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
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
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
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.
Reduced blood oxygen saturation leadsReduced blood oxygen saturation leads
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
Related to orthodontics-Related to orthodontics-
Peculiar cranio-facial & soft tissuePeculiar cranio-facial & soft tissue
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.
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
Sedative medicationSedative medication
Certain medical conditionCertain medical condition
MildMild: 5 to 15 involuntary sleep episodes: 5 to 15 involuntary sleep episodes
occurring during activities that require littleoccurring during activities that require little
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
Epidemiology of obstructive apnea syndrome
Mc NamaraMc Namara found 1-9% prevalence offound 1-9% prevalence of
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.
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-
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
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.
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
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.
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.
Tensor palatiTensor palati
Levator palatiLevator palati
Musculus uvulaeMusculus uvulae
Enlarged soft palate- Might be contributingEnlarged soft palate- Might be contributing
factor in OSASfactor in OSAS
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
Laryngopharynx- from base of tongue toLaryngopharynx- from base of tongue to
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
Palatal uvular hypertrophy or edemaPalatal uvular hypertrophy or edema
Oropharyngeal patency can beOropharyngeal patency can be
compromised by-compromised by-
Palatine tonsil hypertrophy orPalatine tonsil hypertrophy or
Palatal or uvular enlargementsPalatal or uvular enlargements
Hypo pharyngeal patency can beHypo pharyngeal patency can be
Posterior & superior displacements of hyoidPosterior & superior displacements of hyoid
Muscular gland situated at floor ofMuscular gland situated at floor of
Intrinsic ExtrinsicIntrinsic Extrinsic
Superior longitudinal GenioglossusSuperior longitudinal Genioglossus
Inferior longitudinal HyoglossusInferior longitudinal Hyoglossus
Transverse StyloglossusTransverse Styloglossus
Vertical PalatoglossusVertical Palatoglossus
Etiology & pathophysiology of OSASEtiology & pathophysiology of OSAS
Predisposing factors still debatedPredisposing factors still debated
Syndrome can be-Syndrome can be-
Obstructive (most common)Obstructive (most common)
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.
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.
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.
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
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
Lymphoma or hodgkins dsLymphoma or hodgkins ds
Ectopic thyroidEctopic thyroid
Upper airway radiation edema or fibrosisUpper airway radiation edema or fibrosis
Severe kyposcoliosisSevere kyposcoliosis
Correlation of velopharyngeal incompetence inCorrelation of velopharyngeal incompetence in
Cushings dsCushings ds
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
Flurazepam & other sedative hypnotic agentsFlurazepam & other sedative hypnotic agents
Alcohol ingestionAlcohol ingestion
Testosterone administrationTestosterone administration
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.
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
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
Early morning headachesEarly morning headaches
Impaired concentration & impotenceImpaired concentration & impotence
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
nocturnal enuresisnocturnal enuresis
Diagnostic Aids in OSADiagnostic Aids in OSA
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.
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
Relation of tongue to oropharynxRelation of tongue to oropharynx
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
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
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.
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.
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.
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.
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.
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
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.
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.
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 &
Study in AJO 1986
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.
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.
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.
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
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
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
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.
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.
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
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
Mandibular advancementMandibular advancement
Surgical optionsSurgical options
Elimination of aggravating factorsElimination of aggravating factors
Chronic obstructive airway dsChronic obstructive airway ds
Other such medical conditions that may 1Other such medical conditions that may 1stst
be eliminatedbe eliminated
Alcohol intakeAlcohol intake
Sedative medicationSedative medication
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.
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
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.
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.
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
Should be worn 6hrs at night, 7 days a week.Should be worn 6hrs at night, 7 days a week.
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-
Easy to fabricateEasy to fabricate
Quite well tolerated by pt.Quite well tolerated by pt.
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
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.
Almost 32 commercial appliancesAlmost 32 commercial appliances
Basically two types:Basically two types:
Mandibular advancement devices (MAD) andMandibular advancement devices (MAD) and
Tongue repositioning devices.Tongue repositioning devices.
Described byDescribed by Cartwright & SamelsonCartwright & Samelson inin
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.
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.
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
Offset fluctuation of the genioglossus muscle.Offset fluctuation of the genioglossus muscle.
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.
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
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.
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.
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)
2 piece appliance2 piece appliance
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
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
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.
Results showed-Results showed-
Improvement in sleepImprovement in sleep
Snoring decreased or completelySnoring decreased or completely
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.
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
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.
Seventy-five per cent of maximal protrusion has
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
Suitable designs include cribbed activator,
vacuum formed devices & removable herbst.
Magnetic applianceMagnetic appliance
Maximal attractive force b/w magnets wasMaximal attractive force b/w magnets was
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.
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.
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.
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.
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
The EqualizerThe Equalizer
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
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
Shows good prognosis in mild to moderate cases.Shows good prognosis in mild to moderate cases.
Many showed immediate symptomaticMany showed immediate symptomatic
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
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.
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
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.
Surgical management of OSASurgical management of OSA
Current surgical techniques used-Current surgical techniques used-
Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)
Osteomy (anterior sagittal) with hyoid myotomy &Osteomy (anterior sagittal) with hyoid myotomy &
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
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.
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.
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
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.
Flap is advanced & sutured to anterior tonsillarFlap is advanced & sutured to anterior tonsillar
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
Kamami technicKamami technic
Proposed laser assisted uvuloProposed laser assisted uvulo
Carbon dioxide laser at 20 watts (continuousCarbon dioxide laser at 20 watts (continuous
Reports success rates comparable or betterReports success rates comparable or better
than convectional UPPP.than convectional UPPP.
Inferior sagittal osteotomy of the mandible withInferior sagittal osteotomy of the mandible with
hyoid myotomy & suspensionhyoid myotomy & suspension
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
Supra hyoid myotomy: to elevate the redundant lateral
pharyngeal tissues sometimes accomplished with
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.
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.
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
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 &
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
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.
Thank youThank you
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