The document discusses obstructive sleep apnea, detailing its definitions, prevalence, clinical features, and diagnostic procedures. It highlights the significant morbidity associated with the condition, encompassing cardiovascular risks and its impact on quality of life, while outlining the anatomical aspects and management strategies including CPAP and oral appliances. Additionally, it emphasizes the importance of proper diagnosis through polysomnography and clinical examination to effectively assess and manage the disorder.

1. DEPARTMENT OF ORTHODONTICS AND
DENTOFACIAL ORTHOPEADICS
PRESENTED BY
Dr. Roshni Krishnan
Final Year PG Student

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

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.

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

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 problems

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”

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

8. Anatomic aspects of
Obstructive Sleep Apnea

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

10. Nasal Turbinates and Deviated
Nasal Septum

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

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

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

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

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

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

18. Patho-Physiologic aspect of
Obstructive Sleep Apnea

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

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

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

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 Apnea

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
position

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

25. Retrognathic mandibles
Large tongue and soft palate
Large anteroposterior discrepancies between maxilla and mandible
Micrognathia
Acromegaly
Downs’ syndrome

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

27. Clinical features of Obstructive
Sleep Apnea

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

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

30. Orofacial characteristics in
Obstructive Sleep Apnea
Retrognathic mandible
Narrow palate
Large neck circumference
Long soft palate
Tonsillar hypertrophy
Nasal septal deviation
Relative macroglossia

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 terrors

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

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

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

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

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

37. Diagnostic procedures in
Obstructive Sleep Apnea

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

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.

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

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 .

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

43. Epworth Sleepiness Scale

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 airway

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.

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

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.

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.

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.

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

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).

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
disorder

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.”

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.

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

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.

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.

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 .

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.

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

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 .

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.

64. Upper Airway Imaging

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.

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.

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.

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.

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.

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 micrognathia

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.

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

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.

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.

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.

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.

77. Management of Obstructive
Sleep Apnea

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.

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.

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

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.

82. Nasal continuous positive airway
pressure Apparatus

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
causes

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.

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.

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.

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.

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.

89. 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

90. ORAL APPLIANCES IN THERAPY OF
OBSTRUCTIVE SLEEP APNEA

91. 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

92. 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.

93. 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.

94. 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

95. 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.

96. 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.

98. Mandibular Advancement
Devices

99. 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

100. 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

101. 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

102. 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.

103. 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

104. 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.

105. Adjustable Herbts appliance

106. 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.

108. 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.

109. 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

110. 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.

111. 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.

112. 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.

113. 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.

114. 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

115. 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 RDI

116. 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.

117. 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.

118. 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.

119. 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.

120. 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

121. 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 .

122. 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.

123. 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.

124. 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.

125. 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.

126. 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 .

127. 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.

128. 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 incisors

129. 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

130. 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.

131. SURGICAL MANAGEMENT OF OSA

132. 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.

133. 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.

134. 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

135. 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

136. 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

137. 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

138. 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

139. 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
mucosa

140. 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 area

141. 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.

142. 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.

143. 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.

144. 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

145. 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%

146. 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
wall

147. 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 mandible

148. Inferior sagittal osteotomy of
mandible

149. 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

150. 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.

151. 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.

153. 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.

154. 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

155. 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

156. 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.

157. 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.

158. 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.

159. 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.

160. 16. Anat Gavish, Alexander D. Vardimon, Heled Rachima, Micheal
Bloom, Esther Gazit. Cephalometric and polysomnographic
analyses of functional magnetic system therapy in patients
with obstructive sleep apnea. Am J Orthod Dentofacial
Orthop. 2001 Oct;120(2):169-77
17. Peter G. Miles, Peter S. Vig, Robert J. Weyant, Thomas D.
Forrest, Howard E. Rockette, Jr. Craniofacial structure and
obstructive sleep apnea syndrome—a qualitative analysis and
meta-analysis of the literature. Am J Orthod Dentofacial
Orthop. 1996 Feb;109(2):163-72
18. Edmund C. Rose, Gabriele M. Barthlen, Richard Staats,
Irmtrud E. Jonas.Therapeutic efficacy of an oral appliance in
the treatment of obstructive sleep apnea: A 2-year follow-up.
Am J Orthod Dentofacial Orthop. 2002 March;121(3):273-79
19. Mats Bernhold, Lars Bondemark. A magnetic appliance for
treatment of snoring patients with and without obstructive
sleep apnea. Am J Orthod Dentofacial Orthop. 1998
Feb;113(2):144-48