EFFECT OF DISEASES 9F TONSILS AND ADENOIDS

ON DENTOFACIAL MORPHOLOGY

J. DANIEL SUBTELNY, D.D.S.

ROCHESTER, NEW YORK

For many years past, it has been be- information has and can be gained from
lieved that the nasorespiratory area plays a radiographic registration representa-
an important role in dentofacial develop- tive of the midsagittal plane. On the
ment and in the developing facial con- lateral radiograph, adenoid tissue lo-
figuration. One has only to peruse the cated in the nasopharyngeal area may be
literature to find frequent reference to visualized as a somewhat convex promi-
the so-called "adenoid-type" face. In es- nence facing the superior or nasal sur-
sence, it is descriptive of a particular face of the soft palate. Its attachment
facial expression, supposedly typifying to the roof of the nasopharynx may ex-
individuals with a super abundance of tend anteriorly as far forward as the pos-
adenoid tissue and a resulting mouth- terior nasal choanae, from which the an-
breathing habit. In individuals with a terior border of the adenoid tissue may
mouthbreathing habit; of course, the be observed to extend downward, ap-
mouth characteristically stays open, the proaching the soft palate to varying de-
upper lip may appear short, the lower grees. The inferior border of the adenoid
lip may be somewhat everted in posture tissue is then observed to extend posteri-
and if the face manifests a certain degree orly to join and blend into the posterior
of narrowness the individual is supposed- pharyngeal wall, at the approximate
ly afflicted with an adenoid type face. level of the anterior tubercle of the atlas.
Since adenoid tissue and/or excessive hy- It has been observed that the adenoid
pertrophy of this tissue may affect facial tissue may occupy varying amounts of
conformity, much interest has been en- the nasopharyngeal cavity. In some in-
gendered in ~athering information per- stances the inferior border of this tissue
taining to adenoid tissue and its sur- may be far removed from the nasal sur-
rounding nasopharyngeal spaces and in face of the soft palate. In other instances,
investigating its influence on facial de- it may be in close approximation with
velopment. the nasal surface of the soft palate.
To this end, many orthodontists have In studying the growth of adenoid
utilized oriented cephalometric x-rays to tissue, serial cephalometric x-rays taken
investigate the location, configuration, on the same individual indicate that the
and growth of the adenoid tissue and to nasopharyngeal lymphatic tissue follows
evaluate its influence on the postural re- a specific growth cycle. From all indica-
lationships of structures closely associ- tions, adenoid tissue seems to have a
ated with the nasal-oral-pharyngeal com- specific growth potential of its own upon
plex. Soft tissue structures as well as which may be superimposed the hyper-
hard tissue structures are readily visible trophic reactions of nasorespiratory in-
on a cephalometric radiograph. It is en- fections and allergies. During the early
tirely possible to examine the oronaso- years of life, as evidenced by the radio-
pharyngeal areas radiographically and graphic registrations, the increase in the
to appraise the soft tissues inside as well mass of adenoid tissue seemed quite
as outside of the oral-nasal cavities. Un- rapid and, by approximately three years
fortunatelv, adenoid tissue cannot be of age, was seen to occupy a sizable por-
radiographically visualized as a three- tion of the nasopharyngeal cavity. In
dimensional object but certainly much some individuals, it was observed that
50
 DENTOFACIAL MORPHOLOGY 51

as much as one-half of the nasopharyn- tissues and skeletal tissues of the cranio-
geal cavity was occupied by lymphatic facial complex to understand the signifi-
tissue. Subsequent radiographs indicated cance of this observation relative to
that the adenoid tissue continues to facial configuration.
grow, predominantly in a downward and
forward direction, but at a somewhat In most instances, growth of the ade-
retarded rate until its peak of growth noid tissue and growth of the nasophar-
or greatest bulk is attained. In the sam- yngeal area seems to strike a fine state
ple studied, the peak mass was observed of equilibrium. During the early years,
to occur somewhere between 10 to ap- the adenoid tissue may be growing rap-
proximately 14 to 15 yearsof age. After idly but the upper face is concomitantly
the peak of adenoid growth was attained, growing at a rapid pace permitting the
the growth process seemed to reverse it- maintenance of an adequate airway
self. The adenoid tissue was observed space in the sense that the distance be-
to progressively decrease in mass and tween the nasal surface of the resting
regress away from the nasal aspect of soft palate and the inferior surface of ad-
the soft palate, towards the bony roof enoid tissue is sufficiently open for naso-
of the nasopharynx. By adulthood, the respiratory needs. In most instances, this
adenoid tissue had atrophied and the state of equilibrium persists until the
greatest dimension to the nasopharyn- peak of adenoid growth is reached. Sub-
geal airway space was established. sequently, of course, the airway space
may become larger as the adenoid com-
It is of upmost importance to recog- mences to atrophy. At times, there may
nize that this tissue is growing within a be a disturbance in this delicate balance
constantly changing environment. Not and this equilibrium in differential
only is the nasopharyngeal cavity contin- growth may be disrupted as the adenoid
uously growing and changing in con- tissue can be observed to increase in
figuration, but the whole craniofacial mass at a faster rate than the increase in
complex itself is concomitantly growing the dimensions of the nasopharyngeal
and changing in configuration. It is the cavity. Whether this is a result of exces-
differential timing of growth as well as sive adenoid growth or a reaction to
the differential amounts of growth of infectious or allergic agents resulting in
all of the involved structures that may excessive hvpertrophv of the lymphatic
actually affect dentofacial development. tissue is difficult to determine. However,
In considering the influence of differ- in any case an approximation or a near
ential growth on facial configuration, one approximation of the adenoid tissue with
concept must be kept in mind. Different the nasal surface of the soft palate will
parts of the human body grow at differ- create a blockage of the nasopharyngeal
ent rates and at different times. During cavity causing difficulty in nasal breath-
overall body growth, one can readily ing and the development of a mouth-
substantiate the concept of dispropor- breathing habit. Oral respiration neces-
tional growth. At the time of birth, the sitates numerous changes in the postural
head measures approximately one-quar- relationships of the structures involved.
ter of total body length. With progres- The lips, in repose, part, and the tongue
sion of time into maturity, the head may moves downward and forward away
proportionately measure approximately from the soft palate with an accompany-
one-eighth of total body length. This ing deoression in the posture of the
does not mean the head has not been mandible. Quite recently, this relation-
growing; it simply means that the head shin of parts has been shown to have an
has been growing disproportionately rel- influence on the configuration of the de-
ative to other parts of the human body. veloping face, in a study conducted by
This is also true within the craniofacial Sten Linder-Aronson. In his Ph.D. study,
complex; different parts of the human Linder-Aronson used cephalometric ra-
head grow at different rates and at dif- diography to evaluate 81 children who
ferent times. One has only to understand were selected for an adenoidectomy by
the progressive development of the soft an otolaryngologist. He compared these
52 ]. DANIEL SUBTELNY
individuals with a comparable control
group of children of the same age and
sex who seemed to have no nasal-respir-
atory problems. In the group scheduled
for adenoidectomies, 26% of the children
were judged to have what has been
called an adenoid face, whereas this
was true in only 4% of the control sub-
jects. In evaluating the facial morphology
of the youngsters scheduled for ade-
noidectomy, he found them to have a
Ionzer and narrower face than the con-
trol group. The height of the face below
the level of the anterior nasal spine
seemed to be greater, there was a great-
er steepness to the lower border of the
mandibular jaw which might indicate
a more open gonial angle in the experi-
mental group, there seemed to be a
greater tendency for a retrusion of the
maxillary and mandibular jaws as well
as a smaller sagittal depth to the naso-
pharynx. In comparing the occlusion of
the youngsters scheduled for an ade-
noidectomy with those in the control
group, he found a narrower upper arch,
a tendency towards an anterior open bite
and a retroinclination of the upper and
lower incisor teeth in the experimental
group. On the cephalometric radio-
graphs, taken at rest, he found a lower
tongue position in the so-called "ade-
noid" subjects which might be coinci-
dental with the mouthbreathing habit.
Thus, it seems that excessive adenoid tis-
sue which may require a mouthbreath-
ing habit may cause an alteration in the
developing dentofacial form.
Interestingly enough, these same cases
were evaluated over a five-year postop-
erative period in order to ascertain
chanzes incident to the removal of the
mouthbreathing habit and a reinitiation
of nasal respiration. Upon evaluation of
the progressive cephalometric radio-
graphs some interesting features were re-
ported. There was an increase in the
sagittal depth of the bony nasopharynx
and, with growth, changes in the facial
skeleton and in the dentition seem to
occur in the direction of the control
group so that these subjects more closely
resembled that group after a period of
time. With continued growth and the
change to nasal respiration there seemed
to be a proportional decrease in the low-
er facial height with a concomitant re-
duction in the angulation or steepness of
the lower border of the mandible rela-
tive to the palatal plane or the roof of
the mouth. Linder-Aronson calls this a
"normalization" in skeletal relationships.
When the dentition was evaluated, he
noted an increase in the width of the
upper dental arch in the region of the
molars and an increase in the proclina-
tion of the upper and lower incisor teeth.
Tongue position was raised with the
elimination of the mouthbreathing habit
and, of course, lips could approximate
each other. Nasal respiration seemed to
be more conducive to good facial dental
development with increment in age.
Objective and subjective determina-
tions can be made from lateral cephalo-
metric roentgenograms, so that the pres-
ence and amount of adenoid tissue can
be substantiated and quantified, as well
as evaluated in its positional relationship
to contiguous structures. Linder-Aronson
su~gests that under certain conditions
adenoids be removed to enhance nasal
respiration and permit proper dento-
facial development. It should be em-
phasized that not all children with ade-
noid tissue will develop a mouthbreath-
in~ habit causing improper facial de-
velopment. The nasopharyngeal air pas-
sage must be obstructed to the extent
that nasal respiration is substituted by
oral respiration. It is equally true that
most children who are mouthbreathers
because of enlarged adenoids will prob-
ably outgrow the habit. With continued
growth and development, the adenoid
tissue will atrophy, but this transforma-
tion may occur too late to prevent any
of the developing dentofacial problems.
Unfortunately, a good proportion of
craniofacial growth and development
will have occurred by the time the ade-
noid tissue commences to atrophy. It
must also be remembered that adenoid
growth reaches a peak mass long before
facial growth is complete. The adenoid
tissue may reach its peak mass prior to
the timing of the prepubertal growth
spurt in many individuals.
During early stages of craniofacial de-
 DENTOFACIAL MORPHOLOGY
velopment, other lymphatic tissue in the
naso-oral-pharyngeal respiratory tract
may be present and may have an influ-
ence on dentofacial development. Even
if adenoid tissue is not creating a naso-
respiratory blockage, tonsillar tissue lo-
cated between the faucial pillars could
be a problem. Grossly enlarged tonsil-
lar tissue can create an obstruction in the
oropharyngeal area posterior to the root
of the tongue. Unfavorable tongue pos-
tures have been noted in some subjects
with grossly enlarged tonsils. If the ob-
struction is severe enough, the tongue
may be forced to posture considerably
forward to its normal position because
of the physiologic need to maintain an
adequate oropharyngeal space for res-
piration and for the passage of food.
Clinically, the tongue may be observed
to rest between the anterior teeth inci-
dent to the forward posturing of the
tongue. In such instances, forward tongue
posturing must be considered in relation
to the stage of facial growth and devel-
opment. At birth, and for a significant
number of years subsequent to birth, the
tongue is disproportionately large rela-
tive to the oral cavity, in that it occupies
a disproportionately large part of the
oropharyngeal cavities. At early ages,
because of its relative size, the tongue
may posture in a protruded position rel-
ative to the dentoalveolar complex. This
postural relationship will usually change
as a function of time. In most instances,
changes will usually occur in the rela-
tive disproportion because of continued
maxillary and mandibular growth and a
comparative reduction in the amount of
tongue growth. Eventually, and usually,
jaw growth will be adequate to contain
the tongue within the confines of the
upper and lower jaw structures. To a
degree, this can explain the spontaneous
closure of open bite malocclusions inci-
dent to time and growth, as is sometimes
observed at later age levels. However,
during prepubertal age levels, the man-
dible may still not have grown sufficient-
ly to encompass the tongue mass. In the
late deciduous dentition and the early
transitional dentition period, it is not
unusual to observe youngsters suffering
with enlarged tonsils. In essence, this
adds insult to injury. The large tonsillar
53
masses may cause a still comparatively
large tongue to be postured excessively
forward, keeping the root of the tongue
and the tonsillar tissue away from the
posterior pharyngeal wall to maintain an
open port posteriorly for respiratory pur-
poses. The tonsils, in conjunction to some
comparative largeness to the tongue, may
necessitate an anterior tongue posture,
some depression of the mandibular jaw,
and may be instrumental in causing an
open bite deformation. Furthermore, the
mandibular jaw is still growing and
during the early and rapid growth
phases it would seem that the mandible
may be subject to some deformation.
With anterior tongue posturing and with
some degree of openness of the mandi-
bular jaw relative to the roof of the
mouth, it is conceivable that increment
in the steepness of the lower border of
the mandibular jaw may occur with
continued growth and development. This,
in conjunction with potential eruption of
posterior teeth, may lead to increased
facial dimension between the level of
the palate and the lower aspect of the
chin. That is, increased lower facial
height, much as was seen in the adenoid
cases studied by Sten Linder-Aronson.
In essence, at times, the removal of the
enlarged tonsillar tissue may be desir-
able. This concept may be illustrated by
longitudinal cephalometric roentgeno-
grams obtained on patients with anterior
open bite malocclusion and excessive
oro-pharyngeal lymphatic tissue. In
many instances after surgical removal of
enlarged tonsillar masses, a change in
tongue posture and occlusion can be ob-
served. A retropositioning of the tongue,
more posteriorly into the oral cavity, can
be observed and further eruption of an-
terior teeth can be noted. At times, an
anterior open bite may self-correct inci-
dent to the judicious removal of tonsil-
lar tissue and with continued growth
and development of the jaws.
Once again, it is stressed that these
oropharyngeal and nasopharyngeal ob-
structions may occur before and during
the prepubertal growth spurt stage of
development. During these ages, the
skeletal jaws are continuously growing.
At present, an interesting concept has
54 }. DANIEL SUBTELNY
been put forward relative to the mecha-
nism of growth of the craniofacial struc-
tures, generally called the "functional
matrix theory: In essence, it is hypo-
thesized that craniofacial growth is close-
ly associated with the functional activi-
ties carried out by different components
of the head and neck area and the soft
tissues involved in these functions. Res-
piration is one such functional element,
while mastication and deglutition would
be examples of other functional elements
carried out in the head and neck area.
Considering this doctrine of functional
matrices, if there are obstructions in the
nasorespiratory and ororespiratory area,
some influence may be exerted on the
direction of growth of the skeletal struc-
tures of the face incident to the need for
continued reposturing of soft tissue and
skeletal structures. We should be cog-
nizant of this potential influence on facial
configuration since it may be possible
to prevent maldevelopment and to en-
hance acceptable facial development. It
is strongly suggested that time be spent
on a careful radiographic evaluation of
the size and configuration of the nasal-
oral-pharyngeal cavity spaces and the
soft tissue relationships within these cav-
ities. These observations should be inter-
preted in conjunction with clinical ex-
aminations. Treatment procedures could
be undertaken to facilitate more accept-
able postural relationships of the soft
tissues within these cavities, which may
enhance facial development.