Obstructive sleep apnea

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Obstructive sleep apnea

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. ContentsContents  IntroductionIntroduction  EpidemiologyEpidemiology  Normal upper airway anatomyNormal upper airway anatomy  Etiology & pathogenesisEtiology & pathogenesis  Clinical featuresClinical features  Diagnostic aidsDiagnostic aids  Treatment modalitiesTreatment modalities  ConclusionConclusion www.indiandentalacademy.comwww.indiandentalacademy.com
  3. 3. IntroductionIntroduction  Obstructive Sleep Apnea (OSA) was firstObstructive Sleep Apnea (OSA) was first described bydescribed by Charles Dickens inCharles Dickens in TheThe Pickwick papersPickwick papers in 1836in 1836  In 1906In 1906 William OslerWilliam Osler said “ ansaid “ an extraordinary phenomenon in excessivelyextraordinary phenomenon in excessively fat young persons with an uncontrolledfat young persons with an uncontrolled tendency to sleeptendency to sleep www.indiandentalacademy.comwww.indiandentalacademy.com
  4. 4.  In 1950’s the research in sleep disorders gainedIn 1950’s the research in sleep disorders gained momentum after the works ofmomentum after the works of Aserinsky,Aserinsky, Klutman and DematKlutman and Demat who also termed the REMwho also termed the REM and non – REM sleepand non – REM sleep  In 1956In 1956 BurwellBurwell first described the features offirst described the features of Obesity, hypersomnolesence, decreasedObesity, hypersomnolesence, decreased alveolar ventilation and cor pulmonale, nowalveolar ventilation and cor pulmonale, now termed OSA, termed it astermed OSA, termed it as Pickwickan syndromePickwickan syndrome  In 1980’s research showed high incidence ofIn 1980’s research showed high incidence of mortality and also oral appliances came intomortality and also oral appliances came into beingbeing www.indiandentalacademy.comwww.indiandentalacademy.com
  5. 5.  Obstructive sleep apnea syndrome-Obstructive sleep apnea syndrome- Characterized by constellation of s/s relatedCharacterized by constellation of s/s related to arterial oxygen desaturation & sleepto arterial oxygen desaturation & sleep fragmentation caused by pharyngealfragmentation caused by pharyngeal obstruction during sleep.obstruction during sleep. Potentially life threatening conditionPotentially life threatening condition Periodic cessation of breathing during sleepPeriodic cessation of breathing during sleep inspite of inspiratory effort.inspite of inspiratory effort. Significant morbiditySignificant morbidity www.indiandentalacademy.comwww.indiandentalacademy.com
  6. 6.  It was 1It was 1stst described bydescribed by Gastaut- disorder- disorder associated with repetitive cessation ofassociated with repetitive cessation of breathing during sleep.breathing during sleep.  Sleep apnea defined as 30 or more apneicSleep apnea defined as 30 or more apneic episodes (cessation of airflow for moreepisodes (cessation of airflow for more than 10 sec) occurring during 7hrs ofthan 10 sec) occurring during 7hrs of nocturnal sleep.nocturnal sleep.  Most common is obstructive type.Most common is obstructive type. www.indiandentalacademy.comwww.indiandentalacademy.com
  7. 7.  Reduced blood oxygen saturation leadsReduced blood oxygen saturation leads to-to- HypertensionHypertension Cardiac arrhythmiasCardiac arrhythmias Nocturnal anginaNocturnal angina Myocardial ischemiaMyocardial ischemia  Impaired sleep quality leads to-Impaired sleep quality leads to- Reduced concentrationReduced concentration Risk of falling asleep during dayRisk of falling asleep during day Behavioral changesBehavioral changeswww.indiandentalacademy.comwww.indiandentalacademy.com
  8. 8.  Related to orthodontics-Related to orthodontics- Peculiar cranio-facial & soft tissuePeculiar cranio-facial & soft tissue morphologymorphology Non-invasive modes of therapy i.e dentalNon-invasive modes of therapy i.e dental appliances used in treatment of syndrome.appliances used in treatment of syndrome. www.indiandentalacademy.comwww.indiandentalacademy.com
  9. 9.  Snoring-Snoring- produced by vibration of softproduced by vibration of soft palate or oropharyngeal tissues.palate or oropharyngeal tissues. Various factors related-Various factors related- Sleep related loss of m. toneSleep related loss of m. tone Large tonsilsLarge tonsils Large tongueLarge tongue RetrognathiaRetrognathia ObesityObesity AlcoholAlcohol Sedative medicationSedative medication Certain medical conditionCertain medical condition www.indiandentalacademy.comwww.indiandentalacademy.com
  10. 10.  ClassificationClassification:: MildMild: 5 to 15 involuntary sleep episodes: 5 to 15 involuntary sleep episodes occurring during activities that require littleoccurring during activities that require little attentionattention ModerateModerate: 15 to 30 sleep episodes during: 15 to 30 sleep episodes during activities that require some attentionactivities that require some attention SevereSevere: > than 30 episodes of sleep during: > than 30 episodes of sleep during conversation, walking, eatingconversation, walking, eating www.indiandentalacademy.comwww.indiandentalacademy.com
  11. 11. Epidemiology of obstructive apnea syndrome  Mc NamaraMc Namara found 1-9% prevalence offound 1-9% prevalence of OSASOSAS  Recent study byRecent study by Young et alYoung et al suggestedsuggested prevalence of OSAS to be at least 9% inprevalence of OSAS to be at least 9% in males & 4% in femalesmales & 4% in females  LugaresiLugaresi reported incidence of snoring to bereported incidence of snoring to be 19% in adult population & increased19% in adult population & increased significantly with agesignificantly with age  KatsantonicsKatsantonics reported snoring 53% in men,reported snoring 53% in men, 38% in women.38% in women. www.indiandentalacademy.comwww.indiandentalacademy.com
  12. 12. Normal upper airway anatomyNormal upper airway anatomy  NoseNose- extends from external nares to- extends from external nares to posterior nasal apertures & subdivided intoposterior nasal apertures & subdivided into by nasal septum.by nasal septum.  Nasal septum-Nasal septum-  osteocartilagenous partition.osteocartilagenous partition.  Bony part-Bony part-  VomerVomer  Perpendicular plate of ethmoidPerpendicular plate of ethmoid  Nasal spine of frontalNasal spine of frontal  Rostrum of sphenoidRostrum of sphenoid  Nasal crests of palatine boneNasal crests of palatine bone  Maxillary bonesMaxillary bones www.indiandentalacademy.comwww.indiandentalacademy.com
  13. 13.  Cartilaginous part-Cartilaginous part- Septal cartilageSeptal cartilage Septal process of interior nasal cartilageSeptal process of interior nasal cartilage  Cuticular part- fibro fatty tissueCuticular part- fibro fatty tissue covered with skin lower margin ofcovered with skin lower margin of septum called columella.septum called columella. www.indiandentalacademy.comwww.indiandentalacademy.com
  14. 14. www.indiandentalacademy.comwww.indiandentalacademy.com
  15. 15. Lateral wallLateral wall Bony part Cartilaginous partBony part Cartilaginous part Frontal process of maxilla nasal cartilagesFrontal process of maxilla nasal cartilages Nasal bone 3-4 cartilages of alaNasal bone 3-4 cartilages of ala Lacrimal boneLacrimal bone Labyrinth of EthmoidLabyrinth of Ethmoid (superior & middle concha)(superior & middle concha) Inferior nasal conchaInferior nasal concha Perpendicular plate of palatinePerpendicular plate of palatine Medial pterygoid platedMedial pterygoid plated www.indiandentalacademy.comwww.indiandentalacademy.com
  16. 16. www.indiandentalacademy.comwww.indiandentalacademy.com
  17. 17. Decreased nasal patency may contribute to OSASDecreased nasal patency may contribute to OSAS in many ways-in many ways-  Nasal obstruction with closed mouth may result inNasal obstruction with closed mouth may result in obstructed airway, resulting in arousal.obstructed airway, resulting in arousal.  Nasal congestion may induce mouth breathing which inNasal congestion may induce mouth breathing which in turn leads to posterior positioning of mandible causingturn leads to posterior positioning of mandible causing hypo pharyngeal narrowing.hypo pharyngeal narrowing.  With nasal congestion there is large inspiratory pressureWith nasal congestion there is large inspiratory pressure drop across nose leading to sub-atmospheric pressuredrop across nose leading to sub-atmospheric pressure within potentially collapsible pharynx.within potentially collapsible pharynx. www.indiandentalacademy.comwww.indiandentalacademy.com
  18. 18. Soft palateSoft palate  Movable muscular fold suspended fromMovable muscular fold suspended from posterior aspect of hard palate. Separatesposterior aspect of hard palate. Separates nasopharynx from oro-pharynx.nasopharynx from oro-pharynx.  Muscles-Muscles-  Tensor palatiTensor palati  Levator palatiLevator palati  Musculus uvulaeMusculus uvulae  PalatopharyngeasPalatopharyngeas  PalatoglossusPalatoglossus  Enlarged soft palate- Might be contributingEnlarged soft palate- Might be contributing factor in OSASfactor in OSAS www.indiandentalacademy.comwww.indiandentalacademy.com
  19. 19. PharynxPharynx  3 parts-3 parts- Nasopharynx- posterior aspect of nasalNasopharynx- posterior aspect of nasal turbinates to soft palateturbinates to soft palate Oro-pharynx- from soft palate to base ofOro-pharynx- from soft palate to base of tonguetongue Laryngopharynx- from base of tongue toLaryngopharynx- from base of tongue to larynxlarynx www.indiandentalacademy.comwww.indiandentalacademy.com
  20. 20. www.indiandentalacademy.comwww.indiandentalacademy.com
  21. 21. Muscles of pharynxMuscles of pharynx Superior Constrictor StylopharyngeusSuperior Constrictor Stylopharyngeus Middle constrictor PalatopharyngeusMiddle constrictor Palatopharyngeus Inferior constrictor SalpinopharyngeusInferior constrictor Salpinopharyngeus www.indiandentalacademy.comwww.indiandentalacademy.com
  22. 22. www.indiandentalacademy.comwww.indiandentalacademy.com
  23. 23.  Nasopharyngeal patency can beNasopharyngeal patency can be compromised by-compromised by- Local mass lesionsLocal mass lesions Scarring secondary to surgeryScarring secondary to surgery Under development of local bonyUnder development of local bony structuresstructures Palatal uvular hypertrophy or edemaPalatal uvular hypertrophy or edema AdenoidsAdenoids www.indiandentalacademy.comwww.indiandentalacademy.com
  24. 24.  Oropharyngeal patency can beOropharyngeal patency can be compromised by-compromised by- Palatine tonsil hypertrophy orPalatine tonsil hypertrophy or inflammationinflammation Palatal or uvular enlargementsPalatal or uvular enlargements MacroglossiaMacroglossia www.indiandentalacademy.comwww.indiandentalacademy.com
  25. 25.  Hypo pharyngeal patency can beHypo pharyngeal patency can be compromised-compromised- MacroglossiaMacroglossia Posterior & superior displacements of hyoidPosterior & superior displacements of hyoid bonebone www.indiandentalacademy.comwww.indiandentalacademy.com
  26. 26. TongueTongue  Muscular gland situated at floor ofMuscular gland situated at floor of mouth.mouth.  Muscles-Muscles- Intrinsic ExtrinsicIntrinsic Extrinsic Superior longitudinal GenioglossusSuperior longitudinal Genioglossus Inferior longitudinal HyoglossusInferior longitudinal Hyoglossus Transverse StyloglossusTransverse Styloglossus Vertical PalatoglossusVertical Palatoglossus www.indiandentalacademy.comwww.indiandentalacademy.com
  27. 27. www.indiandentalacademy.comwww.indiandentalacademy.com
  28. 28. Hyoid boneHyoid bone  Semi circular bone found in midlineSemi circular bone found in midline b/w mandible & thyroid cartilage.b/w mandible & thyroid cartilage.  Muscles-Muscles- Suprahyoid InfrahyoidSuprahyoid Infrahyoid Digastric OmohyoidDigastric Omohyoid Geniohyiod SternohyoidGeniohyiod Sternohyoid Stylohyoid SternothyroidStylohyoid Sternothyroid Mylohyoid ThyrohyoidMylohyoid Thyrohyoid www.indiandentalacademy.comwww.indiandentalacademy.com
  29. 29. www.indiandentalacademy.comwww.indiandentalacademy.com
  30. 30. Etiology & pathophysiology of OSASEtiology & pathophysiology of OSAS  Predisposing factors still debatedPredisposing factors still debated  Syndrome can be-Syndrome can be- CentralCentral Obstructive (most common)Obstructive (most common) Sub-obstructiveSub-obstructive mixedmixed www.indiandentalacademy.comwww.indiandentalacademy.com
  31. 31.  Obstruction prevented by action ofObstruction prevented by action of pharyngeal dilator & abductorpharyngeal dilator & abductor muscles- sleep reduces activity-muscles- sleep reduces activity- airway resistance increases.airway resistance increases.  Genioglossus largest & best studiedGenioglossus largest & best studied upper airway m. Conditions that retractupper airway m. Conditions that retract mandible lead to posterior movementmandible lead to posterior movement of tongue & narrowing of airway- canof tongue & narrowing of airway- can be overcome by moving jaw forward.be overcome by moving jaw forward. www.indiandentalacademy.comwww.indiandentalacademy.com
  32. 32.  Balance b/w pharyngeal musculatureBalance b/w pharyngeal musculature & negative intrapharyngeal pressure of& negative intrapharyngeal pressure of inspiration determines patency ofinspiration determines patency of upper airway. Structural narrowing ofupper airway. Structural narrowing of airway- hinders muscular componentairway- hinders muscular component of balance even at rest.of balance even at rest.  Most pts with OSAS have narrowedMost pts with OSAS have narrowed airway- confirmed by CT scan.airway- confirmed by CT scan. www.indiandentalacademy.comwww.indiandentalacademy.com
  33. 33.  Alterations in facial morphology may alsoAlterations in facial morphology may also be responsible for airway abnormality asbe responsible for airway abnormality as pharyngeal musculature intimately relatedpharyngeal musculature intimately related to bony structure. Eg- positive correlationto bony structure. Eg- positive correlation b/w OSAS & short or posteriorly displacedb/w OSAS & short or posteriorly displaced mandible in many pts.mandible in many pts. www.indiandentalacademy.comwww.indiandentalacademy.com
  34. 34.  Most of obstruction in OSAS pts seen inMost of obstruction in OSAS pts seen in oropharynx & associated with large tongueoropharynx & associated with large tongue volumes & also mainly in obese personsvolumes & also mainly in obese persons (excess peripharyngeal & subcutaneous fat)(excess peripharyngeal & subcutaneous fat)  Sleep with their jaws open- passive or activeSleep with their jaws open- passive or active jaw opening- triggers afferents in TMJ-jaw opening- triggers afferents in TMJ- reflexly inhibit Genioglossus m.reflexly inhibit Genioglossus m.  Anatomic aberration of pharyngeal airwayAnatomic aberration of pharyngeal airway &/or neurogenic failure to preserve patency&/or neurogenic failure to preserve patency of pharyngeal airway- 2 most commonof pharyngeal airway- 2 most common theories.theories. www.indiandentalacademy.comwww.indiandentalacademy.com
  35. 35. Table 1 www.indiandentalacademy.comwww.indiandentalacademy.com
  36. 36.  Many hereditary or acquired variables have alsoMany hereditary or acquired variables have also been described that precipitate OSAS-been described that precipitate OSAS- Adenoid & tonsillar hypertrophy in children & adultsAdenoid & tonsillar hypertrophy in children & adults Glottic websGlottic webs Vocal cord paralysisVocal cord paralysis AcromegalyAcromegaly Lymphoma or hodgkins dsLymphoma or hodgkins ds MicrognathiaMicrognathia Ectopic thyroidEctopic thyroid Upper airway radiation edema or fibrosisUpper airway radiation edema or fibrosis RetrognathiaRetrognathia Severe kyposcoliosisSevere kyposcoliosis Correlation of velopharyngeal incompetence inCorrelation of velopharyngeal incompetence in infantsinfants Cushings dsCushings ds www.indiandentalacademy.comwww.indiandentalacademy.com
  37. 37.  Physiologic abnormalities predisposing to OSAS-Physiologic abnormalities predisposing to OSAS- Poliomyelitis, muscular dystrophies, amyotrophicPoliomyelitis, muscular dystrophies, amyotrophic lateral sclerosis & other ds with bulbar incordinationlateral sclerosis & other ds with bulbar incordination sec. to brain stem abnormalities.sec. to brain stem abnormalities. Acquired dysautonomiaAcquired dysautonomia HypothyroidismHypothyroidism Flurazepam & other sedative hypnotic agentsFlurazepam & other sedative hypnotic agents Alcohol ingestionAlcohol ingestion Testosterone administrationTestosterone administration EpilepsyEpilepsy EncephalitisEncephalitis www.indiandentalacademy.comwww.indiandentalacademy.com
  38. 38. Mouth breathing and OSAMouth breathing and OSA  The tongue is no more in contact with theThe tongue is no more in contact with the anterior palate hence producing a dorsal motionanterior palate hence producing a dorsal motion of the belly of the genioglossus that falls backof the belly of the genioglossus that falls back into the pharynx.into the pharynx.  Diminishes the axis of action of the genioglossusDiminishes the axis of action of the genioglossus hence decreasing the efficiency of pulling thehence decreasing the efficiency of pulling the genioglossus out of the airway.genioglossus out of the airway.  Also the pressure is now exerted across theAlso the pressure is now exerted across the palate hence further narrowing the soft palate.palate hence further narrowing the soft palate. www.indiandentalacademy.comwww.indiandentalacademy.com
  39. 39.  Opening of the mouth by 1.5cm pushes back theOpening of the mouth by 1.5cm pushes back the gonial angle by 1cm, which decreases thegonial angle by 1cm, which decreases the distance between the ventral attachment of thedistance between the ventral attachment of the genioglossus and the posterior pharyngeal wallgenioglossus and the posterior pharyngeal wall hence decreasing the lumen by 1cmhence decreasing the lumen by 1cm  Decrease in nasal airflow decreases theDecrease in nasal airflow decreases the neuroregulatory mechanism of respirationneuroregulatory mechanism of respiration -bringing about depression of respiration --bringing about depression of respiration - predisposing to apneapredisposing to apnea www.indiandentalacademy.comwww.indiandentalacademy.com
  40. 40. Clinical & demographic features of OSASClinical & demographic features of OSAS  2 cardinal symptoms-2 cardinal symptoms-  Nocturnal symptom- snoringNocturnal symptom- snoring  Diurnal symptom- excessive day-time sleepinessDiurnal symptom- excessive day-time sleepiness  Other symptoms of sleep deprivation-Other symptoms of sleep deprivation-  Excessive fatigueExcessive fatigue  LethargyLethargy  Early morning headachesEarly morning headaches  Impaired concentration & impotenceImpaired concentration & impotence www.indiandentalacademy.comwww.indiandentalacademy.com
  41. 41.  Clinical spectrum of sleep apnea-Clinical spectrum of sleep apnea- Heavy habitual snoringHeavy habitual snoring Excessive day-time sleepinessExcessive day-time sleepiness Short term memory deficitsShort term memory deficits Intellectual deteriorationIntellectual deterioration Personality changesPersonality changes Abnormal motor behaviorAbnormal motor behavior ImpotenceImpotence nocturnal enuresisnocturnal enuresis www.indiandentalacademy.comwww.indiandentalacademy.com
  42. 42.  Other features includes-Other features includes-  Nocturnal choking & coughingNocturnal choking & coughing  OrthopneaOrthopnea  Ankle edemaAnkle edema  Right sided heart failureRight sided heart failure  Pulmonary hypertensionPulmonary hypertension  Central cyanosisCentral cyanosis  Systemic arterial hypertensionSystemic arterial hypertension  Cardiac arrhythmiasCardiac arrhythmias  PolycythemiaPolycythemia  ObesityObesity  HypothyroidismHypothyroidism  AcromegalyAcromegaly  Short thick neckShort thick neck  RetrognathiaRetrognathia  Nasal obstructionNasal obstruction www.indiandentalacademy.comwww.indiandentalacademy.com
  43. 43. www.indiandentalacademy.comwww.indiandentalacademy.com
  44. 44. Diagnostic Aids in OSADiagnostic Aids in OSA www.indiandentalacademy.comwww.indiandentalacademy.com
  45. 45. Diagnostic aids in OSASDiagnostic aids in OSAS  History –History – Snoring- 4-5 loud snores followed by silence,Snoring- 4-5 loud snores followed by silence, followed again by series of loud snoresfollowed again by series of loud snores Excessive day-time sleepinessExcessive day-time sleepiness  Clinical examination-Clinical examination- Examination of the entire upperExamination of the entire upper aerodigestive tract.aerodigestive tract. www.indiandentalacademy.comwww.indiandentalacademy.com
  46. 46.  Nasal examination:Nasal examination: Nose : nasal valve examination, alar collapseNose : nasal valve examination, alar collapse Nasal speculum examination for mucosaNasal speculum examination for mucosa changes, turbinates, DNS, pathology likechanges, turbinates, DNS, pathology like cysts and polyps.cysts and polyps.  Oral cavity and the oropharynx:Oral cavity and the oropharynx: Tongue : size , shape and the position.Tongue : size , shape and the position. High arched palateHigh arched palate TonsilsTonsils Relation of tongue to oropharynxRelation of tongue to oropharynx www.indiandentalacademy.comwww.indiandentalacademy.com
  47. 47.  Evaluate presence of disproportionate anatomy:Evaluate presence of disproportionate anatomy: Long soft palate, uvula, base of the tongue, andLong soft palate, uvula, base of the tongue, and retrognathic mandible and maxillaretrognathic mandible and maxilla  Evaluate hypo pharynx and larynx for presenceEvaluate hypo pharynx and larynx for presence of tumors, large epiglottal folds, lingual tonsils,of tumors, large epiglottal folds, lingual tonsils, vocal cords usually done with fibropticvocal cords usually done with fibroptic endoscopeendoscope www.indiandentalacademy.comwww.indiandentalacademy.com
  48. 48.  Sleep monitoring (polysomnography)-Sleep monitoring (polysomnography)- Simultaneous recording of no. of physiologicalSimultaneous recording of no. of physiological variables during sleep.variables during sleep. Electroencephalogram- brain activityElectroencephalogram- brain activity Electromyogram- muscle activityElectromyogram- muscle activity Electro ophthalmogram- eye movementsElectro ophthalmogram- eye movements Electro cardiogram- cardiac activityElectro cardiogram- cardiac activity Ear oximeter- oxygen saturationEar oximeter- oxygen saturation Nasal & oral sensors- nasal & oral airflowNasal & oral sensors- nasal & oral airflow Plethysmograph- thoracic & abdominal movementsPlethysmograph- thoracic & abdominal movements www.indiandentalacademy.comwww.indiandentalacademy.com
  49. 49. www.indiandentalacademy.comwww.indiandentalacademy.com
  50. 50. www.indiandentalacademy.comwww.indiandentalacademy.com
  51. 51.  It is best done at night with atleast 4hrs ofIt is best done at night with atleast 4hrs of sleep time recorded. Most sleep studiessleep time recorded. Most sleep studies are conducted for atleast 2 consecutiveare conducted for atleast 2 consecutive nights.nights.  Extreme sleep apnea includes oxygenExtreme sleep apnea includes oxygen saturations level below 60%, an apneicsaturations level below 60%, an apneic index greater than 50, prolonged apneaindex greater than 50, prolonged apnea lasting more than 45 sec. & concurrentlasting more than 45 sec. & concurrent cardiac arrhythmias.cardiac arrhythmias. www.indiandentalacademy.comwww.indiandentalacademy.com
  52. 52.  Abdominal or thoracic strain gaugesAbdominal or thoracic strain gauges provide movement tracings duringprovide movement tracings during respiratory efforts.respiratory efforts.  When there is simultaneous pause ofWhen there is simultaneous pause of airflow & thoracic or abdominal movement,airflow & thoracic or abdominal movement, aa central type of apneacentral type of apnea has occurred.has occurred.  If airflow ceases but respiratory effortIf airflow ceases but respiratory effort continues,continues, obstructive type of apnea.obstructive type of apnea. www.indiandentalacademy.comwww.indiandentalacademy.com
  53. 53.  Data then scrutinized. Duration & total no.Data then scrutinized. Duration & total no. of apnoeic periods, oxygen saturation,of apnoeic periods, oxygen saturation, time during which oxygen saturation leveltime during which oxygen saturation level below 90%, no. of arousals, quantity ofbelow 90%, no. of arousals, quantity of REM sleep seen.REM sleep seen. www.indiandentalacademy.comwww.indiandentalacademy.com
  54. 54.  Obstructive apnea- upper airway obstruction causesupper airway obstruction causes cessation of airflow with concomitant continuation ofcessation of airflow with concomitant continuation of thoracic breathing movements.thoracic breathing movements.  Central apnea- simultaneous cessation of both airflow &simultaneous cessation of both airflow & thoracic breathing movements.thoracic breathing movements.  Mixed apnea- episodes of central apnea lasts 10 sec orepisodes of central apnea lasts 10 sec or longer followed by obstructive apnea.longer followed by obstructive apnea.  Apnea – cessation of airflow for more than 10 sec.– cessation of airflow for more than 10 sec.  Hypoapnea – reduction in tidal volume accompanied by– reduction in tidal volume accompanied by fall in blood oxygen saturation, lasting more than 10 sec.fall in blood oxygen saturation, lasting more than 10 sec. www.indiandentalacademy.comwww.indiandentalacademy.com
  55. 55. To diagnose OSA  30 or more apnoeic episodes within a course of30 or more apnoeic episodes within a course of 7hrs of sleep, resulting in excessive sleepiness7hrs of sleep, resulting in excessive sleepiness during waking hrs.during waking hrs.  5 episodes of apnea or hypo apnea must occur5 episodes of apnea or hypo apnea must occur per hrper hr  To make diagnosis & access severity of dsTo make diagnosis & access severity of ds  To determine need & urgency of treatment.To determine need & urgency of treatment. www.indiandentalacademy.comwww.indiandentalacademy.com
  56. 56. Epworth sleepiness scaleEpworth sleepiness scale  A questionnaire designed to assess how likelyA questionnaire designed to assess how likely person would doze off in 8 specific situations-person would doze off in 8 specific situations-  Sitting & readingSitting & reading  Watching TVWatching TV  As a passenger sitting in car for an hrAs a passenger sitting in car for an hr  Sitting inactive in public placeSitting inactive in public place  Lying down to rest in afternoonLying down to rest in afternoon  Sitting & talking to someoneSitting & talking to someone  Sitting quietly after lunch, without having consumedSitting quietly after lunch, without having consumed alcohol.alcohol.  As a driver of a car, stopped for a few min in traffic.As a driver of a car, stopped for a few min in traffic. www.indiandentalacademy.comwww.indiandentalacademy.com
  57. 57.  Scores-Scores- 0 – no chance0 – no chance 1 – low likelihood1 – low likelihood 2 – moderately possible2 – moderately possible 3 – high chance3 – high chance  A score above 12 indicates subject isA score above 12 indicates subject is more sleepy than normal individual.more sleepy than normal individual. www.indiandentalacademy.comwww.indiandentalacademy.com
  58. 58.  Computerized tomography-Computerized tomography- Non invasive scanning techniqueNon invasive scanning technique Confines radiation to plane of interestConfines radiation to plane of interest Minimizes blurringMinimizes blurring Permits visualization of small variations inPermits visualization of small variations in tissue density.tissue density. 3 dimensional description of airway, tongue &3 dimensional description of airway, tongue & other associated structures.other associated structures. But it is time consuming procedure &But it is time consuming procedure & expensive.expensive. www.indiandentalacademy.comwww.indiandentalacademy.com
  59. 59. Study in AJO 1986 www.indiandentalacademy.comwww.indiandentalacademy.com
  60. 60.  Many studies shown-Many studies shown- Lowe et al-Lowe et al- large tongue , soft palate &large tongue , soft palate & reduced airway volumes. Majority ofreduced airway volumes. Majority of constriction occurred in oropharynxconstriction occurred in oropharynx Hapnik et al-Hapnik et al- reduced cross sectional areas ofreduced cross sectional areas of nasopharynx, oropharynx & hypopharynx.nasopharynx, oropharynx & hypopharynx. Subjects with severe OSA- larger tongue &Subjects with severe OSA- larger tongue & smaller airway surface volume.smaller airway surface volume. More obese subjects- large tongue surfaceMore obese subjects- large tongue surface areas & smaller airway surface areas.areas & smaller airway surface areas. www.indiandentalacademy.comwww.indiandentalacademy.com
  61. 61.  Magnetic resonance imaging-Magnetic resonance imaging-  Produces high resolution images without use ofProduces high resolution images without use of ionizing radiation & yields both transverse & sagittalionizing radiation & yields both transverse & sagittal sections of pharynx.sections of pharynx.  Ideally suited in assessing conditions with increasedIdeally suited in assessing conditions with increased tissue water content.tissue water content.  Horner et al – used MRI to assess upper airway in– used MRI to assess upper airway in obese pts showed an excess on fat deposition in softobese pts showed an excess on fat deposition in soft palate, tongue & surrounding collapsible segment ofpalate, tongue & surrounding collapsible segment of the pharynx.the pharynx. www.indiandentalacademy.comwww.indiandentalacademy.com
  62. 62.  Fibre optic endoscopy-Fibre optic endoscopy- Of value in location site of obstruction inOf value in location site of obstruction in upper airwayupper airway Particular emphasis is on the base of tongue,Particular emphasis is on the base of tongue, its position & its forward movement onits position & its forward movement on protrusion pf jaws.protrusion pf jaws. www.indiandentalacademy.comwww.indiandentalacademy.com
  63. 63.  Electromyography-Electromyography- Genioglossus m. activity in OSAGenioglossus m. activity in OSA Timing relationship b/w genioglossusTiming relationship b/w genioglossus inspiratory effort is of physiologic importanceinspiratory effort is of physiologic importance in pathogenesis in OSAin pathogenesis in OSA www.indiandentalacademy.comwww.indiandentalacademy.com
  64. 64.  Cephalometry –Cephalometry –  Lowe et al showed following hard & soft tissueshowed following hard & soft tissue morphological characteristics in pts. with OSA-morphological characteristics in pts. with OSA-  Hard tissue features-Hard tissue features- Small mandible which is retropositionedSmall mandible which is retropositioned Increase in anterior facial htIncrease in anterior facial ht Enlarged occlusal & mandibular plane angleEnlarged occlusal & mandibular plane angle Over erupted maxillary & mandibular molarsOver erupted maxillary & mandibular molars Steep occlusal planeSteep occlusal plane Posteriorly positioned maxillae & mandiblePosteriorly positioned maxillae & mandible Proclined incisorsProclined incisors Decreased overbiteDecreased overbite Inferior position of hyoid boneInferior position of hyoid bone www.indiandentalacademy.comwww.indiandentalacademy.com
  65. 65.  Soft tissue features-Soft tissue features- Elongated tongue, soft palate & pharyngeal ltElongated tongue, soft palate & pharyngeal lt Thickened soft palateThickened soft palate Decreased A-P pharyngeal space at superior,Decreased A-P pharyngeal space at superior, middle & inferior levelsmiddle & inferior levels Enlarged cross-sectional areas of tongue &Enlarged cross-sectional areas of tongue & soft palatesoft palate Decreased cross-sectional areas ofDecreased cross-sectional areas of oropharynx & hypopharynxoropharynx & hypopharynx www.indiandentalacademy.comwww.indiandentalacademy.com
  66. 66.  Lyberg and KronstadLyberg and Kronstad also documented similaralso documented similar craniofacial features. Also noticed that in all theircraniofacial features. Also noticed that in all their patients the hyoid bone was inferiorly positionedpatients the hyoid bone was inferiorly positioned (usually at junction of C3 and C4) had shifted(usually at junction of C3 and C4) had shifted much lower to C4, C5, C6 suggesting it couldmuch lower to C4, C5, C6 suggesting it could be pushed down by the tongue.be pushed down by the tongue.  Large deposits of submental andLarge deposits of submental and submandibular fat.submandibular fat. www.indiandentalacademy.comwww.indiandentalacademy.com
  67. 67. www.indiandentalacademy.comwww.indiandentalacademy.com
  68. 68. www.indiandentalacademy.comwww.indiandentalacademy.com
  69. 69. www.indiandentalacademy.comwww.indiandentalacademy.com
  70. 70. Study in angle 1996www.indiandentalacademy.comwww.indiandentalacademy.com
  71. 71. www.indiandentalacademy.comwww.indiandentalacademy.com
  72. 72. www.indiandentalacademy.comwww.indiandentalacademy.com
  73. 73. Nasopharyngoscopy:Nasopharyngoscopy: Widely available easily performed, no radiation,Widely available easily performed, no radiation, performed sitting or supine, Muller’s maneuver canperformed sitting or supine, Muller’s maneuver can be performed possibility of predicting the outcomebe performed possibility of predicting the outcome of UPPP depending on the site of obstructionof UPPP depending on the site of obstruction Invasive and requires nasal anesthesia, evaluateInvasive and requires nasal anesthesia, evaluate only the airway lumen and not surrounding softonly the airway lumen and not surrounding soft tissue and patient is usually awake.tissue and patient is usually awake. www.indiandentalacademy.comwww.indiandentalacademy.com
  74. 74. Management of OSAManagement of OSA  Since etiology not precisely understood soSince etiology not precisely understood so diversity of treatment options.diversity of treatment options.  Treatment of OSA depend on –Treatment of OSA depend on – Severity of symptomsSeverity of symptoms Magnitude of clinical complicationsMagnitude of clinical complications Etiology of upper airway obstructionEtiology of upper airway obstruction www.indiandentalacademy.comwww.indiandentalacademy.com
  75. 75.  Normally accepted options as outlined byNormally accepted options as outlined by J.M Battagel-J.M Battagel- Wt reductionWt reduction Elimination of aggravating factorsElimination of aggravating factors ENT assessment plus any necessaryENT assessment plus any necessary treatmenttreatment CPAPCPAP Mandibular advancementMandibular advancement Surgical optionsSurgical options www.indiandentalacademy.comwww.indiandentalacademy.com
  76. 76. Elimination of aggravating factorsElimination of aggravating factors  Chronic obstructive airway dsChronic obstructive airway ds  AsthmaAsthma  HypothyroidismHypothyroidism  Other such medical conditions that may 1Other such medical conditions that may 1stst be eliminatedbe eliminated  Alcohol intakeAlcohol intake  Sedative medicationSedative medication www.indiandentalacademy.comwww.indiandentalacademy.com
  77. 77. Weight loss  Dramatic loss in wt. can result inDramatic loss in wt. can result in significant decrease in apneic episodes insignificant decrease in apneic episodes in obese pts suffering from OSA.obese pts suffering from OSA.  Recommended as 1Recommended as 1stst form of therapy inform of therapy in mild to moderate cases.mild to moderate cases. www.indiandentalacademy.comwww.indiandentalacademy.com
  78. 78. Sleep posture  CartwrightCartwright suggested that change in sleepsuggested that change in sleep posture from supine posture to a lateralposture from supine posture to a lateral decubital position can reduce tendency fordecubital position can reduce tendency for airway collapse.airway collapse.  In supine position especially during REMIn supine position especially during REM sleep, gravity & reduced tone ofsleep, gravity & reduced tone of genioglossus m. increase the possibility ofgenioglossus m. increase the possibility of obstruction.obstruction. www.indiandentalacademy.comwww.indiandentalacademy.com
  79. 79. Drug therapyDrug therapy  Progesterone has been used in an effortProgesterone has been used in an effort to diminish obstructive apneas duringto diminish obstructive apneas during sleep by acting as respiratory stimulant tosleep by acting as respiratory stimulant to airway, diaphragm & intercostals.airway, diaphragm & intercostals. www.indiandentalacademy.comwww.indiandentalacademy.com
  80. 80. Nasopharyngeal airwayNasopharyngeal airway  Placed beyond clinical obstruction site canPlaced beyond clinical obstruction site can have positive effect in OSA pts.have positive effect in OSA pts. www.indiandentalacademy.comwww.indiandentalacademy.com
  81. 81. Continuous positive airway pressure (CPAP)  Discovered byDiscovered by Collin SullivanCollin Sullivan in Sydneyin Sydney  Continuous stream of air under pressure isContinuous stream of air under pressure is filtered & delivered to pharynx via a nasal mask.filtered & delivered to pharynx via a nasal mask.  Act asAct as pneumatic splintpneumatic splint..  This constant flow enough to prevent airwayThis constant flow enough to prevent airway from collapsing but yet not enough to preventfrom collapsing but yet not enough to prevent periodic expiration. So to be secured firmly inperiodic expiration. So to be secured firmly in place.place.  Should be worn 6hrs at night, 7 days a week.Should be worn 6hrs at night, 7 days a week. www.indiandentalacademy.comwww.indiandentalacademy.com
  82. 82.  Advantages –Advantages –  Most common & successful treatment for OSAMost common & successful treatment for OSA  Subject no longer dozes offSubject no longer dozes off  Sleeps well & feel less irritableSleeps well & feel less irritable  Disadvantages –Disadvantages –  Studies byStudies by Clark et al found 10-20% of subjects foundfound 10-20% of subjects found it extremely uncomfortable & discontinued it.it extremely uncomfortable & discontinued it.  Overall long term compliance with this device-Overall long term compliance with this device- 60-70%60-70% www.indiandentalacademy.comwww.indiandentalacademy.com
  83. 83. www.indiandentalacademy.comwww.indiandentalacademy.com
  84. 84. Dental appliances  InexpensiveInexpensive  Non-invasiveNon-invasive  Easy to fabricateEasy to fabricate  Quite well tolerated by pt.Quite well tolerated by pt. www.indiandentalacademy.comwww.indiandentalacademy.com
  85. 85. 3 rationales  Reposition tongue in a more forwardReposition tongue in a more forward position (TRD)position (TRD)  Reposition mandible forward (nocturnalReposition mandible forward (nocturnal airway potency appliance NAPA, snoreairway potency appliance NAPA, snore guard, herbst, mandibular positioner)guard, herbst, mandibular positioner)  To lift soft palate or reposition the uvulaTo lift soft palate or reposition the uvula (equalizer)(equalizer) www.indiandentalacademy.comwww.indiandentalacademy.com
  86. 86. Approach to patientApproach to patient  Evaluate for periodontal health, dental restorations,Evaluate for periodontal health, dental restorations, occlusion, TMJ function, mandibular movement andocclusion, TMJ function, mandibular movement and craniofacial skeletal typecraniofacial skeletal type  Enough teeth must be present – at least 6 teeth in eachEnough teeth must be present – at least 6 teeth in each arch and one good posterior teeth in each quadrant.arch and one good posterior teeth in each quadrant. patient should be able to protrude the mandible at least 5patient should be able to protrude the mandible at least 5 mm without discomfortmm without discomfort  A patient with deep palate, long soft palate and steepA patient with deep palate, long soft palate and steep mandibular plane may not be a good candidate, thoughmandibular plane may not be a good candidate, though there is no set criteria.there is no set criteria.  After insertion and final adjustment a PSG must be doneAfter insertion and final adjustment a PSG must be done to evaluate the efficiency and a base line Ceph, mustto evaluate the efficiency and a base line Ceph, must have been obtained.have been obtained. www.indiandentalacademy.comwww.indiandentalacademy.com
  87. 87. AppliancesAppliances  Almost 32 commercial appliancesAlmost 32 commercial appliances available:available: Basically two types:Basically two types: Mandibular advancement devices (MAD) andMandibular advancement devices (MAD) and Tongue repositioning devices.Tongue repositioning devices. www.indiandentalacademy.comwww.indiandentalacademy.com
  88. 88. TRDTRD  Described byDescribed by Cartwright & SamelsonCartwright & Samelson inin 1982.1982.  To keep tongue in forward position- placesTo keep tongue in forward position- places it into cup or bubble positioned in theit into cup or bubble positioned in the anterior region with surface adhesionanterior region with surface adhesion holding tongue in position.holding tongue in position.  Jaws to be kept in partly open position.Jaws to be kept in partly open position. www.indiandentalacademy.comwww.indiandentalacademy.com
  89. 89. Disadvantages  Tongue not always held in forwardTongue not always held in forward position- surface adhesion lostposition- surface adhesion lost  Esthetically intolerableEsthetically intolerable  Forces nasal breathing- may beForces nasal breathing- may be troublesome in some pts.troublesome in some pts.  Tongue may get irritated becoz of lack ofTongue may get irritated becoz of lack of blood supply.blood supply. www.indiandentalacademy.comwww.indiandentalacademy.com
  90. 90.  Advantages:Advantages: Can be used in edentulous patients,Can be used in edentulous patients, Will not loosen restoration as they do notWill not loosen restoration as they do not require retention,require retention, Minimal or no adjustment and no sensitivity toMinimal or no adjustment and no sensitivity to teethteeth Offset fluctuation of the genioglossus muscle.Offset fluctuation of the genioglossus muscle. www.indiandentalacademy.comwww.indiandentalacademy.com
  91. 91. Anterior tongue repositioner www.indiandentalacademy.comwww.indiandentalacademy.com
  92. 92.  Ferguson et al 1996-Ferguson et al 1996- TRD mostTRD most successful in pts who are less than 50%successful in pts who are less than 50% above ideal wt & in whom OSA is worseabove ideal wt & in whom OSA is worse when they sleep in supine position.when they sleep in supine position.  Clark et al 1989-Clark et al 1989- TRD effective in 75% ofTRD effective in 75% of mild to moderate cases compared tomild to moderate cases compared to CPAP, more easily tolerated.CPAP, more easily tolerated. www.indiandentalacademy.comwww.indiandentalacademy.com
  93. 93. TRD & genioglossus m. activityTRD & genioglossus m. activity  Cartwright et al 1982-Cartwright et al 1982- alteredaltered genioglossus m. activity significantlygenioglossus m. activity significantly improved with TRD.improved with TRD.  Ono et al 1996-Ono et al 1996- 2 tongue retaining devices made for each2 tongue retaining devices made for each subjects- TRD A & TRD Bsubjects- TRD A & TRD B TRD A- no anterior bulbTRD A- no anterior bulb TRD B- has bulbTRD B- has bulb www.indiandentalacademy.comwww.indiandentalacademy.com
  94. 94.  Both TRD A & B- reduced apnea-hypoapneaBoth TRD A & B- reduced apnea-hypoapnea index (AH index)index (AH index)  TRD A-TRD A- activation of genioglossus m. activity byactivation of genioglossus m. activity by creating passive jaw opening- TMJ receptorscreating passive jaw opening- TMJ receptors send information to CNS regarding jaw rotationsend information to CNS regarding jaw rotation which affects tongue protrusion by genioglossuswhich affects tongue protrusion by genioglossus m. activity.m. activity.  TRD B-TRD B- normalized time lag b/w peak inspiratorynormalized time lag b/w peak inspiratory genioglossus m. EMG activity & max. inspiratorygenioglossus m. EMG activity & max. inspiratory effort. Also normalized amplitude of peakeffort. Also normalized amplitude of peak genioglossus m. EMG activity that fluctuatedgenioglossus m. EMG activity that fluctuated during AH episodes while used TRD A.during AH episodes while used TRD A. www.indiandentalacademy.comwww.indiandentalacademy.com
  95. 95.  Anterior tongue position with TRDAnterior tongue position with TRD alleviates narrowing of upper airway thatalleviates narrowing of upper airway that produces more positive pressure duringproduces more positive pressure during inspiration. OSA pts otherwise will sufferinspiration. OSA pts otherwise will suffer from scarcity of negative pressure-drivenfrom scarcity of negative pressure-driven reflex during sleep.reflex during sleep. www.indiandentalacademy.comwww.indiandentalacademy.com
  96. 96. Anterior mandibular positioning devicesAnterior mandibular positioning devices  Many designs thereMany designs there  2 consistent features-2 consistent features- Moves mandible forward several mmsMoves mandible forward several mms Maintains jaw in forward position even thoughMaintains jaw in forward position even though pt is asleeppt is asleep  Could be 1 piece appliance or 2 pieceCould be 1 piece appliance or 2 piece appliance with tube & rod attachmentappliance with tube & rod attachment (herbst appliance)(herbst appliance) www.indiandentalacademy.comwww.indiandentalacademy.com
  97. 97. 2 piece appliance2 piece appliance  Advantages-Advantages-  Maintains constant forward position of tongueMaintains constant forward position of tongue  Can be designed to allow continued oral breathingCan be designed to allow continued oral breathing  More esthetically pleasingMore esthetically pleasing  Disadvantages-Disadvantages-  Deleterious effect such as TMJ remodeling &Deleterious effect such as TMJ remodeling & subsequent dysfunctionsubsequent dysfunction  Occlusal change- proclination or crowding of lowerOcclusal change- proclination or crowding of lower anteriorsanteriors www.indiandentalacademy.comwww.indiandentalacademy.com
  98. 98. Nocturnal airway patency applianceNocturnal airway patency appliance  Designed by George 1987Designed by George 1987  Designed to keep airway open duringDesigned to keep airway open during sleep by-sleep by- Posturing tongue more anteriorlyPosturing tongue more anteriorly Inhibiting wide jaw openingInhibiting wide jaw opening Assuring adequate air intake through mouthAssuring adequate air intake through mouth whenever nasal obstruction occurs.whenever nasal obstruction occurs. www.indiandentalacademy.comwww.indiandentalacademy.com
  99. 99. Nocturnal airway patency appliance www.indiandentalacademy.comwww.indiandentalacademy.com
  100. 100.  Results showed-Results showed- Improvement in sleepImprovement in sleep Snoring decreased or completelySnoring decreased or completely disappeared.disappeared. Daytime somnolence diminished markedly.Daytime somnolence diminished markedly. Does produce some discomfort at night butDoes produce some discomfort at night but pts get used to it.pts get used to it. www.indiandentalacademy.comwww.indiandentalacademy.com
  101. 101. Mandibular advancement splintsMandibular advancement splints  Like CPAP, mandibular advancement splints are a non- Invasive and therefore reversible form of treatment, and are worn only during sleep.  Many designs have been described, but essentially these resemble a functional appliance: full coverage upper and lower splints are constructed to a protrusive working bite.  To be effective, the appliance must have good retention to both upper and lower teeth, sufficient protrusion to prevent pharyngeal collapse in the supine position and as little vertical opening as possible.  An anterior space between upper and lower segments of the splint is helpful for those who are mouth breathers. www.indiandentalacademy.comwww.indiandentalacademy.com
  102. 102.  Seventy-five per cent of maximal protrusion has been advised.  Furthermore, the amount of protrusion must be tolerated by the individual. Since tolerance increases with time, splints which are capable of incremental advancement would seem to have clear advantages.  Suitable designs include cribbed activator, vacuum formed devices & removable herbst. www.indiandentalacademy.comwww.indiandentalacademy.com
  103. 103. Mandibular advancement splint www.indiandentalacademy.comwww.indiandentalacademy.com
  104. 104. Magnetic applianceMagnetic appliance  Maximal attractive force b/w magnets wasMaximal attractive force b/w magnets was 8.5N.8.5N.  Intermagnetic distance 0.6-1mm, whichIntermagnetic distance 0.6-1mm, which reduce force magnitude for mandibularreduce force magnitude for mandibular advancement to 5-6.5N.advancement to 5-6.5N.  Clasps for additional retention provided.Clasps for additional retention provided.  It is seen decrease in day time sleepinessIt is seen decrease in day time sleepiness & nocturnal snoring. Blood saturation level& nocturnal snoring. Blood saturation level improved in some pts. No effect on TMJ.improved in some pts. No effect on TMJ. www.indiandentalacademy.comwww.indiandentalacademy.com
  105. 105. Magnetic appliance www.indiandentalacademy.comwww.indiandentalacademy.com
  106. 106. Karwetzky activatorKarwetzky activator  Acc. ToAcc. To Marklund et al therapeutic efficacy of activator is optimal when pts had A-H index less than 10 events/hr. Results showed- respiratory parameters significantly improved, decrease snoring & day time sleepiness. A-H index increased. www.indiandentalacademy.comwww.indiandentalacademy.com
  107. 107. Karwetzky activator www.indiandentalacademy.comwww.indiandentalacademy.com
  108. 108. Herbst applianceHerbst appliance  Introduced byIntroduced by Emil Herbst in 1905 &Emil Herbst in 1905 & reintroduced in 1970’s by Hans Pancherz.reintroduced in 1970’s by Hans Pancherz.  Clark et al in 1993Clark et al in 1993 evaluated the effect of herbstevaluated the effect of herbst type of anterior mandibular positioning device intype of anterior mandibular positioning device in 24 OSA pts. Results were satisfactory & follow24 OSA pts. Results were satisfactory & follow up investigation 3 yrs later showed appliance toup investigation 3 yrs later showed appliance to have been used successfully & continually usedhave been used successfully & continually used in 52% of the sample.in 52% of the sample. www.indiandentalacademy.comwww.indiandentalacademy.com
  109. 109.  Potential complications include-Potential complications include- TMJ remodeling & dysfunctionTMJ remodeling & dysfunction Jaw painJaw pain Occlusal changes like lower incisor crowdingOcclusal changes like lower incisor crowding If not protruded by 75% it did not work.If not protruded by 75% it did not work. www.indiandentalacademy.comwww.indiandentalacademy.com
  110. 110. www.indiandentalacademy.comwww.indiandentalacademy.com
  111. 111.  Constructed of vinyl and repositions theConstructed of vinyl and repositions the mandible in a “neuromuscular balancedmandible in a “neuromuscular balanced position” determined by “myomonitorposition” determined by “myomonitor (TENS)”, incorporating “equalizing tubes”(TENS)”, incorporating “equalizing tubes” which are believed to “decrease thewhich are believed to “decrease the negative pressure in oropharynx” duringnegative pressure in oropharynx” during inspiration.inspiration. The EqualizerThe Equalizer www.indiandentalacademy.comwww.indiandentalacademy.com
  112. 112. www.indiandentalacademy.comwww.indiandentalacademy.com
  113. 113. www.indiandentalacademy.comwww.indiandentalacademy.com
  114. 114. AdjustmentAdjustment  Initially 70 – 75% of maximum forwardInitially 70 – 75% of maximum forward positioning of the mandiblepositioning of the mandible  Kept so for a week and if symptoms do notKept so for a week and if symptoms do not subside then further advancement at asubside then further advancement at a rate of .25mm per week till symptomsrate of .25mm per week till symptoms subside or TMJ limitations start to showsubside or TMJ limitations start to show  Recalls at every 2 weeks; 1 month; 6Recalls at every 2 weeks; 1 month; 6 monthsmonths www.indiandentalacademy.comwww.indiandentalacademy.com
  115. 115. ProblemsProblems  Disocclussion of the posterior teethDisocclussion of the posterior teeth  Forward movement of the lower teethForward movement of the lower teeth  Excessive salivationExcessive salivation  Feeling of fullnessFeeling of fullness  TMJ sensitivity and sensitivity of teethTMJ sensitivity and sensitivity of teeth www.indiandentalacademy.comwww.indiandentalacademy.com
  116. 116. EfficiencyEfficiency  Shows good prognosis in mild to moderate cases.Shows good prognosis in mild to moderate cases.  Many showed immediate symptomaticMany showed immediate symptomatic improvement.improvement.  Base of the tongue was advanced and dorsalBase of the tongue was advanced and dorsal surface appeared more superiorsurface appeared more superior  Hyoid bone positioned anteriorly and cross sectionHyoid bone positioned anteriorly and cross section of oropharynx increased from 41.6 mm to 92.3of oropharynx increased from 41.6 mm to 92.3 mmmm  Airway volume increased by 27.6% and tongueAirway volume increased by 27.6% and tongue volume decreased by 17.6% due to the forwardvolume decreased by 17.6% due to the forward and superior tongue posture.and superior tongue posture. www.indiandentalacademy.comwww.indiandentalacademy.com
  117. 117. Antisnoring devicesAntisnoring devices  Clark & Nakano 1989Clark & Nakano 1989 described 2 devicesdescribed 2 devices to have an effect at reducing snoring-to have an effect at reducing snoring- Labial shield-Labial shield- Prevent mouth breathing & forces nasalPrevent mouth breathing & forces nasal breathingbreathing Maintains patency b/w soft palate & pharynxMaintains patency b/w soft palate & pharynx Palatal lift-Palatal lift- Stop soft palate vibration so reduces snoring.Stop soft palate vibration so reduces snoring. www.indiandentalacademy.comwww.indiandentalacademy.com
  118. 118. Surgical management of OSASurgical management of OSA  Current surgical techniques used-Current surgical techniques used-  TracheostomyTracheostomy  Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)  Osteomy (anterior sagittal) with hyoid myotomy &Osteomy (anterior sagittal) with hyoid myotomy & suspension.suspension.  Maxillary, mandibular & hyoid advancement.Maxillary, mandibular & hyoid advancement.  Genioglossus advancementGenioglossus advancement  Partial glossectomyPartial glossectomy  Radiofrequency volumetric shrinkage of soft palate &Radiofrequency volumetric shrinkage of soft palate & tongue basetongue base  Tongue base suspension suturesTongue base suspension sutures www.indiandentalacademy.comwww.indiandentalacademy.com
  119. 119. TracheostomyTracheostomy  11stst reported as treatment of OSA in 1969 byreported as treatment of OSA in 1969 by Guilleminault et alGuilleminault et al..  Indications –Indications –  Disabling sleepiness with severe familial & socio-Disabling sleepiness with severe familial & socio- economic impacteconomic impact  Severe cardiac arrhythmias with sleep apnea.Severe cardiac arrhythmias with sleep apnea.  A high apneic index (>60)A high apneic index (>60)  Notable oxygen desaturation level during sleep i.eNotable oxygen desaturation level during sleep i.e below 40%below 40%  No improvement of clinical symptoms orNo improvement of clinical symptoms or polysomnographic findings after medical trials.polysomnographic findings after medical trials. www.indiandentalacademy.comwww.indiandentalacademy.com
  120. 120.  Results showed-Results showed- Surgery may result in sec. local & generalSurgery may result in sec. local & general acute & subacute complications.acute & subacute complications. But on long term basis pts were completelyBut on long term basis pts were completely relieved of clinical symptoms.relieved of clinical symptoms. www.indiandentalacademy.comwww.indiandentalacademy.com
  121. 121. UvulopalatopharyngoplastyUvulopalatopharyngoplasty  Proposed byProposed by Ikematsu in 1964 & introduced byIkematsu in 1964 & introduced by Fujita et al in 1981.Fujita et al in 1981.  Resect posterior margin of the soft palate &Resect posterior margin of the soft palate & redundant lateral pharyngeal wall mucosa.redundant lateral pharyngeal wall mucosa.  Soft palate resection ranges from 8-15mmSoft palate resection ranges from 8-15mm stopping short of thick muscular part of thestopping short of thick muscular part of the palate.palate.  Lateral pharyngeal wall treated by resectingLateral pharyngeal wall treated by resecting redundant mucosa & developing a flap along theredundant mucosa & developing a flap along the posterior wall.posterior wall. www.indiandentalacademy.comwww.indiandentalacademy.com
  122. 122.  Flap is advanced & sutured to anterior tonsillarFlap is advanced & sutured to anterior tonsillar pillar.pillar.  When sites of obstruction included excessiveWhen sites of obstruction included excessive pharyngeal tissues combined with low-archedpharyngeal tissues combined with low-arched palates response rate is increased.palates response rate is increased.  Complications of UPPP-Complications of UPPP-  Pharyngeal drynessPharyngeal dryness  Loss of tasteLoss of taste  Nasopharyngeal stenosisNasopharyngeal stenosis www.indiandentalacademy.comwww.indiandentalacademy.com
  123. 123. www.indiandentalacademy.comwww.indiandentalacademy.com
  124. 124. Kamami technicKamami technic  Proposed laser assisted uvuloProposed laser assisted uvulo palatoplasty.palatoplasty. Carbon dioxide laser at 20 watts (continuousCarbon dioxide laser at 20 watts (continuous mode)mode) Reports success rates comparable or betterReports success rates comparable or better than convectional UPPP.than convectional UPPP. www.indiandentalacademy.comwww.indiandentalacademy.com
  125. 125. Inferior sagittal osteotomy of the mandible withInferior sagittal osteotomy of the mandible with hyoid myotomy & suspensionhyoid myotomy & suspension  11stst reported byreported by Riley et al 1984Riley et al 1984  He treated 55 pts-He treated 55 pts- 67% good response67% good response 33% non responders33% non responders www.indiandentalacademy.comwww.indiandentalacademy.com
  126. 126. Supra hyoid myotomy: to elevate the redundant lateral pharyngeal tissues sometimes accomplished with genioglossal advancement www.indiandentalacademy.comwww.indiandentalacademy.com
  127. 127. Genioglossus suspension sutures www.indiandentalacademy.comwww.indiandentalacademy.com
  128. 128. Maxillary, mandibular & hyoid advancement  Lefort I osteotomy & sagittal split osteotomyLefort I osteotomy & sagittal split osteotomy  Gives more predictable resultsGives more predictable results  Best alternative to Tracheostomy.Best alternative to Tracheostomy.  Indications –Indications –  Pts with normal skeletal development & severe OSAPts with normal skeletal development & severe OSA  Morbidly obese ptsMorbidly obese pts  Severe skeletal deficiencySevere skeletal deficiency  Other modes of treatment failed.Other modes of treatment failed. www.indiandentalacademy.comwww.indiandentalacademy.com
  129. 129. www.indiandentalacademy.comwww.indiandentalacademy.com
  130. 130. ConclusionConclusion  High prevalence of OSA has only been recentlyHigh prevalence of OSA has only been recently appreciated in part becoz s/s of chronic sleepappreciated in part becoz s/s of chronic sleep disruption are often overlooked inspite ofdisruption are often overlooked inspite of debilitating consequences.debilitating consequences.  Challenge to clinician is to routinely consider theChallenge to clinician is to routinely consider the diagnosis & to incorporate several basicdiagnosis & to incorporate several basic questions in the historical review of symptomsquestions in the historical review of symptoms regarding daytime or inappropriate sleepiness.regarding daytime or inappropriate sleepiness. www.indiandentalacademy.comwww.indiandentalacademy.com
  131. 131.  Clinician s/b aware of the role ofClinician s/b aware of the role of orthodontists in prevention & treatment oforthodontists in prevention & treatment of sleep disorders by various orthodonticsleep disorders by various orthodontic appliances.appliances.  Team approach for management of suchTeam approach for management of such pts with OSA currently includes support ofpts with OSA currently includes support of pulmonologist, neurologist, sleep labpulmonologist, neurologist, sleep lab technician, oral surgeon &technician, oral surgeon & otolaryngologist.otolaryngologist. www.indiandentalacademy.comwww.indiandentalacademy.com
  132. 132.  Most recently consistent use of cephMost recently consistent use of ceph analysis has been recommended to aid inanalysis has been recommended to aid in diagnosis & treatment planning for OSAdiagnosis & treatment planning for OSA pts.pts.  This coupled with new & promisingThis coupled with new & promising treatment alternative of the orthodontictreatment alternative of the orthodontic appliances, would suggest that theappliances, would suggest that the orthodontist could contribute to teamorthodontist could contribute to team management of these pts.management of these pts. www.indiandentalacademy.comwww.indiandentalacademy.com
  133. 133. Thank youThank you For more details please visitFor more details please visit www.indiandentalacademy.comwww.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com

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