Introduction to Sleep apnea for Orthodontists


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A small presentation for orthodontists

  • Jean-Marc, I am so happy to hear the mention of bi-maxillary retrusion from within an orthodontic department. Since I learned the concept just a few years ago (after 25 years in orthodontic practice). I realize there is no place for it in current orthodontic thinking, even though it is in the literature. Now applying the concept to children by connecting the dots backward from the adult sleep apenic, it presents a whole new way of thinking about early treamtent orthodontics.
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  • Dear JEAN-MARC

    On slide #19 you allude to the possibility that, in addition to retrognathic mandible in class II its., the maxilla might also be retro-positioned in OSA its.; I have added McNamara's 'McNamara Line' measurement (negative A-point distance from N-perp. to Frankfort indicates maxillary retrusion-McNamara 1981 Angle Orthod.) to your ceph tracing on slide # 23 to illustrate how correct this assumption of yours is. Please send me your email address and I will send you some very impressive material, from pre-Industrial Age museum specimens, to support that Bi-maxillary retrusion has become the new norm....and thus genomically incorrect. If you trace cephs with Bolton profile norms this will become very clear to you I think

    Kevin Boyd, DDS
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Introduction to Sleep apnea for Orthodontists

  1. 1. Welcome to the 1st CAO webinar on Obstructive Sleep Apnea Today’s presentation will be animated by Dr Jean-Marc Retrouvey, the Director of theDivision of Orthodontics at McGill University. Today, we will : • Define OSA • Discuss the manifestations of OSA. • Describe the typical type(s) of patients affected by OSA • Recognize the difference between OSA and snoring • Suggest different therapeutic approaches for the treatment of OSA
  2. 2. Obstructive Sleep ApneaThe Role of the Orthodontist:The role of orthodontics in improving breathing in children, teenagers and adults who suffer from sleep apnea Dr Jean Marc Retrouvey Director of Orthodontics McGill University
  3. 3. ObjectivesDefine OSADiscuss the manifestations of OSA.Describe the typical type(s) of patientsaffected by OSARecognize the difference between OSAand snoringSuggest different therapeutic approachesfor the treatment of OSA
  4. 4. Apnea–hypopnea index WIKIPEDIA• The apnea–hypopnea index (AHI) is an index of sleep apnea severity that combines apneas and hypopneas.• AHI values are typically categorized as 5– 15/hr = mild;• 15–30/hr = moderate;• > 30/h = severe.)
  5. 5. Apnea–hypopnea index WIKIPEDIA• The apnea–hypopnea index (AHI) is an index of sleep apnea severity that combines apneas and hypopneas. AHI values are typically categorized as: • 5–15/hr = mild • 15–30/hr = moderate • > 30/h = severe
  6. 6. Obstructive Sleep Apnea 27 % of Snoring patients may exhibit snoring Upper Airway UARS Resistance Syndrome 4% Obstructive OSA Sleep Apnea 2-3%Snoring and obstructive sleep apneaBy David N. F. Fairbanks, Samuel A. Mickelson, B. Tucker Woodson, p 243
  7. 7. Snoring: Benign condition(annoying but notdangerous) UARS: Sleep disturbances but no severe oxygen desaturation (No cardiac sequellae) OSA: Oxygen desaturation and sleep disturbances (Cardiac disturbances: Strokes, hypertension arrhythmias) Collpo N. Semin Respir Crit Care Med 2005; 26(1): 13-24 Pediatric Care Med 2005; 26(1): 13-24
  8. 8. 1. Excessive daytime somnolence Daytimesymptoms in 2. Abnormal daytimechildren with behavior obstructivesleep apnea 3. Learning problems 4. Bizarre behavior 5. Morning headaches 6. Failure to thrive or obesity 7. Repetitive upper airway infections 8. Acute cardiac failure Guilleminault C, Korobkin R, and R Winkle. A Review of 9. Cor pulmonale 50 Children with Obstructive Sleep Apnea Syndrome. Lung 10. Hypertension 1981.
  9. 9. Most common contributing factorsObesity Allergies and Combinations Genetics (ex: Skeletal malocclusions)
  10. 10. 1. Obesity A fairly direct correlation has been established between obesity and OSA in children1 and adolescents2 Apnea Hypoxia Index (AHI) scores are higher in obese than in normal-weight children with OSA31 - The Correlation Among Obesity, Apnea-Hypopnea Index, and Tonsil Size in ChildrenYuen-yu Lam, FHKAM(Paed), et al. Chest 2006: 1751-17562 - Obesity increases the risk for persisting obstructive sleep apnea after treatment in childrenLouise M. O’Brien et al . International Journal of Pediatric Otorhinolaryngology (2006) 70, 1555—15603 - Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight childrenRon B. Mitchell, MD, and James Kelly, PhD, St Louis, MO; Albuquerque, NM . Otolaryngology–Head andNeck Surgery (2007) 137, 43-48
  11. 11. 1. ObesityWhat about treating OSA in obese kids? Both groups show a dramatic improvement in AHI after adenotonsillectomy, but persistent OSA is more common in obese children.Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight childrenRon B. Mitchell, MD, and James Kelly, PhD, St Louis, MO; Albuquerque, NM . Otolaryngology–Head and Neck Surgery (2007) 137, 43-48
  12. 12. 1. ObesityWith treatment, improvement in OSA but….. Weight gain!Recommendation : Lose weight and improve physicalcondition before starting OSA treatment.Soultan, Z., et al., Effect of treating obstructive sleep apnea by tonsillectomy and/or adenoidectomy onobesity in children. Archives of Pediatrics and Adolescent Medicine, 1999. 153(1): p. 33.
  13. 13. Treatment of OSA or UARS in non-obese children Impact of Orthodontic treatment
  14. 14. Common Contributing Observations Severely enlarged tonsils and adenoids in the young patient presenting either UARS or OSA page/pi_id/303
  15. 15. Consequence of Enlarged Tonsils and AdenoidsDr Harvold, from the University of Toronto, performed studies on Monkeys which showedthat: If you block nasal respiration, mouth breathing follows and a severe malocclusion is observed (variable response)Harvold EP et al. Primate experiments on oral respiration. Am J Orthod 79(4):359-72, 1981Harvold EP et al. Experiments on the development of dental malocclusion. Am J Orthod 61:38-44, 1972.
  16. 16. Recognize early!OSA will have an impact on normal growthand development (early treatment must beseriously considered)• Growth hormone is mainly released during the stage 3 of NREM sleep.•
  17. 17. Importance of Early Detection and TreatmentSuch changes are also influenced by genetic factors. Facial growth is nearly complete between the ages of 15and 16 years in girls and between 18 and 19 years in boys, but the largest increments of growth occurduring the earliest years of life: By the age of 4 years, the craniofacialskeleton has attained 60% of adult size, and by the age of 12years it is 90% of adult size. Thus both genetic and environmental factors play a role inteenage facial determination.Our findings suggest that specific morphometric features may have been present in certain children ottonsilectomy and adenoectomy, some aspect of facial growth may evenhave been modified by the early airway obstruction. Morphometric facial changes and obstructive sleep apnea in adolescents Christian Guilleminault, MD, Markku Partinen, MD, Jean Paul Praud, MD, Maria-Antonia Quera-Salva, MD, Nelson Powell, MD, and Robert Riley, DDS, MD From Stanford University Medical Center, Stanford, California, Ullanlinnan Sleep Disorders Clinic, Helsinki, Finland, Laboratoire dExplorations Fonctionelles, Hopital Antoine Beclere, Clamart, France, and Hopital Raymond Poincarré, Garches, France A, Jand ournal of Pediatrics 1989
  18. 18. Examination of a Patient Suffering from OSA or UARS1 • Reference to pneumologist for polysomnography2 • Extra oral findings3 • Intra oral findings4 • Cephalometric or Cone Beam assessment5 • Final diagnosis6 • Treatment options
  19. 19. Examination of a Patient Suffering from OSA or UARS 2 Extra oral findings • Facial features • ―Pockets‖ under the eyes • Evidence of mouth breathing • Retrusive mandible (Cl II malocclusion) • Retrusive maxilla?
  20. 20. Examination of a Patient Suffering from OSA or UARS3 Intra oral findings • Openbite • Narrow palate • Curve of Spee • Lower arch form • Severe malocclusion • Usually Cl II
  21. 21. Examination of a Patient Suffering from OSA or UARS3 Intra oral findings Compared with 48 asymptomatic children from the same cohort, the obstructed children had a narrower maxilla, a deeper palatal height, and a shorter lower dental arch. In addition, the prevalence of lateral crossbite was significantly higher among the obstructed children. Breathing obstruction in relation to craniofacial and dental arch morphology in 4-year-old children B Löfstrand-Tideström European Journal of Orthodontics Volume 21, Issue 4 , 1999 Pp. 323-332
  22. 22. Examination of a Patient Suffering from OSA or UARS4 Cephalometric or Cone Beam assessment • Consistent for a large number of OSA pediatric patients
  23. 23. • Retrognathic mandible• Steep mandibular plane angle• Long anterior face height• Short posterior face height
  24. 24. Examination of a Patient Suffering from OSA or UARS65 Treatment options 1. Tonsillectomy 2. Rapid Palatal Expansion 3. Mandibular Advancement
  25. 25. 1. Tonsillectomy?Children, who were tonsillectomized because of sleep apneawere examined with respect to facial growth and dental archmorphology.The findings were compared to data from children withouttonsillary obstruction. A higher proportion of malocclusionthan normal, especially openbite and crossbite, was noticedbefore surgery.Two years after surgery, 77% of the open bites were normalizedand 50-65% of the buccal and anterior crossbites. The bestresults were seen in children operated before the age of 6.E. Hultcrantz E., Larson M. , Hellquist R. , Ahlquist-Rastad J. , Svanholm H. and JakobssonO.P. : The influence of tonsillar obstruction and tonsillectomy on facial growth and dental archmorphologyInternational Journal of Pediatric Otorhinolaryngology 22,2: 125-134 1991
  26. 26. 2. Rapid Palatal expansion• Multiple articles point towards an improvement in the sleep apnea condition.• Expansion is done via RPE and averages 4.5mm to 6 mm at the palatal suture.• On sleep apnea patients, the earlier the better.
  27. 27. Selection Criteria for RPE patients• High narrow palate• Deep bite• Retrusive mandibleVilla, M.P., et al., Rapid maxillaryexpansion in children with obstructivesleep apnea syndrome: 12-monthfollow-up. Sleep medicine, 2007. 8(2):p. 128-134.
  28. 28. 3. Mandibular advancementHas the same effect in growing children asrapid palatal expansionRandomized Controlled Study of an Oral Jaw-Positioning Appliance for the Treatment of Obstructive Sleep Apnea inChildren with Malocclusion. MARIA P. Villa, edoardo bernkopf, jacopo pagani, vanna broia, Marilisa montesano androberto ronchetti.
  29. 29. Impact of Orthodontics on Pediatric OSA ManagementTreatment will depend on the severity of the OSA, itsinfluence on the degree of malocclusion and the age ofthe patient.Take Home Message : Early recognition (before age 7) • Educate parents and dentists Constant collaboration with the treating physician (Respirologist, Plastics, ENT), the Orthodontist and the Dentist. Treat early and aggressively • Through RPE; Mandibulat advancement and Maxillary Vertical Control
  30. 30. OSA Treatment in the adult Role of the orthodontist?Therapy ProviderCPAP Pneumologist or Sleep centerSoft tissue surgery ENTMADs Sleep center Dentist – TMJ specialist Orthodontist?MMA surgery OMFSSARPE Orthodontist
  31. 31. Mandibular advancement devices• May be efficient for moderate OSA• Do not replace the CPAP in severe cases
  32. 32. Future: CAD-CAM Manufactured ApplianceSlide from Dr Arcache
  33. 33. What about SARPE?Dr Fiore (Fiore et al., U de Montreal, 2012)testing 9 patients treated with Sarpe andcomprehensive orthodontics.Showed a small but not significant reductionin respiratoy index.Significant change in snoring index.
  34. 34. Maxillary Mandibular Advancement.Surgical goal: Improvement of thepharyngeal airway along its entire length
  35. 35. 43 yr male with snoring and witnessed apneas.• Sleep study – RDI 67/hr, LSAT 83%• Sleep study with CPAP – RDI 15/hr, LSAT 86%• Does not tolerate CPAP
  36. 36. Pre-operative Cephalogram • Bimaxillary retrusion • Cl II bimaxillary retrusion malocclusion • Blocked airway
  37. 37. Surgical Procedure• Maxillary advancement 8mm• Mandibular advancement 8mm• Advancement genioplasty 4mm• Hyoid suspension 10mm
  38. 38. Post-operative Cephalogram
  39. 39. ResultsPre- operative sleep study: - RDI 67/hr6 month post- operative sleep study – RDI 9/hr, (was down to 15 with CPAP) RDI : Respiratory Disturbance Index LSAT: Saturation in oxygen
  40. 40. Long Term Follow up of a TMJ- OSA PatientPatient presenting with Long facesyndrome : – Narrow palate – Retrusive mandible – Anterior tongue posture – Severe to moderate crowding of dental arches – Painful bilateral TMJ clicks – Moderate OSA ( No C Pap used)
  41. 41. Treatments1. Maxillary expansion at 8 years old (failed)2. Dental alignment (camouflage failed)3. Extractions were contemplated by previous orthodontist (failed to recognize OSA)4. Mandibular protraction appliance contra- indicated (High MP angle)
  42. 42. Long term Follow up of TMJ and OSA Patient In 2004, afterfirst rapid palatal expansion attempt
  43. 43. 2009: Ready for Ortho-SurgeryOrthodontics: 3 piece maxilla preparation Uprighting of lower arch
  44. 44. Immediately Post Surgery (4 weeks)
  45. 45. Results:TMJ pain is resolved ( nosplint worn)Snoring and symptoms ofOSA have subsidedPatient is satisfied withaesthetic result.
  46. 46. ConclusionsOSA is a medical condition and may bepotentially lethalA positive diagnosis of OSA should beobtained before starting any treatmentThe dental profession has an important rolein screening young patientsOrthodontists have a greater role to play(back to the future: treat early andaggressively)
  47. 47. ConclusionsTonsillectomy is making a comeback in preventivetherapy for this type of patients (OSA-UARS)CPAP machine is still standard of care in adultsGrowth modification may play an important aspectof OSA treatment Maxillary expansion Mandibular protraction seem to have a positive effect on OSA Must start as early as possible ( do not allow upper molars descent)