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Forum on the tonsil and adenoid problem in orthodontics Respiratory obstruction syndrome
Respiratory obstruction syndrome ROBERT Pacific
M. Palisades,
RICKETTS,D.D.S.,
M.S.,
F.A.C.D.
Calif.
THE role of the functional environment of the denture as an etiologic factor in malocclusion has been argued from the time orthodontics became a science. From the beginning, orthodontists have sought to explain malocclusions on a functional basis. Throughout history, forceful arguments have been presented for the ease of environment as the principal cause, and equally dogmatic statements have been made by those laying the cause of malocclusions at the feet of the geneticists. It would seem that during the 1940’s and 1950’s the role of heredity had its day. Earlier, however, during the 1920’s and 1930’s, adenoids and tonsils had been extracted on a wholesale basis. The promiscuity was well exemplified in the popular play, Cheaper by the Dozen, in which the father presented all twelve of his children for tonsillectomies at a cut-rate fee. Strong arguments presented by opposing views in any science usually do not prove either side correct. Such arguments prove only that a serious problem exists. It is also true of many branches of science throughout history that, when the facts finally came to light, both sides of an argument were correct to some extent. Following the advent of sulfonamides in the early 1940’s and penicillin and other antibiotics in the late 1940’s and 1950’s, and particularly with the proving of the protective influence of Waldeyer’s ring, there developed a great deal of conservatism with respect to tonsils and adenoids. I share this belief in the need for preservation of adenoid and tonsil tissue. It is a tragic experience to encounter a patient who has developed cleft palate speech following removal of a large adenoidal mass. These conditions are well known to all cleft palate centers, It has been my hope to influence the pediatrician or the otolaryngologist, as well as the general medical practitioner, concerning the usefulness of head films for the diagnosis and prognosis of nasopharyngeal problems. Some rhinologists already have acquired this equipment (the cephalometer or the headholding apparatus) and have taken the trouble to study conditions of the bony framework, including the base of the skull, prior to any decision concerning surgical procedures involving the nasopharynx (Fig. 1). I have been committed to a study of this area since 1947, when I started taking midsagittal laminagraph sections and studying the bony framework of the nasopharynx and oropharynx and its relationship to soft tissues. In my first study, which was published in 1954,l I was particularly interested in the influence of the basic skeletal morphology in certain clinical conditions of the nasopharynx. We had in our files at the Cleft Palate Center a series of cases 495
in which the patients spoke as if they possessed cleft, palutc rondit,ions; yrt thcil palates were intact. and in some paticnt,s the range of function of the soft I)alat(l was within normal limits. With midsagittal body-section laminagraphy, we WCI’C able to eliminate the lateral borders of the throat which sec~medto bc the problem most objected to by many of those who denied the usefulness of’ x-rays for soft-tissue diagnosis. Arguments against t,he soft-tissue (n&lines revealed in the regular lateral x-ray film have not provc~l valid. l~atcral tissues of the roof of the nasophargnx are located in an oblique plant and al-e not registered as a line of demarcation. Therefore, structures in the mitllinc ant1 muscles of the lntc~ral throat wall can be reliably identified (Fig. 21. It was shown in many of these so-called submucous c*left palate patients, latcl called pharyngopalatal mcompetency (WI) patients, that the cranial base was unusually obtuse. The basioccipital WBHlocated upward and baekwarcl. The tlivus, toget.her with the anterior arch of the atlas and the t,hroat wall, was positioned higher and farther backward than in t,vpical patient,s (Fig. 3). It was furthrr demonstrated that the amount of adenoid tissue present was not the principal consideration. It was the bony dimensions of the nasopharynx which htacame the primary concern in the study. The angle or drape of the soft palate was strongly correlated with the anteroposterior dimension of the bony nasopharpnx. If the nasopharynx was deep, the pala,te was usually observed to be flat, If t,hc anteroposterior nasopharynx was shallow, the soft palate was usually dropped precipitously, yielding an acute angle at its junction with the palate at the posterior nasal spine (Fig. 4). In these conditions, particularl?- in patients with long fac<‘s. the tonguca wonltl not
Fig. 2. Above: Lateral film showing nasopharynx completely occluded by adenoid (A). Note that the lips are chronically parted and an airway is established through the oral cavity by the space between the lowered tongue and the soft palate. This Class I crowded case relapsed severely after early mixed-dentition treatment. Adenoid had not involuted adequately at age 20. In the author’s opinion, prognosis would have been improved with adenoidectomy, which was rejected by parent. Below: Lateral film showing adenoid (9) and tonsil (2’). Note “altered” contour of the soft palate in an attempt to adjust to massive lymphoid tissue. Both subjects were chronic mouth-breathers.
always occupy its normal position superiorly in the oral cavity unless it displaced the palate upward and backward, which would close the nasopharynx. Therefore, in the interest of maintaining the nasal airway, the soft palate would tend to be held downward and the tongue would conditionally acquire a forward or downward posture in the mouth as a result of th,e functional demands of the soft palate. A forward and downward tongue posture was even more marked when the nasopharynx was filled with adenoid (Fig. 5, A). There tended to be a strong relationship between adenoidal or tonsillar tissue and tongue position. This sug-
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Fig. 3. Tracings of a female patient with cleft palate speech but ‘)LO cleft palate. Dimensions of nasopharynx are too large for the soft palate to make closure. Sote severely obtuse cranial base, with an NSBa angle of 152 degrees and an SBa-opisthion angle of 154 degrees. These factors lead to a high and backward location of the anterior arch of the atlas, which pulls the entire posterior throat wall out of functional juxtaposition to the hard palate. Actually, adenoid tissue is present and the patient should be warned not to have adenoids removed at the risk of further speech incompetency. Compare with Fig. 4. The distance from basion to PNS is 57 mm. and the direct distance from a middle anterior point on the arch of the atlas to the soft palate is 33 mm. The angle of the soft palate to the palatal plane is 36 degrees.
Fig, 4. The antithesis of the patient illustrated in Fig. 3. This male patient also has a wide nasopharyngeal airway, but it is in the vertical dimension as compared to Patient S. C. Note the long precipitous palate and forward location of the anterior arch of the atlas and, consequently, the throat wall. Cranial base angles are 114 and 121 degrees, respectively. The distance from basion to PNS is 42 mm., or 15 mm. 1~s than in Patient S. C. The dimension from the center of the anterior arch of the atlas directly to the soft palate is only 14 mm. Thus, Patient 8. C. shows almost, 2 cm. more need for compensat,ion of soft palate and throat wall than Patient B. R. Ironically, both patients have Class II, Division 1 malocclusions, but they are of entirely different types, although both patients are essentially the same age. In Patient B. R,. the angle of the soft palate to the palatal plane is 37 degrees.
Tonsil and adenoid problem
499
PO 6-6
Fig. 5. A, Tracings of a patient 6 years 8 months of age with essentially normal cranial dimensions. The average NSBa angle is 130 2 4 degrees. Note, however, that PR’S is slightly forward at 70 degrees (Ba-S-PNS). (The mean is 60 degrees.) The occlusion of this patient is seen in B and C. Note the presence of adenoid and tonsil and low tongue. R, Patient starts t,o close mouth and strikes deciduous canine on left side, which deflects the mandible to the left into unilateral cross-bite. C, Patient in cross-bite, which is a functional cross-bite. It is speculated that respiratory obstruction led to lowered tongue and denied lingual support to the developing upper arch, which was moderately narrowed. The patient therefore moved the mandible to prevent interference in function. After removal of tonsils and adenoids, there was tongue elevation, downward flexion of the head, and spontaneous correction of the cross-bite with no orthodontic intervention.
Fig. 6. Serial records of respiratory and growth case (Patient S. D.). A, Tracing made at age of 8 years 9 months. Note compensatory mandibular posturing and suggestion of condyle 5attening on forward side. Clinically, the patient had a Class 1 cross-bite and open-bite with characteristics of Ricketts’ respiratory obstruction syndrome. B, Same patient 11 months later (at 9 years 8 months). Mandible had retracted following removal of adenoids and tonsils. Soft palate showed elevation. Patient now demonstrated bilateral Class II, Division 1 open-bite at the age of 14 years 6 malocclusion, but tongue-thrust was still present. (‘, Same patient months, following extractions of four premolars and after slight anterior relapse. The paNote the presence of a lingw~l tonsil tient did not seem to respond to tongue training. throughout.
gested the hypothesis that conditions of the nasopharynx were important to the environmental needs of the tongue. Therefore, it was speculated that respiration was one factor predisposing to malocclusion of the teeth through the influence of tongue posturing and possibly even the positioning of the mandible (Fig. 2, A andB). It is well known in orthodontics that the teeth, on erupt,ing from the arched form of the basal bone, wedge themselves into the form of an arch between the muscular organs of the tongue on the inside and the lips and cheeks on the outside. During the process of erupting, the teeth respond to very light, continuous forces in the range of only a few grams. Therefore, the functional environment should be understood, because light, subtle forces not only direct the teeth but are their permanent retainers. Pursuing this problem, by 1957 I had accumulated serial records on approximately forty patients who had not undergone orthodontic treatment but whose tonsils and adenoids had been removed. Also, I began to observe, on a clinical basis, the high frequency of collateral findings in the presence of adenoids and tonsils. I described a condition which was termed the respimtory obstruction syndrome.
Clinically, some of the following characteristics were usually observed: a patient would display cross-bite; tonsils or adenoids would be present, or a history of problems would be reported (Fig. 5) ; an open-bite would be exhibited; the tongue would be thrust on swallowing; the patient would be a mouth breather; in unilateral conditions, a. so-called functional cross-bite would be present, as laminagraphs would show the condyle to be normal or slightly backward on one side whereas the other condyle would be forward; clinically, in the attempt to close in a straight upward position, the mandible would be deflected by the deciduous canines to either one side or the other (Fig. 5, B and C). (Some patients were observed to chew on one side at one time and reveal a cross-bite to the opposite side at a later examination.) If the maxilla were constricted bilaterally, the mandible would be deflected to one side in a “functional cross-bite. If the constriction were more severe, the patient would reveal a bilateral cross-bite with no mandibular deflection to the side, but sometimes it was deflected forward, producing a pseudo-Class I condition (Fig. 6, ~$61, aml C) . The histories and examinations of these patients began to reveal a marked frequency of some kind of respiratory obstruction. With the help of several physicians in my area who were kind enough to collaborate, I followed these patients following surgical removal of adenoids or tonsils. No orthodontic treatment was employed for several months. Three paGents of this group showed spontaneous correction of their cross-bite with no orthodontic treatment. This study was reported in 1958 at the cleft palate meeting in San Francisco and was published in abstract in the Cleft Palate Joun~aL2 A side investigation in conjunct,ion with that study proved quite interesting. It was shown that the tongue could elevate in the oral cavity several millimeters, but it was further shown that when such activity was demonstrated it was also usually accompanied by a downward rotation of the heud OWLthe cervical asis. It was almost as if originally the head was extended or tipped backward in an
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t’tv)ir~lli(a mouth t 111’ hc;trl. including the masilla, now WU.Shrvu!qhf t!orc*~ OZYt’ the t~,,rq,c(. 13~ this physic)logic phenotncnon, the upper arch \VilS h1*ought d0w1i over t Ilv iotrpii~~ ;~ncl t hv upper denture hccamc splayed nioi*(’ outw;lrtl.yi Peterson, 1 in 193’1, iITIt1 .~C\VJlIUH,” it1 l!):?ri, sinthl (w~asions oi’ bhkinlcls who still consumed primitive diets. Both inv&igators showed ;I frcyuc~cy of higll cuspids and constricted arches in the anterior portion of thcl tlcntitl WWIIW Any environmental role was largely discv~utnted and the inl’ercnce rr~mained that genetics was the greatest factor. It is known, houcvrr, that gcncticall,v vcrtain races possess narrow mouths with tight lips. If, in the prrscncc of tight lips. small tongues arc also presrnt, marked dental retraction and cronding arca ptvduc~tl. When, in addition, a delicate skeletal structure is combined with tight lips, severe crowding can bc prclsent. throughout thcb arch. HOWVW, t,hc Eskimo occlusions seemed limited to anterior crowding. TO say that all conditions oi’ this t?-l)tl are acyuirccl through ht~rrdity aloncx does not quite explain genetic crowding. If 20 pears of orthodontic experience means anything, 1 can say with no resrrcation whatsoever that open-bite tongue problems constitute the most. annoying situation that I hare csperirnced on a clinical lcvcl in preort~hodontic, ortl~ndontir, postorthodontic, and nonorthodontic patients (Fig. 6, (T). It is also 1~1).suspicion t,hat many tongnc problems are in some way basically related to rcspiratoty problems, cithcr at prcscnt or in Ihr~ past history of pcvsons with the ~~rohlems. Findings concerning the Eskimo’s anterior crowded dentition only c~omplicat~~the c~xplanation. Konrad Lorcnz’; has shown that muscle characteristics and buhavioral patterns can be inherited and transmitted gc~nctically. +lust as the c~olor of our cycs, our skin, and our hair is inherited and thv pattern of our handnriting is pccnliar to each of us, it is likely also that tongur tnovcmcnts, peculiarities of lip tonicit? and activity, and pattrrns of speech and chewing also RIV, to a degree, inherited. However, who is to say when the gcnctir fowcs will hr overcome by environmental circumstances when the aggregate of all cnrironmrnt is calculated? Nutrition. states of health and disease. climate, ps)-chologic~ favtoty stress phtYIOJTltlrla 01 all kinds, endocrine patt,et-ns and hotly chemistry, and, finally, the physical fwctors of function arc all constitntcnts oi’ thr rn\+rorimcnt and cannot hr disrvgarded. Certainly, genetics of heredity is the primary c4ioiogic factor, but, this is only the basic frame and starting place. Environment is superimposed on these look at the nasal cayit>in the light of a conbasic patterns. Let us, thcreforv, cept of all factors t,hat van lend to an obstruction of’ thr normal rrspiratory airwav. . These can be discussed in two main groups : ( 1) general skAeta1 cha~wtwistics as a structural frame and (2) soft-tissue and local conditions. The first skeletal condition is a naturally small nose, sometimes rallcd nasal IIOSC
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Fig. 7. Patient R. 5. A, The lateral view shows beautiful congruous dimensions and “normal” airway, but clinically the patient was a mouth breather. B, Frontal view shows a narrowed maxilla with extremely narrow nasal cavity. The septum is very thin or the nasal airway would be more restricted. Both frontal and lateral nasal dimensions must be considered in evaluation of speech and breathing. Note the narrowness of the upper intercanine dimensions and more normal lower canine positions.
atresia or natural impatency (Fig. 7). The choanal opening and piriform aperture are too small to permit enough air flow. It has been shown that vertical maxillary asymmetries may follow abnormal growth of the mandible. As observed in isolated patients, therefore, mandibular growth can be a factor in the nasal airway space. For instance, the lack of posterior ramus height has suggested lack of development of maxillary height on a unilateral basis. A condition leading to nasal air hindrance is dysplasia of the cranial base, such as cranial dysostosis. In this disease a growth failure occurs in the sphenoethmoidal and the spheno-occipital area. The entire skull becomes dysplastic. High and forward displacement of the cervical vertebrae results from lack of descent of the occipital condyles.
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Fig. 8. Patient V. O., the antithesis of Patient R. S. -4, Tracing shows abundant adenoid and tonsil but deep nasopharynx. Also, the hard palate tips upward anteriorly. The patient had a severe thumb-sucking habit for many yearn. The angle of the palatal plane to Frankfort horizontal is minus 13 degrees. R, Frontal view shows what might he classified a microrhinodysplasia (Bimler). The maxillary, nasal cavity, and intercanint > dimensions \wre much more favorable than in Patient R. 8. The lower canines were forward and close to the midline, which yields a poor prognosis. Horizontal lines on frontal tracings are drawn through zygomatic frontal sutures at lateral border of orbit. Vrrtical lines are erected from orbital zygomatic frontal suture points to a crest on t,lw nlandible at the inftxrior border at the area of the anteriormost insertion of the mass&w muscle point {Mm.) This forms a parameter for c>omparison of maxillary widths.
Another factor is extreme deflection of the cranial base angles, whatever the cause (Figs. 3 and 4), The base of the skull may be normal in size but the acuity of the angle from basion to sella to nasion may cause the maxilla to be retropositioned as bhe anterior cranial base is tilted downward relative to the clivus. Other basal factors may cause the clivus to bc inclined rcrtically and the occipital condyles positioned forward, thus rrcluving the climcnsions of the nasopharynx (Figs. 3 and 4). These cranial factors combine perhaps into what BinlIe? has called a “microrhino-dysplasia” (Fig. 8). FI WC the anterior portion of the palatal plane is
Volunbe Number
54 7
Fig. 9. Lateral film of adult female with thirty-two teeth present. Note large nasopharyngeal space; position of the tongue in the oral cavity; and level of hyoid bone at about the junrtion of the third and fourth cervical vertebrae and also on a level slightly brlow the chin.
elevated to standard cranial planes as if it has fa.iled to descend. This is almost an atavistic tendency, as the nostrils face outward instead of downward. In these conditions, it is as if the entire piriform aperture and the nasal and maxillary bones have failed to develop properly. The amount of inhibition of the normal airway, if any, is unknown, but the lip is also characteristically short and the teeth are protruded, and these abnormalities contribute somewhat to mouth breathing. The foregoing conditions are skeletal problems observable in lateral and frontal head films. Other conditions are mostly local or environmental in naturc. First, there is the possibility of trophic influences on growth of the nose or maxilla as a component of skeletal form. The subject of vascular effects on growth of the face has hardly been touched by research workers. However, strictly local factors include conditions within the immediate nasal cavity, the nasopharynx, or the oral pharynx instead of the outer bony configuration. Because it is so easily recognized, the primary local factor is lymphoid tissue size and location in a particular nasopharyngeal frame (Figs, 1, 2, 5, and 6). When the adenoid is in a particularly upward and forward location, especially when t.he inferior t,urbinates are long, obstruction seems to be imminent and most pronounced. There are other local factors, however. Chronic rhinitis, recurrent upper respiratory infections, allergies, asthmas, polyps, foreign bodies, deviated septa, unreduced fractures, and ambitious surgical treatment of cleft palate conditions can produce varieties of obstruction to the natural flow of air through the nasal cavity. It should not be forgotten that., in some patients, there is also a lingual tonsil (Fig. 6). Although this is not located in the nasopharynx, it can be a factor in
posturing Of tll? IOllgllC~ IHV*allSck 0C its lOc~:ltloti iIll(l its c.Cttliig:.lic)llsl’f’liltionsliil) to stlvctlll’c~s irl tllcl tlll*o;rl. \Y(s IlnYcl itl(Wific~tt lill#iiill torlsils 111 iwo ill’ thrcrx patients with unrcsl~onding 1o11~11c~-th1*~1sl. I am iol~l t 11i11 sr~tywi~s 110 no1 desire to l’cnlov(’ lingual tonsils l)W;111s(~this is a hlootl!~ illl(l vt’I’>. sc~riolls i?-I),’ Of procedure. HOWWI’, Jcsbcrg” ’dntl ollirrs lia~c~dexcribc~tl good l(~(*htliqu~5. The tonsils and adenoids-the subjoc~i of this l)an(‘l discussioIr---;I IX t hrrc+ot*c~ only one consideration, albeit an importrlnt, enc. I would like now to refer to a public~ation by MCJY~I*K. %Iarks!’ of’ the I)()partment of Pediatrics at the I-ni\-c>rsity of Nami School of Medic~ino. In tht~ Jouwml of A Ueryy of Nay, 1965. 11~ma k(ls a strong point when he statt’s : ill~llOl’lllill
Sensitization of nasal mucow mcwhranc~s from early f’wtlirq of (‘OK’S milk gives riw to persistent edema. Cow’s milk in the neonatal period may be the -priming, sensitizing f&or which propels the allergic infant toward progwssively swerc allergic manifestations, one of A !?C /‘fJidly t?dC?nfitou~Y TLma~ WLd ~i~7r’lLn&Slk~ mucoUS which may be dentofxcial deformity . . membrantx cause ~‘~~~uozc.sstasis iu tkc mtrzillniy tlrdnl wch clrrti swwuntlin,q s/ructw~a from pressure on LY&S. In atldition, thcx action of hirtaminc: c~~user market1 dilatation of thl‘ capillary bed in the affected nasal, palatal, and alveolar areas. . . . Primitive peoples were said to be comparatively free from allergic diseases. Balyeat and Rowen remarked on the paucity of allcrgi~ manifestations and ~tt~ntofaoial abnormalitic~s in Oklahoma Indians. Rineock statc,d that IIC hart never seen (‘hippewa Indians with hay fever, asthma, or ~CZNUL He attributed thaw findings to Indian babies heing breast-fed for fully nine months or longcar without supplrnwntal foods or \r:ttclr. When early feeding of cow’s milk and adult foods was intro~luc%l, CCZNI~:L and othclr allergic manifestations appeared. . . . Ballard found a corwlation twtwwn lips-apart poi-turc, n~aloeclusion, and the incidence of asthma and rccurrcnt uppw wspiratory tract infwtions. c Italic added.)
Marks ends his articlr with the following Although mouth breathing is chronic nasal allergy already may No&h breathing in the infant and proved otherwise. Early diagnosis forestall at least one major factor formity. (Italics added.)
remarks :
usually self-corrected before adolescence, the patient witlt have malocclusion of the teeth, wit,h orofacial deformities. child should be regarded as an dergio maxnn’festa,tion until and early efficient modern allergy management can often contribut,ing to the progressive effects of dentofacial tl~-
In a recent private conversation with the speech pathologist in our office, it, was agreed that practically everyone with a stubborn tongue-thrust habit exhibits breathing problems of some form. This conclusion prevails in spite of the excellent work of EastmanlO on “allergics” who (lid not support the hypothesis of the environmental factor in malocclusion. At this point, I would like to summarize our present. thinking. The normal patient should breathe through the nasal cavity. The mouth should be closed with little or no strain. At rest, the posterior part of the tongue is usually in contact with the soft palate and the center of the tongue is located no lower than about halfway between the crown of the upper molars and the vault of the palate, preferably almost in contact (Fig. 7). .I!nder normal circumstances, the teeth should remain closed during deglutition as the mandible is fixed or braced via the teeth for active swallowing. The tongue tip contacts a broad surface from the lingual aspect of the lower incisors to the cingulum of the upper incisors and up
t,he ruga,e of the palate. A wave of contact travels the length of the palate as the bolus is squeezed into the pharynx in the act of normal swallowing. The hyoid bone moves upward and forward on a smooth arc to a level of the lower border of the mandible, from whence it returns in a smooth arc. The normal face and the dentofacial complex usually are reasonably symmetrical, and the range of variat,ion from slight concavity to moderate convexity is well within normal range. The palatal plane is usually very near the Frankfort horizontal plane in angulation and, if anything, is tilted slightly downward in front. It should he recognizctl that facial forms vary extensively and berome the frame of reference for orthopedic orthodontics. CONCLUSION
Genetics is a basic consideration for all morphology. It is possible, however, that long-term environmental conditions may be erroneously passed off as genetic t,endencies or as simply a part of the “pattern.” Several factors, both deep and peripheral, enter into respiratory problems. Environmental influences on the respiratory and deglutition systems or the food and air tracts must be considered concurrently as a part of orthodontic diagnosis. Clinical trophic influences on growth of the maxilla, which are basic to nasal cavity form and airway space, have not been investigated in a sophisticated manner. Finally, very little is known of the reasons for cranial base configurations which constitute the basic framework of the nasopharynx and postural relations which, through the cervical vertebrae, influence the oral pharynx. It would be regrettable if this thesis were taken as a brief for promiscuous extraction of tonsils or adenoids. On the other hand, the functional balance and stability of orthodontic results have seemcld to he enhanced by removal of respiratory obstructions and the attainment of normal nasal breathing and correct patterns of deglutition. REFERENCES
The Cranial Base and Soft Structures in Cleft Palate Speech aud 1. Ricketts, R. M.: Breathing, Plast. & Reconstruct. Surg. 14: 47, 1954. 2. Ricketts, R. M.: Respiratory Obstructions and Their Relation to Tongue Posture, Cleft Palate Bull. 8: 3, 1958. 3. Ricketts, R. M.: The Functional Diagnosis of Malocclusion, Tr. European Orthodont. Sot. pp. l-21, 1958. 4. Peterson, P. 0.: Investigations Into Dental Conditions of Ancient and Modern Grtew landers, D. Record 4: 191-198, 1938. 5. Newman, G. V.: The Eskimo’s Dento-Facial Complex-Effects of Environmental and Genetic Factors, U. S. Armed Forces M. J. 3: 1653-1662, 1952. 6. Lorenz, Konrad Z. : The Evolution of Behaviour, Scientific American July-December, 1958. 7. Bimler, Hans P.: La Microrrino-Displasia, Rev. Esp. Estomat. 14: July-August, 1966. 8. Jesberg, Norman: Chronic, Hypertrophic, Lingual Tonsillitis. Arch. Otolaryng. 9. Marks, Meyer B.: Allergy in Relation to Orofaeial Dental Deformities in Children; a Review, J. Allergy 36: 293.302, 1965. 10. Eastman, George A. : Oropharyngeal Muscular Inter-Relationships in Chronic Nasorespiratory Allergy-A Cephalometric Study, Thesis, Rackham School of Graduate Studies, University of Michigan, June, 1963.
M. Palisades,
RICKETTS,D.D.S.,
M.S.,
F.A.C.D.
Calif.
THE role of the functional environment of the denture as an etiologic factor in malocclusion has been argued from the time orthodontics became a science. From the beginning, orthodontists have sought to explain malocclusions on a functional basis. Throughout history, forceful arguments have been presented for the ease of environment as the principal cause, and equally dogmatic statements have been made by those laying the cause of malocclusions at the feet of the geneticists. It would seem that during the 1940’s and 1950’s the role of heredity had its day. Earlier, however, during the 1920’s and 1930’s, adenoids and tonsils had been extracted on a wholesale basis. The promiscuity was well exemplified in the popular play, Cheaper by the Dozen, in which the father presented all twelve of his children for tonsillectomies at a cut-rate fee. Strong arguments presented by opposing views in any science usually do not prove either side correct. Such arguments prove only that a serious problem exists. It is also true of many branches of science throughout history that, when the facts finally came to light, both sides of an argument were correct to some extent. Following the advent of sulfonamides in the early 1940’s and penicillin and other antibiotics in the late 1940’s and 1950’s, and particularly with the proving of the protective influence of Waldeyer’s ring, there developed a great deal of conservatism with respect to tonsils and adenoids. I share this belief in the need for preservation of adenoid and tonsil tissue. It is a tragic experience to encounter a patient who has developed cleft palate speech following removal of a large adenoidal mass. These conditions are well known to all cleft palate centers, It has been my hope to influence the pediatrician or the otolaryngologist, as well as the general medical practitioner, concerning the usefulness of head films for the diagnosis and prognosis of nasopharyngeal problems. Some rhinologists already have acquired this equipment (the cephalometer or the headholding apparatus) and have taken the trouble to study conditions of the bony framework, including the base of the skull, prior to any decision concerning surgical procedures involving the nasopharynx (Fig. 1). I have been committed to a study of this area since 1947, when I started taking midsagittal laminagraph sections and studying the bony framework of the nasopharynx and oropharynx and its relationship to soft tissues. In my first study, which was published in 1954,l I was particularly interested in the influence of the basic skeletal morphology in certain clinical conditions of the nasopharynx. We had in our files at the Cleft Palate Center a series of cases 495
in which the patients spoke as if they possessed cleft, palutc rondit,ions; yrt thcil palates were intact. and in some paticnt,s the range of function of the soft I)alat(l was within normal limits. With midsagittal body-section laminagraphy, we WCI’C able to eliminate the lateral borders of the throat which sec~medto bc the problem most objected to by many of those who denied the usefulness of’ x-rays for soft-tissue diagnosis. Arguments against t,he soft-tissue (n&lines revealed in the regular lateral x-ray film have not provc~l valid. l~atcral tissues of the roof of the nasophargnx are located in an oblique plant and al-e not registered as a line of demarcation. Therefore, structures in the mitllinc ant1 muscles of the lntc~ral throat wall can be reliably identified (Fig. 21. It was shown in many of these so-called submucous c*left palate patients, latcl called pharyngopalatal mcompetency (WI) patients, that the cranial base was unusually obtuse. The basioccipital WBHlocated upward and baekwarcl. The tlivus, toget.her with the anterior arch of the atlas and the t,hroat wall, was positioned higher and farther backward than in t,vpical patient,s (Fig. 3). It was furthrr demonstrated that the amount of adenoid tissue present was not the principal consideration. It was the bony dimensions of the nasopharynx which htacame the primary concern in the study. The angle or drape of the soft palate was strongly correlated with the anteroposterior dimension of the bony nasopharpnx. If the nasopharynx was deep, the pala,te was usually observed to be flat, If t,hc anteroposterior nasopharynx was shallow, the soft palate was usually dropped precipitously, yielding an acute angle at its junction with the palate at the posterior nasal spine (Fig. 4). In these conditions, particularl?- in patients with long fac<‘s. the tonguca wonltl not
Fig. 2. Above: Lateral film showing nasopharynx completely occluded by adenoid (A). Note that the lips are chronically parted and an airway is established through the oral cavity by the space between the lowered tongue and the soft palate. This Class I crowded case relapsed severely after early mixed-dentition treatment. Adenoid had not involuted adequately at age 20. In the author’s opinion, prognosis would have been improved with adenoidectomy, which was rejected by parent. Below: Lateral film showing adenoid (9) and tonsil (2’). Note “altered” contour of the soft palate in an attempt to adjust to massive lymphoid tissue. Both subjects were chronic mouth-breathers.
always occupy its normal position superiorly in the oral cavity unless it displaced the palate upward and backward, which would close the nasopharynx. Therefore, in the interest of maintaining the nasal airway, the soft palate would tend to be held downward and the tongue would conditionally acquire a forward or downward posture in the mouth as a result of th,e functional demands of the soft palate. A forward and downward tongue posture was even more marked when the nasopharynx was filled with adenoid (Fig. 5, A). There tended to be a strong relationship between adenoidal or tonsillar tissue and tongue position. This sug-
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Fig. 3. Tracings of a female patient with cleft palate speech but ‘)LO cleft palate. Dimensions of nasopharynx are too large for the soft palate to make closure. Sote severely obtuse cranial base, with an NSBa angle of 152 degrees and an SBa-opisthion angle of 154 degrees. These factors lead to a high and backward location of the anterior arch of the atlas, which pulls the entire posterior throat wall out of functional juxtaposition to the hard palate. Actually, adenoid tissue is present and the patient should be warned not to have adenoids removed at the risk of further speech incompetency. Compare with Fig. 4. The distance from basion to PNS is 57 mm. and the direct distance from a middle anterior point on the arch of the atlas to the soft palate is 33 mm. The angle of the soft palate to the palatal plane is 36 degrees.
Fig, 4. The antithesis of the patient illustrated in Fig. 3. This male patient also has a wide nasopharyngeal airway, but it is in the vertical dimension as compared to Patient S. C. Note the long precipitous palate and forward location of the anterior arch of the atlas and, consequently, the throat wall. Cranial base angles are 114 and 121 degrees, respectively. The distance from basion to PNS is 42 mm., or 15 mm. 1~s than in Patient S. C. The dimension from the center of the anterior arch of the atlas directly to the soft palate is only 14 mm. Thus, Patient 8. C. shows almost, 2 cm. more need for compensat,ion of soft palate and throat wall than Patient B. R. Ironically, both patients have Class II, Division 1 malocclusions, but they are of entirely different types, although both patients are essentially the same age. In Patient B. R,. the angle of the soft palate to the palatal plane is 37 degrees.
Tonsil and adenoid problem
499
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Fig. 5. A, Tracings of a patient 6 years 8 months of age with essentially normal cranial dimensions. The average NSBa angle is 130 2 4 degrees. Note, however, that PR’S is slightly forward at 70 degrees (Ba-S-PNS). (The mean is 60 degrees.) The occlusion of this patient is seen in B and C. Note the presence of adenoid and tonsil and low tongue. R, Patient starts t,o close mouth and strikes deciduous canine on left side, which deflects the mandible to the left into unilateral cross-bite. C, Patient in cross-bite, which is a functional cross-bite. It is speculated that respiratory obstruction led to lowered tongue and denied lingual support to the developing upper arch, which was moderately narrowed. The patient therefore moved the mandible to prevent interference in function. After removal of tonsils and adenoids, there was tongue elevation, downward flexion of the head, and spontaneous correction of the cross-bite with no orthodontic intervention.
Fig. 6. Serial records of respiratory and growth case (Patient S. D.). A, Tracing made at age of 8 years 9 months. Note compensatory mandibular posturing and suggestion of condyle 5attening on forward side. Clinically, the patient had a Class 1 cross-bite and open-bite with characteristics of Ricketts’ respiratory obstruction syndrome. B, Same patient 11 months later (at 9 years 8 months). Mandible had retracted following removal of adenoids and tonsils. Soft palate showed elevation. Patient now demonstrated bilateral Class II, Division 1 open-bite at the age of 14 years 6 malocclusion, but tongue-thrust was still present. (‘, Same patient months, following extractions of four premolars and after slight anterior relapse. The paNote the presence of a lingw~l tonsil tient did not seem to respond to tongue training. throughout.
gested the hypothesis that conditions of the nasopharynx were important to the environmental needs of the tongue. Therefore, it was speculated that respiration was one factor predisposing to malocclusion of the teeth through the influence of tongue posturing and possibly even the positioning of the mandible (Fig. 2, A andB). It is well known in orthodontics that the teeth, on erupt,ing from the arched form of the basal bone, wedge themselves into the form of an arch between the muscular organs of the tongue on the inside and the lips and cheeks on the outside. During the process of erupting, the teeth respond to very light, continuous forces in the range of only a few grams. Therefore, the functional environment should be understood, because light, subtle forces not only direct the teeth but are their permanent retainers. Pursuing this problem, by 1957 I had accumulated serial records on approximately forty patients who had not undergone orthodontic treatment but whose tonsils and adenoids had been removed. Also, I began to observe, on a clinical basis, the high frequency of collateral findings in the presence of adenoids and tonsils. I described a condition which was termed the respimtory obstruction syndrome.
Clinically, some of the following characteristics were usually observed: a patient would display cross-bite; tonsils or adenoids would be present, or a history of problems would be reported (Fig. 5) ; an open-bite would be exhibited; the tongue would be thrust on swallowing; the patient would be a mouth breather; in unilateral conditions, a. so-called functional cross-bite would be present, as laminagraphs would show the condyle to be normal or slightly backward on one side whereas the other condyle would be forward; clinically, in the attempt to close in a straight upward position, the mandible would be deflected by the deciduous canines to either one side or the other (Fig. 5, B and C). (Some patients were observed to chew on one side at one time and reveal a cross-bite to the opposite side at a later examination.) If the maxilla were constricted bilaterally, the mandible would be deflected to one side in a “functional cross-bite. If the constriction were more severe, the patient would reveal a bilateral cross-bite with no mandibular deflection to the side, but sometimes it was deflected forward, producing a pseudo-Class I condition (Fig. 6, ~$61, aml C) . The histories and examinations of these patients began to reveal a marked frequency of some kind of respiratory obstruction. With the help of several physicians in my area who were kind enough to collaborate, I followed these patients following surgical removal of adenoids or tonsils. No orthodontic treatment was employed for several months. Three paGents of this group showed spontaneous correction of their cross-bite with no orthodontic treatment. This study was reported in 1958 at the cleft palate meeting in San Francisco and was published in abstract in the Cleft Palate Joun~aL2 A side investigation in conjunct,ion with that study proved quite interesting. It was shown that the tongue could elevate in the oral cavity several millimeters, but it was further shown that when such activity was demonstrated it was also usually accompanied by a downward rotation of the heud OWLthe cervical asis. It was almost as if originally the head was extended or tipped backward in an
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t’tv)ir~lli(a mouth t 111’ hc;trl. including the masilla, now WU.Shrvu!qhf t!orc*~ OZYt’ the t~,,rq,c(. 13~ this physic)logic phenotncnon, the upper arch \VilS h1*ought d0w1i over t Ilv iotrpii~~ ;~ncl t hv upper denture hccamc splayed nioi*(’ outw;lrtl.yi Peterson, 1 in 193’1, iITIt1 .~C\VJlIUH,” it1 l!):?ri, sinthl (w~asions oi’ bhkinlcls who still consumed primitive diets. Both inv&igators showed ;I frcyuc~cy of higll cuspids and constricted arches in the anterior portion of thcl tlcntitl WWIIW Any environmental role was largely discv~utnted and the inl’ercnce rr~mained that genetics was the greatest factor. It is known, houcvrr, that gcncticall,v vcrtain races possess narrow mouths with tight lips. If, in the prrscncc of tight lips. small tongues arc also presrnt, marked dental retraction and cronding arca ptvduc~tl. When, in addition, a delicate skeletal structure is combined with tight lips, severe crowding can bc prclsent. throughout thcb arch. HOWVW, t,hc Eskimo occlusions seemed limited to anterior crowding. TO say that all conditions oi’ this t?-l)tl are acyuirccl through ht~rrdity aloncx does not quite explain genetic crowding. If 20 pears of orthodontic experience means anything, 1 can say with no resrrcation whatsoever that open-bite tongue problems constitute the most. annoying situation that I hare csperirnced on a clinical lcvcl in preort~hodontic, ortl~ndontir, postorthodontic, and nonorthodontic patients (Fig. 6, (T). It is also 1~1).suspicion t,hat many tongnc problems are in some way basically related to rcspiratoty problems, cithcr at prcscnt or in Ihr~ past history of pcvsons with the ~~rohlems. Findings concerning the Eskimo’s anterior crowded dentition only c~omplicat~~the c~xplanation. Konrad Lorcnz’; has shown that muscle characteristics and buhavioral patterns can be inherited and transmitted gc~nctically. +lust as the c~olor of our cycs, our skin, and our hair is inherited and thv pattern of our handnriting is pccnliar to each of us, it is likely also that tongur tnovcmcnts, peculiarities of lip tonicit? and activity, and pattrrns of speech and chewing also RIV, to a degree, inherited. However, who is to say when the gcnctir fowcs will hr overcome by environmental circumstances when the aggregate of all cnrironmrnt is calculated? Nutrition. states of health and disease. climate, ps)-chologic~ favtoty stress phtYIOJTltlrla 01 all kinds, endocrine patt,et-ns and hotly chemistry, and, finally, the physical fwctors of function arc all constitntcnts oi’ thr rn\+rorimcnt and cannot hr disrvgarded. Certainly, genetics of heredity is the primary c4ioiogic factor, but, this is only the basic frame and starting place. Environment is superimposed on these look at the nasal cayit>in the light of a conbasic patterns. Let us, thcreforv, cept of all factors t,hat van lend to an obstruction of’ thr normal rrspiratory airwav. . These can be discussed in two main groups : ( 1) general skAeta1 cha~wtwistics as a structural frame and (2) soft-tissue and local conditions. The first skeletal condition is a naturally small nose, sometimes rallcd nasal IIOSC
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Fig. 7. Patient R. 5. A, The lateral view shows beautiful congruous dimensions and “normal” airway, but clinically the patient was a mouth breather. B, Frontal view shows a narrowed maxilla with extremely narrow nasal cavity. The septum is very thin or the nasal airway would be more restricted. Both frontal and lateral nasal dimensions must be considered in evaluation of speech and breathing. Note the narrowness of the upper intercanine dimensions and more normal lower canine positions.
atresia or natural impatency (Fig. 7). The choanal opening and piriform aperture are too small to permit enough air flow. It has been shown that vertical maxillary asymmetries may follow abnormal growth of the mandible. As observed in isolated patients, therefore, mandibular growth can be a factor in the nasal airway space. For instance, the lack of posterior ramus height has suggested lack of development of maxillary height on a unilateral basis. A condition leading to nasal air hindrance is dysplasia of the cranial base, such as cranial dysostosis. In this disease a growth failure occurs in the sphenoethmoidal and the spheno-occipital area. The entire skull becomes dysplastic. High and forward displacement of the cervical vertebrae results from lack of descent of the occipital condyles.
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Fig. 8. Patient V. O., the antithesis of Patient R. S. -4, Tracing shows abundant adenoid and tonsil but deep nasopharynx. Also, the hard palate tips upward anteriorly. The patient had a severe thumb-sucking habit for many yearn. The angle of the palatal plane to Frankfort horizontal is minus 13 degrees. R, Frontal view shows what might he classified a microrhinodysplasia (Bimler). The maxillary, nasal cavity, and intercanint > dimensions \wre much more favorable than in Patient R. 8. The lower canines were forward and close to the midline, which yields a poor prognosis. Horizontal lines on frontal tracings are drawn through zygomatic frontal sutures at lateral border of orbit. Vrrtical lines are erected from orbital zygomatic frontal suture points to a crest on t,lw nlandible at the inftxrior border at the area of the anteriormost insertion of the mass&w muscle point {Mm.) This forms a parameter for c>omparison of maxillary widths.
Another factor is extreme deflection of the cranial base angles, whatever the cause (Figs. 3 and 4), The base of the skull may be normal in size but the acuity of the angle from basion to sella to nasion may cause the maxilla to be retropositioned as bhe anterior cranial base is tilted downward relative to the clivus. Other basal factors may cause the clivus to bc inclined rcrtically and the occipital condyles positioned forward, thus rrcluving the climcnsions of the nasopharynx (Figs. 3 and 4). These cranial factors combine perhaps into what BinlIe? has called a “microrhino-dysplasia” (Fig. 8). FI WC the anterior portion of the palatal plane is
Volunbe Number
54 7
Fig. 9. Lateral film of adult female with thirty-two teeth present. Note large nasopharyngeal space; position of the tongue in the oral cavity; and level of hyoid bone at about the junrtion of the third and fourth cervical vertebrae and also on a level slightly brlow the chin.
elevated to standard cranial planes as if it has fa.iled to descend. This is almost an atavistic tendency, as the nostrils face outward instead of downward. In these conditions, it is as if the entire piriform aperture and the nasal and maxillary bones have failed to develop properly. The amount of inhibition of the normal airway, if any, is unknown, but the lip is also characteristically short and the teeth are protruded, and these abnormalities contribute somewhat to mouth breathing. The foregoing conditions are skeletal problems observable in lateral and frontal head films. Other conditions are mostly local or environmental in naturc. First, there is the possibility of trophic influences on growth of the nose or maxilla as a component of skeletal form. The subject of vascular effects on growth of the face has hardly been touched by research workers. However, strictly local factors include conditions within the immediate nasal cavity, the nasopharynx, or the oral pharynx instead of the outer bony configuration. Because it is so easily recognized, the primary local factor is lymphoid tissue size and location in a particular nasopharyngeal frame (Figs, 1, 2, 5, and 6). When the adenoid is in a particularly upward and forward location, especially when t.he inferior t,urbinates are long, obstruction seems to be imminent and most pronounced. There are other local factors, however. Chronic rhinitis, recurrent upper respiratory infections, allergies, asthmas, polyps, foreign bodies, deviated septa, unreduced fractures, and ambitious surgical treatment of cleft palate conditions can produce varieties of obstruction to the natural flow of air through the nasal cavity. It should not be forgotten that., in some patients, there is also a lingual tonsil (Fig. 6). Although this is not located in the nasopharynx, it can be a factor in
posturing Of tll? IOllgllC~ IHV*allSck 0C its lOc~:ltloti iIll(l its c.Cttliig:.lic)llsl’f’liltionsliil) to stlvctlll’c~s irl tllcl tlll*o;rl. \Y(s IlnYcl itl(Wific~tt lill#iiill torlsils 111 iwo ill’ thrcrx patients with unrcsl~onding 1o11~11c~-th1*~1sl. I am iol~l t 11i11 sr~tywi~s 110 no1 desire to l’cnlov(’ lingual tonsils l)W;111s(~this is a hlootl!~ illl(l vt’I’>. sc~riolls i?-I),’ Of procedure. HOWWI’, Jcsbcrg” ’dntl ollirrs lia~c~dexcribc~tl good l(~(*htliqu~5. The tonsils and adenoids-the subjoc~i of this l)an(‘l discussioIr---;I IX t hrrc+ot*c~ only one consideration, albeit an importrlnt, enc. I would like now to refer to a public~ation by MCJY~I*K. %Iarks!’ of’ the I)()partment of Pediatrics at the I-ni\-c>rsity of Nami School of Medic~ino. In tht~ Jouwml of A Ueryy of Nay, 1965. 11~ma k(ls a strong point when he statt’s : ill~llOl’lllill
Sensitization of nasal mucow mcwhranc~s from early f’wtlirq of (‘OK’S milk gives riw to persistent edema. Cow’s milk in the neonatal period may be the -priming, sensitizing f&or which propels the allergic infant toward progwssively swerc allergic manifestations, one of A !?C /‘fJidly t?dC?nfitou~Y TLma~ WLd ~i~7r’lLn&Slk~ mucoUS which may be dentofxcial deformity . . membrantx cause ~‘~~~uozc.sstasis iu tkc mtrzillniy tlrdnl wch clrrti swwuntlin,q s/ructw~a from pressure on LY&S. In atldition, thcx action of hirtaminc: c~~user market1 dilatation of thl‘ capillary bed in the affected nasal, palatal, and alveolar areas. . . . Primitive peoples were said to be comparatively free from allergic diseases. Balyeat and Rowen remarked on the paucity of allcrgi~ manifestations and ~tt~ntofaoial abnormalitic~s in Oklahoma Indians. Rineock statc,d that IIC hart never seen (‘hippewa Indians with hay fever, asthma, or ~CZNUL He attributed thaw findings to Indian babies heing breast-fed for fully nine months or longcar without supplrnwntal foods or \r:ttclr. When early feeding of cow’s milk and adult foods was intro~luc%l, CCZNI~:L and othclr allergic manifestations appeared. . . . Ballard found a corwlation twtwwn lips-apart poi-turc, n~aloeclusion, and the incidence of asthma and rccurrcnt uppw wspiratory tract infwtions. c Italic added.)
Marks ends his articlr with the following Although mouth breathing is chronic nasal allergy already may No&h breathing in the infant and proved otherwise. Early diagnosis forestall at least one major factor formity. (Italics added.)
remarks :
usually self-corrected before adolescence, the patient witlt have malocclusion of the teeth, wit,h orofacial deformities. child should be regarded as an dergio maxnn’festa,tion until and early efficient modern allergy management can often contribut,ing to the progressive effects of dentofacial tl~-
In a recent private conversation with the speech pathologist in our office, it, was agreed that practically everyone with a stubborn tongue-thrust habit exhibits breathing problems of some form. This conclusion prevails in spite of the excellent work of EastmanlO on “allergics” who (lid not support the hypothesis of the environmental factor in malocclusion. At this point, I would like to summarize our present. thinking. The normal patient should breathe through the nasal cavity. The mouth should be closed with little or no strain. At rest, the posterior part of the tongue is usually in contact with the soft palate and the center of the tongue is located no lower than about halfway between the crown of the upper molars and the vault of the palate, preferably almost in contact (Fig. 7). .I!nder normal circumstances, the teeth should remain closed during deglutition as the mandible is fixed or braced via the teeth for active swallowing. The tongue tip contacts a broad surface from the lingual aspect of the lower incisors to the cingulum of the upper incisors and up
t,he ruga,e of the palate. A wave of contact travels the length of the palate as the bolus is squeezed into the pharynx in the act of normal swallowing. The hyoid bone moves upward and forward on a smooth arc to a level of the lower border of the mandible, from whence it returns in a smooth arc. The normal face and the dentofacial complex usually are reasonably symmetrical, and the range of variat,ion from slight concavity to moderate convexity is well within normal range. The palatal plane is usually very near the Frankfort horizontal plane in angulation and, if anything, is tilted slightly downward in front. It should he recognizctl that facial forms vary extensively and berome the frame of reference for orthopedic orthodontics. CONCLUSION
Genetics is a basic consideration for all morphology. It is possible, however, that long-term environmental conditions may be erroneously passed off as genetic t,endencies or as simply a part of the “pattern.” Several factors, both deep and peripheral, enter into respiratory problems. Environmental influences on the respiratory and deglutition systems or the food and air tracts must be considered concurrently as a part of orthodontic diagnosis. Clinical trophic influences on growth of the maxilla, which are basic to nasal cavity form and airway space, have not been investigated in a sophisticated manner. Finally, very little is known of the reasons for cranial base configurations which constitute the basic framework of the nasopharynx and postural relations which, through the cervical vertebrae, influence the oral pharynx. It would be regrettable if this thesis were taken as a brief for promiscuous extraction of tonsils or adenoids. On the other hand, the functional balance and stability of orthodontic results have seemcld to he enhanced by removal of respiratory obstructions and the attainment of normal nasal breathing and correct patterns of deglutition. REFERENCES
The Cranial Base and Soft Structures in Cleft Palate Speech aud 1. Ricketts, R. M.: Breathing, Plast. & Reconstruct. Surg. 14: 47, 1954. 2. Ricketts, R. M.: Respiratory Obstructions and Their Relation to Tongue Posture, Cleft Palate Bull. 8: 3, 1958. 3. Ricketts, R. M.: The Functional Diagnosis of Malocclusion, Tr. European Orthodont. Sot. pp. l-21, 1958. 4. Peterson, P. 0.: Investigations Into Dental Conditions of Ancient and Modern Grtew landers, D. Record 4: 191-198, 1938. 5. Newman, G. V.: The Eskimo’s Dento-Facial Complex-Effects of Environmental and Genetic Factors, U. S. Armed Forces M. J. 3: 1653-1662, 1952. 6. Lorenz, Konrad Z. : The Evolution of Behaviour, Scientific American July-December, 1958. 7. Bimler, Hans P.: La Microrrino-Displasia, Rev. Esp. Estomat. 14: July-August, 1966. 8. Jesberg, Norman: Chronic, Hypertrophic, Lingual Tonsillitis. Arch. Otolaryng. 9. Marks, Meyer B.: Allergy in Relation to Orofaeial Dental Deformities in Children; a Review, J. Allergy 36: 293.302, 1965. 10. Eastman, George A. : Oropharyngeal Muscular Inter-Relationships in Chronic Nasorespiratory Allergy-A Cephalometric Study, Thesis, Rackham School of Graduate Studies, University of Michigan, June, 1963.