To explore reasons about obstructive sleep apnea and snoring

1. OBSTRUCTIVE SLEEP APNEA
MANAGEMENT BY ORAL APPLIANCES

2. • APNEA :
Cessation of air flow > 10seconds
• HYPOPNEA :
Decreased airflow > 30% from baseline
lasting > 10seconds
associated with > 4% oxyhemoglobin saturation
• SLEEP :
A normal, reversible, recurring behavioural state
of disengagement and unresponsiveness to
the environment that is characterized by typical
changes in the electroencephelogram.

3. • SNORING :
A respiratory sound generated in the upper
airway during sleep, particularly deep (slow-
wave) sleep and REM sleep.
• OBSTRUCTIVE SLEEP APNEA (OSA)
SYNDROME :
A sleep-associated disorder of breathing with a
reduction or complete airflow obstruction
despite an ongoing effort by patient for
breathing.

4. MUSCLES HOLD
AIRWAY OPEN
NORMAL BREATHING
AIRWAY NARROWS
WHEN MUSCLES
RELAX
SNORING
AIRWAY COLLAPSES
OR BLOCKED WHEN
MUSCLES OVER
RELAX
OBSTRUCTIVE SLEEP
APNEA

6. Sleep
Disruption
Intermittent
Hypoxia

11. DIAGNOSIS

12. DIAGNOSTIC METHODS
• APNEA-HYPOPNEA INDEX (AHI) :
Number of apneas and hypopneas per hour
of sleep
• RESPIRATORY DISTURBANCE INDEX
(RDI) :
Number of apneas + hypopneas + RERAs
per hour of sleep

13. Forms of OSAHS on basis of
AHI Score
S.No. Forms of OSAHS AHI Score
1 Mild AHI 5-14/hr
2 Moderate AHI 15-30/hr
3 Severe AHI >30/hr
4 Very severe AHI >40/hr

14. Subjective assessment by
Epworth Sleepiness Scale (ESS)
S.No. Types of Sleepiness ESS Score
1 Normal range ESS <11
2 mild subjective
daytime sleepiness ESS =11
3 moderate subjective
daytime sleepiness ESS =16
4 Severe subjective
daytime sleepiness ESS >18

15. Objective assessment by
Multiple Sleep Latency Test (MSLT)
• Used to measure the time to fall asleep
(using EEG criteria). This is performed in a
dark room on at least four separate
occasions across the day. This period of
time is called as sleep latency.

16. Overnight Polysomnography
• Electro-encephalography (EEG) - brain wave monitoring
• Electromyography (EMG) - muscle tone monitoring
• Recording thoracic-abdominal movements - chest and
abdomen movements
• Recording oro-nasal airflow - mouth and nose airflow
• Pulse oximetry - heart rate and blood oxygen level monitoring
• Electrocardiography (ECG) - heart monitoring
• Sound and video recording

18. OXIMETRY
• Cheap recording pulse oximeters are readily
available; therefore oximetry is used as the first
screening tool for OSAHS.
• These are spectrophometric devices that are
used for the detection and calculation of the
differential absorption of light by presence of
oxygenated and deoxygenated haemoglobin in
blood.
• This is a method for detection of the blood
oxygen saturation

19. The techniques to visualize
pharynx
• Cineradiography,
• Fiberoptic bronchoscopy,
• Acoustic reflectance,
• Forced expiratory maneuvers,
• CT scanning and
• lateral cephalometry ( more commonly
used.)

20. CEPHALOMETRIC DIAGNOSIS
• Adjunctive procedure for assessing craniofacial patterns
associatedwith OSAS
• Evaluation of nasopharyngeal obstruction, position of base of
tongue, and pharyngeal relationship through specific airway
parameters done.
• Helps in :-
• measuring posterior airway space
• volume of pharyngeal airway
• small size of nasopharyngeal airway with snoring.
• depth of soft tissue of the posterior wall with nasal respiratory
resistance
• size of adenoidal mass and itsdistance from the posterior wall
of antrum

22. TREATMENT
• Behavioural interventions
• Non-surgical interventions
• Surgical interventions

23. Behavioural Interventions
Lose weight
Eliminate the use of alcohol, tobacco, and
sedatives
Sleep on one side
Regularize sleep hours

24. Non-surgical Interventions
Continuous positive airway pressure (CPAP):
– Pneumatic splint to maintain upper airway patency throughout all
phases of sleep
– Treatment of choice
– Improves subjective and objective sleepiness, cognitive function,
vigilance, mood and quality of life measures.
– Best results are obtained in those with an AHI of >15
– Side effects: epistaxis, sinusitis, rhinitis, dryness of the nasal
passages, nasal bridge sores, claustrophobia, abdominal bloating,
mouth leaks and noise

27. Oral appliance therapy
• adjustable and nonadjustable
– Anterior tongue repositioners
– Mandibular posturing devices
– Soft palate or uvula lifting devices

28. INDICATIONS :-
1) Patients with snoring or mild OSA who do not respond for
treatment with behavioral measures.
2) Patients with moderate to severe OSA who refuse treatment
with nasal CPAP.
3) Patients who are not appropriate for tonsillectomy,
adenoidectomy, and tracheostomy.
ADVANTAGES :-
• Significant reduction in breathing pauses
• Improvement of airflow for some patient with apnea
• Reduction in the snoring and
• High compliance level as compared to CPAP
DISADVANTAGES :
• Reciprocal forces are generated on the teeth and jaw by
mandibular advancement splints which results in dry mouth,
gum soreness, salivation, tooth pain, headaches, and TMJ
problems

30. Anterior Tongue Repositioners
• advances the tongue
• tongue & mandible together with adjacent soft tissue
• increases the posterior airway space
• increases the activity of the genioglossal & lateral pterygoid
muscles
• effects a stretch induction of the pharyngeal motor system

31. Tongue- Retaining Devices
(TRD)

32. Mandibular Posturing Devices
Nocturnal Airway-
Patency Appliance
(NAPA)
Thornton
Adjustable
Positioner (TAP)
Klearway Appliance
Silicone Positioner
Appliance
OASYS Oral/Nasal
Airway System
HERBST
APPLIANCE

33. SOFT PALATE OR UVULA
LIFTING DEVICE

34. RETRUDED JAW NARROW AIRWAY Mandibular Repositioning Device Lower jaw moves forward
Constricted palate Closed airway Palatal expansion screw Arch expands

35. Macroglossia Obstructed airway Tongue retaining devices Pulls tongue forward
Thick soft plate Closed airway Soft palate lifter Lifts palate upwards &
open airways
Retruded jaw Closed airway Mandible advancement surgery Jaw moves forward
and airways enlarge

36. Surgical interventions
• Uvulopalatopharyngoplasty (UPPP) – poor and unpredictable
• Tonsillectomy
• Tracheostomy
• Mandibular advancement
• Bariatric surgery
• Nasal surgery

37. CONCLUSION
• Orthodontic diagnosis may discover
anatomic conditions that could cause
respiratory obstructive sleep apnea
• Enlarged tonsils or adenoids in a lateral
cephalometric radiograph, or maxillary
width deficiency and narrow nasal cavity in
a P-A radiograph, are indications for
questioning the patient about other
symptoms.

38. • The clinician should be aware of the role
of orthodontics in prevention and
treatment of sleep disorders.
• Four-bicuspid extraction therapy in an
already hypoplastic skeletal pattern could
further reduce tongue space and increase
the possibility of sleep disorders later in
life.

39. • Prevention of obstructive sleep apnea may
be possible in young children through
dentofacial orthopedics to maximize the
development of the glossopharyngeal
space, the nasomaxillary complex, and
other dentofacial components.