Obstructive sleep apnea /certified fixed orthodontic courses by Indian dental academy

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Obstructive sleep apnea /certified fixed orthodontic courses by Indian dental academy

  1. 1. www.indiandentalacademy.com INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
  2. 2. Contents • Introduction • Anatomic aspects • Patho-Physiologic aspect • Clinical features • Morbidity of Obstructive Sleep Apnea • Diagnostic procedures • Upper Airway Imaging techniques • Management – Nasal continuous positive airway pressure – Oral Appliances – Surgical management • Conclusion • References www.indiandentalacademy.com
  3. 3. Introduction • Over the past two decades, medicine and dentistry have focused on breathing disorders during sleep • These are commonly considered to be snoring, upper airway resistance syndrome and obstructive sleep apnea. www.indiandentalacademy.com
  4. 4. Snoring • Snoring, the commonest of sleep disorders is found in 25% of adult males • Snoring is the result of base of tongue compromising the upper airway when the patient falls asleep • The patient increases the speed of airflow in an attempt to maintain required oxygen, which causes vibration of soft tissues - Snoring www.indiandentalacademy.com
  5. 5. • Snoring by itself is not considered a serious problem, because its mainly a problem that creates irritation and loss of sleep in their bed partners • However, because almost all patients with Obstructive Sleep Apnea snore, it must be considered a potential indicator of significant medical problemswww.indiandentalacademy.com
  6. 6. Definition of Obstructive Sleep Apnea • Broadbent (1877), described Obstructive Sleep Apnea as ― there will be perfect silence through two, three, or four respiratory periods, in which there are ineffectual chest movements; finally air enters with a loud snort, after which there are several compensatory deep inspirations‖ www.indiandentalacademy.com
  7. 7. • Obstructive Sleep Apnea is potentially life threatening condition in which periodic cessation of breathing occurs during sleep in the presence of inspiratory effort • Obstructive Sleep Apnea affects not only the quality of life but also has significant morbidity • The reduction in blood oxygen saturation may give rise to hypertension, cardiac arrhythmias, nocturnal angina and myocardial ischemia www.indiandentalacademy.com
  8. 8. Anatomic aspects of Obstructive Sleep Apnea www.indiandentalacademy.com
  9. 9. • Upper airway can be viewed in four areas (1) Nasopharynx – – Mainly involves the nose, begins with nares and ends at superior portion of hard palate – Structures of major concern – Nasal Turbinates and Nasal Septum – Inferior turbinates, the largest of the three, is commonest to enlarge causing blockade of nasal passage – Deviated nasal septum may affect nasal respiration www.indiandentalacademy.com
  10. 10. Nasal Turbinates and Deviated Nasal Septum www.indiandentalacademy.com
  11. 11. • (2) Velopharynx – It extends from hard palate to the inferior tip of soft palate – It includes uvula and upper part of posterior wall of pharynx – The muscles of major concern are the Tensor Palatini and Levator Palatini www.indiandentalacademy.com
  12. 12. • (3) Oropharynx – It comprised of oral cavity, beginning with back portion of mouth till base of the tongue – Major components – Tongue and Tonsils – Enlargement of these structures causes airway obstruction – Within this area there are number of muscles that control posture of tongue and mandible, and these muscles also serves to maintain airway www.indiandentalacademy.com
  13. 13. (4) Hypopharynx • It extends from epiglottis to the lower portion of airway at larynx • Large number of muscles affect this portion can have varying effect depending on concurrent activity of related muscles www.indiandentalacademy.com
  14. 14. www.indiandentalacademy.com
  15. 15. Muscular relationships and functions • Palatoglossus and Palatopharyngeus – Located in anterior and posterior tonsillar pillar – As the mandible is advanced, these muscles are spread apart, causing tension on palatoglossus. – This is transferred to soft tissue, thus reducing vibration – Hence snoring may be reduced or eliminated by mandibular advancement www.indiandentalacademy.com
  16. 16. • Muscles of the neck –These support the cervical spine –Alteration in the cervical spine can modify the airway, primarily through the effect on hyoid bone, which in turn can affect mandibular position –Therefore, its important that during the clinical examination, posture of individual and its potential impact on airway be considered www.indiandentalacademy.com
  17. 17. Other muscles that might influence airway • Levator Palatini and Tensor Palatini • Muscles of the Tongue • Suprahyoids and Infrahyoids • Constrictor muscles of pharynx • Stylopharyngeus and Salphingopharyngeus – during speech and swallowing www.indiandentalacademy.com
  18. 18. Patho-Physiologic aspect of Obstructive Sleep Apnea www.indiandentalacademy.com
  19. 19. • Although Sleep Apnea might be central, obstructive and mixed pattern in origin, the Obstructive type is the most common form • It is characterized by cessation of airflow because of upper airway obstruction despite simultaneous respiratory effort • The respiratory effort continues despite obstruction until the individual is aroused from sleep www.indiandentalacademy.com
  20. 20. Normal alterations during sleep • Normal physiologic alterations that are associated with sleep may predispose individual to Obstructive Sleep Apnea • During sleep – The upper airway is more collapsible than during wakefulness, – Ventilation and inspiratory flow decreases, – Upper airway resistance increases and – Arterial carbon dioxide tension increases www.indiandentalacademy.com
  21. 21. Hypotonicity of muscles of upper airway • Hypotonicity of muscles of upper airway is the primary factor predisposing normal upper airway to increased collapsibility in sleep • Upper airway inspiratory muscles and thoracic muscles work in apposition • Upper airway inspiratory muscles exerting a dilatory effect, while thoracic muscles produce sub atmospheric intra-airway pressure which has collapsing effect on upper airway www.indiandentalacademy.com
  22. 22. Constriction of upper airway • Frequently, sleep apnea patients have constricted upper airways that increase pharyngeal resistance during inspiration • This necessitates an increase in pharyngeal dilator muscle contraction to maintain patency • Such increase has been shown in Obstructive Sleep Apnea patients during wakefulness, but it decreases during sleep, thus contributing to development of Obstructive Sleep Apneawww.indiandentalacademy.com
  23. 23. Predisposing factors • Obesity – airway is compromised because of more fat deposits in soft palate, tongue and surrounding pharynx • Alcohol ingestion – decrease in hypoglossal nerve output while phrenic nerve output is spared • REM sleep – muscles of airway are most hypotonic in this stage of sleep • Pharyngeal length was found to be longer in apnea patients in supine position compared with upright positionwww.indiandentalacademy.com
  24. 24. Anatomic alterations reducing airway – Ivanhoe - J Prosth Dent 1999 • Posteriorly positioned maxilla and mandible • Steep occlusal plane • Overerupted anterior teeth • Large gonial angle • Anterior openbite associated with large tongue • Posteriorly placed pharyngeal walls www.indiandentalacademy.com
  25. 25. • Retrognathic mandibles • Large tongue and soft palate • Large anteroposterior discrepancies between maxilla and mandible • Micrognathia • Acromegaly • Downs’ syndrome www.indiandentalacademy.com
  26. 26. Hereditary variables • Adenoid and tonsillar hypertrophy • Glottic webs • Vocal cord paralysis • Lymphoma or Hodgkin’s disease • Ectopic thyroid • Systemic disease involving mandible like Rheumatoid arthritis • Severe Kypho-Scoliosis • Cushing syndrome www.indiandentalacademy.com
  27. 27. Clinical features of Obstructive Sleep Apnea www.indiandentalacademy.com
  28. 28. Clinical features 1.Excessive sleepiness 2.Morning headaches 3.Gastro-esophageal reflux disease 4.Impaired concentration 5.Depression 6.Decreased libido 7.Irritability 1.Snoring 2.Drooling 3.Xerostomia 4.Diaphoresis 5.Choking or gasping Nocturnal symptoms Daytime symptoms www.indiandentalacademy.com
  29. 29. Mishra P and Valiathan A – J Nep Med Assoc - 1995 Sleep onset Apnea Oxygen , pH, carbon dioxide Arousal from sleep Resumption of Airflow Return to Sleep Negative oro-pharyngeal pressure Reduced upper airway muscle activity Small pharyngeal cavity High pharyngeal compliance High upstream resistance Baseline arterial Oxygen concentration Degree of diffuse airway Obstruction Lung volume Chemoreceptor sensitivity CNS abnormality www.indiandentalacademy.com
  30. 30. Orofacial characteristics in Obstructive Sleep Apnea • Retrognathic mandible • Narrow palate • Large neck circumference • Long soft palate • Tonsillar hypertrophy • Nasal septal deviation • Relative macroglossia www.indiandentalacademy.com
  31. 31. Obstructive Sleep Apnea in children • Snoring is the characteristics of Obstructive Sleep Apnea in children • Nonetheless many children may not have snoring as a major complaint even in presence of severe upper airway obstruction • Other associated clinical features are – Difficulty in breathing during sleep – Restless sleep – Morning headaches – Enuresis – Sleep terrorswww.indiandentalacademy.com
  32. 32. • Day time abnormalities includes sleepiness, attention span problems, poor social performance • Other symptoms which may be seen are – Upper airway infections – Sinusitis – Otitis media – Failure to thrive – In severe cases pulmonary hypertension or cor pulmonale can develop www.indiandentalacademy.com
  33. 33. Epidemiology • Estimates of prevalence of Obstructive Sleep Apnea vary widely. Largely because of different cutoff point for diagnosis • Battagel BJO 1996 stated that figures for middle-aged adults range from 1.3 to 24% • Almost all studies report higher incidence in males than in females, and agree that the condition is greater in obese • The prevalence is normally described as increasing with age www.indiandentalacademy.com
  34. 34. Morbidity of Obstructive Sleep Apnea • Morbidity of Obstructive Sleep Apnea relates principally to cardiovascular system • Rigorous epidemiological studies have shown that Sleep Apnea is a risk factor for development of Arterial Hypertension, independent of associated obesity, alcohol intake, sex, and age • Now studies have found increasing evidence to demonstrate that Obstructive Sleep Apnea is an independent risk factor for Stroke www.indiandentalacademy.com
  35. 35. • Lavie 2003 investigated repeated apnea related events to atherogenesis through initiation of oxidative stress, hypothesizing a molecular biological association between hypoxia- reoxygenation episodes of Obstructive Sleep Apnea and cardiovascular disease • Among other consequences of Sleep Apnea, excessive daytime sleepiness, cognitive impairment, impaired ability to drive motor vehicle and increased automobile accident have been documented www.indiandentalacademy.com
  36. 36. • Many studies have agreed that patients with Obstructive Sleep Apnea have reduced quality of life • Jennum 2002 showed clear association between headache and sleep disturbances, however the cause and effect of this relationship is not clear • Patients with headache also report more daytime symptoms like fatigue, tiredness or sleepiness • Identifying sleep disorders in chronic headache patients is worthwhile, as improvement of headache may follow treatment of sleep disorders in this group www.indiandentalacademy.com
  37. 37. Diagnostic procedures in Obstructive Sleep Apnea www.indiandentalacademy.com
  38. 38. • The diagnosis of Obstructive Sleep Apnea is best done by a pulmonologist or other physician specialized in sleep breathing problems. • Confirmation requires sleep testing with polysomnography, which consists of continuous measurement of arterial oxygen saturation www.indiandentalacademy.com
  39. 39. I. Clinical Examination • Taking a good history requires an above- average knowledge of the discipline involved • Recording the chief complaints is a major portion of the history taking that ultimately will assist in making the diagnosis • It is important to know about any previous treatment. The patient may have had surgery previously and failed to attain the expected result. www.indiandentalacademy.com
  40. 40. Physical condition of the patient • Neck size – A neck size greater than 40cm (16inches), regardless of gender, has s sensitivity of 61% and a specificity of 93% for having obstructive sleep apnea syndrome – According to some authors, a neck size of 17 inches or greater for men and 15.5 inches or greater for women, indicate an increased risk for sleep apnea www.indiandentalacademy.com
  41. 41. Body Mass Index (BMI) • Patient’s body mass index (BMI) directly affects the predilection for sleep apnea. • The BMI is computed by dividing the person’s weight in kilograms (kg) by their height in meters squared (m2). • In men, obesity is defined as a BMI of 27.8; for women, obesity is a BMI of 27.3. • An individual with a BMI of at least 25 kg/m2 has been found to have a sensitivity of 93% and specificity of 74% for having Obstructive Sleep Apnea .www.indiandentalacademy.com
  42. 42. • Blood pressure must also be recorded • It is both informative and good practice to record blood pressure at the initial visit and at subsequent visits as a means of determining potential outcomes associated with treatment. • Another helpful tool for screening is the Epworth Sleepiness Scale www.indiandentalacademy.com
  43. 43. Epworth Sleepiness Scale www.indiandentalacademy.com
  44. 44. II. Airway Evaluation • The evaluation of the airway begins at the tongue and proceeds into the oral pharynx. • The condition of the tongue, its size, and related anatomic changes should be observed and noted, in a relaxed state. • The Mallampati Score has been used in anesthesia for many years as a means of determining the difficulty of performing an intubation as the tongue increasingly seems to obstruct the airwaywww.indiandentalacademy.com
  45. 45. • It has been found that this score is also a predictor for determining severity of sleep apnea in some people. • Friedman et al (1999) stated that patients with a Mallampati Score of III or IV are at a greater risk for sleep apnea than those with a score of I or II. www.indiandentalacademy.com
  46. 46. • Tonsillar size has a direct relation to the severity of sleep apnea. • It is well recognized that increased tonsillar size reduces the airway size and can contribute to sleep-related breathing disorders. • Tonsil size is graded on a universally recognized standard www.indiandentalacademy.com
  47. 47. • The size of the uvula and observations of the soft palate should also be recorded. • In snoring, mouth-breathing, or Obstructive Sleep Apnea patients, these structures are subjected to trauma repeatedly throughout the night, causing a change in their appearance and size. • Nasal examination - the Nasal turbinates should be evaluated to determine if those structures are contributing to nasal airway obstruction and encouraging oral breathing. www.indiandentalacademy.com
  48. 48. III. Temporomandibular Joint Assessment • Preexisting TMJ findings should be noted, especially if mandibular advancement with an oral appliance is being planned. • If an appliance is used, one with posterior support that functions as a splint may address both issues at the same time. • Additionally, patients who are using nasal CPAP may experience jaw and subsequent TMJ problems if the mask is held too tightly or chin straps are required to hold the mouth closed to prevent leakage around the mask or mouth breathing. www.indiandentalacademy.com
  49. 49. • IV. Headache Status –Headache is a common finding among patients with sleep-disordered breathing and in some instances headache may be the symptom for which the patient seeks medical attention. –If headache is present, it is appropriate to determine if the status of the headache improves in conjunction with the management of the sleep disorder. www.indiandentalacademy.com
  50. 50. • V. Muscle Assessment –It is important to evaluate and determine tenderness of the muscles of the head and neck region –Many patients with sleep-related breathing disorders may be fatiguing the muscles of the head and neck region and have coexisting jaw, face, or neck pain. These muscles may be responsible for pain referral that is expressed as headache www.indiandentalacademy.com
  51. 51. VI. Polysomnography • First proposed by Holland et al 1974 • A Polysomnography is a physiologic study, usually attended by a trained technologist, performed for at least 6 hours during a patient’s normal sleep hours. • The study records sleep staging and other physiologic variables. • Sleep staging includes electroencephalography (EEG), electro-oculography (EOG), and electromyography (EMG). www.indiandentalacademy.com
  52. 52. • Other physiologic parameters and variables that may be measured include ECG monitoring, airflow, respiratory effort, gas exchange, gastroesophageal reflux, continual blood pressure monitoring, snoring, and body position. • Video monitoring is recorded for each patient to distinguish better among potential abnormal sleep behaviors including nightmares, nocturnal seizures, or rapid-eye-movement (REM) sleep behavioral disorderwww.indiandentalacademy.com
  53. 53. • During analysis of the Polysomnography, each episode of apnea and hypopnea is identified and counted. • Consensus guidelines for research do not distinguish between apneas and hypopneas, defining them as events lasting at least 10 seconds, during which there is either a ―>50% decrease from baseline in the amplitude of a valid measure of breathing during sleep,‖ or a ―clear (but not 50%) amplitude reduction of a validated measure of breathing during sleep, associated with either an oxygen desaturation of 3% or an arousal.‖ www.indiandentalacademy.com
  54. 54. • The Apnea-Hypopnea Index, also known as the Respiratory Disturbance Index (RDI) is the number of apneas and hypopneas per hour of sleep. • It is used to assess the severity of obstructive sleep apnea. • The usual definition of slight Obstructive Sleep Apnea is an Respiratory Disturbance Index of 5- 14, moderate Obstructive Sleep Apnea is an Respiratory Disturbance Index of 15 to 30, and severe Obstructive Sleep Apnea is an Respiratory Disturbance Index greater than 30. • The apnea-hyponea index has been shown to be a reproducible measure within a patient as well as predictor of associated cardiovascular disease. www.indiandentalacademy.com
  55. 55. • It is now accepted that a diagnosis of clinically significant Obstructive Sleep Apnea should be accompanied by compatible signs and symptoms and not based on an arbitrary Respiratory Disturbance Index threshold. • According to Kryger (2002) the syndrome should be defined when an index of abnormal obstructed breathing events, or arousals caused by them, exceeds a threshold in a patient with clinical features or symptoms related to the abnormal respiratory pattern during sleep www.indiandentalacademy.com
  56. 56. • The Polysomnography summary report usually describes the overall Respiratory Disturbance Index , the Respiratory Disturbance Index while supine, the Respiratory Disturbance Index while in REM sleep, and the lowest oxygen desaturation. Sleep architecture is displayed as a graph through the night, termed a hypnogram. www.indiandentalacademy.com
  57. 57. VII. Split Night Studies • To establish optimal therapeutic pressure, Continuous Positive Airway Pressure (CPAP) usually is initiated during polysomnography in the sleep center. • The pressure is titrated upward in small increments until apneic episodes are controlled or eliminated • A more reliable titration to effective pressure often requires an entire night of testing and may, for some patients, require a second Polysomnography study dedicated to Continuous Positive Airway Pressure titration. www.indiandentalacademy.com
  58. 58. • In some cases it is possible to condense this process into one split-night Polysomnography • During a split-night study the technologist performs a standard diagnostic Polysomnography without Continuous Positive Airway Pressure for about 2 hours. • Continuous positive airway pressure is then initiated and titrated by the technologist to eliminate snoring and sleep apnea. • A split-night study is especially useful after the physician has thoroughly discussed sleep apnea treatment options with the patient, and when the patient has a good idea of the nature, inconvenience, and treatment value of Continuous Positive Airway Pressure .www.indiandentalacademy.com
  59. 59. Limitations of Split Night Studies: • A split night protocol requires that the technologist make the initial diagnosis based on a partial night recording. • Another limitation of split-night studies is that apneic episodes often are more frequent or more severe during REM sleep, and REM sleep usually occurs in the latter half of the night; therefore a 2-hour initial baseline Polysomnography may significantly underestimate the baseline severity of apnea. • Further, the effects of body position on breathing may be missed during a time- abbreviated diagnostic study. www.indiandentalacademy.com
  60. 60. VIII. Portable studies • Portable sleep studies are helpful for patients who cannot easily come to the sleep center and for certain limited studies such as follow-up studies after surgery for sleep apnea • An attended portable study is usually more costly to perform than a laboratory study because a technologist usually attends only one patient during a portable study but usually attends two patients in the laboratory www.indiandentalacademy.com
  61. 61. IX. Pulse Oximetry • Arterial oxygen saturation can be monitored continuously by pulse oximetry in the emergency room, during surgery, and during Polysomnography. • Pulse oximetry is relatively simple and reliable • Despite limitations, oximetry may be a useful diagnostic tool over a wide range in Obstructive Sleep Apnea severity. • Oximetry may be useful to evaluate response to treatment after surgery or airway dilator placement in patients with known Obstructive Sleep Apnea . www.indiandentalacademy.com
  62. 62. www.indiandentalacademy.com
  63. 63. • A full-night polysomnography remains the standard of reliability and accuracy for diagnosing Sleep Disordered Breathing, • Split-night testing with Continuous positive airway pressure titration or cardio-respiratory sleep studies may be most useful in patients who have a high pretest probability of Obstructive Sleep Apnea , and clinical prediction formulas may help sleep specialists identify those patients. • Oximetry is a viable alternative in some clinical situations because of its ease of use, its reliability, and its portability. www.indiandentalacademy.com
  64. 64. Upper Airway Imaging www.indiandentalacademy.com
  65. 65. I. Acoustic reflection - Philipson 1992 • Acoustic reflection is a noninvasive imaging technique based on analyzing sound waves reflected from upper airway structures. • The phase and amplitude of the reflected sound waves can be transformed into an area-distance relationship by calculation of upper airway area as a function of distance from the incisors in the mouth. • The technique is generally performed through the mouth, is free of radiation, and because it is both fast (images can be obtained at 0.2 second intervals) and reproducible, permits dynamic imaging of the upper airway. www.indiandentalacademy.com
  66. 66. • Unfortunately, acoustic reflection does not provide information on airway structure or geometry • Moreover, measurements are usually performed in the sitting position with an oral mouthpiece. • Mouthpieces present difficulties for the examination of upper airway anatomy because opening the mouth alters upper airway geometry • Accordingly, acoustic reflection may not be comparable with other modalities in which the mouth is closed during imaging. • Acoustic reflection thus far has been used primarily as a research tool. www.indiandentalacademy.com
  67. 67. II. Fluoroscopy • Fluoroscopy has also been used to study upper airway closure in patients with sleep apnea. • Fluoroscopic studies during sleep have demonstrated that upper airway closure occurs in the retropalatal region for most patients with sleep apnea. • Although fluoroscopy can provide a dynamic evaluation of the upper airway during wakefulness and sleep, radiation exposure makes this study impractical for routine use. www.indiandentalacademy.com
  68. 68. III. Nasopharyngoscopy • Nasopharyngoscopy is commonly used to evaluate the nasal passages, oropharynx, and vocal cords. • Although it is invasive, nasopharyngoscopy is easily performed and does not involve radiation exposure. • Moreover, it permits direct observation of the dynamic appearance of the pharynx. • However, it examines only the lumen of the upper airway and does not provide measurement of the surrounding soft tissue structures. www.indiandentalacademy.com
  69. 69. • The utility of nasopharyngoscopy in evaluating the upper airway seems to be increased if a Muller’s maneuver is performed during the examination. • The Muller’s maneuver is a voluntary inspiration against a closed mouth and obstructed nares. • It is thought to simulate the upper airway collapse that occurs during an apnea. • Although the degree of obstruction on negative inspiration with a Muller’s maneuver is not a direct correlate of the site of upper airway collapse during sleep, Muller’s maneuver has been shown to add important information on possible sites of obstruction. www.indiandentalacademy.com
  70. 70. III. Cephalometry • This technique is widely available, easily performed, and much less expensive than either CT scanning or MR imaging • Cephalometrics have also been used to evaluate skeletal structures before facial surgery (mandibular advancement, bimaxillary advancement, sliding genioplasty) and to evaluate the efficacy of oral appliances • Cephalometry is considered useful for evaluating and quantifying craniofacial (mandibular and hyoid position) and soft tissue structures (tongue and soft palate) in patients with retrognathia or micrognathiawww.indiandentalacademy.com
  71. 71. • Nonetheless, the low cost and widespread availability of Cephalometrics make it useful for sleep apnea patients being treated with oral appliances and undergoing craniofacial surgery. www.indiandentalacademy.com
  72. 72. IV. Computed Tomography • Computed tomographic scanning is widely available and is ideal for imaging the lumen of the upper airway because it accurately measures the cross-sectional area. • Computed tomography also provides excellent resolution for upper airway soft tissue and craniofacial structures. • Three-dimensional volumetric reconstructions of upper airway, soft tissue, and bony structures can be obtained • Dynamic imaging of the upper airway can be performed with electron beam CT www.indiandentalacademy.com
  73. 73. • Compared with MR images, however, CT scanning has limited soft tissue contrast resolution, particularly for upper airway adipose tissue. • In addition, CT scanning is relatively expensive and exposes the patient to radiation. • The radiation exposure particularly limits state- dependent imaging and studies that require repeat scanning. • Despite these limitations, studies using CT scanning have led to important insights into the pathogenesis of airway closure in patients with obstructive sleep apnea. www.indiandentalacademy.com
  74. 74. V. Magnetic Resonance Imaging • MR imaging is perhaps the most useful imaging technique for studying obstructive sleep apnea because it: – Provides excellent resolution of upper airway and soft tissue (including adipose tissue), – Accurately measures cross-sectional airway area and volume, – Allows imaging in the axial, sagittal, and coronal planes – Provides data suitable for three-dimensional reconstructions of upper airway soft tissue and craniofacial structures – Can be performed during wakefulness and sleep, and does not expose subjects to radiation. www.indiandentalacademy.com
  75. 75. • MR imaging, however, is expensive and is not available in all hospitals. • Further, MR studies cannot be performed on patients with ferromagnetic implants or pacemakers, patients who weigh more than 300 pounds, or patients who are claustrophobic (a relative contraindication). • Moreover, Suto et al, (1993) reported that achieving sleep in the MR scanner is difficult because of the associated noise. www.indiandentalacademy.com
  76. 76. Clinical utility of upper airway imaging • Upper airway imaging is not indicated in routine diagnostic evaluation of most patients with obstructive sleep apnea • Imaging of the airway is also not indicated in patients with sleep apnea treated successfully with Continuous positive airway pressure . • MR imaging and nasopharyngoscopy are the imaging modalities of choice in patients undergoing a Uvulopalatopharyngoplasty. • Cephalometrics should be considered in patients being treated with mandibular repositioning devices. • In patients undergoing maxillomandibular advancement surgery or sliding genioplasty, CT scanning with three dimensional reconstructions and cephalometrics may be indicated. www.indiandentalacademy.com
  77. 77. Management of Obstructive Sleep Apnea www.indiandentalacademy.com
  78. 78. • The treatment of Obstructive sleep apnea depends on several factors such as the severity of the symptoms, site of airway obstruction, and co-operation of the patient. • There are several modalities ranging from simple lifestyle measures such as weight loss and avoidance of alcohol, to more substantial measures such as continuous positive airway pressure, or oral appliances, and in more severe cases, even surgical intervention. www.indiandentalacademy.com
  79. 79. NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE • Nasal continuous positive airway pressure (N- CPAP) is a highly effective and safe treatment for obstructive sleep apnea and is generally considered to be the current primary treatment of obstructive sleep apnea • Sullivan et al (1981) first reported the use of nasal continuous airway pressure for obstructive sleep apnea in adults. Their device consisted of intranasal tubes attached to a blower unit. • Sanders et al (1983) introduced the nasal mask delivery system, which made continuous positive airway pressure more user-friendly. www.indiandentalacademy.com
  80. 80. • Fundamentally, the application of a therapeutic level of continuous positive airway pressure results in immediate relief in the upper airway obstruction. • This benefit has been attributed to the continuous positive airway pressure functioning as a pneumatic splint for the upper airway. • Additional physiologic benefits of continuous positive airway pressure application to include improvement in the function of pharyngeal dilator muscles, ventilator drive, and upper airway morphology www.indiandentalacademy.com
  81. 81. Nasal continuous positive airway pressure Apparatus • It consists of an inspiratory limb, which uses compressed air from a standard hospital wall source regulated by a flow meter. • To prevent mucosal drying, a humidifier containing a one-way valve is used which ends in the nasal mask. • The expiratory flow limb begins at the mask and ends with a threshold water column positive end expiratory pressure (PEEP). • The level of Nasal continuous positive airway pressure could then be adjusted by manipulating the amount of flow and the level of water in the PEEP column. www.indiandentalacademy.com
  82. 82. Nasal continuous positive airway pressure Apparatus www.indiandentalacademy.com
  83. 83. Benefits of Nasal continuous positive airway pressure therapy • Patient’s perceived quality of life increases • Interestingly, the spouses of obstructive sleep apnea patients also gained from this therapy • Reduced sleepiness and the improved ability to steer a motor vehicle and hence frequency of driving accidents were reduced • Health-related quality of life of obstructive sleep apnea patients improves with long-term continuous positive airway pressure treatment • Randomized placebo-controlled studies demonstrated a reduction in blood pressure levels with continuous positive airway pressure therapy. • Reduces long-term morbidity and mortality from cardiovascular causeswww.indiandentalacademy.com
  84. 84. Disadvantages of Nasal continuous positive airway pressure therapy • While current effective management of moderate to severe sleep apnea is still largely dependent on nasal continuous positive airway pressure , the process is still cumbersome • Approximately 10-50% of subjects find the continuous positive airway pressure (CPAP) intolerably uncomfortable and discontinue its use with in a short period of time. www.indiandentalacademy.com
  85. 85. • Inspiration is facilitated and expiration is impeded, a new balance between inspiratory muscle effort and lung elastic recoil is established. • This results in the following: – Reduced cardiac output and renal function. – Increased pressure in the sinus, which might decrease drainage and cause problems in patients with preexisting abnormalities. – Drying of the airway mucosa is another complication, which can be overcome by the inclusion of a humidifier in the circuit. www.indiandentalacademy.com
  86. 86. • Mechanical failure of continuous positive airway pressure – occlusion of the exhaust line could theoretically cause hyper-inflation of the lungs and perhaps even lung rupture. This does not happen if a low pressure pump is used. • Since the pressure is applied through the nose, the mouth will act as a blow-off valve and result in reduction of the pressure. When this happens, the patient will go back to his usual state of upper airway obstruction. This is prevented by using face-masks covering both the nose and the mouth. www.indiandentalacademy.com
  87. 87. Auto Nasal continuous positive airway pressure • The device continuously adjusts the applied air- pressure to an optimum level throughout the night and appears to improve compliance. • Upper airway resistance is influenced by many dynamic factors that may change, such as body position, sleep stages, sleep deprivation, body weight and fluctuations of nasal congestion. • Therefore, a single pressure level, as with standard continuous positive airway pressure could result in insufficient air pressure at certain times, particularly after alcohol consumption. www.indiandentalacademy.com
  88. 88. • Auto continuous positive airway pressure is expected to become more popular in the future as it facilitates the initiation and follow up of the treatment, especially the process of optimal initial pressure titration, and the elimination of repeated titrations over prolonged years of therapy. www.indiandentalacademy.com
  89. 89. ORAL APPLIANCES IN THERAPY OF OBSTRUCTIVE SLEEP APNEA www.indiandentalacademy.com
  90. 90. • Although Nasal continuous positive airway pressure is a logical first step, some patients cannot tolerate Nasal continuous positive airway pressure, creating a demand for alternative non- surgical treatment modalities. • Dental devices were being promoted as an alternative conservative, noninvasive modality for management of some patients with mild Obstructive Sleep Apnea symptoms and those subjects who have a history of disruptive snoring www.indiandentalacademy.com
  91. 91. Classification of Oral Appliances • Dental appliances in the treatment of Obstructive Sleep Apnea can be divided into three categories: 1. One type of appliance is designed to reposition the tongue in a more forward position (Tongue retaining device). 2. A second type of devices positions the mandible forward. The rationale for this movement is that the tongue is attached to the genial tubercles of the mandible and positioning the mandible forward moves the tongue forward. These mandibular repositioning appliances also change hyoid bone position and modify the lower airway space below the level of the base of the tongue. www.indiandentalacademy.com
  92. 92. 3. The third type of intra oral device is designed to lift the soft palate or reposition the uvula (equalizer). The rationale for the use of palate lifting devices is to reduce the vibration of the soft palate that causes the snoring sound. www.indiandentalacademy.com
  93. 93. Tongue retaining devices • The Tongue retaining devices is a custom-made appliance designed to allow the tongue to remain in a forward position between the anterior teeth by holding the tongue in an anterior bulb with negative pressure during sleep. • Tongue protrusion increases the oropharyngeal, velopharyngeal and hypopharyngeal cross-sectional areas of the upper airway, thereby improving airway patency and function and reducing the airflow resistance www.indiandentalacademy.com
  94. 94. • The advantages of tongue retaining devices over mandibular advancement devices are as follows: – They can be used on edentulous patients, whereas the latter need ample dentition for retention purposes. – They do not loosen restorations. – They require minimal or no adjustments. – They cause minimal sensitivity in teeth or in the TMJ. www.indiandentalacademy.com
  95. 95. • The effectiveness of Tongue retaining devices in Sleep apnea subjects may be partially related to the forward tongue posture that compensates for the altered Genioglossus muscle activity. • Tongue-retaining devices appear to be effective in over 75% percentage of the mild to moderate cases of obstructive sleep apnea. • Compared to the most commonly performed non-surgical treatment (continuous positive airway pressure ), the Tongue-retaining devices is more easily tolerated and has fewer long-term compliance problems. www.indiandentalacademy.com
  96. 96. www.indiandentalacademy.com
  97. 97. Mandibular Advancement Devices www.indiandentalacademy.com
  98. 98. • In 1934, Pierre Robin first described the concept of advancing the mandible with a monobloc functional appliance to treat airway obstruction in infants with micrognathia. • His method was not accepted and it was not until 1985 that Meier-Ewert next described an intra-oral protraction device for the treatment of sleep apnea. • In general, MAD’s consist of form-fitting trays that fit over the maxillary and mandibular teeth www.indiandentalacademy.com
  99. 99. • They may be fixed-position with no allowance for adjustability for advancement or retrusion of the mandible, or may be adjustable • Adjustable oral appliances are generally preferred because they can be adjusted in an antero-posterior position until an acceptable level of symptom improvement has occurred, while teeth or temporomandibular joint sensitivity is controlled. • Some oral appliances may be made from a pre- fabricated standard set, similar to alginate impression trays and can be fabricated chair side in the clinical setting. • Others must be custom fabricated on a set of casts by a laboratory www.indiandentalacademy.com
  100. 100. Designs of Mandibular Advancement Devices • Removable Activator type Mandibular Advancement Device – Every posterior tooth has full occlusal coverage with acrylic. – All anterior teeth were capped on the incisal, lingual, and labial surfaces by acrylic. – Openings were cut through the acrylic between the maxillary and mandibular arches to allow respiration if the subject developed nasal congestion www.indiandentalacademy.com
  101. 101. • Anterior Mandibular Positioner – The oral appliance consisted of a titanium hinge with 5 adjustment holes that connected full- coverage upper and lower, hard acrylic splints. www.indiandentalacademy.com
  102. 102. • The Karwetzky activator : Rose et al (EJOS 2002) – Passive tooth-and tissue borne device – It is a bimaxillary, tooth- and tissue-borne activator with a loose fit. – The activator is divided along the occlusal plane. – Two U-loops are fixed in the lingual acrylic in the area of the first molars, allowing sagittal adjustment of the mandibular protrusion. – This design permits lateral and vertical jaw movements during sleep www.indiandentalacademy.com
  103. 103. • Intra oral sleep apnea device (ISAD) – It consists of two thin thermoplastic splints, worn on the upper and lower jaws, connected by two adjustable telescopic guide rods. – It works by advancing and slightly depressing the mandible and tongue while imparting a slight vertical clockwise rotation. www.indiandentalacademy.com
  104. 104. Adjustable Herbts appliance www.indiandentalacademy.com
  105. 105. • Magnetic appliances for treatment of OSA – Inherent magnetic forces directly transfer active forces to the jaws and thereby constrain the lower jaw in a forward position. – During sleep, when the masticatory muscles are physiologically relaxed, there is an obvious risk that the mandibular complex moves backward and closes the airflow in the upper airway space. – In such situations, a magnetic appliance may be more effective than the conventional passive functional appliance, because the magnet forces prevent the closing by providing direct and continuous mandibular advancement.www.indiandentalacademy.com
  106. 106. www.indiandentalacademy.com
  107. 107. • The following advantages of the magnetic appliance were enumerated: – The inherent magnetic forces constrain the lower jaw directly in an advanced position even during sleep when the masticatory muscles are relaxed. – It is less bulky than the conventional monoblock type and allows freedom of function and, consequently, patient compliance is improved. – If there is a need to change the advanced position of the mandible, this can easily be done by changing the positions of the magnets in the splints. www.indiandentalacademy.com
  108. 108. • One shortcoming of the rare earth magnets, particularly the neodymium-iron- boron alloy, is that the alloy is very susceptible to corrosion assault by the saliva. – When a magnet corrodes, there is considerable risk of destroyed magnetic properties and loss of force. Furthermore, there is a risk of liberation of cytotoxic components www.indiandentalacademy.com
  109. 109. • The Modified Monobloc: Cozza ( JCO 2004) – The device was fabricated from clear acrylic resin, with full tooth coverage in both arches and a central screw. – The incisal edges and superior labial surfaces of the mandibular incisors were capped to prevent tipping. – The construction bite positioned the mandible anteriorly into an edge-to edge incisal relationship, with a vertical bite opening of 2-3 mm. – A Tucat’s Pearl sliding on a wire in the anterior lingual portion of the appliance was added as reference point for anterior positioning of the tongue.www.indiandentalacademy.com
  110. 110. • Chrome-cobalt mandibular advancement devices: Ash and Smith ( JO 2004) – They emphasized the physical weakness of conventional mandibular advancement devices, which normally are made of acrylic, or may have a stainless steel shaft and piston fixed linkage mechanism, – These parts are subject to considerable forces and may undergo fracture. – The chrome cobalt advancement devices are fabricated according to the principles of prosthetic dentistry, with surveying of stone models for construction of the chrome cobalt framework. – Clasps are incorporated for additional retention in both the upper and lower appliances. www.indiandentalacademy.com
  111. 111. • The advantages of the appliance were its superior strength, reduced bulk, kindness to soft tissues, and enhanced retention and stability. • The possible disadvantages include financial cost, additional clinical and laboratory stages, and the need for a new appliance if the patient experiences tooth loss. www.indiandentalacademy.com
  112. 112. • The Glasgow approach – Simple one-piece mandibular advancement device using a semi-soft material. – The advantage of this appliance was that it placed no restriction on the dental status of the patients accepted for treatment. – Softened impression compound placed between the anterior teeth is used to obtain the protrusive jaw position, following which, aluminium impregnated wax is pressed around the buccal surfaces of the teeth and the impression compound. – The appliances are made with polyvinyl acetate polyethylene, 4mm thick and trimmed to shape. – They are then placed on the articulator and joined together. www.indiandentalacademy.com
  113. 113. • Advantages – simplicity and low cost of this appliance compared with other treatment options. • Disadvantages – longevity has been questioned and would require a replacement after 12-18 months – Other side effects like hypersalivation www.indiandentalacademy.com
  114. 114. Hans et al AJO 1997 • Device designed to increase vertical dimension and protrude the mandible (device A). • Device designed to minimally increase vertical opening without protruding the mandible (device B). • Device A reduced RDI scores in 9 of 10 subjects • Device B showed no change or an increased RDI score in 8 of 8 subjects. • Subjects who showed no improvement with device B were then fitted with device A. • Four of those seven subjects showed a reduction in RDIwww.indiandentalacademy.com
  115. 115. Randomized controlled trials comparing Oral Appliances with CPAP • Ferguson et al (1996) – They compared one-piece, hard acrylic, nonadjustable oral appliance, Snore Guard to continuous positive airway pressure in patients with mild to moderate obstructive sleep apnea. – It was found that the treatment of 48.5 % of SnoreGuard and 62% of continuous positive airway pressure patients was considered successful. – While patients preferred the SnoreGuard treatment to the continuous positive airway pressure therapy, the former was not as effective as was the continuous positive airway pressure treatment in relieving symptoms of excessive daytime sleepiness.www.indiandentalacademy.com
  116. 116. • Randerath et al (2002) – Compared the effectiveness of an individually adjustable intra oral sleep apnea device (ISAD) with that of continuous positive airway pressure . – The intra oral sleep apnea device reduced snoring in the long term, but significantly improved the RDI only in the early phase of treatment. – In contrast, continuous positive airway pressure normalized RDI, snoring and arousals throughout the entire treatment period. www.indiandentalacademy.com
  117. 117. • They concluded that in patients with mild to moderate obstructive sleep apnea, continuous positive airway pressure is superior to treatment with mandibular advancement device. • However, as one third of patients respond sufficiently to treatment with the intra oral sleep apnea device , in patients who refuse continuous positive airway pressure , the use of mandibular advancement devices should be considered. www.indiandentalacademy.com
  118. 118. • Ferguson et al (2006) – Conducted an evidence-based review of literature regarding the use of oral appliances in the treatment of snoring and obstructive sleep apnea syndrome from 1995 – In comparison to continuous positive airway pressure, oral appliances are less efficacious in reducing the apnea hypopnea index (AHI), but oral appliances appear to be used more (at least by self report), and in many studies were preferred over continuous positive airway pressure when the treatments were compared. www.indiandentalacademy.com
  119. 119. Randomized controlled trials comparing different designs of oral appliances • Lawton, Battagel and Kotecha (EJO 2005) – They analyzed the efficacy of the Twin Block in relation to the Herbst appliance as a mandibular advancement splint (MAS). – The results suggested that there was no difference in the treatment performance of the Twin Block and Herbst for AHI , snoring frequency, arterial blood oxygen saturation, quality of life and side-effects. – The Herbst proved to be the more effective appliance for reducing daytime sleepiness and was the more popular appliance among the patients. – The Twin Block appliance is bulkier than the Herbst and it may be that the additional reduction in airway volume was enough to negate the positional benefits of the appliance www.indiandentalacademy.com
  120. 120. • Bloch et al (2000) – Studied the effectiveness and side effects of an adjustable Herbst appliance with those of a fixed single-piece mandibular advancement device (Monobloc) with equal advancement. – This project was one of the first to compare the effectiveness of mandibular advancement devices with different designs. – Patient preference and trends of polysomnographic data showed the Monobloc to have greater patient acceptability and to be more effective than the Herbst appliance in the treatment of obstructive sleep apnea . www.indiandentalacademy.com
  121. 121. Clinical aspects of insertion and titration of oral appliances • General technique for oral appliances that are selected from a prefabricated set – The oral appliance that incorporates thermoplastic material is initially heated in warm or hot water – Once the thermoplastic material is softened, the oral appliance is inserted, and any excess thermoplastic material is adapted to the buccal and lingual surfaces of the teeth using the fingers. – The oral appliance should be removed and reinserted several times as the material chills to prevent it from becoming locked into undercut areas. www.indiandentalacademy.com
  122. 122. • Titration of oral appliances – It consists of slowly moving the mandible either anteriorly or posteriorly using the adjustable mechanism until successful results are achieved with the minimum possible protrusive position. – The titration of oral appliances may be tedious, requiring several weeks to months. – Once completed, titration may become necessary again at some future time if sleep disorder symptoms recur or tooth or temporomandibular joint sensitivity appear. www.indiandentalacademy.com
  123. 123. • The following titration process is for a device with a screw-type mechanism: – The patient generally begins with the mandible advanced to 70-75% of his or her maximum protrusive position relative to the most retrusive position. – The oral appliance is inserted and not titrated for several days until the patient has become accustomed to wearing the appliance. – If, as frequently happens, successful results are achieved, titration is not necessary. – If the symptoms have not been reduced acceptably, the mandible is slowly protruded, often in increments of 0.25 mm per night. www.indiandentalacademy.com
  124. 124. • After approximately 2 weeks, the patient must be re-examined if the desired results have been achieved. • If the patient reports sensitive teeth, it may be necessary to adjust the oral appliance around the sensitive teeth. • Teeth or Tempromandibular joint sensitivity may also require that the mandible be slowly retruded until the problem is addressed. • Once the sensitivity is corrected, it may be necessary again to protrude the mandible until the sleep disorder symptoms are addressed. • If the obstructive sleep apnea has worsened, the patient is not allowed to continue with the oral appliance therapy. www.indiandentalacademy.com
  125. 125. Treatment Considerations • Clinicians should explain the possible side effects of treatment including the possibility that the appliance may loosen or break dental restorations, excess salivation, xerostomia, TMJ pain, soreness of the masseter muscle, and tooth discomfort • Mandibular protrusion devices should only be used when a patient has at least 8 teeth in each arch and is able to demonstrate a mandibular protrusion of at least 5 mm and a bite opening of greater than 25 mm. • Totally edentulous patients are usually not good candidates for mandibular repositioners, but tongue-retaining devices may be used in edentulous patients for snoring, and not obstructive sleep apnea .www.indiandentalacademy.com
  126. 126. • Patients who are treated with a mandibular protruding device for obstructive sleep apnea may find that when they wear the appliance, their occlusion feel different for a short while after the appliance is removed • Obstructive sleep apnea patients who present with more severe TMJ pain are probably not good candidates for treatment with mandibular protrusion devices. • Patients with significant bruxism can frequently damage mandibular protrusion devices and thus make this treatment approach costly and inefficient, • While very obese patients, with some exceptions, are best treated by other means than mandibular protrusion.www.indiandentalacademy.com
  127. 127. Amount of bite opening • As the mouth opens, the anterior attachment of the tongue swings not only down but also backward carrying the tongue toward the airway. • For this reason, L’Estrange et al (1997) concluded that Mandibular Advancement Device should keep jaw opening to an ―absolute minimum • Meurice et al (1996), concluded that pharyngeal airway was more likely to obstruct when the mandible opened 15 mm at the incisors • There are no published polysomnographic studies that establish the optimum vertical dimension for the Mandibular Advancement Device • The most commonly selected bite opening is about 2 mm between the incisorswww.indiandentalacademy.com
  128. 128. • Vicomi et al (1988) showed good apnea reduction with an Mandibular Advancement Device that advances the mandible 6 to 9 mm while opening it vertically 17 mm. • Mandibular Advancement Device expand the airway not only behind the tongue but also behind the soft palate. • The mechanism for this velopharyngeal expansion is the pull on the palatoglossus muscle www.indiandentalacademy.com
  129. 129. • The superior pharyngeal constrictor muscle attaches directly and indirectly to the mandible. • Opening the mouth, therefore, exerts a downward force on the lateral walls of the pharyngeal airway, stretching them longitudinally. • This stretching improves airway patency by reducing folds, compliance and extrinsic compression. • Another advantage of increasing the jaw opening beyond 2 mm is that it helps part the lips allowing a passage for oral breathing. www.indiandentalacademy.com
  130. 130. SURGICAL MANAGEMENT OF OSA www.indiandentalacademy.com
  131. 131. • Surgical management of Obstructive sleep apnea is generally recommended when the applicable conservative therapies are unsuccessful or not well tolerated, as well as or patients who have an identifiable underlying surgically correctable abnormality that is causing the Obstructive sleep apnea . • Surgery can provide definitive treatment, thus eliminating patient compliance issues, but only if performed competently, both in terms of technical skill and on the correct site or area of upper airway obstruction. www.indiandentalacademy.com
  132. 132. Presurgical Evaluation • The upper airway can be divided into three main regions for evaluation • Nose and Nasopharynx – The nose should be evaluated for septal deviation, turbinate hypertrophy, nasal polyps, infectious and edematous conditions such as rhinosinusitis, rhinitis and neoplasms, as well as patency of internal nasal valve. – The nasopharynx is examined for adenoid hypertrophy, polyps, cysts, and obstructing masses. www.indiandentalacademy.com
  133. 133. • Oral Cavity and Oropharynx – The tongue is estimated to be of normal size if it sits at or below the level of the occlusal plane at rest. It is subjectively described to be mildly, moderately or severely enlarged if above the occlusal plane – The position of the soft palate with respect to the tongue is noted at rest and is graded using the modified Malampatti Score, I through IV – The pharyngeal tonsils are graded 1,2,3 or 4, dividing the airway into less than 25%, 25 to 50%, 50-75% or greater than 75% respectively www.indiandentalacademy.com
  134. 134. • The hypopharynx and larynx – The hypopharynx and larynx are best evaluated from above with the flexible endoscope. – The base of the tongue, epiglottis, vocal folds, arytenoids and the presence of lingual tonsils are noted www.indiandentalacademy.com
  135. 135. • The current surgical procedures used for Obstructive sleep apnea are – Tracheostomy, – Uvulopalatopharyngoplasty, – Laser assisted uvulopalatoplasty, – Surgical reduction of the tongue, – Mandibular osteotomy with genioglossus advancemnt, – Hyoid myotomy and suspension, as well as maxillomandibular advancement www.indiandentalacademy.com
  136. 136. I) TRACHEOSTOMY FOR THE TREATMENT OF OSA • Before the introduction of uvulopalatopharyngoplasty and continuous positive airway pressure, tracheostomy was the only treatment available. • At present this procedure is usually reserved for the most severe Obstructive sleep apnea patients • It is 100% effective in alleviating Obstructive sleep apnea by bypassing all upper airway obstructive sites • Tracheostomy has been shown by several authors to reduce mortality in patients with sleep apnea www.indiandentalacademy.com
  137. 137. Indications of tracheostomy in patients with Obstructive sleep apnea • Disabling sleepiness with severe familial and socioeconomic impact. • Severe cardiac arrhythmias associated with respiratory events. • A high apnea index. (> 60). • Notable oxygen desaturation level during sleep i.e. oxygen desaturation level below 60%. • No improvement of clinical symptoms or polysomnography findings after medical trials. • Tracheostomy may also be performed to protect the airway from obstruction due to edema while the patient undergoes upper airway reconstructive surgery www.indiandentalacademy.com
  138. 138. II) UVULOPALATOPHARYNGOPLASTY For Obstructive sleep apnea • In 1979, Fujita et al began to look for alternatives for tracheostomy for the treatment of patients with obstructive sleep apnea. • In 1980 they introduced a new operation for the correction of anatomic abnormalities in the pharynx, which was referred to as a Uvulopalatopharyngoplasty • This is designed to decrease oropharyngeal collapsibility by reducing the soft palate, uvula, posterior and lateral pharyngeal walls, and tonsils when present. • The goals of surgery are to resect the posterior margins of the soft palate and redundant lateral pharyngeal wall mucosawww.indiandentalacademy.com
  139. 139. • The soft palate resection ranges from 8-15 mm, stopping short of the thick muscular part of the palate. • The lateral pharyngeal wall is treated by resecting redundant mucosa and developing a flap along the posterior wall. • The flap is advanced and sutured to the anterior tonsillar pillar areawww.indiandentalacademy.com
  140. 140. Complications of Uvulopalatopharyngoplasty • Early complications: – Transient velopharyngeal incompetence. – Wound dehiscence. – Hemorrhage. – Wound infection • Late complications: – Pharyngeal discomfort, dryness, tightness – Postnasal secretion – Inability to initiate swallowing – Prolonged sore throat – Taste disturbance – Speech disturbance – Permanent velopharyngeal incompetence – Nasopharyngeal stenosis.www.indiandentalacademy.com
  141. 141. III. LASER ASSISTED UVULOPALATOPLASTY (KAMAMI TECHNIQUE) • Kamami (1990) first described laser assisted uvulopalatoplasty (LAUP) for the treatment of snoring • Laser assisted uvulupalatoplasty stiffens and possibly enlarges the antero-posterior retopalatal airway and is associated with an extremely low complication rate when compared with Uvulopalatopharyngoplasty • The technique can be performed under local anesthesia as a multiple out-patient procedure. • The laser usually used is CO2 laser at 20 watts in continuous mode. www.indiandentalacademy.com
  142. 142. • The key disadvantages with laser assisted uvulopalatoplasty are however the early drop off in the success rate and the severe degree of post-operative pain encountered • One of the biggest disadvantages of the laser assisted uvulopalatoplasty procedure from the physician’s point of view has been the high cost of the equipment. www.indiandentalacademy.com
  143. 143. IV. SURGICAL PROCEDURES FOR THE TONGUE • Midline glossectomy – A laser midline glossectomy is accomplished by vaporizing a 2 cm by 5 cm rectangular portion or the midline tongue with a laser. – A lingual tonsillectomy, reduction of aryepiglottic folds, and a partial epiglottectomy can be done concomitantly if indicated – Complications of this procedure include bleeding, dysphagia and altered taste www.indiandentalacademy.com
  144. 144. • Linguloplasty – The linguloplasty differs from the laser midline glossectomy in that the tongue excision is extended more posteriorly and laterally. – The defect is closed, by suturing the posterior margin anteriorly, which advances the tongue base anteriorly. – The anterior rotation of the posterior margin significantly improves the success rate to around 77% www.indiandentalacademy.com
  145. 145. Tongue-base suspension sutures: (Coleman and Bick, 1999) • A non-resorbable suspension suture is placed in the tongue and is then attached to a titanium bone screw inserted into the geniotubercle of the posterior aspect of the mandible. • The suture tension prevents posterior tongue displacement and occlusion with the posterior pharyngeal wallwww.indiandentalacademy.com
  146. 146. V. INFERIOR SAGITTAL OSTEOTOMY OF THE MANDIBLE • This method allows isolated advancement of the genial tubercle and genioglossus muscle • The surgical approach to the mandible is through the submental incision. • A rectangular osteotomy is accomplished around the geniotubercle on the labial surface of the anterior mandible. • It is desirable to leave 8-10 mm of inferior border to decrease the chance of fracture. • The genial segment with its genioglossus attachment is advanced, rotated and rigidly fixed to the mandiblewww.indiandentalacademy.com
  147. 147. Inferior sagittal osteotomy of mandible www.indiandentalacademy.com
  148. 148. VI. MAXILLOMANDIBULAR ADVANCMENT SURGERY • Maxillomandibular advancement or MMA surgery, anteriorly repositions the maxillary and mandibular framework and their attending muscular attachments. • It pulls forward the anterior pharyngeal tissues attached to the maxilla, mandible and hyoid to structurally enlarge the entire velopharynx, • As well as to enhance the neuromuscular tone of the pharyngeal dilator muscles via an extra- pharyngeal operation www.indiandentalacademy.com
  149. 149. • Procedure: – The maxillary surgery performed is a standard LeFort I osteotomy which is advanced 10-14 mm and stabilized with rigid internal fixation. – Bone grafts are required to fill in the gaps created by the large advancement. – The mandible is advanced 10-14 mm by a bilateral sagittal split osteotomy and stabilized with rigid internal fixation with bicortical screws. – Additional maxillomandibular skeletal fixation can help prevent skeletal relapse. www.indiandentalacademy.com
  150. 150. VII. DISTRACTION OSTEOGENESIS FOR TREATMENT OF OSAHS • Advantages: – It eliminates the need for bone grafting, which is usually required when large amounts of skeletal advancement are performed – It involves less surgical dissection because the lengthening is the result of natural bone healing in a gap created by a simple osteotomy. – The incremental skeletal movement allows accommodation of the soft tissues, thus enabling large skeletal movement that cannot be achieved by conventional techniques. – The improved soft tissue accommodation also improves the stability of the new skeletal position.www.indiandentalacademy.com
  151. 151. www.indiandentalacademy.com
  152. 152. • Disadvantages: – Although less surgical dissection is necessary, procedure is highly technique sensitive. Parallelism of the distraction vectors is extremely important to avoid malocclusion. This can be quite difficult in simultaneous maxillo-mandibular advancement with 4 distraction devices. – The most significant disadvantage for distraction osteogenesis in the treatment of sleep apnea in adult patients is the length of treatment time (may take up to 4 months) – The weakness of regenerated bone and the presence of distraction devices and arch bars significantly affect the patient’s mastication and speech. www.indiandentalacademy.com
  153. 153. Conclusion • In rapidly industrializing country like India, with soaring rates of obesity, it is quite likely that prevalence of Obstructive Sleep Apnea is far higher than detected and rising rapidly • Although this disease traditionally thought to affect mainly middle aged obese person of male sex, over recent years there has been increasing evidence of occurrence of this disease in persons with certain craniofacial structures and female sex • The Orthodontist, in concert with trained medical personnel can render valuable service in diagnosis and treatment of OSA www.indiandentalacademy.com
  154. 154. • At present there are several mandibular advancement appliances, which has been shown to enjoy high compliance rates and achieve excellent resolution of symptoms • It is important however for these patients to undergo regular medical referrals to monitor their condition and switch to an alternative treatment plan if required • Thus, there can be no doubt that Orthodontist has a vital role to play in identifying as well as treating OSA patients • It would thus be important for Orthodontist to make themselves aware of the procedures and responsibilites involved in multi-disciplinary management of OSA www.indiandentalacademy.com
  155. 155. References 1. Hamada T, Ono T, Otsuka R, Honda E, Harada K, Kurabayashi T, Ohyama K. Mandibular distraction osteogenesis in a skeletal Class II patient with obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 2007 Mar;131(3):415-25. 2. Otsuka R, Almeida FR, Lowe AA. The effects of oral appliance therapy on occlusal function in patients with obstructive sleep apnea: a short-term prospective study. Am J Orthod Dentofacial Orthop. 2007 Feb;131(2):176-83. 3. Shoaf SC. Sleep disorders and oral appliances: what every orthodontist should know. J Clin Orthod. 2006 Dec;40(12):719-22.www.indiandentalacademy.com
  156. 156. 4. Hou HM, Sam K, Hägg U, Rabie AB, Bendeus M, Yam LY, Ip MS. Long-term dentofacial changes in Chinese obstructive sleep apnea patients after treatment with a mandibular advancement device. Angle Orthod. 2006 May;76(3):432-40. 5. Otsuka R, Almeida FR, Lowe AA, Ryan F. A comparison of responders and nonresponders to oral appliance therapy for the treatment of obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 2006 Feb;129(2):222-9. 6. Marklund M. Predictors of long-term orthodontic side effects from mandibular advancement devices in patients with snoring and obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 2006 Feb;129(2):214-21. 7. Conley RS, Legan HL. Correction of severe obstructive sleep apnea with bimaxillary transverse distraction osteogenesis and maxillomandibular advancement. Am J Orthod Dentofacial Orthop. 2006 Feb;129(2):283-92. www.indiandentalacademy.com
  157. 157. 8. Almeida FR, Lowe AA, Otsuka R, Fastlicht S, Farbood M, Tsuiki S. Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: Part 2. Study-model analysis. Am J Orthod Dentofacial Orthop. 2006 Feb;129(2):205-13. 9. Almeida FR, Lowe AA, Sung JO, Tsuiki S, Otsuka R. Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: Part 1. Cephalometric analysis. Am J Orthod Dentofacial Orthop. 2006 Feb;129(2):195-204. 10. Lowe AA. Orthodontists and sleep-disordered breathing. Am J Orthod Dentofacial Orthop. 2006 Feb;129(2):194. 11. Hans MG, Nelson S, Pracharktam N, Baek SJ, Strohl K, Redline S. Subgrouping persons with snoring and/or apnea by using anthropometric and cephalometric measures. Sleep Breath. 2001 Jun;5(2):79-91. www.indiandentalacademy.com
  158. 158. 12. Horiuchi A, Suzuki M, Ookubo M, Ikeda K, Mitani H, Sugawara J. Measurement techniques predicting the effectiveness of an oral appliance for obstructive sleep apnea hypopnea syndrome. Angle Orthod. 2005 Nov;75(6):1003-11. 13. Tsuiki S, Almeida FR, Lowe AA, Su J, Fleetham JA. The interaction between changes in upright mandibular position and supine airway size in patients with obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 2005 Oct;128(4):504-12. 14. Johal A, Battagel JM, Kotecha BT. Sleep nasendoscopy: a diagnostic tool for predicting treatment success with mandibular advancement splints in obstructive sleep apnoea. Eur J Orthod. 2005 Dec;27(6):607-14. 15. Hans MG, Nelson S, Luks VG, Lorkovich P, Baek SJ. Comparison of two dental devices for treatment of obstructive sleep apnea syndrome (OSAS). Am J Orthod Dentofacial Orthop. 1997 May;111(5):562-70.www.indiandentalacademy.com
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