9.
Chief complaints: right jaw locking, limited
mouth opening, jaw clicking, ear congestion,
and nocturnal teeth grinding
BMI = 27.9
Retruded mandible, Deep bite
10.
Revealed enlarged tonsils
Forward head posture
Referred to ENT for tonsillar evaluation and referred to physical therapist for
postural re-education
11. Breastfeed for at least 2 months
Make sure your child is a nasal breather
Avoid thumb sucking and pacifiers
Find an orthodontist from AAPMD.org
No extraction of permanent teeth except 3rds
Avoid retractive headgear
Get tonsils and adenoids out early
Get your child a sleep study if they have SDB,
ADHD, bedwetting, Nightterrors, colic
Early intervention ( 0-5) is a team effort
Airway Centric
13. SUBJECT: 74 year old Female
CHIEF COMPLAINTS
• Back pain
• Headaches
• Neck pain
• Sinus Congestion
• Fatigue
DIAGNOSIS
•
Anterior disc displacement
• Reduction in Right and Left TMJ
• Capsulitis of Right and Left TMJ
19. CBCT TMJ Findings
Pre-Treatment
2-2009
Mild degenerative changes to
Right and Left TMJs ossesous
structures.
Retruded Right and Left TMJs.
Progress
1-2013
Right and Left TMJ noticeably
removed from the eminence.
Increased joint space.
Right TMJ
Pre-Treatment
2009
Right TMJ
Progress
2013
20. Oral Examination
2-2009.
Retruded Mandible causing compression of
Auriculotemporal Nerve
4-2009.
Daytime Mandibular NYU Orthopedic appliance
prior to prosthetic work.
Vertical dimension reestablished; pain eliminated.
3-2011.
Transitional Snap-on-Smile.
Restoration of vertical dimension of occlusion.
23. SUBJECT: 44 Year Old Male
Chief Complaints:
Frequent heavy snoring
Linea Alba
Obstructive Sleep Apnea
Baseline
PSG
03-182008
CPAP
Titration
03-18-2008
@
8 CM H2O
pressure
Follow-up
with Oasys
03-15-2013
* Snoring below
40db
AHI
0
3.8
Stag
e N3
Epworth sleepiness scale = 7
15.6
4%
4%
18.82%
REM
22.3%
17.34%
24. Clinical Findings:
Narrow Maxilla
Vaulted Maxilla
Hypertrophic masseters
The occlusal plane cants up to the right, the right
ear and right eye are higher than the left
Bilateral pain and compression of the
auriculotemporal nerves
Previous Laup procedure
Previous Septoplasty surgery
ASSESSMENT
1.
2.
3.
Obstructive Sleep Apnea
Macroglossia
Anterior Disc Displacement
with Reduction of the Right and
Left TMJ
TREATMENT PLAN:
Contributing Factors
Enlarged tongue
Clenching
Narrow Maxilla
Severely Constricted Airway
1. Mandibular NYU to decompress
the right and left TMJ for 6-8
weeks
2. Oasys Sleep appliance at night
3. Patient takes Zyrtec and Flonase
for allergies to decrease
congestion
25. ICAT imaging (07/20/2012)
revealed
• Hypoplasia of the left condyle
• Periodontal recession
throughout posterior bicuspids
and molars- all four quadrants
26. Axiel view
Sagittal view
Preliminary scan July 2012 confirms a 1mm anterior-posterior airway when standing
Follow up CBCT with Oasys shows stabilized airway
27. Min area= 62.1mm2
Open Airway= 178.3mm2
After 6 months of oral appliance therapy with an Oasys repositioning appliance, the
airwayAirway increased by 116.2mm2.
28. Changes to the Patient’s Centric Bite as a
result of OA Therapy
Before treatment July 2012
Class II dental relationship
Overbite is present
7 months utilizing Oasys at night & NYU
during the day February 2013
Protruded mandible
Edge to Edge dental relationship
No overbite
30. Sleep parameters for success include:
•
•
•
•
•
•
Airway stabilization to increase oxygen saturation, sleep architecture
Less strain on the vital organs
Decrease endothelial Dysfunction
Improve sleep quality
Increasing energy
Decrease sleep bruxism
6 Months into treatment the patient reports:
1.
2.
3.
4.
5.
Spouse’s sleep is no longer disrupted
Sleeping throughout the night
Snoring is virtually gone
No jaw pain
Temple headaches are now a rare occurrence
39.
58-year-old female first presented with
LRQ teeth pain
Numbness in the right mental nerve area
Swollen salivary gland
Clinical examination:
Large tongue, high tongue level, Mallampati Class
III airway
Issue a sleep study!
Revealed an AHI = 32.87 and RDI = 33.2
40.
58-year-old female first presented with
LRQ teeth pain
Numbness in the right mental nerve area
Swollen salivary gland
Clinical examination:
Large tongue, high tongue level, Mallampati Class
III airway
Issue a sleep study!
Revealed an AHI = 32.87 and RDI = 33.2
42. CHIEF COMPLAINTS
• Sensitive teeth: lower right
quadrant
• Intermittent jaw pain: Upper right
and lower right quadrants
• Numbness in the right mental
nerve region
• Swollen gland
• Right ear pain
OBJECTIVE FINDINGS
#30 tested + to percussion
with tooth sleuth
• Lingual fracture line observed
with periapical tenderness
•
44. Diagnostic sleep report: Severe OSA
Follow –up Sleep Study with Respire- Mild OSA
Benefits of OA therapy:
AHI decreased
RDI decreased
Increased oxygenationless desaturation
events
Increased REM Sleep
45. SUBJECT: 56 year old female
•
•
•
•
•
CHIEF COMPLAINTS
Left sided jaw locking
Left sided clicking & popping
Left jaw pain radiating into sinus
and ear
Neck pain
Fatigue
DIAGNOSTIC INFORMATION
• Epworth Sleepiness Scale= 8
Medical Hx:
•
•
•
•
•
•
•
Asthma
Sinusitis
High Cholesterol
Acid Reflux
Arthritis
Insomnia
Torn rotator cuff
CONTRIBUTING FACTORS
• Decreased vertical dimension of occlusion
• Retruded mandible with 10mm overjet
• Clenching (#1 indicator for sleep disorder)
46. Pre-Treatment
5-8-2012
ASSESSMENT
•
Pain and compression of the left
auriculo-temporal nerve
•
Anterior Disc Displacement with
Reduction of the left TMJ
• Capsulitis of the left TMJ
• Myofascial Pain
• Tension Headaches
Treatment Plan:
• Beginning 5-15-2012
• NYU 6-8 Weeks
• Modified Farrar
Progress
1-8-2013
Progress
9-10-2013
47. Pre-Treatment
5-8-2012
ASSESSMENT
•
Pain and compression of the left
auriculo-temporal nerve
•
Anterior Disc Displacement with
Reduction of the left TMJ
• Capsulitis of the left TMJ
• Myofascial Pain
• Tension Headaches
Treatment Plan:
• Beginning 5-15-2012
• NYU 6-8 Weeks
• Modified Farrar
Progress
1-8-2013
Progress
9-10-2013
54. Pre-Treatment
Progress
CBCT TMJ Findings
Pre-Treatment
5-8-2012
Mild degenerative changes to
Right and Left TMJs ossesous
structures.
Retruded Right and Left TMJs.
RIGHT TMJ
RIGHT TMJ
Progress with Farrar
2-26-13
Right and Left TMJ noticeably
removed from the eminence.
Increased joint space.
LEFT TMJ
LEFT TMJ
55. Before Treatment 5/8/2012
Without Appliance: Deep overbite
Beginning Treatment 5/15/2012
NYU
Beginning Treatment 5/15/2012
Modified Farrar
Progress 2/26/2013
Modified Farrar
Restored Vertical Height
64. Jinkwan Kim, Fahed Hakim, Leila Kheirandish-Gozal, David Gozal, Inflammatory pathways in children with insufficient or disordered sleep, Respiratory Physiology & Neurobiology,
Volume 178, Issue 3, 30 September 2011, Pages 465-474, ISSN 1569-9048, 10.1016/j.resp.2011.04.024.
(http://www.sciencedirect.com/science/article/pii/S1569904811001625)
65. Obstructive Sleep Apnoea Syndrome as a Systemic Low-Grade Inflammatory Disorder
Carlos Zamarrón1, Emilio Morete1 and Felix del Campo Matias2
71. Chief complaints:
1. Significant daytime somnolence
2. Feeling groggy on awakening
3. Obstructive sleep apnea
4. Frequent heavy snoring
5. CPAP intolerance
6. Neck stiffness
The patient is CPAP intolerant; due to
discomfort from headgear, disturbed or
interrupted sleep, CPAP restricted
movements during sleep, CPAP does not
seem to be effective, claustrophobic
associations, does not resolve symptoms,
noisy and cumbersome.
Airway Centric
75.
Clinical examination revealed:
Masseters are hypertrophic upon cotton roll clench.
lingual orientation of the maxillary dentition teeth as well as a100 degree
nasiolabial angle.
Class II (retruded lower jaw) dental relationship.
a late opening and a late closing click in the left temporomandibular joint.
Mandibular range of motion measurements revealed maximum interincisal
opening of 44 mm and mandible is off to the LEFT by 2 mm.
a level III (high) tongue.
A Mallampati airway inspection showed a Class IV airway
The uvula is small
Maxilla is buttressed and retruded by 4mm
A small mandibular torus was present
Figure: Tongue Level III
Figure: Mallampati
Classification IV
76. Imaging Findings:
Cone beam CT scan (06/12/2012) revealed
1) Osteoarthritic degeneration of the right
condyle- lateral aspect
2) Flattening of the superior portion of
both condyles
3) Decreased airway space by 1mm
4) Right ramus measurement is 69.mm
5) Left ramus measurement is 62.99mm
6) Decreased joint space on the left
77. Airway Views
Turbinates' & sinuses are clear
Narrowed airway
Severe airway constriction posterior to
soft palate and tongue
Retruded mandible and lack of maxillary
labial support
79. Treatment Plan
1. The treatment plan consists of a Telescoping Herbst oral sleep appliance which will
be worn every night while sleeping.
2. The treatment plan consists of a mandibular (NYU) orthopedic appliance to realign
the mandible. The patient will wear the appliance full time for the first 6-8 weeks. As
treatment progresses and the symptoms improve, we will wean the patient off of
day wear.
3. The hard/soft mandibular mouth guard will be worn when the patient exercises.
4. A follow up sleep study will be performed to monitor OSA
80. CHIEF COMPLAINTS
Bilateral temple and jaw
pain
Headaches
Left TMJ clicking
Ringing in the ears
Excessive daytime
somnolence
Teeth don't line up properly
Left facial swelling- slight
THE EPWORTH SLEEPINESS SCALE SCORE WAS
12, WHICH MAY INDICATE EXCESSIVE
SLEEPINESS DEPENDING ON THE SITUATION.
THE PATIENT MAY WANT TO SEEK MEDICAL
ATTENTION.
Clinical Findings:
Class III (protruded lower
jaw) dental relationship.
a level III (high) tongue
a Class IV airway
"Tonsils Grade 3"
81. MRI (10/03/2012)
revealed:
Lack of full anterior
translation on openingbilaterally
Flattening of the left
condyle- degenerative in
nature
Flattening of the articular
disc of both condylesdegenerative in nature
Anterior displacement of
the articular disc of the left
TMJ
Diagnosis:
Anterior Disc Displacement
with Reduction (left side)
Osteoarthritis of the left
mandibular condyle
Tension Type Headache
83. Facial Asymmetry
Subject: 22 y/o male
Preliminary
11-21-2012
Pain & compression of
the left auriculotemporal
nerve
Masseteric Hypertrophy
on the Left
Mandible is off to the
right
4 month Progress without
appliances 3-12-2013
NO compression on the
left
Improved facial
symmetry
Muscles are more
relaxed
Improved posture
4 month follow up with NYU
3-12-2013
No pain or compression on
the left
Significantly less headaches
Left masseter still
hypertrophic- administered 20
units of Botox
85. Subject: 63 yr old female
Chief Complaints:
Mandible is shifted to the right
Clinical Findings:
Currently in braces on the
maxillary and mandibular
arches
Anterior Open Bite
C5-C6 rotated to the right
No joint clicking
No pain or compression
Enlarged level III tongue
Mallampati Class II
Diagnosis
Myofascial Pain
Sleep Bruxism
Osteoarthritis of the left TMJ
Treatment Plan & Sequence
Removal of braces
1. Maxillary Farrar with anti retrusion
ramp to use during sleep
2. Lower full coverage appliance to
ideal jaw position- bringing the
mandible to the midline position
3. Once jaw is stabilized, possible
bonding to establish canine
guidance and anterior support (
PRENEW/ PREVIEW)
89. Post NYU Therapy In January 2013
Prenew- Preview Case In
February 2013
• Improved incisal contacts #2-15
• Midline is idealized
• Mandible is brought to the center to decomress
the right TMJ
90. Frontal soft tissue model with bone and dentition reveals:
• Mandible is off to the right
AirwayCentric TM refers to a new brand in dentistry . AirwayCentric TM mouthwear includes oral appliances for enhancing breathing and oxygenation as well as devices for performance and headache and clenching management . AirwayCentric TM educational services provide multidisciplinary training , education and awairness to medical, dental and other healthcare professionals as well as the public. AirwayRestorativeDentistry is the future of dentistry and a branch of medicine dedicated to the well being of the patient . It is dentistry for wellness not repair. Maintsinance of an open airway and easy breathing is the cornerstone of AirwayCentric TM Airway restorative Breathing. For the last 75 years , dentistry in the United States has closed the airway making breathing more difficult and expending extra energy .AirwayOrthodontics places the focus on developing an open airway starting as early as birth with breastfeeding and lactation education . Early intervention combining palatal expansion with T and A and myofunctionaltherpapy is recommended before age 5 as early as age 3 .
Gel-B TM oral products optimize breathing , balance and the bite. Gel-B TM oral devices optimize athletic performance using the Gelb 4/7 TM jaw position .
This 20 year old came in with a locked jaw and headache and neck pain. It turns out she had 4 bicuspids extracted and moderate sleep apnea . Depression , inability to focus, learn , remember were comorbidities.
Before 2009
After 2012
All symptoms resolved with combination oral appliance therapy and Medication.
Places the jaw in Gelb4/7 during the day
Used at night to prevent the jaw from dropping out of gelb 4/7
A typical nightguard places the jaw in terminal hinge a position from the 1930s.
The jaw is way back closing the airway and increasing headahce
