Naso respiratory function and growth sleep apnea /certified fixed orthodontic courses by Indian dental academy

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Naso respiratory function and growth sleep apnea /certified fixed orthodontic courses by Indian dental academy

  1. 1. NASO-RESPIRATORY FUNCTION AND GROWTH, SLEEP APNEA INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com 1
  2. 2. www.indiandentalacademy.com 2
  3. 3. CONTENTS Introduction  Anatomy  Mechanism of Breathing  Diagnosis  Animal studies  Human studies  Relationships between dentofacial deformities and nasal airway inadequacy  www.indiandentalacademy.com 3
  4. 4. Introduction Nasal and oral cavities serve as pathways for respiratory airflow.  Inspiratory and expiratory air streams are channeled through nose.  Nasal airway inadequacy – oral breathing results.  Conflicting views regarding close relationship b/n dentofacial deformities and nasal inadequacy.  www.indiandentalacademy.com 4
  5. 5. Anatomy www.indiandentalacademy.com 5
  6. 6. Anatomy www.indiandentalacademy.com 6
  7. 7. Inspiratory & expiratory muscles www.indiandentalacademy.com 7
  8. 8. Mechanism of breathing www.indiandentalacademy.com 8
  9. 9. RESPIRATORY PHYSIOLOGY Pulmonary alveoli and respiratory tract. Function      Exchange of O2 and CO2 between environment and body cells. O2 – intercellular metabolism. CO2 – End product. Exchange through alveoli Alveolar membrane permits O2 and CO2 transport. www.indiandentalacademy.com 9
  10. 10. Alveoli www.indiandentalacademy.com 10
  11. 11. Rhythmic activity – alters the level of gases – alveoli and pulmonary capillaries - ↓ pressure gradients.  Respiratory tract results in transfer between alveoli and environment.  Respiratory tract – nasal and oral passages which connect pharynx, larynx and trachea.  Trachea – Bronchi Bronchioles  www.indiandentalacademy.com 11
  12. 12. www.indiandentalacademy.com 12
  13. 13. Airway Resistance www.indiandentalacademy.com 13
  14. 14. Airway Resistance   Changes in dimensions of respiratory tract - ↓ airflow e.g. enlarged adenoids and tonsils.Solow(79) Compensatory mechanisms Respiratory muscles – increased work –change in intrapulmonary pressure. Modification of respiration by sensory feed back. www.indiandentalacademy.com 14
  15. 15. Sensory feedback Sensory receptors Respiratory tract Cardiovascular system- baroreceptors Joints- increase pulm ventilation Pulmonary stretch receptors www.indiandentalacademy.com 15
  16. 16.   Chemoreceptors most affectted. Monitor levels of O2 and CO2. Carotid bodies – O2 sensitive Aortic bodies Ventral surface of medulla – CO2 sensitive Obstruction of upper airway – ↓ airflow and O2 conc. – inspiration ↓ airflow and inc CO2 conc. – expiration Transient hypoxia – Neural receptor stimulated. www.indiandentalacademy.com 16
  17. 17. Neuromuscular control www.indiandentalacademy.com 17
  18. 18. Diagnosis Nasal breathers – lips touch lightly at rest Nares dilate on command inspiration. Mouth breathers – lips parted at rest nares maintain size  Use of a two surface steel mirror Use of a cotton butterfly.  www.indiandentalacademy.com 18
  19. 19. Diagnosis www.indiandentalacademy.com 19
  20. 20. Diagnosis www.indiandentalacademy.com 20
  21. 21. Craniofacial Adaptation to Nasal obstruction – Rhythmicity Animal Experiments: Aim: Determine which craniofacial muscles were rhythmically active, discharging periodically with primary respiratory muscles.  16 muscles surveyed – 4 regions. Mandibular elevators Mandibular depressors Tongue Facial muscles Fine wires – placed intramuscularly www.indiandentalacademy.com 21 Electromyographic records taken 
  22. 22. Longterm Adaptation 16 adult rhesus monkeys.  8-experimental and 8-controls Results – Control - No rhythmic activity in jaw elevator muscles. Experimental - rhythmic activity – temporalis, masseter, medial pterygoid, suprahyoid, genioglossus, orbicularis oris.  www.indiandentalacademy.com 22
  23. 23. Rhythmicity during Early adaptation 26 young rhesus monkeys – 13 mouth breathers – 13 controls. Results: Experimental group – rhythmicity in 1. muscles of upper lip and tongue 2. Geniohyoid, digastric, temporalis, zygomaticus, medial and lateral pterygoid.  www.indiandentalacademy.com 23
  24. 24. www.indiandentalacademy.com 24
  25. 25. ELECTROMYOGRAPHY  It is a test that measures muscle response to nervous stimulation(electrical activity within muscle fiber) www.indiandentalacademy.com 25
  26. 26. Patterns of Rhythmicity     Craniofacial muscles – 2 discharge patterns. Primary respiratory muscles – 1 discharge pattern. Diaphragm – Slowly builds – max-tension. Lip ,nares and tongue muscle attain maxtension immediately. www.indiandentalacademy.com 26
  27. 27.  To summarize rhythmic activity correlated with respiration is normally present in five craniofacial muscles – control animals.  Experimental animals – adapt to oral respiration – four additional muscles involved.  This reflexivity induces changes in neuromuscular function of craniofacial muscles. inducing periodicity in discharge initiating a sustained tonic discharge www.indiandentalacademy.com 27
  28. 28. Growth in the sagittal depth of bony nasopharynx in relation to some other facial variables Sten Linder - Aronson Size of nasopharynx important – mode of breathing  Lymphoid tissue – posterior wall of nasopharynx.  Adenoid vegetations   Size of adenoids – crucial www.indiandentalacademy.com 28
  29. 29.  Difference of opinions  Rosenberger 1934 – nasopharynx ↑ in conjunction with growth of the cranial base.  Brodie 1941 – depth established during the first year or two of life – constant afterwards.  King 1952 – examined nasopharyngeal dimensions from 3 months to 16 years – similar views. www.indiandentalacademy.com 29
  30. 30.  In contrast Subtelny 1957 – Serial cephalometric study of 30 subjects → - Nasopharynx ↑ from 3 years to 17 years - First 11 years periods of apparent increase / decrease - After 12 years – steady increase www.indiandentalacademy.com 30
  31. 31. Handelman and Osborne 1976 – nasopharyngeal depth constant in females  In Males increased moderately from 3 years, 9 months to maturity.  www.indiandentalacademy.com 31
  32. 32.  Materials – longitudinal  study – 6 to 20 years children. 140 boys and 120 girls – Burlington Growth Center.  Method variables measured: - Ba-S - S-N - Ba-ptm - Ba-N - Ptm-Sn - Sn-Gn - N-Sn www.indiandentalacademy.com 32
  33. 33.  Results Males – steady increase in sagittal depth of nasopharynx – 6-20 yrs 6-12 yrs – 2.4mm 12-18 yrs – 4.7mm Females – Growth of nasopharynx after 16 years negligible. 6-12 yrs – 3.5mm 12-18 yrs – 1.6mm www.indiandentalacademy.com 33
  34. 34. Correlations done  Results – Highest correlation coefficient b/n depth of nasopharynx and length of total cranial base – r = 0.63 - 0.75 .  Very weak correlation b/n depth of nasopharynx and length of maxilla r=0.18 – 0.40 www.indiandentalacademy.com 34
  35. 35. No correlation b/n depth of nasopharynx and facial heights www.indiandentalacademy.com 35
  36. 36. In earlier investigations – Linder Aronson 1972- sagittal depth of bony nasopharynx influenced by mode of breathing.  Mouth breathers nasopharynx smaller.  Nasopharynx normalized – following change to nose breathing.  www.indiandentalacademy.com 36
  37. 37. www.indiandentalacademy.com 37
  38. 38. Summary 1. Sagittal depth of nasopharynx ↑ in small steady increments upto 16 yrs of age in females and 20 yrs in males. 2. The velocity of sagittal depth ↑ peaked – 12 to 14 yrs in males – 3. In females – ↓ after 12 yrs of age 4. There was great variation among individual velocity curves in both the age at which it peaked and magnitude of growth increments. 5. Sagittal depth of bony nasal pharynx is relatively independent of other cephalometric dimensions of the facial complex. www.indiandentalacademy.com 38
  39. 39. Relationships between dentofacial deformities and nasal airway inadequacy - Conflicting topic - Judgement of mode of breathing www.indiandentalacademy.com 39
  40. 40. Relationships between dentofacial deformities and nasal airway inadequacy - Most prevalent view – mouthbreathing – associated with Retrognathic mandible Protruding maxillary anterior teeth High palatal vault Constricted maxillary arch Flaccid and short upper lip. Dull appearance www.indiandentalacademy.com 40
  41. 41.  Angle 1907 – – “This form of malocclusion is always accompanied and atleast in its early stages, aggravated, if indeed not caused by mouth breathing due to some form of nasal obstructions”. Hunter 1971 – Did not find a relationship b/n allergic rhinitis and malocclusion. Linder Aronson, Aschan – Enlarged adenoids - Adenoid facies Moffat 1963 – Related protrusion of maxillary incisors to mouth breathing. www.indiandentalacademy.com 41
  42. 42. Relationships between dentofacial deformities and nasal airway inadequacy Harvold 1973 – Palatal anatomy and impaired nasal breathing related. Korkhaus 1960 – Maxillary arch form important in determining nasal cavity size  and hence breathing mode www.indiandentalacademy.com 42
  43. 43. Relationships between dentofacial deformities and nasal airway inadequacy    Derichsweiler 1956 – contradicts nasal obstruction as a primary etiologic factor in dentofacial deformity. Choanal atresia Watson 1968 – mouth breathing – not always associated with skeletal deformity. 23% of mouth breathers due to habit rather than physiologic need. www.indiandentalacademy.com 43
  44. 44. Relationships between dentofacial deformities and nasal airway inadequacy To summarize - Malocclusion may or may not be associated with an inadequate nasal airway. - Certain nasal or nasopharyngeal abnormalities may produce a mouth breathing pattern. www.indiandentalacademy.com 44
  45. 45. Maxillary expansion and nasal airway resistance - Hershey et al 1976 – 45% reduction in nasal airway resistance after RME Turby fill – 1976 – 53% decrease in airway resistance in 17 subjects. www.indiandentalacademy.com 45
  46. 46. Craniocervical angulation and nasal respiratory resistance  Solow Thompson – Changed craniofacial morphology – due to changed head posture .  Schwarz 1926 – Head bent backwards i.r.t. neck in nasal obstruction.  Ricketts 68, Koski 75, Quinn and Pickrell 78 – similar views. www.indiandentalacademy.com 46
  47. 47. Head posture and craniofacial morphology Bjork 1961 – – Retrognathic facial type – head in extended position. – Prognathic facial type – head in lower position Bench 1963 – neck -curved in square faces Straight – long faces. Sallow and Tallgren 1976 – of the posture variables the craniocervical angulation showed the most comprehensive correlation with craniofacial morphology. www.indiandentalacademy.com 47
  48. 48.  Extended head position – - Large inclination of mandible Small post and large ant facial heights Facial retrognathism www.indiandentalacademy.com 48
  49. 49.  Average craniofacial morphology in persons who had a large craniocervical angulation resembled to those persons who had a large mandibular plane angle. www.indiandentalacademy.com 49
  50. 50. Soft tissues stretching hypothesis Solow and Kreiborg 1977 – posturally induced stretching of the facial soft tissue layer might influence craniofacial morphological development.  Extension of head – entails a passive stretching of the facial soft tissue layer draping the face and the neck.  Slight backward and downward forces  www.indiandentalacademy.com 50
  51. 51. Soft tissues stretching hypothesis www.indiandentalacademy.com 51
  52. 52. Conclusions 1. 2. Before adenoidectomy a large craniocercival angulation was seen in connection with a large nasalrespiratory resistance. After adenoidectomy reduction of the craniocervical angulation occurred in children in whom nasal respiratory resistance was reduced. www.indiandentalacademy.com 52
  53. 53. Nasorespiratory function and Craniofacial growth-Linder Aronson Distinction between mouth and nose breathers  Mouth breathing  » Refers to those individuals who have a certain degree of nose breathing capacity but, for one reason or another, breathe mainly through the mouth. Conditions - E.g. Bilateral Chonanalatresi, alea nasi insufficiency – pure mouth breathers. Reduced nasal respiratory function – pts with enlarged adenoidal masses www.indiandentalacademy.com 53
  54. 54. Effects of reduced nasal respiratory function on the development of facial skeleton and occlusion  Last 100 yrs – lot of research  Wilhelm Meyer 1868 – patients with reduced nasal respiration – poor hearing & poor general health.  Tomes 1872 – mouth breathers- narrow dental arches (vshape).  Nordlund 1918 – theory of compression - Disturbance of balance b/n tongue and cheek musculature  Korner 1891 – mouth breathing 1. Narrow dental arches. 2. Underdevelopment of nasal cavity. www.indiandentalacademy.com 3. Reduced maxillary size. 54
  55. 55. Woodside 1968 – Obstructed nasal ventilation – Class II malocclusion.  Harvold et al 1973-79 – Animal experiments  --change to mouth breathing narrowing of the maxilla. post rotation of mandible . Nordlund, Brash et al Reduced nasal breathing result of existing facial and dental morphology. www.indiandentalacademy.com 55
  56. 56. Adenoid faces   Associated with long history of mouth breathing. C/F: – – – – – – – – – Open mouth posture. Flattened nose. Pinched nostrils. Short upper lip. Voluminous and pouting lower lip. Vacant facial expression. Proclined upper incisors. V-shape upper jaw – high palatal vault. Skeletal Class II relationship. www.indiandentalacademy.com 56
  57. 57. Adenoid faces www.indiandentalacademy.com 57
  58. 58. Effects on the dentition& facial skeleton of a change from mouth to nose breathing-Linder Aronson 1973 www.indiandentalacademy.com 58
  59. 59. 5 yr follow up study of children undergone adenoidectomies to clear obstructed nasal passages.  Purpose – Examine effects of a change in the mode of breathing on 1. U/L incisal inclination 2. Upper arch width 3. Sagittal depth of nasopharynx. 4. Anterior facial height. 5. Inclination of the maxilla to mandible. Sample: 41 children – changed from mouth to nose breathing. 54 children – control  www.indiandentalacademy.com 59
  60. 60. Method: Children examined 1 and 5 yrs post op www.indiandentalacademy.com 60
  61. 61. Results Upper incisal inclination - Relatively greater increase in upper incisor inclination. - Normalization of upper incisor inclination to SNduring the five year postop period . www.indiandentalacademy.com 61
  62. 62. Results Inclination of the lower incisors    Greater change during first year post-op Next 4yrs no significant change Normalization of lower incisors inclination occur during the 1st year post-op www.indiandentalacademy.com 62
  63. 63. Results Changes in arch width  1st year greatest change 0. 9mm – statistically significant.  Normalization of arch width took place following adenoidectomy www.indiandentalacademy.com 63
  64. 64. Results Effect on the nasopharynx Normalization of the depth of nasopharynx occurs during the 1st yr post-op www.indiandentalacademy.com 64
  65. 65. Results Effect on maxillomandibular angle    1st yr post-op – 0.4° not significant Next 5 yrs - greater change ML/MN angle ↓ after change from mouth to nose breathing. www.indiandentalacademy.com 65
  66. 66. Mechanisms of change in dentition & facial morphology www.indiandentalacademy.com 66
  67. 67. Changes in head posture Mouth breathers – unconsciously maintain an extended head posture.  16 pts – undergone adenoidectomy 16 pts – controls Method: Inclination of SN – measured relative to a vertical reference line. SN / vert angle – decreased in extended head posture.  www.indiandentalacademy.com 67
  68. 68. www.indiandentalacademy.com 68
  69. 69. Patients evaluated – before and 1 month after surgery.  Pt in a relaxed position infront of mirror – outside the cephalostat.  Light cross as a reference  Pencil mark following the horizontal line of light cross. .  www.indiandentalacademy.com 69
  70. 70. Results:  Significant differences in the size of SN/Vert angle before adenoidectomy.  No difference after adenoidectomy b/n two groups www.indiandentalacademy.com 70
  71. 71. Implications:  Mouth breathers small SN/Vert angle  Large value for lower facial height. www.indiandentalacademy.com 71
  72. 72. Pierre Robin syndrome www.indiandentalacademy.com 72
  73. 73. The role of tonsils and adenoids in the obstruction of respiration Tonsillectomy and adenoidectomy - in combination or separately  1 Recurrent or chronic throat infection. 2 Hypertrophy 3 Recurrent attacks of acute otitis media. Chronic otitis media with effusion.  www.indiandentalacademy.com 73
  74. 74. Prevalence  Upper resp infection – peaked – 1 & 6 years and significantly ↓ thereafter.  Hypertrophy of tonsils and adenoids – more common in boys – under 6 yrs .  Hypertrophy tonsils –twice in adult female.  Otitis media – 2nd common disease in childhood. All these conditions - ↓ - after 6 yrs.  www.indiandentalacademy.com 74
  75. 75. Urgent indications for surgery: -Alveolar hypoventilation -Tonsil enlargement – difficulty in swalowing. Tonsillectomy –– foll conditions 1) Recurrent tonsillitis 2) Chronic tonsillitis Adenoidectomy indicated in – persistent nasal obstruction recurrent otitis media with effusion. www.indiandentalacademy.com 75
  76. 76. Factors influencing the degree of obstruction     Degree of obstruction is primarily related to the size of the tonsils and adenoids relative to their surr compartment. Recurrent chronic inflammation – ↑ the degree of obstruction. Acute rhinitis – moderately obstructing adenoids marked ↓ in nasal airflow. Body position – Recumbency in general – ↑ upper airway obstruction www.indiandentalacademy.com 76
  77. 77. Anatomic factors – –Affect the degree of obstruction –Syndromes – e.g. Downs syndrome – extreme form – respiratory compromise. -Anatomic variation – pedunculated tonsils -Deformity of nasal cavity e.g. septal deviation, Choanal stenosis www.indiandentalacademy.com 77
  78. 78. Methods of assessing degree of respiratory obstruction  Thorough history & physical examination – Sleeping habits Snoring Mouth breathing Distortion of speech Hypersomnia Headaches Lethargy Weight gain Nightmares Difficulty in awakening Physical examination – head neck, chest & abdomen areas www.indiandentalacademy.com 78
  79. 79. Adenoid inspection: 1) Direct inspection through the nasal cavities Topical decongestant 2) Right angle telescope 3) Flexible fibreoptic nasopharyngoscope Tonsil inspection www.indiandentalacademy.com 79
  80. 80. Classification 1 ± tonsils not visible behind the ant pillar 2 ± tonsils visible just beyond the pillar 3 ± tonsils are almost touching 4 ± tonsils meet in the midline Radiographic films – lateral, posterioanterior & submento vertex views www.indiandentalacademy.com 80
  81. 81. Mandibular growth direction following adenoidectomy – Linder Aronson – AJO 1989 Materials: 38 Swedish children – 38 controls Age: 7-12 yrs After adenoidectomy Method: Serial cephalometric study Post-operative assessment  www.indiandentalacademy.com 81
  82. 82. Results Experimental group – initially – steeper MP angles, longer lower face heights  5 yrs postoperative – more horizontal growth pattern  www.indiandentalacademy.com 82
  83. 83. Association of lip posture & the dimensions of tonsils and sagittal air way with facial morphology - Trotman et al – Angle Orthod 1997  Method: clinical & ceph data – 207 children (adenoid or tonsil problems)  Conclusions: – More open lip posture - backwardly rotated face & ↑ lower face height. – Reduced airway size – backward relocation of max & mand. . www.indiandentalacademy.com 83
  84. 84. Effects of maxillary protraction on craniofacial structures and upper airway dimensions – Shigetoshi et al – Angle Orthod 2002 Aim: To examine the effect of max. protraction appliance on upper airway dimensions.  Material: - 25 pts – mean age 9.8yrs Class III malocclusion Method: Lateral cephalogram evaluation Conclusions: The max growth had significant positive effect on the superior airway dimension. www.indiandentalacademy.com 84 
  85. 85. Conclusions 1. 2. 3. ↑ in max growth Inhibition of mand growth Clockwise rotation of mandible. www.indiandentalacademy.com 85
  86. 86. Does the timing & method of RME have an effect on the changes in nasal dimension – Karaman, Bascifti – Angle Orthod 2002  Aim: To assess the effects of RME on nasopharyngeal area  Sample: 30 pts – perm dent. Max. constriction and post crossbite Method: Lateral & frontal cephalograms – before & after RME www.indiandentalacademy.com 86
  87. 87. Results Respiratory area ↑  Nasal cavity width & max. width - ↑  Decrease in nasal airway resistance  MP suture seperated - ↑ in the internasal volume  Nasal resistance decreased & respiratory area ↑ after RME  www.indiandentalacademy.com 87
  88. 88. Comparison of nasopharyngeal endoscopy & lateral cephalometric radiography in diagnosis of nasopharyngeal airway obstruction – Daniel Filho – AJO 2001 Aim: 2 methods of diagnosing nasopharyngeal airway obstruction were compared  Material: 30 orthodontic pts – 7-12 yrs Mouth breathers  Method : Nasopharyngeal endoscopy & radiographic examination – same day  www.indiandentalacademy.com 88
  89. 89.  Conclusions Lateral cephalometric radiography – sufficiently reproducible for diagnosing hypertrophy of the middle and inferior turbinates .  Lateral cephalometric radiography – overestimates turbinate hypertrophy – false positive findings.  Nasopharyngeal videoendoscopy – more suitable in diagnosing obstruction of nasopharyngeal origin. Nasal septal deviations Hypertrophy of the inferior & middle turbinates www.indiandentalacademy.com 89
  90. 90. Cleft palate studies 12 yr old female – submucous cleft, nasal speech.  Velopharyngeal flap – to reduce nasopharyngeal leakage.  5 yrs postop change from nose to mouth breathing.  Marked opening overbite & increase in lower face height  www.indiandentalacademy.com 90
  91. 91. Subtelny 1978 – Pharyngeal flap surgery – 24 children Results: Chin position downward & backward No difference in growth of mandible  Warren 1975 –velopharyngeal flap surgery Increased resistance to nose breathing  www.indiandentalacademy.com 91
  92. 92. Comparison of the sizes of adenoidal tissues and upper airways of subjects with and without CLCP - Imawaru Shigetoshi AJO Aug 2002 Sample  1. 90 juvenile with CLP(CLP/J) 90 controls – control/J 2. 40 adolescents with CLP – CLP/A 40 controls – control/A  www.indiandentalacademy.com 92
  93. 93.  Method – measurements using Lat. Ceph  Results – Adenoid tissue significantly larger in CLP/J than in control/J no significant difference betn CLP/A & control/A adenoids smaller in CLP/A than in CLP/J www.indiandentalacademy.com 93
  94. 94. Upper Airway Significantly smaller in CLP/J than in control/J  Significantly smaller in CLP/A than in control/A  CLP/A- increased airway than CLP/J  Control/A larger than control/J  Larger adenoids in CLP/J group decreased to a smaller size with aging  www.indiandentalacademy.com 94
  95. 95. Sleep Apnea Defn – It is defined as an intermittent cessation of air flow at the nose and mouth during sleep.  10 sec duration – imp.  Sleep apnea syndrome – refers to a clinical disorder that arises from recurrent apneas during sleep.  www.indiandentalacademy.com 95
  96. 96. Etiology Loss of muscle tone  Obstruction of nasal passages  Large tonsils  Large tongue  Retrognathic mandible  Obesity  Alcohol  Sedative medications  www.indiandentalacademy.com 96
  97. 97. Classification 1. Central  2. Obstructive  3. Mixed  www.indiandentalacademy.com 97
  98. 98. Pathogenesis Occlusion at the level of oropharynx  Progressive asphyxia – brief arousal from sleep – airway restored – sleep.  400-500 times per night  Critical subatmospheric pressure  Sleep – reduces the activity of upper airway muscles  Alcohol – imp. Cofactor  depressant action  www.indiandentalacademy.com 98
  99. 99. Anatomic disturbances – adenotonsillar hypertrophy  retrognathia  macroglossia  Obesity  Snoring  www.indiandentalacademy.com 99
  100. 100. Clinical features Behavioral disturbances  Fragmentation of sleep  Nocturnal cerebral hypoxia  Excessive day time sleepiness  Intellectual impairment  Memory loss  Impotence – in men  www.indiandentalacademy.com 100
  101. 101. manifestations Bradycardia – during apnea  Tachycardia – 90 – 120 beats/min  www.indiandentalacademy.com 101
  102. 102. Prevalence Increases with age  More prevalent in women  Moderate obesity  Mild to moderate hypertension  www.indiandentalacademy.com 102
  103. 103. Diagnosis  Definitive investigations – – – Poly somnography Arterial O2 saturation Heart rate www.indiandentalacademy.com 103
  104. 104. Treatment www.indiandentalacademy.com 104
  105. 105. www.indiandentalacademy.com 105
  106. 106. www.indiandentalacademy.com 106
  107. 107. herbst www.indiandentalacademy.com 107
  108. 108. www.indiandentalacademy.com 108
  109. 109. www.indiandentalacademy.com 109
  110. 110. Modified functional appliance for treatment of sleep apnea Sleep apnea – sleep with mouth open  Reduced tonicity of genioglossal mucsletongue sucked back  Diagnosis - best by pulmonologist  www.indiandentalacademy.com 110
  111. 111. New appliance – NAPA Nocturnal airway patency appliance  Mechanism –  – Posturing the tongue more anteriorly – Inhibiting wide jaw opening – Assuring adequate air intake when nasal obstruction exists www.indiandentalacademy.com 111
  112. 112. Construction  Constructed using wire and acrylic www.indiandentalacademy.com 112
  113. 113. Case report 5 OSA patients – polysomnography  Results – substantial reduction in no. of apneas/hr  All 5 ptns – improvement in sleep  www.indiandentalacademy.com 113
  114. 114. summary Mandible was protruded to advance the tongue to the posterior pharyngeal wall  Genioglossus originates from the inner surface of the mandibular symphysis  ¾ distance b/w centric occlusion and full protrusion was selected  5-7 mm of protrusion  Oral breathing beak – ptns with nasal congestion  www.indiandentalacademy.com 114
  115. 115.  Ptns – clench their teeth 3 times for 5 secs every morn. – relaxes the lat.pty muscle www.indiandentalacademy.com 115
  116. 116. Removable Herbst appliance for treatment OSA – Ernest A.Rider 16 SA ptns  Plunger mechanism  Sustained pharyngeal patency  Advancement  – Edge to edge position www.indiandentalacademy.com 116
  117. 117. Results  70 – 100 % improvement – 12 ptns www.indiandentalacademy.com 117
  118. 118. Therapeutic efficacy of an oral appliance in the treatment of OSA – 2 yr follow up  Purpose – the long term efficacy of Karwetzky activator www.indiandentalacademy.com 118
  119. 119. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com 119

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