Obstructive sleep apnea /certified fixed orthodontic courses by Indian dental academy

www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
Leader in continuing dental education

Contents
• Introduction
• Anatomic aspects
• Patho-Physiologic aspect
• Clinical features
• Morbidity of Obstructive Sleep Apnea
• Diagnostic procedures
• Upper Airway Imaging techniques
• Management
– Nasal continuous positive airway pressure
– Oral Appliances
– Surgical management
• Conclusion
• References www.indiandentalacademy.com

Introduction
• Over the past two decades, medicine and
dentistry have focused on breathing
disorders during sleep
• These are commonly considered to be
snoring, upper airway resistance
syndrome and obstructive sleep apnea.

Snoring
• Snoring, the commonest of sleep
disorders is found in 25% of adult males
• Snoring is the result of base of tongue
compromising the upper airway when the
patient falls asleep
• The patient increases the speed of airflow
in an attempt to maintain required
oxygen, which causes vibration of soft
tissues - Snoring

• Snoring by itself is not
considered a serious
problem, because its mainly a
problem that creates irritation
and loss of sleep in their bed
partners
• However, because almost all
patients with Obstructive Sleep
Apnea snore, it must be
considered a potential indicator
of significant medical problemswww.indiandentalacademy.com

Definition of Obstructive Sleep
Apnea
• Broadbent (1877), described Obstructive
Sleep Apnea as ― there will be perfect
silence through two, three, or four
respiratory periods, in which there are
ineffectual chest movements; finally air
enters with a loud snort, after which there
are several compensatory deep
inspirations‖

• Obstructive Sleep Apnea is potentially life
threatening condition in which periodic
cessation of breathing occurs during sleep
in the presence of inspiratory effort
• Obstructive Sleep Apnea affects not only
the quality of life but also has significant
morbidity
• The reduction in blood oxygen saturation
may give rise to hypertension, cardiac
arrhythmias, nocturnal angina and
myocardial ischemia

Anatomic aspects of
Obstructive Sleep Apnea

• Upper airway can be viewed in four areas
(1) Nasopharynx –
– Mainly involves the nose, begins with nares
and ends at superior portion of hard palate
– Structures of major concern – Nasal
Turbinates and Nasal Septum
– Inferior turbinates, the largest of the three, is
commonest to enlarge causing blockade of
nasal passage
– Deviated nasal septum may affect nasal
respiration www.indiandentalacademy.com

Nasal Turbinates and Deviated
Nasal Septum

• (2) Velopharynx
– It extends from hard palate to the inferior tip of
soft palate
– It includes uvula and upper part of posterior
wall of pharynx
– The muscles of major concern are the Tensor
Palatini and Levator Palatini

• (3) Oropharynx
– It comprised of oral cavity, beginning with
back portion of mouth till base of the tongue
– Major components – Tongue and Tonsils
– Enlargement of these structures causes
airway obstruction
– Within this area there are number of muscles
that control posture of tongue and
mandible, and these muscles also serves to
maintain airway

(4) Hypopharynx
• It extends from epiglottis to the lower
portion of airway at larynx
• Large number of muscles affect this
portion can have varying effect depending
on concurrent activity of related muscles

Muscular relationships and
functions
• Palatoglossus and
Palatopharyngeus
– Located in anterior and
posterior tonsillar pillar
– As the mandible is
advanced, these muscles are
spread apart, causing tension
on palatoglossus.
– This is transferred to soft
tissue, thus reducing vibration
– Hence snoring may be reduced
or eliminated by mandibular
advancement

• Muscles of the neck
–These support the cervical spine
–Alteration in the cervical spine can
modify the airway, primarily through the
effect on hyoid bone, which in turn can
affect mandibular position
–Therefore, its important that during the
clinical examination, posture of
individual and its potential impact on
airway be considered

Other muscles that might influence
airway
• Levator Palatini and Tensor Palatini
• Muscles of the Tongue
• Suprahyoids and Infrahyoids
• Constrictor muscles of pharynx
• Stylopharyngeus and
Salphingopharyngeus – during speech
and swallowing

Patho-Physiologic aspect of

• Although Sleep Apnea might be
central, obstructive and mixed pattern in
origin, the Obstructive type is the most
common form
• It is characterized by cessation of airflow
because of upper airway obstruction
despite simultaneous respiratory effort
• The respiratory effort continues despite
obstruction until the individual is aroused
from sleep

Normal alterations during sleep
• Normal physiologic alterations that are
associated with sleep may predispose
individual to Obstructive Sleep Apnea
• During sleep
– The upper airway is more collapsible than
during wakefulness,
– Ventilation and inspiratory flow decreases,
– Upper airway resistance increases and
– Arterial carbon dioxide tension increases

Hypotonicity of muscles of upper
airway
• Hypotonicity of muscles of upper airway is
the primary factor predisposing normal
upper airway to increased collapsibility in
sleep
• Upper airway inspiratory muscles and
thoracic muscles work in apposition
• Upper airway inspiratory muscles exerting
a dilatory effect, while thoracic muscles
produce sub atmospheric intra-airway
pressure which has collapsing effect on
upper airway www.indiandentalacademy.com

Constriction of upper airway
• Frequently, sleep apnea patients have
constricted upper airways that increase
pharyngeal resistance during inspiration
• This necessitates an increase in
pharyngeal dilator muscle contraction to
maintain patency
• Such increase has been shown in
Obstructive Sleep Apnea patients during
wakefulness, but it decreases during
sleep, thus contributing to development of
Obstructive Sleep Apneawww.indiandentalacademy.com

Predisposing factors
• Obesity – airway is compromised because of
more fat deposits in soft palate, tongue and
surrounding pharynx
• Alcohol ingestion – decrease in hypoglossal
nerve output while phrenic nerve output is
spared
• REM sleep – muscles of airway are most
hypotonic in this stage of sleep
• Pharyngeal length was found to be longer in
apnea patients in supine position compared with
upright positionwww.indiandentalacademy.com

Anatomic alterations reducing airway –
Ivanhoe - J Prosth Dent 1999
• Posteriorly positioned maxilla and
mandible
• Steep occlusal plane
• Overerupted anterior teeth
• Large gonial angle
• Anterior openbite associated with large
tongue
• Posteriorly placed pharyngeal walls

• Retrognathic mandibles
• Large tongue and soft palate
• Large anteroposterior discrepancies
between maxilla and mandible
• Micrognathia
• Acromegaly
• Downs’ syndrome

Hereditary variables
• Adenoid and tonsillar hypertrophy
• Glottic webs
• Vocal cord paralysis
• Lymphoma or Hodgkin’s disease
• Ectopic thyroid
• Systemic disease involving mandible like
Rheumatoid arthritis
• Severe Kypho-Scoliosis
• Cushing syndrome

Clinical features of

Clinical features
1.Excessive sleepiness
2.Morning headaches
3.Gastro-esophageal
reflux disease
4.Impaired concentration
5.Depression
6.Decreased libido
7.Irritability
1.Snoring
2.Drooling
3.Xerostomia
4.Diaphoresis
5.Choking or
gasping
Nocturnal symptoms Daytime symptoms

Mishra P and Valiathan A –
J Nep Med Assoc - 1995
Sleep onset
Apnea
Oxygen
, pH, carbon
dioxide
Arousal from sleep
Resumption of Airflow
Return to Sleep
Negative oro-pharyngeal pressure
Reduced upper airway muscle activity
Small pharyngeal cavity
High pharyngeal compliance
High upstream resistance
Baseline arterial Oxygen concentration
Degree of diffuse airway
Obstruction
Lung volume
Chemoreceptor sensitivity
CNS abnormality www.indiandentalacademy.com

Orofacial characteristics in
• Retrognathic mandible
• Narrow palate
• Large neck circumference
• Long soft palate
• Tonsillar hypertrophy
• Nasal septal deviation
• Relative macroglossia

Obstructive Sleep Apnea in
children
• Snoring is the characteristics of Obstructive
Sleep Apnea in children
• Nonetheless many children may not have
snoring as a major complaint even in
presence of severe upper airway obstruction
• Other associated clinical features are
– Difficulty in breathing during sleep
– Restless sleep
– Morning headaches
– Enuresis
– Sleep terrorswww.indiandentalacademy.com

• Day time abnormalities includes
sleepiness, attention span problems, poor
social performance
• Other symptoms which may be seen are
– Upper airway infections
– Sinusitis
– Otitis media
– Failure to thrive
– In severe cases pulmonary hypertension or
cor pulmonale can develop

Epidemiology
• Estimates of prevalence of Obstructive
Sleep Apnea vary widely. Largely because
of different cutoff point for diagnosis
• Battagel BJO 1996 stated that figures for
middle-aged adults range from 1.3 to 24%
• Almost all studies report higher incidence
in males than in females, and agree that
the condition is greater in obese
• The prevalence is normally described as
increasing with age

Morbidity of Obstructive Sleep
Apnea
• Morbidity of Obstructive Sleep Apnea relates
principally to cardiovascular system
• Rigorous epidemiological studies have shown
that Sleep Apnea is a risk factor for development
of Arterial Hypertension, independent of
associated obesity, alcohol intake, sex, and age
• Now studies have found increasing evidence to
demonstrate that Obstructive Sleep Apnea is an
independent risk factor for Stroke

• Lavie 2003 investigated repeated apnea related
events to atherogenesis through initiation of
oxidative stress, hypothesizing a molecular
biological association between hypoxia-
reoxygenation episodes of Obstructive Sleep
Apnea and cardiovascular disease
• Among other consequences of Sleep
Apnea, excessive daytime sleepiness, cognitive
impairment, impaired ability to drive motor
vehicle and increased automobile accident have
been documented

• Many studies have agreed that patients with
Obstructive Sleep Apnea have reduced quality
of life
• Jennum 2002 showed clear association between
headache and sleep disturbances, however the
cause and effect of this relationship is not clear
• Patients with headache also report more
daytime symptoms like fatigue, tiredness or
sleepiness
• Identifying sleep disorders in chronic headache
patients is worthwhile, as improvement of
headache may follow treatment of sleep
disorders in this group

Diagnostic procedures in

• The diagnosis of Obstructive Sleep Apnea
is best done by a pulmonologist or other
physician specialized in sleep breathing
problems.
• Confirmation requires sleep testing with
polysomnography, which consists of
continuous measurement of arterial
oxygen saturation

I. Clinical Examination
• Taking a good history requires an above-
average knowledge of the discipline
involved
• Recording the chief complaints is a major
portion of the history taking that ultimately
will assist in making the diagnosis
• It is important to know about any previous
treatment. The patient may have had
surgery previously and failed to attain the
expected result.

Physical condition of the patient
• Neck size
– A neck size greater than 40cm
(16inches), regardless of
gender, has s sensitivity of 61%
and a specificity of 93% for
having obstructive sleep apnea
syndrome
– According to some authors, a
neck size of 17 inches or greater
for men and 15.5 inches or
greater for women, indicate an
increased risk for sleep apnea

Body Mass Index (BMI)
• Patient’s body mass index (BMI) directly
affects the predilection for sleep apnea.
• The BMI is computed by dividing the
person’s weight in kilograms (kg) by their
height in meters squared (m2).
• In men, obesity is defined as a BMI of
27.8; for women, obesity is a BMI of 27.3.
• An individual with a BMI of at least 25
kg/m2 has been found to have a sensitivity
of 93% and specificity of 74% for having
Obstructive Sleep Apnea .www.indiandentalacademy.com

• Blood pressure must also be recorded
• It is both informative and good practice to
record blood pressure at the initial visit
and at subsequent visits as a means of
determining potential outcomes associated
with treatment.
• Another helpful tool for screening is the
Epworth Sleepiness Scale

Epworth Sleepiness Scale

II. Airway Evaluation
• The evaluation of the airway begins at the
tongue and proceeds into the oral
pharynx.
• The condition of the tongue, its size, and
related anatomic changes should be
observed and noted, in a relaxed state.
• The Mallampati Score has been used in
anesthesia for many years as a means of
determining the difficulty of performing an
intubation as the tongue increasingly
seems to obstruct the airwaywww.indiandentalacademy.com

• It has been found that
this score is also a
predictor for
determining severity
of sleep apnea in
some people.
• Friedman et al (1999)
stated that patients
with a Mallampati
Score of III or IV are
at a greater risk for
sleep apnea than
those with a score of I
or II. www.indiandentalacademy.com

• Tonsillar size has a
direct relation to the
severity of sleep apnea.
• It is well recognized that
increased tonsillar size
reduces the airway size
and can contribute to
sleep-related breathing
disorders.
• Tonsil size is graded on
a universally recognized
standard

• The size of the uvula and observations of
the soft palate should also be recorded.
• In snoring, mouth-breathing, or
Obstructive Sleep Apnea patients, these
structures are subjected to trauma
repeatedly throughout the night, causing a
change in their appearance and size.
• Nasal examination - the Nasal turbinates
should be evaluated to determine if those
structures are contributing to nasal airway
obstruction and encouraging oral
breathing.

III. Temporomandibular Joint
Assessment
• Preexisting TMJ findings should be
noted, especially if mandibular advancement with
an oral appliance is being planned.
• If an appliance is used, one with posterior support
that functions as a splint may address both issues
at the same time.
• Additionally, patients who are using nasal CPAP
may experience jaw and subsequent TMJ
problems if the mask is held too tightly or chin
straps are required to hold the mouth closed to
prevent leakage around the mask or mouth
breathing.

• IV. Headache Status
–Headache is a common finding among
patients with sleep-disordered breathing
and in some instances headache may be
the symptom for which the patient seeks
medical attention.
–If headache is present, it is appropriate to
determine if the status of the headache
improves in conjunction with the
management of the sleep disorder.

• V. Muscle Assessment
–It is important to evaluate and determine
tenderness of the muscles of the head
and neck region
–Many patients with sleep-related
breathing disorders may be fatiguing the
muscles of the head and neck region
and have coexisting jaw, face, or neck
pain. These muscles may be
responsible for pain referral that is
expressed as headache

VI. Polysomnography
• First proposed by Holland et al 1974
• A Polysomnography is a physiologic study,
usually attended by a trained technologist,
performed for at least 6 hours during a patient’s
normal sleep hours.
• The study records sleep staging and other
physiologic variables.
• Sleep staging includes electroencephalography
(EEG), electro-oculography (EOG), and
electromyography (EMG).

• Other physiologic parameters and variables that
may be measured include ECG
monitoring, airflow, respiratory effort, gas
exchange, gastroesophageal reflux, continual
blood pressure monitoring, snoring, and body
position.
• Video monitoring is recorded for each patient to
distinguish better among potential abnormal
sleep behaviors including nightmares, nocturnal
seizures, or rapid-eye-movement (REM) sleep
behavioral disorderwww.indiandentalacademy.com

• During analysis of the Polysomnography, each
episode of apnea and hypopnea is identified and
counted.
• Consensus guidelines for research do not
distinguish between apneas and
hypopneas, defining them as events lasting at
least 10 seconds, during which there is either a
―>50% decrease from baseline in the amplitude
of a valid measure of breathing during sleep,‖ or
a ―clear (but not 50%) amplitude reduction of a
validated measure of breathing during
sleep, associated with either an oxygen
desaturation of 3% or an arousal.‖

• The Apnea-Hypopnea Index, also known as the
Respiratory Disturbance Index (RDI) is the
number of apneas and hypopneas per hour of
sleep.
• It is used to assess the severity of obstructive
sleep apnea.
• The usual definition of slight Obstructive Sleep
Apnea is an Respiratory Disturbance Index of 5-
14, moderate Obstructive Sleep Apnea is an
Respiratory Disturbance Index of 15 to 30, and
severe Obstructive Sleep Apnea is an
Respiratory Disturbance Index greater than 30.
• The apnea-hyponea index has been shown to
be a reproducible measure within a patient as
well as predictor of associated cardiovascular
disease.

• It is now accepted that a diagnosis of clinically
significant Obstructive Sleep Apnea should be
accompanied by compatible signs and
symptoms and not based on an arbitrary
Respiratory Disturbance Index threshold.
• According to Kryger (2002) the syndrome
should be defined when an index of abnormal
obstructed breathing events, or arousals caused
by them, exceeds a threshold in a patient with
clinical features or symptoms related to the
abnormal respiratory pattern during sleep

• The Polysomnography summary report
usually describes the overall Respiratory
Disturbance Index , the Respiratory
Disturbance Index while supine, the
Respiratory Disturbance Index while in
REM sleep, and the lowest oxygen
desaturation. Sleep architecture is
displayed as a graph through the
night, termed a hypnogram.

VII. Split Night Studies
• To establish optimal therapeutic pressure,
Continuous Positive Airway Pressure (CPAP)
usually is initiated during polysomnography in
the sleep center.
• The pressure is titrated upward in small
increments until apneic episodes are controlled
or eliminated
• A more reliable titration to effective pressure
often requires an entire night of testing and may,
for some patients, require a second
Polysomnography study dedicated to
Continuous Positive Airway Pressure titration.

• In some cases it is possible to condense this
process into one split-night Polysomnography
• During a split-night study the technologist
performs a standard diagnostic
Polysomnography without Continuous Positive
Airway Pressure for about 2 hours.
• Continuous positive airway pressure is then
initiated and titrated by the technologist to
eliminate snoring and sleep apnea.
• A split-night study is especially useful after the
physician has thoroughly discussed sleep apnea
treatment options with the patient, and when the
patient has a good idea of the
nature, inconvenience, and treatment value of
Continuous Positive Airway Pressure .www.indiandentalacademy.com

Limitations of Split Night Studies:
• A split night protocol requires that the
technologist make the initial diagnosis based on
a partial night recording.
• Another limitation of split-night studies is that
apneic episodes often are more frequent or
more severe during REM sleep, and REM sleep
usually occurs in the latter half of the night;
therefore a 2-hour initial baseline
Polysomnography may significantly
underestimate the baseline severity of apnea.
• Further, the effects of body position on
breathing may be missed during a time-
abbreviated diagnostic study.

VIII. Portable studies
• Portable sleep studies are helpful for patients
who cannot easily come to the sleep center and
for certain limited studies such as follow-up
studies after surgery for sleep apnea
• An attended portable study is usually more
costly to perform than a laboratory study
because a technologist usually attends only one
patient during a portable study but usually
attends two patients in the laboratory

IX. Pulse Oximetry
• Arterial oxygen saturation can be monitored
continuously by pulse oximetry in the emergency
room, during surgery, and during
Polysomnography.
• Pulse oximetry is relatively simple and reliable
• Despite limitations, oximetry may be a useful
diagnostic tool over a wide range in Obstructive
Sleep Apnea severity.
• Oximetry may be useful to evaluate response to
treatment after surgery or airway dilator
placement in patients with known Obstructive
Sleep Apnea .

• A full-night polysomnography remains the
standard of reliability and accuracy for
diagnosing Sleep Disordered Breathing,
• Split-night testing with Continuous positive
airway pressure titration or cardio-respiratory
sleep studies may be most useful in patients
who have a high pretest probability of
Obstructive Sleep Apnea , and clinical prediction
formulas may help sleep specialists identify
those patients.
• Oximetry is a viable alternative in some clinical
situations because of its ease of use, its
reliability, and its portability.

Upper Airway Imaging

I. Acoustic reflection - Philipson
1992
• Acoustic reflection is a noninvasive imaging
technique based on analyzing sound waves
reflected from upper airway structures.
• The phase and amplitude of the reflected sound
waves can be transformed into an area-distance
relationship by calculation of upper airway area
as a function of distance from the incisors in the
mouth.
• The technique is generally performed through
the mouth, is free of radiation, and because it is
both fast (images can be obtained at 0.2 second
intervals) and reproducible, permits dynamic
imaging of the upper airway.

• Unfortunately, acoustic reflection does not
provide information on airway structure or
geometry
• Moreover, measurements are usually performed
in the sitting position with an oral mouthpiece.
• Mouthpieces present difficulties for the
examination of upper airway anatomy because
opening the mouth alters upper airway geometry
• Accordingly, acoustic reflection may not be
comparable with other modalities in which the
mouth is closed during imaging.
• Acoustic reflection thus far has been used
primarily as a research tool.

II. Fluoroscopy
• Fluoroscopy has also been used to study upper
airway closure in patients with sleep apnea.
• Fluoroscopic studies during sleep have
demonstrated that upper airway closure occurs
in the retropalatal region for most patients with
sleep apnea.
• Although fluoroscopy can provide a dynamic
evaluation of the upper airway during
wakefulness and sleep, radiation exposure
makes this study impractical for routine use.

III. Nasopharyngoscopy
• Nasopharyngoscopy is commonly used to
evaluate the nasal passages, oropharynx, and
vocal cords.
• Although it is invasive, nasopharyngoscopy is
easily performed and does not involve radiation
exposure.
• Moreover, it permits direct observation of the
dynamic appearance of the pharynx.
• However, it examines only the lumen of the
upper airway and does not provide
measurement of the surrounding soft tissue
structures.

• The utility of nasopharyngoscopy in evaluating
the upper airway seems to be increased if a
Muller’s maneuver is performed during the
examination.
• The Muller’s maneuver is a voluntary inspiration
against a closed mouth and obstructed nares.
• It is thought to simulate the upper airway
collapse that occurs during an apnea.
• Although the degree of obstruction on negative
inspiration with a Muller’s maneuver is not a
direct correlate of the site of upper airway
collapse during sleep, Muller’s maneuver has
been shown to add important information on
possible sites of obstruction.

III. Cephalometry
• This technique is widely available, easily
performed, and much less expensive than either
CT scanning or MR imaging
• Cephalometrics have also been used to
evaluate skeletal structures before facial surgery
(mandibular advancement, bimaxillary
advancement, sliding genioplasty) and to
evaluate the efficacy of oral appliances
• Cephalometry is considered useful for
evaluating and quantifying craniofacial
(mandibular and hyoid position) and soft tissue
structures (tongue and soft palate) in patients
with retrognathia or micrognathiawww.indiandentalacademy.com

• Nonetheless, the low cost and widespread
availability of Cephalometrics make it
useful for sleep apnea patients being
treated with oral appliances and
undergoing craniofacial surgery.

IV. Computed Tomography
• Computed tomographic scanning is widely
available and is ideal for imaging the lumen of
the upper airway because it accurately
measures the cross-sectional area.
• Computed tomography also provides excellent
resolution for upper airway soft tissue and
craniofacial structures.
• Three-dimensional volumetric reconstructions of
upper airway, soft tissue, and bony structures
can be obtained
• Dynamic imaging of the upper airway can be
performed with electron beam CT

• Compared with MR images, however, CT
scanning has limited soft tissue contrast
resolution, particularly for upper airway adipose
tissue.
• In addition, CT scanning is relatively expensive
and exposes the patient to radiation.
• The radiation exposure particularly limits state-
dependent imaging and studies that require
repeat scanning.
• Despite these limitations, studies using CT
scanning have led to important insights into the
pathogenesis of airway closure in patients with
obstructive sleep apnea.

V. Magnetic Resonance Imaging
• MR imaging is perhaps the most useful imaging
technique for studying obstructive sleep apnea
because it:
– Provides excellent resolution of upper airway and soft
tissue (including adipose tissue),
– Accurately measures cross-sectional airway area and
volume,
– Allows imaging in the axial, sagittal, and coronal
planes
– Provides data suitable for three-dimensional
reconstructions of upper airway soft tissue and
craniofacial structures
– Can be performed during wakefulness and sleep, and
does not expose subjects to radiation.

• MR imaging, however, is expensive and is not
available in all hospitals.
• Further, MR studies cannot be performed on
patients with ferromagnetic implants or
pacemakers, patients who weigh more than 300
pounds, or patients who are claustrophobic (a
relative contraindication).
• Moreover, Suto et al, (1993) reported that
achieving sleep in the MR scanner is difficult
because of the associated noise.

Clinical utility of upper airway
imaging
• Upper airway imaging is not indicated in routine
diagnostic evaluation of most patients with obstructive
sleep apnea
• Imaging of the airway is also not indicated in patients
with sleep apnea treated successfully with Continuous
positive airway pressure .
• MR imaging and nasopharyngoscopy are the imaging
modalities of choice in patients undergoing a
Uvulopalatopharyngoplasty.
• Cephalometrics should be considered in patients being
treated with mandibular repositioning devices.
• In patients undergoing maxillomandibular advancement
surgery or sliding genioplasty, CT scanning with three
dimensional reconstructions and cephalometrics may be
indicated. www.indiandentalacademy.com

Management of

• The treatment of Obstructive sleep apnea
depends on several factors such as the severity
of the symptoms, site of airway obstruction, and
co-operation of the patient.
• There are several modalities ranging from
simple lifestyle measures such as weight loss
and avoidance of alcohol, to more substantial
measures such as continuous positive airway
pressure, or oral appliances, and in more severe
cases, even surgical intervention.

NASAL CONTINUOUS POSITIVE
AIRWAY PRESSURE
• Nasal continuous positive airway pressure (N-
CPAP) is a highly effective and safe treatment
for obstructive sleep apnea and is generally
considered to be the current primary treatment
of obstructive sleep apnea
• Sullivan et al (1981) first reported the use of
nasal continuous airway pressure for obstructive
sleep apnea in adults. Their device consisted of
intranasal tubes attached to a blower unit.
• Sanders et al (1983) introduced the nasal mask
delivery system, which made continuous positive
airway pressure more user-friendly.

• Fundamentally, the application of a therapeutic
level of continuous positive airway pressure
results in immediate relief in the upper airway
obstruction.
• This benefit has been attributed to the
continuous positive airway pressure functioning
as a pneumatic splint for the upper airway.
• Additional physiologic benefits of continuous
positive airway pressure application to include
improvement in the function of pharyngeal
dilator muscles, ventilator drive, and upper
airway morphology

Nasal continuous positive airway
pressure Apparatus
• It consists of an inspiratory limb, which uses
compressed air from a standard hospital wall
source regulated by a flow meter.
• To prevent mucosal drying, a humidifier
containing a one-way valve is used which ends
in the nasal mask.
• The expiratory flow limb begins at the mask and
ends with a threshold water column positive end
expiratory pressure (PEEP).
• The level of Nasal continuous positive airway
pressure could then be adjusted by manipulating
the amount of flow and the level of water in the
PEEP column.

Nasal continuous positive airway
pressure Apparatus

Benefits of Nasal continuous
positive airway pressure therapy
• Patient’s perceived quality of life increases
• Interestingly, the spouses of obstructive sleep apnea
patients also gained from this therapy
• Reduced sleepiness and the improved ability to steer a
motor vehicle and hence frequency of driving accidents
were reduced
• Health-related quality of life of obstructive sleep apnea
patients improves with long-term continuous positive
airway pressure treatment
• Randomized placebo-controlled studies demonstrated a
reduction in blood pressure levels with continuous
positive airway pressure therapy.
• Reduces long-term morbidity and mortality from
cardiovascular causeswww.indiandentalacademy.com

Disadvantages of Nasal continuous
positive airway pressure therapy
• While current effective management of moderate
to severe sleep apnea is still largely dependent
on nasal continuous positive airway pressure
, the process is still cumbersome
• Approximately 10-50% of subjects find the
continuous positive airway pressure (CPAP)
intolerably uncomfortable and discontinue its
use with in a short period of time.

• Inspiration is facilitated and expiration is
impeded, a new balance between
inspiratory muscle effort and lung elastic
recoil is established.
• This results in the following:
– Reduced cardiac output and renal function.
– Increased pressure in the sinus, which might
decrease drainage and cause problems in
patients with preexisting abnormalities.
– Drying of the airway mucosa is another
complication, which can be overcome by the
inclusion of a humidifier in the circuit.

• Mechanical failure of continuous positive airway
pressure – occlusion of the exhaust line could
theoretically cause hyper-inflation of the lungs
and perhaps even lung rupture. This does not
happen if a low pressure pump is used.
• Since the pressure is applied through the nose,
the mouth will act as a blow-off valve and result
in reduction of the pressure. When this happens,
the patient will go back to his usual state of
upper airway obstruction. This is prevented by
using face-masks covering both the nose and
the mouth.

Auto Nasal continuous positive
airway pressure
• The device continuously adjusts the applied air-
pressure to an optimum level throughout the
night and appears to improve compliance.
• Upper airway resistance is influenced by many
dynamic factors that may change, such as body
position, sleep stages, sleep deprivation, body
weight and fluctuations of nasal congestion.
• Therefore, a single pressure level, as with
standard continuous positive airway pressure
could result in insufficient air pressure at certain
times, particularly after alcohol consumption.

• Auto continuous positive airway pressure
is expected to become more popular in the
future as it facilitates the initiation and
follow up of the treatment, especially the
process of optimal initial pressure
titration, and the elimination of repeated
titrations over prolonged years of therapy.

ORAL APPLIANCES IN
THERAPY OF OBSTRUCTIVE
SLEEP APNEA

• Although Nasal continuous positive airway
pressure is a logical first step, some patients
cannot tolerate Nasal continuous positive airway
pressure, creating a demand for alternative non-
surgical treatment modalities.
• Dental devices were being promoted as an
alternative conservative, noninvasive modality
for management of some patients with mild
Obstructive Sleep Apnea symptoms and those
subjects who have a history of disruptive snoring

Classification of Oral Appliances
• Dental appliances in the treatment of
Obstructive Sleep Apnea can be divided into
three categories:
1. One type of appliance is designed to reposition the
tongue in a more forward position (Tongue retaining
device).
2. A second type of devices positions the mandible
forward. The rationale for this movement is that the
tongue is attached to the genial tubercles of the
mandible and positioning the mandible forward
moves the tongue forward. These mandibular
repositioning appliances also change hyoid bone
position and modify the lower airway space below the
level of the base of the tongue.

3. The third type of intra oral device is
designed to lift the soft palate or
reposition the uvula (equalizer). The
rationale for the use of palate lifting
devices is to reduce the vibration of the
soft palate that causes the snoring
sound.

Tongue retaining devices
• The Tongue retaining devices is a custom-made
appliance designed to allow the tongue to
remain in a forward position between the
anterior teeth by holding the tongue in an
anterior bulb with negative pressure during
sleep.
• Tongue protrusion increases the
oropharyngeal, velopharyngeal and
hypopharyngeal cross-sectional areas of the
upper airway, thereby improving airway patency
and function and reducing the airflow resistance

• The advantages of tongue retaining
devices over mandibular advancement
devices are as follows:
– They can be used on edentulous
patients, whereas the latter need ample
dentition for retention purposes.
– They do not loosen restorations.
– They require minimal or no adjustments.
– They cause minimal sensitivity in teeth or in
the TMJ.

• The effectiveness of Tongue retaining devices in
Sleep apnea subjects may be partially related to
the forward tongue posture that compensates for
the altered Genioglossus muscle activity.
• Tongue-retaining devices appear to be effective
in over 75% percentage of the mild to moderate
cases of obstructive sleep apnea.
• Compared to the most commonly performed
non-surgical treatment (continuous positive
airway pressure ), the Tongue-retaining devices
is more easily tolerated and has fewer long-term
compliance problems.

Mandibular Advancement
Devices

• In 1934, Pierre Robin first described the concept
of advancing the mandible with a monobloc
functional appliance to treat airway obstruction
in infants with micrognathia.
• His method was not accepted and it was not
until 1985 that Meier-Ewert next described an
intra-oral protraction device for the treatment of
sleep apnea.
• In general, MAD’s consist of form-fitting trays
that fit over the maxillary and mandibular teeth

• They may be fixed-position with no allowance for
adjustability for advancement or retrusion of the
mandible, or may be adjustable
• Adjustable oral appliances are generally
preferred because they can be adjusted in an
antero-posterior position until an acceptable
level of symptom improvement has
occurred, while teeth or temporomandibular joint
sensitivity is controlled.
• Some oral appliances may be made from a pre-
fabricated standard set, similar to alginate
impression trays and can be fabricated chair
side in the clinical setting.
• Others must be custom fabricated on a set of
casts by a laboratory

Designs of Mandibular Advancement
Devices
• Removable Activator type
Mandibular Advancement
Device
– Every posterior tooth has full
occlusal coverage with acrylic.
– All anterior teeth were capped
on the incisal, lingual, and labial
surfaces by acrylic.
– Openings were cut through the
acrylic between the maxillary
and mandibular arches to allow
respiration if the subject
developed nasal congestion

• Anterior Mandibular
Positioner
– The oral appliance
consisted of a titanium
hinge with 5
adjustment holes that
connected full-
coverage upper and
lower, hard acrylic
splints.

• The Karwetzky activator :
Rose et al (EJOS 2002)
– Passive tooth-and tissue
borne device
– It is a bimaxillary, tooth- and
tissue-borne activator with a
loose fit.
– The activator is divided along
the occlusal plane.
– Two U-loops are fixed in the
lingual acrylic in the area of
the first molars, allowing
sagittal adjustment of the
mandibular protrusion.
– This design permits lateral
and vertical jaw movements
during sleep www.indiandentalacademy.com

• Intra oral sleep apnea
device (ISAD)
– It consists of two thin
thermoplastic
splints, worn on the
upper and lower
jaws, connected by
two adjustable
telescopic guide rods.
– It works by advancing
and slightly depressing
the mandible and
tongue while imparting
a slight vertical
clockwise rotation.

Adjustable Herbts appliance

• Magnetic appliances for treatment of OSA
– Inherent magnetic forces directly transfer
active forces to the jaws and thereby
constrain the lower jaw in a forward position.
– During sleep, when the masticatory muscles
are physiologically relaxed, there is an
obvious risk that the mandibular complex
moves backward and closes the airflow in the
upper airway space.
– In such situations, a magnetic appliance may
be more effective than the conventional
passive functional appliance, because the
magnet forces prevent the closing by
providing direct and continuous mandibular
advancement.www.indiandentalacademy.com

• The following advantages of the magnetic
appliance were enumerated:
– The inherent magnetic forces constrain the lower
jaw directly in an advanced position even during
sleep when the masticatory muscles are relaxed.
– It is less bulky than the conventional monoblock
type and allows freedom of function
and, consequently, patient compliance is
improved.
– If there is a need to change the advanced
position of the mandible, this can easily be done
by changing the positions of the magnets in the
splints. www.indiandentalacademy.com

• One shortcoming of the rare earth
magnets, particularly the neodymium-iron-
boron alloy, is that the alloy is very
susceptible to corrosion assault by the
saliva.
– When a magnet corrodes, there is
considerable risk of destroyed magnetic
properties and loss of force.
Furthermore, there is a risk of liberation of
cytotoxic components

• The Modified Monobloc: Cozza ( JCO
2004)
– The device was fabricated from clear acrylic
resin, with full tooth coverage in both arches
and a central screw.
– The incisal edges and superior labial
surfaces of the mandibular incisors were
capped to prevent tipping.
– The construction bite positioned the
mandible anteriorly into an edge-to edge
incisal relationship, with a vertical bite
opening of 2-3 mm.
– A Tucat’s Pearl sliding on a wire in the
anterior lingual portion of the appliance was
added as reference point for anterior
positioning of the tongue.www.indiandentalacademy.com

• Chrome-cobalt mandibular advancement
devices: Ash and Smith ( JO 2004)
– They emphasized the physical weakness of
conventional mandibular advancement devices, which
normally are made of acrylic, or may have a stainless
steel shaft and piston fixed linkage mechanism,
– These parts are subject to considerable forces and
may undergo fracture.
– The chrome cobalt advancement devices are
fabricated according to the principles of prosthetic
dentistry, with surveying of stone models for
construction of the chrome cobalt framework.
– Clasps are incorporated for additional retention in
both the upper and lower appliances.

• The advantages of the
appliance were its
superior
strength, reduced
bulk, kindness to soft
tissues, and enhanced
retention and stability.
• The possible
disadvantages include
financial cost, additional
clinical and laboratory
stages, and the need for
a new appliance if the
patient experiences tooth
loss.

• The Glasgow approach
– Simple one-piece mandibular advancement device
using a semi-soft material.
– The advantage of this appliance was that it placed no
restriction on the dental status of the patients
accepted for treatment.
– Softened impression compound placed between the
anterior teeth is used to obtain the protrusive jaw
position, following which, aluminium impregnated wax
is pressed around the buccal surfaces of the teeth
and the impression compound.
– The appliances are made with polyvinyl acetate
polyethylene, 4mm thick and trimmed to shape.
– They are then placed on the articulator and joined
together.

• Advantages
– simplicity and low cost of
this appliance compared
with other treatment
options.
• Disadvantages
– longevity has been
questioned and would
require a replacement
after 12-18 months
– Other side effects like
hypersalivation

Hans et al AJO
1997
• Device designed to increase
vertical dimension and protrude
the mandible (device A).
• Device designed to minimally
increase vertical opening without
protruding the mandible (device
B).
• Device A reduced RDI scores in 9
of 10 subjects
• Device B showed no change or an
increased RDI score in 8 of 8
subjects.
• Subjects who showed no
improvement with device B were
then fitted with device A.
• Four of those seven subjects
showed a reduction in RDIwww.indiandentalacademy.com

Randomized controlled trials comparing
Oral Appliances with CPAP
• Ferguson et al (1996)
– They compared one-piece, hard
acrylic, nonadjustable oral appliance, Snore Guard to
continuous positive airway pressure in patients with
mild to moderate obstructive sleep apnea.
– It was found that the treatment of 48.5 % of
SnoreGuard and 62% of continuous positive airway
pressure patients was considered successful.
– While patients preferred the SnoreGuard treatment to
the continuous positive airway pressure therapy, the
former was not as effective as was the continuous
positive airway pressure treatment in relieving
symptoms of excessive daytime sleepiness.www.indiandentalacademy.com

• Randerath et al (2002)
– Compared the effectiveness of an individually
adjustable intra oral sleep apnea device (ISAD) with
that of continuous positive airway pressure .
– The intra oral sleep apnea device reduced snoring in
the long term, but significantly improved the RDI only
in the early phase of treatment.
– In contrast, continuous positive airway pressure
normalized RDI, snoring and arousals throughout the
entire treatment period.

• They concluded that in patients with mild to
moderate obstructive sleep apnea, continuous
positive airway pressure is superior to treatment
with mandibular advancement device.
• However, as one third of patients respond
sufficiently to treatment with the intra oral sleep
apnea device , in patients who refuse
continuous positive airway pressure , the use of
mandibular advancement devices should be
considered.

• Ferguson et al (2006)
– Conducted an evidence-based review of literature
regarding the use of oral appliances in the treatment
of snoring and obstructive sleep apnea syndrome
from 1995
– In comparison to continuous positive airway
pressure, oral appliances are less efficacious in
reducing the apnea hypopnea index (AHI), but oral
appliances appear to be used more (at least by self
report), and in many studies were preferred over
continuous positive airway pressure when the
treatments were compared.

Randomized controlled trials comparing
different designs of oral appliances
• Lawton, Battagel and Kotecha (EJO 2005)
– They analyzed the efficacy of the Twin Block in relation
to the Herbst appliance as a mandibular advancement
splint (MAS).
– The results suggested that there was no difference in
the treatment performance of the Twin Block and Herbst
for AHI , snoring frequency, arterial blood oxygen
saturation, quality of life and side-effects.
– The Herbst proved to be the more effective appliance
for reducing daytime sleepiness and was the more
popular appliance among the patients.
– The Twin Block appliance is bulkier than the Herbst and
it may be that the additional reduction in airway volume
was enough to negate the positional benefits of the
appliance

• Bloch et al (2000)
– Studied the effectiveness and side effects of
an adjustable Herbst appliance with those of a
fixed single-piece mandibular advancement
device (Monobloc) with equal advancement.
– This project was one of the first to compare
the effectiveness of mandibular advancement
devices with different designs.
– Patient preference and trends of
polysomnographic data showed the Monobloc
to have greater patient acceptability and to be
more effective than the Herbst appliance in
the treatment of obstructive sleep apnea .

Clinical aspects of insertion and
titration of oral appliances
• General technique for oral appliances that are
selected from a prefabricated set
– The oral appliance that incorporates thermoplastic
material is initially heated in warm or hot water
– Once the thermoplastic material is softened, the oral
appliance is inserted, and any excess thermoplastic
material is adapted to the buccal and lingual surfaces
of the teeth using the fingers.
– The oral appliance should be removed and reinserted
several times as the material chills to prevent it from
becoming locked into undercut areas.

• Titration of oral appliances
– It consists of slowly moving the mandible
either anteriorly or posteriorly using the
adjustable mechanism until successful results
are achieved with the minimum possible
protrusive position.
– The titration of oral appliances may be
tedious, requiring several weeks to months.
– Once completed, titration may become
necessary again at some future time if sleep
disorder symptoms recur or tooth or
temporomandibular joint sensitivity appear.

• The following titration process is for a device
with a screw-type mechanism:
– The patient generally begins with the mandible
advanced to 70-75% of his or her maximum
protrusive position relative to the most retrusive
position.
– The oral appliance is inserted and not titrated for
several days until the patient has become
accustomed to wearing the appliance.
– If, as frequently happens, successful results are
achieved, titration is not necessary.
– If the symptoms have not been reduced
acceptably, the mandible is slowly protruded, often in
increments of 0.25 mm per night.

• After approximately 2 weeks, the patient must be
re-examined if the desired results have been
achieved.
• If the patient reports sensitive teeth, it may be
necessary to adjust the oral appliance around
the sensitive teeth.
• Teeth or Tempromandibular joint sensitivity may
also require that the mandible be slowly retruded
until the problem is addressed.
• Once the sensitivity is corrected, it may be
necessary again to protrude the mandible until
the sleep disorder symptoms are addressed.
• If the obstructive sleep apnea has worsened, the
patient is not allowed to continue with the oral
appliance therapy.

Treatment Considerations
• Clinicians should explain the possible side
effects of treatment including the possibility that
the appliance may loosen or break dental
restorations, excess salivation, xerostomia, TMJ
pain, soreness of the masseter muscle, and
tooth discomfort
• Mandibular protrusion devices should only be
used when a patient has at least 8 teeth in each
arch and is able to demonstrate a mandibular
protrusion of at least 5 mm and a bite opening of
greater than 25 mm.
• Totally edentulous patients are usually not good
candidates for mandibular repositioners, but
tongue-retaining devices may be used in
edentulous patients for snoring, and not
obstructive sleep apnea .www.indiandentalacademy.com

• Patients who are treated with a mandibular
protruding device for obstructive sleep apnea
may find that when they wear the
appliance, their occlusion feel different for a
short while after the appliance is removed
• Obstructive sleep apnea patients who present
with more severe TMJ pain are probably not
good candidates for treatment with mandibular
protrusion devices.
• Patients with significant bruxism can frequently
damage mandibular protrusion devices and thus
make this treatment approach costly and
inefficient,
• While very obese patients, with some
exceptions, are best treated by other means
than mandibular protrusion.www.indiandentalacademy.com

Amount of bite opening
• As the mouth opens, the anterior attachment of
the tongue swings not only down but also
backward carrying the tongue toward the airway.
• For this reason, L’Estrange et al (1997)
concluded that Mandibular Advancement Device
should keep jaw opening to an ―absolute
minimum
• Meurice et al (1996), concluded that pharyngeal
airway was more likely to obstruct when the
mandible opened 15 mm at the incisors
• There are no published polysomnographic
studies that establish the optimum vertical
dimension for the Mandibular Advancement
Device
• The most commonly selected bite opening is
about 2 mm between the incisorswww.indiandentalacademy.com

• Vicomi et al (1988) showed
good apnea reduction with
an Mandibular Advancement
Device that advances the
mandible 6 to 9 mm while
opening it vertically 17 mm.
• Mandibular Advancement
Device expand the airway
not only behind the tongue
but also behind the soft
palate.
• The mechanism for this
velopharyngeal expansion is
the pull on the palatoglossus
muscle

• The superior pharyngeal constrictor muscle
attaches directly and indirectly to the mandible.
• Opening the mouth, therefore, exerts a
downward force on the lateral walls of the
pharyngeal airway, stretching them
longitudinally.
• This stretching improves airway patency by
reducing folds, compliance and extrinsic
compression.
• Another advantage of increasing the jaw
opening beyond 2 mm is that it helps part the
lips allowing a passage for oral breathing.

SURGICAL MANAGEMENT OF
OSA

• Surgical management of Obstructive sleep
apnea is generally recommended when the
applicable conservative therapies are
unsuccessful or not well tolerated, as well as or
patients who have an identifiable underlying
surgically correctable abnormality that is causing
the Obstructive sleep apnea .
• Surgery can provide definitive treatment, thus
eliminating patient compliance issues, but only if
performed competently, both in terms of
technical skill and on the correct site or area of
upper airway obstruction.

Presurgical Evaluation
• The upper airway can be divided into
three main regions for evaluation
• Nose and Nasopharynx
– The nose should be evaluated for septal
deviation, turbinate hypertrophy, nasal
polyps, infectious and edematous conditions
such as rhinosinusitis, rhinitis and
neoplasms, as well as patency of internal
nasal valve.
– The nasopharynx is examined for adenoid
hypertrophy, polyps, cysts, and obstructing
masses. www.indiandentalacademy.com

• Oral Cavity and Oropharynx
– The tongue is estimated to be of normal size if
it sits at or below the level of the occlusal
plane at rest. It is subjectively described to be
mildly, moderately or severely enlarged if
above the occlusal plane
– The position of the soft palate with respect to
the tongue is noted at rest and is graded
using the modified Malampatti Score, I
through IV
– The pharyngeal tonsils are graded 1,2,3 or
4, dividing the airway into less than 25%, 25
to 50%, 50-75% or greater than 75%
respectively

• The hypopharynx and larynx
– The hypopharynx and larynx are best
evaluated from above with the flexible
endoscope.
– The base of the tongue, epiglottis, vocal
folds, arytenoids and the presence of lingual
tonsils are noted

• The current surgical procedures used for
Obstructive sleep apnea are
– Tracheostomy,
– Uvulopalatopharyngoplasty,
– Laser assisted uvulopalatoplasty,
– Surgical reduction of the tongue,
– Mandibular osteotomy with genioglossus
advancemnt,
– Hyoid myotomy and suspension, as well as
maxillomandibular advancement

I) TRACHEOSTOMY FOR THE
TREATMENT OF OSA
• Before the introduction of
uvulopalatopharyngoplasty and continuous
positive airway pressure, tracheostomy was the
only treatment available.
• At present this procedure is usually reserved for
the most severe Obstructive sleep apnea
patients
• It is 100% effective in alleviating Obstructive
sleep apnea by bypassing all upper airway
obstructive sites
• Tracheostomy has been shown by several
authors to reduce mortality in patients with sleep
apnea

Indications of tracheostomy in patients
with Obstructive sleep apnea
• Disabling sleepiness with severe familial and
socioeconomic impact.
• Severe cardiac arrhythmias associated with
respiratory events.
• A high apnea index. (> 60).
• Notable oxygen desaturation level during sleep
i.e. oxygen desaturation level below 60%.
• No improvement of clinical symptoms or
polysomnography findings after medical trials.
• Tracheostomy may also be performed to protect
the airway from obstruction due to edema while
the patient undergoes upper airway
reconstructive surgery

II) UVULOPALATOPHARYNGOPLASTY
For Obstructive sleep apnea
• In 1979, Fujita et al began to look for alternatives
for tracheostomy for the treatment of patients
with obstructive sleep apnea.
• In 1980 they introduced a new operation for the
correction of anatomic abnormalities in the
pharynx, which was referred to as a
Uvulopalatopharyngoplasty
• This is designed to decrease oropharyngeal
collapsibility by reducing the soft
palate, uvula, posterior and lateral pharyngeal
walls, and tonsils when present.
• The goals of surgery are to resect the posterior
margins of the soft palate and redundant lateral
pharyngeal wall mucosawww.indiandentalacademy.com

• The soft palate resection
ranges from 8-15
mm, stopping short of the
thick muscular part of the
palate.
• The lateral pharyngeal
wall is treated by
resecting redundant
mucosa and developing
a flap along the posterior
wall.
• The flap is advanced and
sutured to the anterior
tonsillar pillar areawww.indiandentalacademy.com

Complications of
Uvulopalatopharyngoplasty
• Early complications:
– Transient velopharyngeal incompetence.
– Wound dehiscence.
– Hemorrhage.
– Wound infection
• Late complications:
– Pharyngeal discomfort, dryness, tightness
– Postnasal secretion
– Inability to initiate swallowing
– Prolonged sore throat
– Taste disturbance
– Speech disturbance
– Permanent velopharyngeal incompetence
– Nasopharyngeal stenosis.www.indiandentalacademy.com

III. LASER ASSISTED
UVULOPALATOPLASTY (KAMAMI
TECHNIQUE)
• Kamami (1990) first described laser assisted
uvulopalatoplasty (LAUP) for the treatment of
snoring
• Laser assisted uvulupalatoplasty stiffens and
possibly enlarges the antero-posterior
retopalatal airway and is associated with an
extremely low complication rate when compared
with Uvulopalatopharyngoplasty
• The technique can be performed under local
anesthesia as a multiple out-patient procedure.
• The laser usually used is CO2 laser at 20 watts
in continuous mode.

• The key disadvantages with laser assisted
uvulopalatoplasty are however the early
drop off in the success rate and the severe
degree of post-operative pain encountered
• One of the biggest disadvantages of the
laser assisted uvulopalatoplasty procedure
from the physician’s point of view has
been the high cost of the equipment.

IV. SURGICAL PROCEDURES FOR
THE TONGUE
• Midline glossectomy
– A laser midline glossectomy is accomplished
by vaporizing a 2 cm by 5 cm rectangular
portion or the midline tongue with a laser.
– A lingual tonsillectomy, reduction of
aryepiglottic folds, and a partial
epiglottectomy can be done concomitantly if
indicated
– Complications of this procedure include
bleeding, dysphagia and altered taste

• Linguloplasty
– The linguloplasty differs from the laser midline
glossectomy in that the tongue excision is
extended more posteriorly and laterally.
– The defect is closed, by suturing the posterior
margin anteriorly, which advances the tongue
base anteriorly.
– The anterior rotation of the posterior margin
significantly improves the success rate to
around 77%

Tongue-base suspension sutures: (Coleman
and Bick, 1999)
• A non-resorbable
suspension suture is
placed in the tongue and
is then attached to a
titanium bone screw
inserted into the
geniotubercle of the
posterior aspect of the
mandible.
• The suture tension
prevents posterior
tongue displacement
and occlusion with the
posterior pharyngeal wallwww.indiandentalacademy.com

V. INFERIOR SAGITTAL OSTEOTOMY
OF THE MANDIBLE
• This method allows isolated advancement of the
genial tubercle and genioglossus muscle
• The surgical approach to the mandible is
through the submental incision.
• A rectangular osteotomy is accomplished
around the geniotubercle on the labial surface of
the anterior mandible.
• It is desirable to leave 8-10 mm of inferior border
to decrease the chance of fracture.
• The genial segment with its genioglossus
attachment is advanced, rotated and rigidly fixed
to the mandiblewww.indiandentalacademy.com

Inferior sagittal osteotomy of
mandible

VI. MAXILLOMANDIBULAR
ADVANCMENT SURGERY
• Maxillomandibular advancement or MMA
surgery, anteriorly repositions the maxillary and
mandibular framework and their attending
muscular attachments.
• It pulls forward the anterior pharyngeal tissues
attached to the maxilla, mandible and hyoid to
structurally enlarge the entire velopharynx,
• As well as to enhance the neuromuscular tone of
the pharyngeal dilator muscles via an extra-
pharyngeal operation

• Procedure:
– The maxillary surgery performed is a standard
LeFort I osteotomy which is advanced 10-14
mm and stabilized with rigid internal fixation.
– Bone grafts are required to fill in the gaps
created by the large advancement.
– The mandible is advanced 10-14 mm by a
bilateral sagittal split osteotomy and stabilized
with rigid internal fixation with bicortical
screws.
– Additional maxillomandibular skeletal fixation
can help prevent skeletal relapse.

VII. DISTRACTION OSTEOGENESIS
FOR TREATMENT OF OSAHS
• Advantages:
– It eliminates the need for bone grafting, which is
usually required when large amounts of skeletal
advancement are performed
– It involves less surgical dissection because the
lengthening is the result of natural bone healing in a
gap created by a simple osteotomy.
– The incremental skeletal movement allows
accommodation of the soft tissues, thus enabling
large skeletal movement that cannot be achieved by
conventional techniques.
– The improved soft tissue accommodation also
improves the stability of the new skeletal position.www.indiandentalacademy.com

• Disadvantages:
– Although less surgical dissection is
necessary, procedure is highly technique
sensitive. Parallelism of the distraction vectors
is extremely important to avoid malocclusion.
This can be quite difficult in simultaneous
maxillo-mandibular advancement with 4
distraction devices.
– The most significant disadvantage for
distraction osteogenesis in the treatment of
sleep apnea in adult patients is the length of
treatment time (may take up to 4 months)
– The weakness of regenerated bone and the
presence of distraction devices and arch bars
significantly affect the patient’s mastication
and speech.

Conclusion
• In rapidly industrializing country like India, with
soaring rates of obesity, it is quite likely that
prevalence of Obstructive Sleep Apnea is far
higher than detected and rising rapidly
• Although this disease traditionally thought to
affect mainly middle aged obese person of male
sex, over recent years there has been
increasing evidence of occurrence of this
disease in persons with certain craniofacial
structures and female sex
• The Orthodontist, in concert with trained medical
personnel can render valuable service in
diagnosis and treatment of OSA

• At present there are several mandibular
advancement appliances, which has been
shown to enjoy high compliance rates and
achieve excellent resolution of symptoms
• It is important however for these patients to
undergo regular medical referrals to monitor
their condition and switch to an alternative
treatment plan if required
• Thus, there can be no doubt that Orthodontist
has a vital role to play in identifying as well as
treating OSA patients
• It would thus be important for Orthodontist to
make themselves aware of the procedures and
responsibilites involved in multi-disciplinary
management of OSA

References
1. Hamada T, Ono T, Otsuka R, Honda
E, Harada K, Kurabayashi T, Ohyama K.
Mandibular distraction osteogenesis in a
skeletal Class II patient with obstructive sleep
apnea. Am J Orthod Dentofacial Orthop. 2007
Mar;131(3):415-25.
2. Otsuka R, Almeida FR, Lowe AA. The effects
of oral appliance therapy on occlusal function
in patients with obstructive sleep apnea: a
short-term prospective study. Am J Orthod
Dentofacial Orthop. 2007 Feb;131(2):176-83.
3. Shoaf SC. Sleep disorders and oral
appliances: what every orthodontist should
know. J Clin Orthod. 2006 Dec;40(12):719-22.www.indiandentalacademy.com

4. Hou HM, Sam K, Hägg U, Rabie AB, Bendeus M, Yam
LY, Ip MS. Long-term dentofacial changes in Chinese
obstructive sleep apnea patients after treatment with a
mandibular advancement device. Angle Orthod. 2006
May;76(3):432-40.
5. Otsuka R, Almeida FR, Lowe AA, Ryan F. A
comparison of responders and nonresponders to oral
appliance therapy for the treatment of obstructive
sleep apnea. Am J Orthod Dentofacial Orthop. 2006
Feb;129(2):222-9.
6. Marklund M. Predictors of long-term orthodontic side
effects from mandibular advancement devices in
patients with snoring and obstructive sleep apnea. Am
J Orthod Dentofacial Orthop. 2006 Feb;129(2):214-21.
7. Conley RS, Legan HL. Correction of severe obstructive
sleep apnea with bimaxillary transverse distraction
osteogenesis and maxillomandibular advancement.
Am J Orthod Dentofacial Orthop. 2006
Feb;129(2):283-92.

8. Almeida FR, Lowe AA, Otsuka R, Fastlicht S, Farbood
M, Tsuiki S. Long-term sequellae of oral appliance
therapy in obstructive sleep apnea patients: Part 2.
Study-model analysis. Am J Orthod Dentofacial
Orthop. 2006 Feb;129(2):205-13.
9. Almeida FR, Lowe AA, Sung JO, Tsuiki S, Otsuka R.
Long-term sequellae of oral appliance therapy in
obstructive sleep apnea patients: Part 1.
Cephalometric analysis. Am J Orthod Dentofacial
Orthop. 2006 Feb;129(2):195-204.
10. Lowe AA. Orthodontists and sleep-disordered
breathing. Am J Orthod Dentofacial Orthop. 2006
Feb;129(2):194.
11. Hans MG, Nelson S, Pracharktam N, Baek SJ, Strohl
K, Redline S. Subgrouping persons with snoring and/or
apnea by using anthropometric and cephalometric
measures. Sleep Breath. 2001 Jun;5(2):79-91.

12. Horiuchi A, Suzuki M, Ookubo M, Ikeda K, Mitani
H, Sugawara J. Measurement techniques predicting
the effectiveness of an oral appliance for obstructive
sleep apnea hypopnea syndrome. Angle Orthod. 2005
Nov;75(6):1003-11.
13. Tsuiki S, Almeida FR, Lowe AA, Su J, Fleetham JA.
The interaction between changes in upright mandibular
position and supine airway size in patients with
obstructive sleep apnea. Am J Orthod Dentofacial
Orthop. 2005 Oct;128(4):504-12.
14. Johal A, Battagel JM, Kotecha BT. Sleep
nasendoscopy: a diagnostic tool for predicting
treatment success with mandibular advancement
splints in obstructive sleep apnoea. Eur J Orthod. 2005
Dec;27(6):607-14.
15. Hans MG, Nelson S, Luks VG, Lorkovich P, Baek SJ.
Comparison of two dental devices for treatment of
obstructive sleep apnea syndrome (OSAS). Am J
Orthod Dentofacial Orthop. 1997 May;111(5):562-70.www.indiandentalacademy.com

16. Anat Gavish, Alexander D. Vardimon, Heled
Rachima, Micheal Bloom, Esther Gazit. Cephalometric
and polysomnographic analyses of functional magnetic
system therapy in patients with obstructive sleep
apnea. Am J Orthod Dentofacial Orthop. 2001
Oct;120(2):169-77
17. Peter G. Miles, Peter S. Vig, Robert J.
Weyant, Thomas D. Forrest, Howard E. Rockette, Jr.
Craniofacial structure and obstructive sleep apnea
syndrome—a qualitative analysis and meta-analysis of
the literature. Am J Orthod Dentofacial Orthop. 1996
Feb;109(2):163-72
18. Edmund C. Rose, Gabriele M. Barthlen, Richard
Staats, Irmtrud E. Jonas.Therapeutic efficacy of an oral
appliance in the treatment of obstructive sleep apnea:
A 2-year follow-up. Am J Orthod Dentofacial Orthop.
2002 March;121(3):273-79
19. Mats Bernhold, Lars Bondemark. A magnetic
appliance for treatment of snoring patients with and
without obstructive sleep apnea. Am J Orthod
Dentofacial Orthop. 1998 Feb;113(2):144-48www.indiandentalacademy.com

20. Battagel JM, L’Estrange PR. The
cephalometric morphology of patients with
Obstructive Sleep Apnea. Eur J Orthod. 1996;
18; 557-569
21. Maglioca KR, Helman JI. Obstructive Sleep
Apnea: Diagnosis, Medical Management and
Dental Implications. J Am Dent Ass 2005; 136:
1121-1129
22. Battagel JM. Obstructive Sleep Apnea: Fact
not Fiction. Br J Orthod 1996. 23: 315-324
23. Ivanhoe J.R., Cibrika R.M, Lefebre C.A. Dental
considerations in upper airway sleep disorders:
A review of literature. J Prosthet Dent 1999;
82: 685-98

24. Valiathan A, georgeT, Midha Y. A cephalometric
comparision of south Indian and north Indian ppulation
using Downs, Steiners, Tweeds and McNamara
analysis. J Int College Of Dentists 1996; 140: 8-14
25. Mishra P, Valiathan A; Obstructive Sleep Apnea
syndrome and Orthodontic Management. J Nep Med
Assoc. 1995; 33; 144-152
26. Sharma SK, Kumpawat S, Banga A, Goel A.
Prevalence and risk factors of factors of Obstructive
Sleep Apnea syndrome in population of Delhi, India.
Chest 2006; 130: 149-56
27. Kiely Jl, McNicholas WT. Cardiovascular risk factors in
patients with Obstructive sleep apnea syndrome. Eur
Resp J 2000; 16: 128-133
28. Jureyda S, Shucard D. Obstructive Sleep Apnea – An
overview of the disorder and its consequences. Semin
Orthod 2004; 10: 63-72

29. Johns MW. A new method for measuring
daytime sleepiness: The Epworth Sleepiness
Scale. Sleep 1991; 14: 540-54
30. Sanders MH, Constantino JP, Strollo PJ. The
impact of split- night polysomnography for
diagnosis and positive pressure therapy
titration on treatment acceptance and
adherence in sleep apnea. Sleep 2000; 23: 17-
24
31. Kau CH, Richmond S, Paloma JM, Hans MG.
Three Dimensional cone-beam computerized
tomography in orthodontics. J Orthod 2005;
32: 282-293
32. Battagel JM, Johal A, Smith AM, Kotecha B.
Postural variation in oropharyngeal dimensions
in subjects with sleep disordered breathing: a
cephalometric study. Eur J Orthod. 2002; 24:
263-76 www.indiandentalacademy.com

33. Hack M, Davies RJ, Mullins R. Randomized
prospective parallel trial of therapeutic verses sub-
therapeutic nasal continuous positive airway pressure
on stimulated steering performance in patients with
Obstructive Sleep Apnea. Thorax 2000; 55: 224-231
34. Engleman HM, Kingshott RN, Wraith PK. Randomized
placebo-controlled crossover trial of continuous
positive airway pressure for mild sleep
apnea/hypopnea syndrome. Am J Resp Crit Care Med
1999: 159: 461-67
35. Warunek S. Oral appliance therapy in sleep apnea
syndromes: A review. Seminars in Orthod 2004; 10:
73-89
36. Rider E. Removable Herbst appliance for treatment of
obstructive sleep apnea. J Clin Orthod 1998; 22: 256-
257

37. Ferguson KA, Ono T, Lowe AA. A randomized
crossover study of an oral appliance versus nasal
continuous positive airway pressure in treatment of
mild to moderate obstructive sleep apnea. Chest 1996;
109: 1269-1275
38. Ferguson KA, Cartwright R, Rogers R. Oral appliances
for snoring and obstructive sleep apnea: A review.
Sleep. 2006; 29: 244-62
39. Cozza P, Ballanti F, Prete L. A modified Monobloc for
treatment of young children with obstructive sleep
apnea. J Clin Orthod 2004; 38: 241-247
40. Ash SP, Smith AM. Chrome cobalt mandibular
advancement appliances for managing snoring and
obstructive sleep apnea. J Orthod 2004; 31: 295-99

41. Marklund M, Franklin KA, Persson M. Orthodontic side
effects of mandibular advancement devices during
treatment of snoring and sleep apnea. Eur J Orthod
2001; 23: 135-144
42. Isono S, Shimada A, Tanaka A, Ishikawa T, Nishino T.
Effects of Uvulopalatopharyngoplasty on collapsibility
of retropalatal airway in patients with obstructive sleep
apnea. Laryngoscope 2003; 113: 362-367
43. Kamami YV. Out patient treatment of snoring with
carbondioxide laser: laser assisted uvulopalatoplasty.
J of Otolaryngology 1990; 23: 391-394
44. Li KK, Guilleminault C, Riley RW, Powel NB.
Obstructive sleep apnea and maxillomandibular
advancement: An assessment of airway changes
using radiographic and nasopharyngoscopic
examinations. J Oral Maxillofac Surg 2002; 60: 530-
566 www.indiandentalacademy.com

45. Conley RS, Legan HL. Correction of severe obstructive
sleep apnea with bimaxillary transverse distraction
osteogenesis and maxillomandibular advancement.
Am J Orthod Dentofacial Orthop 2006; 129: 283-292
46. Yuehua Liu, Alan A. Lowe, John A. Fleetham, Young-
Chel Park. Cephalometric and physiologic predictors of
the efficacy of an adjustable oral appliance for treating
obstructive sleep apnea. Am J Orthod Dentofacial
Orthop 2001; 120: 639-647
47. Tangugsorn V, Skatvedt O, Krogstad O, Lyberg T.
Obstructive sleep apnoea: a cephalometric study. Part
I. Cervico-craniofacial skeletal morphology. Eur J
Orthod 1995;17:45-56.
48. Tangugsorn V, Skatvedt O, Krogstad O, Lyberg T.
Obstructive sleep apnoea: a cephalometric study. Part
II. Uvulo-glossopharyngeal morphology. Eur J Orthod
1995;17:57-67.

48. Vardimon AD, Stutzmann JJ, Graber TM, Voss
LR, Petrovic AG. Functional orthopedic magnetic
appliance (FOMA) II-Modus operandi. Am J Orthod
Dentofac Orthop 1989;95:371-87.
49. Darendeliler MA, Joho JP. Magnetic activator device II
(MAD II) for correction of Class II, Division 1
malocclusions. Am J Orthod Dentofac Orthop
1993;103:223-39.
50. Pracharktam N, Hans MG, Strohl KP, Redline S.
Upright and supine cephalometric evaluation of
obstructive sleep apnea syndrome and snoring
subjects. Angle Orthod. 1994;64(1):63-73.
51. Pracharktam N, Nelson S, Hans MG, Broadbent
BH, Redline S, Rosenberg C, Strohl KP.
Cephalometric assessment in obstructive sleep apnea.
Am J Orthod Dentofacial Orthop. 1996 Apr;109(4):410-
9.

Thank you
For more details please visit

Obstructive sleep apnea /certified fixed orthodontic courses by Indian dental academy

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Obstructive sleep apnea /certified fixed orthodontic courses by Indian dental academy

Similar to Obstructive sleep apnea /certified fixed orthodontic courses by Indian dental academy (20)

More from Indian dental academy

More from Indian dental academy (20)

Recently uploaded

Recently uploaded (20)

Obstructive sleep apnea /certified fixed orthodontic courses by Indian dental academy