32. ?
• What is your treatment approach on Monday
morning?
• What appliance and why?
• How do you determine endpoints?
• What do you do with oral appliance failures?
33. Definition: Sleep Disordered Breathing
• A disorder of breathing during sleep only, or
significantly affected by sleep. In general, the
patient has little or no problem breathing
while awake.
• Not a true sleep disorder
34. Categories
• Mechanical : The inappropriate collapse of the
pharynx during sleep
– Snoring
– Inspiratory Flow Limitation
– Obstructive sleep apnea
• Chemical : Central Sleep Apnea
• Neuromuscular : paralysis of involuntary
muscle (diaphragm), requiring ventilation at
night
35. Continuum of Sleep Disordered
Breathing
Mechanical
SeverityLeast Most
Chemical Neuromuscular
36. Continuum of Sleep Disordered
Breathing:
Treatment
SeverityLeast Most
Chemical
Cpap
Vpap
Oral Appliances
Combination
Oxygen
Neuromuscular
Ventilator
Tracheotomy
Combination
Mechanical
Oral Appliances
CPAP
Combination
Surgery
Tracheostomy
38. Continuum of Mechanical Sleep
Disordered Breathing Treatment
Normal Non-sleepy
snorer
OSA
Uars Mild Moderate Severe
Medical : CPAP
TreatDon’t treat
< 50% success
39. Continuum of Mechanical Sleep
Disordered Breathing Treatment
Normal Non-sleepy
snorer
OSA
Uars Mild Moderate Severe
Dentistry: Home monitor + oral appliance + tap-pap
TreatDon’t treat
> 90% success
50. Patient History
• Loud snoring, excessive fatigue, several wrecks
• Uncontrolled hypertension, 5 different
medications per day
• Morning blood pressure on medication 175/120
• Stroke 5 years previous
• Four psg’s, no osa, no diagnosis, tried and failed
cpap
• HST: RDI 3, significant upper airway resistance
55. Immediate TAP CS
• Moved screw forward to compensate for
maxillary hypoplasia
• Opened vertical 15 mm to accommodate
tongue
• Patient titrated himself 5mm beyond
maximum protrusion in first week
• Blood pressure on awakening 145/90
• No snoring, head aches, fatigue
59. Final TAP III appliance
Initial vertical 8mm
Added 6mm to plate, 3mm to
bar
Total vertical, 17mm
6mm 17mm
60. Neuromuscular Patients
• Post Polio
• ALS
• Muscular dystrophy
• Brain tumors affecting motor function
• Congenital
• Spinal Cord Injuries
61. Neuromuscular Patients
• Generally need ventilatory assistance during
the day
• Paralysis of diaphragm
• Intercostal muscle deterioration
• Limited function of limbs
• Adequate dentition for retention
63. Neuromuscular Patients:
History
45 yo, post polio
Paralyzed from neck down
Mask developed by DRI using
“bite block”
Pressure: 45 cmw
Volume ventilator
Could use intercostals during
day
Inserted by biting into trays
82. Family and Social Hx
• Divorced and remarried
• Father died at age 51 of HA
– Professional football player with very large neck
• Son and grandchild have osa by symptoms
• Orthodontist
– Focused on treating non-extraction and
developing airways
– Very knowledgeable in tmd and occlusion
83. Treatment Hx
• No initial sleep study or consultation with
physician
• Numerous oral appliances tried over 1 yr
– Herbst
– Silencer
– Snore guard
– Silent Knight
• Failure of all appliances
• Appliances still fit
