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Evidence of post-mortem breath movements are rarely reported. We present two cases of broncho-pulmonary aspiration of brain and cartilage tissue following two fatal suicidal gunshots to the head. We also discuss the physiopathological implications for the agony.

Obstructive diseases of children's upper airways are frequent, mostly caused by tonsils and adenoids hypertrophy. A nasal septum deviation or a lower turbinate hypertrophy may also cause a significant obstruction. Tonsillectomy and adenoidectomy must be performed in case of clinical obstruction, sometimes documented by a sleep study. A tonsils' hypertrophy without significant obstruction and clinical symptoms is not an indication of adenotonsillectomy, even in case of snoring or if an orthodontic treatment is planned.

Date of birth: 21/11/1994; gender: female. A.02/11/2004 (age of patient: 10years).Skeletal Class II, hyperdivergent, dental Class II, arch-length discrepancy (ALD), anterior open bite, lingual dysfunction.First functional stage: ENT check-up, tongue rehabilitation using retroincisal spurs. Second orthodontic stage: multibracket appliance with extraction of 15-25-35-45. B. END-OF-TREATMENT RECORDS: 18/09/2007 (age of patient: 12y10m).Upper arch: palatal wire bonded from 12 to 22 and nightguard. Lower arch: bonded lingual wire from 33 to 43. C. END-OF-TREATMENT RECORDS: 20/11/2007 (age of patient: 13years). D.Poor state of teeth: risk of caries.

Optimum treatment timing for orthodontic problems continues to be one of the more controversial topics in orthodontics. Especially regarding the correction of Class III malocclusion, there is little consensus as to proper timing or methods for correcting these problems. The orthopedic approach for growth modification is usually limited to children with growth remaining subjected to non hereditary pattern. If the skeletal malocclusion is within the range of an orthodontic treatment, fixed orthodontic appliances with dentoalveolar compensation mechanism can achieve a normal occlusion. Otherwise in patients with a severe skeletal discrepancy, it will be necessary to consider a combined surgical and orthodontic approach. The purpose of this study was to describe treatment planning according to the age and to the initial diagnosis. The management of skeletal Class III malocclusion is still a challenge to orthodontists especially because of relapse due to the late growth of the mandible.

So-called "primary" or "infantile" forms of deglutition, also termed lingual dyspraxia, are treated in different ways by orthodontists using various appliances to correct the condition and are also managed by speech-therapists and physiotherapists. The results obtained are often unstable. We have developed a more holistic approach to this disorder by attempting to grasp the underlying mechanisms in order to achieve more satisfactory correction. By establishing normal salivary deglutition more rapidly, this manual osteopathic technique complements the methods which use voluntary rehabilitation to impress upon the body's physical reflexes the "motor image" of the act to be accomplished. In order to render this article more lively and accessible, we have chosen to let the tongue speak in the first person--which, after all, is only normal!

Management of occlusal plane inclination in the sagittal dimension is one of the main concerns of practitioners. Inclination maintenance or correction can condition the success and stability of treatment. By means of a clinical case, we will attempt to discuss the different aspects of management from diagnosis to treatment, bearing in mind the local and regional context. The adopted treatment plan takes into consideration the functional and esthetic issues specific to Moroccan patients without neglecting soft tissue harmony.

The goal of this study is to know the modifications of the cranio-cervical posture which accompany the functional anomalies by the nasal breathe of black African children.The study consists of a cephalometric comparison. Sixteen parameters measured on cephalograms of 98 schoolboys from 6 to 15 years were used. The children were divided into two groups according to their usual mode of breathing: 50 mouth-breathing children and 48 nasal breathers. The mode of breathing used three clinical tests: the mirror test, Rosenthal test and nasal reflex.The results show a significant difference of slope the cervical column between the two groups of children (t student). The oral breathers have the rhinopharyngeal airway dimensions more narrowed. The hyoid bone is more distant of the epiglottis and the mandible is more divergent. However, factor analysis of cephalometric variables suggested that craniocervical angulation (C2C4/SN) is independent of the other variables in oral breathers. Its dependence with is clear in nasal breathers.The children with predominantly mouth breathing exhibent a cranio-cervical hyperextension which could not closely be associated hyo-mandibulo-pharyngeal equilibrium.

Congenital nasal pyriform aperture stenosis (CNPAS) is a rare and an unusual cause of airway obstruction in newborns.We report the case of a female neonate delivered by C-section at 39 weeks of amenorrhea for hydramnios and macrosomia. She presented with mandibular retrognathia, nasal saddling, submucous cleft palate, and loud mouth respiration. She presented with cyanosis every time feeding was attempted. CT revealed permeable choans with a single central incisor and nasal pyriform aperture stenosis. Nasal respiration returned to normal progressively after 56 days of hospitalization. The status was unchanged at 5 months.CNPAS is a rare cause of congenital nasal obstruction. It is sometimes associated to a median incisor syndrome. The diagnosis should be made as early as possible for an optimal management. Cyanosis and swallowing disorders may be lethal consequences. Associated abnormalities should be screened for with TDM or MRI. The treatment depends on the severity and may be surgical for a severe stenosis. The prognosis is good if no severe malformation or mental retardation is associated.

Is the poor potential of growth an ineluctable consequence of mesodermal deficiency? Should we agree with the idea that all protocols are equivalent? Actually, these opinions reflect the empiricism of previous generations. We must now become rational and develop a project without compromise to achieve good functions at primary surgery. 'The normal structures are present on either side of the cleft, only modified by the fact of the cleft...' Victor Veau's hypothesis is the conclusion of rigorous anatomical and embryological research. Our current knowledge of the pathological anatomy allows for a better restoration of the normal anatomy. Anatomy is nothing if it is not functional. Every thing should be done to control the healing process to allow the best expression and interaction of the various functions, especially for those concerning nasal ventilation and masticatory efficiency. To correct the deformity, the cleft surgeon must perform a wide subperiosteal and subperichondrial elevation and must learn the skills of this accurate work to preserve the integrity of very fragile structures. The primary treatment must take into account a rational and uncompromising selection of the age of the first operation, of the successive procedures, and their chronology to benefit from the growth spurt of the maxilla, and to avoid the worse scars resulting from secondary epithelialization. Finally, if nasal breathing is the most important function concerning facial growth, it is essential to restore this normal function at the time of the first operation. The oral breathing pattern set at the time of the first operation leaves a cortical imprint that is very difficult to erase, even after clearing the nasal airways. The results of the functional approach we have used in the last decade are particularly consistent and very convincing. In this ambitious and demanding program, the patient comes first; we decrease the burden for him and his family, and give them the benefit of a good social life before school age.

Usually, the nasal sequels of unilateral cleft patient are just considered as an esthetic problem to be addressed after the growth spurt of adolescence. This very narrow vision has led the cleft lip and palate treatment to a deadend. Actually, nasal sequels are the worst in terms of consequence on facial growth. 75% of complete unilateral cleft children are more oral than nasal breathers. Today, we know about the bad consequences of oral breathing on facial growth. It is not surprising to observe a high rate of small maxilla with cleft maxilla scars. In the fetus, the unilateral cleft nose deformities are well explained by the rupture of the facial envelope and the ventilatory dynamics of the amniotic fluid. Every step of the primary treatment threatens the nasal air way patency, whether when repairing lip and nose, suturing the hard palate that is the floor of the nose, or closing the alveolar cleft which controls the width of the piriform aperture. The functional and esthetic nasal sequels reflect the initial deformity, but are also the surgeon's skill and protocol choice. Before undertaking treatment, we must analyze the deformity at every level. Usually, the best option is to reopen the cleft completely to perform a combined revision of the lip, nose, and alveolar cleft after an adequate anterior maxillary expansion. If nasal breathing is necessary for an adequate facial growth, 25 years of experience showed us that it was very difficult to erase the cortical imprint of an early oral breathing pattern. So it is essential to establish a normal nasal breathing mode at the initial surgery. When the initial surgery is efficient and/or the secondary repair is successful, the final esthetic rhinoplasty, when indicated, is just performed for the sake of harmonization, with a classic internal approach and a few refinements.

There has been a recent recrudescence of cranio-mandibular disorders (CMD), predominantly affecting women. Even children can be affected by CMD, often under diagnoses by their families and by medical professionals. Therefore, a multidisciplinary approach is important when evaluating the variety of diagnostic and etiological problems. The search for postural etiology, whether lingual or dental, is always necessary to better act on the etiology of these disorders. The involvement of orthodontics, in the prevention of CMD, has three impacts: functional, aesthetic and psychological, allowing for a better balance of the cranio-mandibular system. This makes the treatment of cranio-facial orthopedics, a successful choice in the recovery of CMD.

This paper evaluates maxillary expansion by synthesizing the scientific literature, focusing its role in treatment of maxillary insufficiency, buccal cross bites, and deviations in mandibular closure as well as its effectiveness in correcting a lack of harmony between tooth and jaw size. By its creation of maxillary bone "capital" it facilitates treatment of arch length discrepancies in an environment of periodontal health. And by restoring the maxilla to normal size it improves the orthopedic effectiveness of Class II treatment of mandibular advancement appliances. In a similar fashion rapid palatal expansion, by relaxing circum-maxillary sutures, prepares the way for maxillary advancement in Class III cases with masks of Delaire or Petit. And, by broadening the floor of the nose, palate splitting improves nasal airflow and helps mouth breathers learn how to breathe through their noses. Most authors emphasize the benefits of early intervention through truly orthopedic movement that eliminates tipping of posterior teeth and reduces the risk of buccal fenestration.

The functional differences between breast-feeding and bottle-feeding may have a significant effect on dento-facial development and on the genesis of some severe malocclusions. Orthodontists should be aware of this sometimes under-estimated aspect of development. They should, in conformity with their role as professional health care providers, advise long-term breast feeding as a way of preventing certain disorders or, at least, reducing their severity.

The cases presented in this paper share a common skeletal characteristic, hyperdivergence, a common therapeutic strategy, similar diagnostic elements, and a common choice of non-symmetrical extractions. Interceptive treatment is especially useful for this type of malocclusion to prevent deep over-bites, atypical habits, and severe malocclusion. In the Tweed-Merrifeld technique, orthodontists use careful dental, occlusal, cephalometric, and esthetic evaluations to establish an appropriate treatment plan and therapeutic strategy whose goal will be: to eliminate unhealthy compensations, re-position, if necessary, alveolar structures on basal bone, reduce anterior-posterior and vertical discrepancies, favor anterior mandibular rotation, improve facial esthetics, restore functional occlusion, and assure stability of results. Because of its consistent capability of achieving predictable resolution of the most varied and complex orthodontic disorders, the author has chosen this technique for routine use in his daily orthodontic practice.

In this paper, the author presents his method of dealing with breathing problems when he conducts an orthodontic consultation. Because they can interfere with growth, the author believes that ventilation disorders should be dealt with promptly so that they cannot cause skeletal discrepancies. After having reviewed the literature, the author presents his clinical procedures for uncovering and treating breathing disorders and then shows treated cases to illustrate his techniques, one of the most important of which, palate splitting, is simple, effective and virtually without risk. In addition to its clear orthodontic benefits, rapid palate expansion can prevent the growth problems that frequently accompany breathing disorders. He believes that the Delaire's facial mask is the ideal preventive device for dealing with problems associated with skeletal Class III malocclusions. He asserts that, when indicated, the device can work well in conjunction with palatal expansion.

The relations between the mode of breathing and the development of the malocclusions were the subject of many studies causing polemic sometimes (2, 3, 7, 9, 20). In fact the impact of the mode of breathing on occlusion is not clarified yet. The goal of this study is to quantify the dental characteristics, which constitute the malocclusion according to the mode of breathing. 100 African melanoderme children old from 6 to 15 years were subjected to a rhinologic evaluation based on the nostril reflex of GUDIN and the test of ROSENTHAL (12). Of this examination these children were left again in a group of 50 nasal respirators and in another group of 50 mouth breathers. Each child underwent a radiographic examination which was used to make a cephalometric analysis and a meeting of catch of dental prints. The statistical analysis of the data recorded on the dental casts and the layouts cephalometric (test t of student) indicate that the mode of breathing is not associated standard initial malocclusion. But, when the facial divergence, which is characteristic of mouth breathing increases, the initial malocclusion becomes significant.

The last decennia more and more patients are aware of the advantages of a good dental health. Dental minded parents in their children visit the dentist (general practitioner, GP) on a regular basis for a routine check up. During this check up, signs of possible future orthodontic problems can be encountered by the GP. In this article guidelines are handed to the GP by means of a flow chart which can be used at the end of the dental examination. Anterior/posterior relation, cross-bites, deep and open bite, habits and crowding shall be briefly discussed. Heaving knowledge of these, the GP can decide referring the patient to the orthodontist for further orthodontic evaluation.

Obstructive sleep apnea and hypoapnea syndrome (OSAHS) is important to orthodontists for several reasons. The authors, after defining OSAHS and describing it briefly, review the literature dealing with the cranio-facial morphology of apnea patients. They report the results of their cephalometric study, which is based on an architectural analysis of 274 patients. Their facial characteristics, especially vertical dimension, are consistent with those displayed by mouth breathing children. Changes in respiratory functioning modify the mechanical behavior and the structures of the upper airways. Osseous tissues also show signs caused by these changes. The authors propose an etiopathogenic model.

In dentofacial orthopedics, rehabilitation concerns the performance of the orofacial functions. Orthodontists will therefore speak of rehabilitation of functions, or functional therapy. Orofacial functions seem to obey a hierarchical system in accordance with their physiological importance; the impact of their disorders on both muscular behavior and facial morphogenesis, proportionally to their physiological importance. Therefore, priority will be given at a very early stage to the rehabilitation of respiration: restoring nasal ventilation is indeed an essential condition to obtain balanced oral functions because oral ventilation conditions both muscular posture and the performance of other functions. A little later, affective immaturity symptoms closely linked to various persisting bad suction habits will be looked after. At last, the rehabilitation of phonation and chewing both affected by the previous dysfunctions will participate in acquiring correct lingual position. The age for intervention will before all depend on the dysfunctional etiopathogeny. The morphological context, the importance of the malocclusion, and some orthodontic appliances also play a role in the the dysfunctional requests and the alterations of oral behavior.

Childhood and perinatal nasal traumatisms involve an anterior septal deviation or an anterior septal lysis. These complications induce a soft nasal tip. Nasal obstruction et oral ventilation are responsible for the development of facial and occlusal sequelae. A better knowledge of anatomy and physiopathology of nasal traumatisms is needed for an earlier treatment.

The author reviews the morphogenetic and functional consequences of oral breathing in childhood.

The aim of this preliminary work is to determine an easy method to diagnose "buccal breather" children and "nasal breather" children. Then, to establish a possible connection with the syndrome of obstructive sleep apnea. 22 children agreed to participate. Clinical, orthophonic, orthodontic, postural and polysomnographical exams have been carried out. The proposed clinical exam turns out to be a good means of diagnosing between buccal breathers and nasal breathers. The aerophonoscope reveals velar inadequacies in buccal breathers. The latter also present osseous discrepancies mainly in the mandible. The polysomnography reveals a higher apnea/hypopnea index and more agitated sleep in buccal breathers. Mandibular lowering movements are more frequent and similar to those of adults suffering from apnea. These elements similar to those encountered in adults suffering from apnea make us think that buccal breathing could be the origin of obstructive sleep apnea, several decades later.

This work presents long term results of rhinopharyngeal desobstructions on nine years old patients. By using several techniques such as: tonsillectomies, adenoïdectomy, adenoïdotonsillectomies, luxation of inferior turbinates, partial turbinectomies or bilateral turbinectomies under endoscopic guidance, and then, following carefully the oral and nasal peak flows for a period as long as one or two years, it becomes obvious that the most efficient desobstruction procedure is accomplished through a combination of E.N.T. rhinopharyngeal procedures, i.e. adenoïdotonsillectomies and inferior turbinectomies under endoscopic guidance. This global E.N.T. procedure is known as "Chimney Sweep". The author demonstrates that tongue behavior is severely affected by rhinopharyngeal obstruction and by the consecutive dysfunction of the upper airway ventilation pattern. Large tongues and normal tongues pushed forward due to enlarged tonsils or adenoïds are also affected by their necessary participation to oral ventilation (mouth breathers). Addition of a selective lingual glossoplasty or a partial glossectomy is sometimes necessary to put the morphogenic function in a proper order during growth and development. All of the above is part of a new pre-orthognathic concept, that helps control growth and development and helps manage orthodontic or orthognathic treatments.

There is a large controversy about the causal relations between dento-facial deformities and mouth-breathing habits. Some postural and morphological changes during long-term adaptation to oral respiration are evoked: opening of the bite with a lowered postural position of the mandible, reduction of upper arch width, downward and backward rotation of the mandible, increased lower facial height and changes in the inclination of the lower and upper incisors. It seems that the altered postural position of the tongue and of the mandible, needed for oral ventilation, could, by soft-tissue stretching, change the growth pattern of the face.

Oral breathing causes changes in pulmonary mechanics as well as in the pressure of arterial blood gases. In response to increased nasal obstruction oro-nasal breathing occurs. The level of oro-nasal partitioning maintains an adequate level of respiratory resistance. Sleep disordered breathing, although not only related to oral breathing, is a common disorder. When upper airway resistance is increased limitation of flow occurs. Snoring indicates a mild degree of reduced airflow. Sleep apnea occurs when upstream pressure falls below a critical pressure (Pcrit). The mechanisms are reviewed.

Myotherapy requires neuromuscular rehabilitation and is also a treatment for a more expressive speech. Rehabilitation procedures are listed.

The diagnosis of dental malocclusions and skeletal deformities associated with an oral mode of breathing, requires a comprehensive orthodontic examination. The importance of dental occlusion and the skeletal morphology is stressed. Lateral sliding of the mandible when the centric occlusion shows the first contact in a cusp-to-cusp relationship; unilateral or bilateral cross-bite, due to the underdevelopment of the maxillary; the sagittal relationship of the jaws (class 1, 2 or 3); a vertical excess of the anterior facial height with postero-rotation of the mandible and open bite context. Cephalometric analysis provides a better understanding of facial architecture and allows a quantitative and qualitative appreciation of dento-skeletal dysmorphism.

All elements resulting from clinical examination of the upper airways are reviewed. The collaboration of the ENT and maxillofacial surgeon is stressed.

Besides nose obstruction other etiological factors can be advanced to explain the development of oral respiration: malformation of the face (Binder's syndrome, Bimler's microrhinodysplasia, Apert's and Crouzon's syndrome); alterations or deviations of the tongue (Robin's syndrome, macroglossia, ankyloglossia); lip closure problems.

Patients with severe alterations of the maxillary growth pattern, due to long term predominant oral respiration, primarily need orthopaedic appliances, rather than common orthodontic mechanics. In cases of maxillary transversal deficiency, rapid expansion is indicated to recover an adequate width. Such treatment improves the ability for nasal ventilation. When the maxilla is sagittally underdeveloped, a facial mask is used to protract the entire maxilla. Other ways of treatment include oral screens, partial glossectomy, myofunctional therapy and respiratory gymnastics. Finally orthodontic treatment can be planned to correct irregularities of the teeth and residual malocclusions.

The speech therapist investigates all elementary functions in mouth breathers (swallowing, breathing, chewing and articulatory practice). Special interest is drawn to head and body postures in the set up of the craniofacial morphology.

Respiratory disorders in the upper respiratory tract during sleep are most often part of a continuous pathological process of long standing. Schematically, three clinical syndromes with increasing severity are described: breathing with the mouth open, snoring and the sleep apnea syndrome. These conditions always include a functional maxillofacial perturbation, which may be associated to a constitutional or acquired morphological disorder. Besides the medical approach itself, the treatment sometimes is surgical, always orthopedic. The earlier it is initiated, the more effective, simple and unconstraining it is.

Mouth breathing induces a low rest posturing of the tongue and tongue thrusting in many cases. This disturbs the development of the oral functions. The first stage of the reeducation is nose breathing's rehabilitation in order to "liberate" the tongue. Nasal breathing cannot be taught exteriorly . It's a result of the physical well-being. It's important to observe the mouth breathers and understand their needs. The second stage of the reeducation concerns the tongue moving tonicity and suppleness. Every exercise relies on the proprioceptive control that makes the child aware of each motion of the tongue. The next stages will be the recovering of the different functions as the rest tongue posture, swallowing, chewing. The use of phonation (lingual alveolar speech sounds) will facilitate the automatism of the new functions, because the children feel the elevation of the tongue.

The authors measured nasal resistance in 53 children aged 5 to 13 years treated for bite disorders. Comparison of the results with a normal control group of children of the same age demonstrated that major nasal incompetence was 4 times more common in the group of children with orthodontic abnormalities. Nasal incompetence with permanent buccal respiration leads to disordered growth and modification of the morphogenesis of the naso-ethmoid-maxillary unit. Adaptation of deglutition and phonation to these new conditions produces modifications in the tension of the velo-pharyngo-facial and pharyngo-hyoglossal musculo-aponeurotic bands with a tendency to produce more vertical mandibular growth in children. The prevention of nasal incompetence in children and its treatment are important for coherent facial growth and guarantee the stability of the results of orthodontic treatment.