A 74-year-old female presented with a chief complaint of fractured teeth, tongue, and cheek from biting during sleep. She has a history of medical issues including arrhythmias and sinus issues. A home sleep study found severe obstructive sleep apnea in REM sleep and mild apnea in NREM sleep. CBCT imaging showed airway limitation in the retro-glossal region. The patient wishes to try oral appliance therapy along with weight loss and improved sleep hygiene, with follow up sleep study in 6 weeks, and is open to CPAP if needed. The dentist reviewed management options and bite registration models.

1. Case Study
74 y o Female.
Chief Complaint: Fractured teeth,
tongue and cheek
biting
Intra Oral : Scalloped tongue, heavily
restored teeth, # fills,

2. Med hx
• Mitral valve prolapse, Arrhythmia, Sinus issues
• Allergies : Bees
• Medication: Flecainide Acetate (anti-
arrhythmia) , Ozmep (tx peptic ulcers),
Paroxetine (SSRI), Ransim (Simvastatin),
Xarelto (oral anticoagulant)
• Non Smoker, O units of Alcohol
• Ht: 160cms, Wt: 90Kg, BMI: 35.2

3. Social/Sleep Hx
• Retired, widowed, lives alone
• Poor sleep hygiene
• Reports eating late
• No set bed time
• No set waking up time
• Pets sleep in bed
• No complaint of day time tiredness, but does nap
most afternoons.
• Epsworth : 5

4. Referrals
• CBCT Airway
• Home Sleep Study
• ENT (patient reports congested sinuses and
post nasal drip)
• JVA quick

5. CBCT Airway
• Limitation of Retro-Glossal region
• Dimension
– Retro palatal (Anterior Posterior ): 13.2mm
(Lateral ) : 25.3mm
– Retro Glossal (Anterior Posterior) :3mm
(Lateral) : 26.2mm

6. Home Sleep Study
“Severe Obstructure Sleep Apnea in REM with
Moderate oxygen desaturation. Remainder of the
study indicates mild obstructure sleep apena.”
AHI : NREM – 6.7/hr, REM -37.2/hr
RDI: NREM -10.1/hr, REM: 45.6/hr
Base line O2: 98% while awake
SpO2 Nadir: NREM – 89%, REM: 86%
Longest: Apnea - 25 Sec, Hypopnea -19 sec

7. ENT
• Report not available at this stage.

8. JVA Quick
• Max Opening: 48mm
• No deviation
• JVA Quick
– Average of 3 studies
• Right TMJ : Normal
• Left TMJ: Normal

9. Models

10. Models

11. Models

12. Geoge Guage Bite at 70% protrusion

13. Geoge Guage Bite at 70% protrusion

14. Geoge Guage Bite at 70% protrusion

15. Management
• Sleep Physician recommendations
– Optimal therapy: CPAP with focus on weight loss
and good sleep hygiene
– Alternatives : EPAP, OAT and ref to ENT for surgery
– Review by sleep physician
– Annual Sleep studies

16. Management
• Patient wishes to try OAT in conjunction with
weight loss and better sleep hygiene
• Follow up sleep study 6 weeks after OAT
inserted
• Currently working on weight management
and better sleep hygiene.
• Willing to consider CPAP follow up sleep study
shows inadequate improvement

17. Questions????
• Is George guage the right choice of bite
registration?
• Which appliance would suit?