DT_August_15_188_fnl

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does
not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment
and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.
Authored by Joseph Yousefian, DMD, MS, MA; Kate Weaver, DDS; Douglas Trimble, DMD, MD;
Robert William DePaso, MD; and Robert Gottlieb, DDS
Upon successful completion of this CE activity, 2 CE credit hours may be awarded
A Peer-Reviewed CE Activity by
Course Number: 188
CorrectionofSevereObstructive
SleepApnea
WithInterdisciplinaryTreatment
Dentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP is a service of the
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ADA CERP at ada.org/goto/cerp.
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Approval does not imply ac-
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June 1, 2015 to
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approval number: 309062
CONTINUING EDUCATION

D
ental practitioners frequently treat patients who may
have dentofacial aesthetic concerns but also suffer from
other medical problems such as obstructive sleep apnea
syndrome (OSAS). OSAS can be debilitating and if not treated
properly can lead to more dangerous health issues including
high blood pressure, diabetes, and cancer.
The patient presented in this article was mainly concerned
about simple dentofacial aesthetic issues but also suffered from
a severe and complex OSAS, high blood pressure, prostrate can-
cer, and developing diabetes.
OSAS is one of the more severe forms of sleep-disordered
breathing (SDB). It can be a debilitating, even life-threatening,
condition. Potential health risk factors associated with OSAS in-
clude tooth grinding, temporomandibular disorders, facial de-
formities, attention deﬁcit hyperactivity disorder,1 gastro-
esophageal reﬂux disease, premature aging, depression, hyper-
tension, sexual impotence, Alzheimer’s disease, metabolic syn-
drome, diabetes, obesity, and more dangerous illnesses such as
1
CorrectionofSevere
ObstructiveSleep
ApneaWithInterdisci-
plinaryTreatment
Dr. Yousefian obtained his DMD degree from Washington University, in St. Louis, in 1987, and completed 3 years of post-gradu-
ate training in orthodontics at The Ohio State University in 1991. He also received the master of science degree in orthodontics
and master of arts degree in physical anthropology. He is a Diplomate of the American Board of Orthodontics and has been in pri-
vate practice in Bellevue, Wash, since 1991. He has served as a clinical assistant professor and orthodontic research associate at
The Ohio State University and the University of Washington in the department of orthodontics. He is an active international lecturer
and has contributed as a main author to numerous publications in orthodontics as well as dental journals and textbooks. He can
be reached via email at joseph@dryousefian.com.
Disclosure: Dr. Yousefian reports no disclosures.
Dr. Weaver graduated from the University of Washington School of Dentistry in 2001. While there, she received multiple awards in comprehensive
patient care and outstanding clinical performance in aesthetic and cosmetic dentistry. She is a graduate of the Kois Center, which provides a didactic and
clinical program with the latest advances in aesthetics, implant, and restorative dentistry. Dr. Weaver and her team are participants in national “Give Kids
a Smile Day” in which 100 kids from low-income families are given free dental services. She also volunteers overseas and thus far has helped many
people in India and Ethiopia. She maintains a private practice in Kirkland, Wash, and can be reached via email at kmweaver@dentistekirkland.com.
Disclosure: Dr. Weaver reports no disclosures.
Dr. Trimble graduated from the University of Manitoba, earning his DMD degree in 1973 and his MD degree in 1976. He completed his residency in oral
and maxillofacial surgery at the University of Washington from 1979 to 1982. His experience includes a general surgery internship in 1977, emergency
room staff in 1978, and an aesthetic surgery fellowship in 1997. He has been in private practice in Bellevue, Wash, for 32 years. He can be reached via
email at idougtrim@gmail.com.
Disclosure: Dr. Trimble reports no disclosures.
Dr. DePaso received his MD degree from the University of Chicago, Pritzker School of Medicine, in 1981, and currently serves as medical director of the
Virginia Mason Sleep Disorders Center. He is a Diplomate of the American Board of Internal Medicine, the American Board of Sleep Medicine, and the
American Board of Internal Medicine, Sleep Disorders. He can be reached via email at william.depaso@virginiamason.org.
Disclosure: Dr. DePaso reports no disclosures.
Dr. Gottlieb received his DDS degree from from the University of Illinois in 1975, and his certificate in periodontics from the University of Washington in
1977. He has taught at the University of Illinois and the University of the Pacific, and served as president of the Washington State Society of Periodontics.
He has lectured throughout the United States on periodontal therapy. He can be reached via email at gotts7@msn.com.
Disclosure: Dr. Gottlieb reports no disclosures.
Learning Objectives: After reading this article the individual will learn:
(1) definition and complications of obstructive sleep apnea syndrome
(OSAS), and (2) interdisciplinary treatment, dentofacial aesthetic con-
cerns, and other health issues involving OSAS.
AbouttheAuthors
Effective Date: 08/01/2015 Expiration Date: 08/01/2018

cancer,2,3 heart disease, and stroke.4 Health issues related to
OSAS contribute to many of the complex socioeconomic prob-
lems endemic to our industrial societies such as poor job per-
formance, academic failure, a sevenfold increase in the
incidence of accidents both at home and work, and severe night-
time snoring, which can have a major negative influence on
family relationships.4
OSAS is a multifactorial disease. Constriction of the upper
airway is recognized as one of the most important factors in the
development of OSAS. Variables that affect the upper airway lu-
minal size include the relative sizes of the jaw and tongue and
the enlarged adenoid and tonsillar bulk in children. Craniofa-
cial abnormalities (eg, retrognathia) also are associated with
SDB and OSAS.5 Case reports correlate the development of OSAS
in individuals with various craniofacial abnormalities.6 Other
risk factors include aging and weight gain.7,8
Developments in the science of sleep medicine, along with
education and media coverage of the subject, especially sleep
apnea, are making the public aware of the consequential impact
of jaw and dental problems as potential causes of airway insuf-
ficiencies during sleep. With increased public awareness and
greater clinical recognition, this trend is likely to escalate.
The field of dentistry and its involvement with the Pharyng-
OroFacial environment provides the dental practitioner with
an opportunity in screening for the presence of OSAS as a com-
plex health condition or participation in its treatment.9 A report
by the Institute of Medicine suggests that dental practitioners
should work closely with other health professionals when pa-
tients have complex health conditions.10 The ADA also empha-
sizes the importance of interdisciplinary professional and pa-
tient collaboration in its strategic plan, which includes a goal
to “improve public health outcomes through a strong collabo-
ration across the spectrum of our external stakeholders.”11
The case presented in this paper demonstrates the effective
participation of the dental practitioner as a member of an inter-
disciplinary dental/medical team collaborating in the treatment
of SDB and OSAS.
CASE REPORT
A 58-year-old male patient visited a new general dentist for po-
tential Invisalign (Align Technology) treatment to improve his
nonaesthetic smile. In the past he had received multidiscipli-
nary oral care provided by a number of reputable dental special-
ists in the area. A review of the patient’s medical history
indicated a healthy lifestyle including healthy diet, routine ex-
ercise, and no history of smoking or alcohol abuse.
The patient reported a history of severe OSAS (an apnea/hy-
popnea index [AHI] of 53 [below 5 is normal]) diagnosed by a
sleep specialist and polysomnography at a sleep center. His ini-
tial clinical symptoms included high blood pressure, excessive
daytime sleepiness affecting his job performance, and falling
asleep while driving. For treatment of his OSAS, he was using a
continuous positive airway pressure device (CPAP) with H2O
pressure of 18 cm. Although his CPAP compliance effort was
good, it was ineffective in reducing his symptoms due to air
leakage around the facial mask. As a result, he was taking
2
CorrectionofSevereObstructiveSleepApneaWithInterdisciplinaryTreatment
Figure 1. Pretreatment extraoral and intraoral photographs. Figure 2. Post-treatment extraoral and intraoral photographs.
Before After

Provigil (Teva Pharmaceuticals) medication as a wakefulness
promoting agent.
The patient had not proceeded with the previously pro-
posed surgical protocol for treatment of his OSAS. Phase one of
this protocol included hyoid suspension, midline glossectomy,
nasal valve stabilization, and septoplasty, followed by phase 2
consisting of maxillomandibular advancement surgery.
A clinical examination showed that the patient had a Class
III skeletal and dental relationship with a moderate retro-
gnathic position of the maxilla and retrusive position of the
dentition in the mandible (Figure 1). His oral hygiene was ex-
cellent. There was no presence of decay or gingival inflamma-
tion, but he had generalized type one periodontitis, with
horizontal bone loss and gingival recession. He was missing
teeth Nos. 1, 2, 16, 23, and 32; teeth Nos. 3, 30, and 31 had been
replaced with implant-supported restorations. Tooth No. 23 was
extracted at childhood. The anterior cross-bite was the patient’s
main aesthetic dissatisfaction with his smile and had never
been addressed properly.
Based on the complexity of the patient’s oral and medical
health issues including his narrow oropharyngeal airway, the
general dentist referred the patient to a new interdisciplinary
dental/medical team.
Treatment began with a combination of orthodontic and
telegnathic surgery for correction of the maxillary/mandibular
vertical, sagittal, and transverse deficiencies. When ortho-
gnathic surgery is used to treat OSAS, it is referred to as teleg-
nathic surgery. An 8-mm surgically assisted mandibular
expansion (SAME) as an outpatient technique was performed
to create a recipient site for future replacement of missing tooth
No. 23 by an implant-supported restoration.
During this stage of treatment, the patient reported a recent
diagnosis of elevated blood sugar and prostate cancer. The inter-
disciplinary medical/dental team—based on the severity of pa-
tient’s OSAS and his intolerance of CPAP—recommended
postponingthe surgical protocol for treatment of prostate cancer
until after the second stage surgery for treatment of his OSAS.
The second stage of telegnathic surgery was performed to
provide definitive OSAS relief. The procedure included a 10-
mm maxillary advancement, a 6-mm maxillary expansion, and
a 5-mm mandibular advancement combined with counter-
clockwise rotation of the maxillomandibular complex. The pa-
tient proceeded with the surgery and treatment protocol for his
prostate cancer 3 months later with complete remission. The
postsurgical orthodontic treatment was completed within 15
months. The implant for the future replacement of missing
tooth No. 23 was installed. The patient received partial connec-
tive tissue grafting to restore the excessive gingival recession.
Treatment Results
A well intercuspated Class I molar and canine relationship was
attained. The general dentist provided a comprehensive equili-
bration followed by the restoration of the implant replacing
missing tooth No. 23. A balanced facial profile with improved
chin protrusion was obtained (Figure 2), but most importantly,
the patient reported a significant improvement in night sleep
3
Figures 3a and 3b. (a) Pretreatment and (b) post-treatment cephalometric radiographs.
a b

and daytime level of alertness. Later tests demonstrated that his
high blood pressure and high blood sugar normalized. His
spouse reported almost no disturbances during sleep, and the
postsurgical polysomnography performed at the sleep lab by his
sleep specialist showed an AHI of 2.1 (below 5 is normal). An in-
crease in the retropalatal, retroglossal, and hypoglossal airway
spaces concomitant with maxillary and mandibular advance-
ment was evident on the cephalometric radiograph (Figure 3).
DISCUSSION
The most favorable treatment for patients with OSAS is treat-
ment provided by an interdisciplinary team that includes mem-
bers from the appropriate dental and medical disciplines.
Prescribed therapies might include weight loss, behavior mod-
ification, oral appliances, soft-tissue surgery, telegnathic sur-
gery, or a combination of the above.12
In the majority of telegnathic cases, only the anteroposte-
rior jaw dimension is addressed, and due to the complexity in
incorporating the transverse dimension, this opportunity is
overlooked. Based on this concern, usually a maxillomandibu-
lar advancement of 10 mm has been considered as one of the
most effective surgical treatments for OSAS.13,14 However, not
all patients diagnosed with OSAS are affected by severe sagittal
discrepancies of maxillary or mandibular skeletal structures.
Therefore, a routine cookbook approach of a 10-mm bimaxil-
lary advancement just to treat OSAS could create a very unaes-
thetic facial result for this category of patients. For this reason,
the literature describes few attempts to incorporate a transverse
expansion in addition to sagittal skeletal corrections for treat-
ment of OSAS patients.9,12,15
In an article entitled, “Correction of Severe Obstructive
Sleep Apnea With Bimaxillary Transverse Distraction Osteoge-
nesis and Maxillomandibular Advancement” published in the
American Journal of Orthodontics and Dentofacial Orthopedics, Con-
ley and Legan12 discussed the role of increased transverse di-
mension by means of mandibular symphyseal distraction
osteogenesis in resolving dentoalveolar crowding in treatment
of OSAS patients. To the authors’ knowledge, currently there
are no reports describing the role of SAME in the development
of implant sites for replacement of missing teeth and the sub-
sequent effectiveness in the treatment of OSAS.
A nonsurgical treatment approach, including the extraction
of one lower incisor or 2 lower first bicuspids, would have ad-
dressed the orthodontic aspects of this patient’s malocclusion.
However, correction of the malocclusion was only one of the
objectives of treatment. The need for treatment of the patient’s
OSAS, which was a more health-threatening condition, over-
shadowed the need for treatment of the patient’s malocclusion.
It also could cause deterioration in facial and dental aesthetics
by retracting the lower lip and magnifying the chin protru-
sion.16-20 Ideally, a treatment plan involving expansion of the
oral environment in all 3 dimensions would be a more effective
treatment for these patients.
SAME procedure as an outpatient protocol produced a
proper recipient site for the installation of an implant to replace
tooth No. 23,21 and combined with the subsequent bimaxillary
advancement surgery provided adequate oral volume to accom-
modate the tongue, thus opening the oropharynx.9
Maxillomandibular counterclockwise rotation and ad-
vancement by expansion of the posterior nasopharyngeal open-
ings also augment the nasal cavity. A nasal cavity volume
increase should reduce the resistance to nasal airflow.22 If the
airway is considered a simple tube, as the radius of the tube in-
creases, the resistance to flow decreases exponentially to the
fourth power (resistance = 8 L η/π r 4).23 Therefore, even small
increases in the diameter of the tube (the nasal cavity) can dra-
matically decrease the resistance to nasal air flow.23
CONCLUSION
Many patients see their dentists more often than their physi-
cians. Some patients may stay with the same dentist throughout
their lifetime.24 Therefore, dentists may have the opportunity
to evaluate their patients for medical conditions and refer these
patients to appropriate physicians for further diagnosis and
therapy. SDB and OSAS are conditions for which dentists may
assist with both diagnosis and therapy, and make a positive con-
tribution to the health of these patients.
The general dentist can effectively monitor the lifetime sta-
bilityofthePharyngOroFacialrehabilitationthroughprophylac-
ticmaintenanceofsupportivedentalandperiodontalstructures.
It has been the authors’ experience that treating this cate-
gory of patients is both a challenging and rewarding aspect of
interprofessional collaboration. An added benefit of this collab-
oration is that the cost of treating these patients, including the
use of oral appliances and telegnathic surgeries, is being par-
tially or fully covered by medical insurance policies more fre-
quently. It seems likely that this trend will continue in the
future.25!
References
1. Youssef NA, Ege M, Angly SS, et al. Is obstructive sleep apnea associated with
ADHD? Ann Clin Psychiatry. 2011;23:213-224.
2. Martínez-García MA, Campos-Rodriguez F, Durán-Cantolla J, et al. Obstructive sleep
apnea is associated with cancer mortality in younger patients. Sleep Med.
2014;15:742-748.
3. Chen JC, Hwang JH. Sleep apnea increased incidence of primary central nervous
system cancers: a nationwide cohort study. Sleep Med. 2014;15:749-754.
4. Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing
among middle-aged adults. N Engl J Med. 1993;328:1230-1235.
5. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics.
4

1998;102(3 pt 1):616-620.
6. Cistulli PA, Sullivan CE. Sleep-disordered breathing in Marfan’s syndrome. Am Rev
Respir Dis. 1993;147:645-648.
7. Iguchi A, Yamakage H, Tochiya M, et al. Effects of weight reduction therapy on ob-
structive sleep apnea syndrome and arterial stiffness in patients with obesity and
metabolic syndrome. J Atheroscler Thromb. 2013;20:807-820.
8. Morong S, Benoist LB, Ravesloot MJ, et al. The effect of weight loss on OSA severity
and position dependence in the bariatric population. Sleep Breath. 2014;18:851-
856.
9. Yousefian J, Moghadam B. The role of contemporary orthodontics in the diagnosis
and treatment of sleep-disordered breathing. In: Girardot RA, Ribbens KA, eds. Goal-
directed Orthodontics. Los Gatos, CA: Roth Williams International Society of Ortho-
dontists; 2013:601-655.
10.Field MJ, Jeffcoat MK. Dental education at the crossroads: a report by the Institute
of Medicine. J Am Dent Assoc. 1995;126:191-195.
11.Jakush J. Board adopts 2011-2014 ADA Strategic Plan. arkansasdentist-
ry.org/2010/06/board-adopts-2011-2014-ada-strategic-plan. Accessed April 17,
2015.
12.Conley RS, Legan HL. Correction of severe obstructive sleep apnea with bimaxillary
transverse distraction osteogenesis and maxillomandibular advancement. Am J Or-
thod Dentofacial Orthop. 2006;129:283-292.
13.Waite PD, Shettar SM. Maxillomandibular advancement (a cure for obstructive sleep
apnea). Oral Maxillofac Surg Clin North Am. 1995;7:327-336.
14.Hochban W, Brandenburg U, Peter JH. Surgical treatment of obstructive sleep apnea
by maxillomandibular advancement. Sleep. 1994;17:624-629.
15.Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with ob-
structive sleep apnea syndrome. Sleep. 2004;27:761-766.
16.Yousefian J, Trimble D, Folkman G. A new look at the treatment of Class II Division
2 malocclusions. Am J Orthod Dentofacial Orthop. 2006;130:771-778.
17.Sarver DM. The importance of incisor positioning in the esthetic smile: the smile
arc. Am J Orthod Dentofacial Orthop. 2001;120:98-111.
18.Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part 2.
Smile analysis and treatment strategies. Am J Orthod Dentofacial Orthop.
2003;124:116-127.
19.Peck S, Peck L. Selected aspects of the art and science of facial esthetics. Semin
Orthod. 1995;1:105-126.
20.Zachrisson BU. Esthetic factors involved in anterior tooth display and the smile: ver-
tical dimension. J Clin Orthod. 1998;32:432-445.
21.Yousefian J. A simple technique for mandibular symphyseal distraction osteogenesis.
J Clin Orthod. 2010;44:731-737.
22.Kunkel M, Hochban W. The influence of maxillary osteotomy on nasal airway patency
and geometry. Mund Kiefer Gesichtschir. 1997;1:194-198.
23.Courtiss EH, Goldwyn RM. The effects of nasal surgery on airflow. Plast Reconstr
Surg. 1983;72:9-21.
24.Dworkin SF. The dentist as biobehavioral clinician. J Dent Educ. 2001;65:1417-
1429.
25.Nierman R. Dentists become durable medical equipment suppliers for sleep apnea
oral appliances. dentistryiq.com/articles/2013/10/dentists-become-durable-med-
ical-equipment-suppliers-for-sleep-apnea-oral-appliances.html. Accessed April 17,
2015.
5

POST EXAMINATION QUESTIONS
1. Obstructive sleep apnea syndrome (OSAS), if not treated properly,
can lead to:
a. High blood pressure.
b. Diabetes.
c. Cancer.
d. All of the above.
2. OSAS is a multifactorial disease. Constriction of the upper
airway is recognized as one of the most important factors in the
development of OSAS.
a. The first statement is true, the second is false.
b. The first statement is false, the second is true.
c. Both statements are true.
d. Both statements are false.
3. A threefold increase in the incidence of accidents both at home
and at work can be attributed to OSAS.
a. True.
b. False.
4. Case reports correlate the development of OSAS in individuals
with various craniofacial abnormalities. Other risk factors for
OSAS include aging and weight gain.
a. The first statement is true, the second is false.
b. The first statement is false, the second is true.
c. Both statements are true.
d. Both statements are false.
5. What is considered a normal apnea/hypopnea index (AHI)?
a. < 5.
b. 5 to 10.
c. 10 to 20.
d. 20 to 30.
6. When orthognathic surgery is used to treat OSAS, it is referred
to as:
a. Transverse surgery.
b. Distraction osteogenesis.
c. Telegnathic surgery.
d. Septoplasty.
7. Prescribed therapies for OSAS may include:
a. Behavior modification.
b. Oral appliances.
c. Weight loss.
d. All of the above.
6
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8. Usually, a maxillomandibular advancement of _____ has been con-
sidered as one of the most effective surgical treatments for OSAS.
a. 5 mm.
b. 8 mm.
c. 10 mm.
d. 15 mm.
9. In the case report presented, the patient’s AHI showed the
following change as a result of interdisciplinary treatment:
a. 35 (pretreatment) to 5.0 (post-treatment).
b. 46 (pretreatment) to 4.3 (post-treatment).
c. 49 (pretreatment) to 4.0 (post-treatment).
d. 53 (pretreatment) to 2.1 (post-treatment).
10. Even small increases in the diameter of the nasal cavity can
dramatically decrease resistance to nasal airflow.
a. True.
b. False.
7

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DT_August_15_188_fnl

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