmo-Lima WT. Changes in facial morphology after adenotonsillectomy in mouth-breathing children. Int J Paediatr Dent. 2011;21(5):389-96.
26. Linder-Aronson S, Henrikson CO. Radio-cephalometric analysis 33. of anteriorposterior nasopharyngeal dimensions in 6 to 12 year old mouth breathers compared with nose breathers. ORL J otorhinolaryngol Relat Spec 1973;35:19-29.
27. Lunstrom A, McWilliams JS. A comparison of vertical and 34. horizontal cephalometric variables with regard to heritability. Eu J Orthod 1987;79:104-108.
28. Agren K, Nordlander B, Linder-Aronson S, Zettergren-Wijk L, 35. Svanborg E. Children with nocturnal upper airway obstruction: Postoperative orthodontic and respiratory improvement. Acta Otolaryngol 1998;118:581-587.
29. Freng A. Dentofacial development in long-lasting nasal stenosis. 36. Scand J Dent Res 1979;87:260-267.
About the Author
Dr. Douglas Musseau graduated from the School of Dentistry at Dalhousie University in Halifax, NS in 1983.
Originally from Port Aux Basques, NL, he has practiced general dentistry in Grand Falls-Windsor, Newfoundland, since 1983 and continues to do so at Exploits Valley Dental
Office which he founded in 1991.
In April 2016, he completed his Senior Instructor’s Training and his Fellowship with the International Association for Orthodontics. He recently published an article, Mouth Breathing and some of its Consequences, in the International Journal of Orthodontics.
Dr. Musseau is a member of the International Association for Orthodontics, The Academy of General Dentistry, The American Academy of Craniofacial Pain, The Canadian Dental Association and The Newfoundland Dental Association.
He may be contacted at 709-290-3660 or by email at firstname.lastname@example.org.