Obstructive sleep apnea Prepared by: Dr Mohammed Alruby من باب الادب استمع للبشر جيدا اما باب الاحتياط فلا تصدق كل ما يقولون Obstructive sleep apnea Apnea: any cessation of breathing for 10 seconds or more OSA: periodic cessation of breathing occurs during sleep in the presence of inspiratory effort It caused by recurrent upper airway obstruction during sleep Snoring: produced by vibration of soft palate or oropharyngeal tissues Factors related: - Large tonsils - Sleep related loss of muscle tone - Large tongue - Retrognathia - Obesity - Alcohol - Sedative medications Types: Ernest 1988 classified sleep apnea into three types: 1- Central: stoppage of the airflow from lack of respiratory effort 2- Obstructive: stoppage of airflow despite great effort to take in air 3- Mixed: starting as central and followed by obstructive History: OSA was first described by Charles Dickins in 1836 at Pickwick paper In 1906 William Oslar said: an extra-ordinary phenomenon is excessively fat young persons with an uncontrolled tendency to sleep 1950: research was made by Aserinky, Klulman and Denat 1966: Burwell describe the features of OSA 1980: more research for oral appliance Prevalence: Middle age adult who ae moderate to severe over weight Women less effected Causes: 1- Abnormal hyoid muscle activity 2- Abnormal genioglossus muscle activity and length (Lowe et al 1993) 3- Macroglossia and Micrognathia (Imes 1977) 4- Decreased airway lumen 5- Adeno-tonsillar hypertrophy (Orr 1980) 6- Sleep posture and faulty deposits in the tissue of the upper airway (Peter 1996) Aggravating factors: 1- Obesity 2- CNS depressant such as alcohol, sedatives and sleeping pills will support relaxation of the pharyngeal musculature 3- Smoking: smoke is an irritant to lung and throat which cause inflammation and fluid retention in upper respiratory airway 4- Pre-existing pulmonary disorder such as: asthma, chronic obstructive airway so decreased blood oxygen tension 5- Hypothyroidism has a well-established link with OSA 6- Old age and male gender Process of Apnea: = during sleep, person’s throat muscles relax allowing the tongue and /or fatty tissues, of the throat to fall back into the airway and block air flow = during this apnea there is a reduction in air flow to the brain, this in turns signals the brain to partially waken from sleep to signal the body that it need to breathe = once a breath is taken, the brain returns to sleep and the process begin once again Mild: 4 -14 episode of interruption in breathing in an hour Moderate: 15 -30 episodes of interruption breathing in an hour Diagnosis: Clinical features: Nocturnal symptoms: - load snoring - Nocturnal - Choking Diurnal symptoms: - Headache - Impaired quality of life - Falling asleep in appropriate times = 24% of people with OSA reported to fall asleep whilst driving at least weakly Medical symptoms: - Nocturnal hypoxemia of prolonged cause hypertension and cardiac p

1. 1
Dr. Mohammed Alruby
Obstructive sleep apnea
Prepared by:
Dr Mohammed Alruby
‫يقولون‬ ‫ما‬ ‫كل‬ ‫تصدق‬ ‫فال‬ ‫االحتياط‬ ‫باب‬ ‫اما‬ ‫جيدا‬ ‫للبشر‬ ‫استمع‬ ‫االدب‬ ‫باب‬ ‫من‬

2. 2
Dr. Mohammed Alruby
Obstructive sleep apnea
Apnea: any cessation of breathing for 10 seconds or more
OSA: periodic cessation of breathing occurs during sleep in the presence of inspiratory effort
It caused by recurrent upper airway obstruction during sleep
Snoring: produced by vibration of soft palate or oropharyngeal tissues
Factors related:
- Large tonsils
- Sleep related loss of muscle tone
- Large tongue
- Retrognathia
- Obesity
- Alcohol
- Sedative medications
Types:
Ernest 1988 classified sleep apnea into three types:
1- Central: stoppage of the airflow from lack of respiratory effort
2- Obstructive: stoppage of airflow despite great effort to take in air
3- Mixed: starting as central and followed by obstructive
History:
OSA was first described by Charles Dickins in 1836 at Pickwick paper
In 1906 William Oslar said: an extra-ordinary phenomenon is excessively fat young persons with
an uncontrolled tendency to sleep
1950: research was made by Aserinky, Klulman and Denat
1966: Burwell describe the features of OSA
1980: more research for oral appliance
Prevalence:
Middle age adult who ae moderate to severe over weight
Women less effected
Causes:
1- Abnormal hyoid muscle activity
2- Abnormal genioglossus muscle activity and length (Lowe et al 1993)
3- Macroglossia and Micrognathia (Imes 1977)
4- Decreased airway lumen
5- Adeno-tonsillar hypertrophy (Orr 1980)
6- Sleep posture and faulty deposits in the tissue of the upper airway (Peter 1996)
Aggravating factors:
1- Obesity
2- CNS depressant such as alcohol, sedatives and sleeping pills will support relaxation of the
pharyngeal musculature
3- Smoking: smoke is an irritant to lung and throat which cause inflammation and fluid
retention in upper respiratory airway
4- Pre-existing pulmonary disorder such as: asthma, chronic obstructive airway so decreased
blood oxygen tension
5- Hypothyroidism has a well-established link with OSA
6- Old age and male gender

3. 3
Dr. Mohammed Alruby
Process of Apnea:
= during sleep, person’s throat muscles relax allowing the tongue and /or fatty tissues, of the throat
to fall back into the airway and block air flow
= during this apnea there is a reduction in air flow to the brain, this in turns signals the brain to
partially waken from sleep to signal the body that it need to breathe
= once a breath is taken, the brain returns to sleep and the process begin once again
Mild: 4 -14 episode of interruption in breathing in an hour
Moderate: 15 -30 episodes of interruption breathing in an hour
Diagnosis:
Clinical features:
Nocturnal symptoms:
- load snoring
- Nocturnal
- Choking
Diurnal symptoms:
- Headache
- Impaired quality of life
- Falling asleep in appropriate times
= 24% of people with OSA reported to fall asleep whilst driving at least weakly
Medical symptoms:
- Nocturnal hypoxemia of prolonged cause hypertension and cardiac problem
- May be hypertension in some cases
- Congestive heart failure
By polysomnography:
Also called sleep study, is a test used to diagnose sleep disorders
Polysomnography records your:
- Brain waves
- The oxygen level in blood
- Heart rate and breathing as well as eye and leg movement
Polysomnography usually is done at sleep disorder unit within the hospital or at a sleep center
Occasionally done during the day to accommodate shift works who habitually sleep during the day
Subjective assessment using Epworth sleepiness scale:
Ess: is a scale intended to measure day time sleepiness that is measured by use of very short
questionnaire, that can be helpful in diagnosis sleep disorder
It introduced in 1991 by Dr Murray Johns of Epworth hospital in Australia
Ortho-diagnostic aids for OSA
1- Epworth sleepiness scale:
A questionnaire designed to assess how likely person would dose in 8 specific situations:
- Sitting and reading
- Watching TV
- As a passenger sitting in a car for an hour
- Sitting in active in public place
- Laying down to rest in afternoon
- Sitting and taking to someone

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Dr. Mohammed Alruby
- Sitting quality after lunch. Without have consumed alcohol
- As a driver of a car, stopped for a few minute in traffic
Scores:
0: no chance
1: low likelihood
2: moderate possible
3: high chance
A score has 12 indicate subject is sleepier than normal individual
2- Computerized tomography:
Permits visualization of small variation in tissue density
3 dimensional description airway, tongue and other structure but it is time consuming procedure
and expensive.
By studies: ----- large tongue, soft palate ----- reduced airway
----- severe OSA ----- large tongue and reduced airway
3- Magnetic resonance imaging:
Horner at al used MRI assess upper airway in obese patients showed an excess on fat deposition
in soft palate, tongue and surrounding collapsible segment of pharynx
4- Fiber optic endoscopy:
Determined the location site of obstruction in upper airway
Particular emphasis on the base of tongue, its position
5- Electromyography:
Determine genioglossus muscle activity
Determine pathogens in muscle activity for OSA patients
6- Soft tissue features:
- Elongated tongue and soft palate
- Thickened soft palate
- Decreased anterior posterior pharyngeal space at superior middle and inferior level
- Enlarged cross-sectional areas of tongue and soft palate
- Decreased cross sectional areas of oropharynx
- Large deposits of submental and submandibular fat
- Inferior deposition of hyoid bone
7- Noso-pharyngeo-scopy:
Invasive and require nasal anesthesia
Evaluate only the airway lumen and not surrounding soft tissue and patients is usually a wake
Respiratory disturbance index RDI
Is a formula used in reporting polysomnography (sleep study) finding
RDI is calculated as the number of apnea event/hour + number of hypopnea event /hour + number
of respiratory effort related arousals (RERA) / hour sleep
Apnea: complete cessation of air flow or obstruction lasting 10 seconds or longer
Hypopnea: partial apnea and 3 % or greater reduction of oxygen
RERA: abnormal breathing event which does not meet the criteria of apnea or hypopnea

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Dr. Mohammed Alruby
RDI: key number:
1- Normal sleep study: ----- less than 5 event / hour
2- Mild apnea: ---------------5 -15 event / hour
3- Moderate apnea: ------ 15-30 event / hour
4- Severe apnea: ---------- more than 30 event / hour
Craniofacial characteristic of sleep apnea
Lowe et al 1986 showed that:
1- Posterior position of maxilla and mandible
2- Steep occlusal plane
3- Over erupted maxillary and mandibular teeth
4- Proclined incisors
5- Steep mandibular plane angle
6- Large gonial angle
7- High upper and lower facial angle height
Fleethan 1995:
1- Retruded mandible with large ANB angle
2- Elongated maxillary and mandibular incisors and molars
3- Large tongue and soft palate volumes
Role of genioglossus muscle activity in OSA
Smaller size airway is associated with hypotonic genioglossus muscle in OSA patients
Contraction of genioglossus muscle and suprahyoid muscles:
- Advance the tongue base
- Dilate the upper airway
- Decrease the airflow resistance
Central sleep apnea: CSA
Occurs when the brain temporarily fails to signal the muscles responsible for controlling breathing
CSA: is also much less common than OSA, some estimate that approximately 20% of sleep apnea
cases are central
CSA: is often caused by medical problem and condition effect the brain
Symptoms:
- Stop breathing or irregular breathing
- Chronic fatigue
- Morning head ache
- Difficult concentrations
- Mood changes
- Snoring
Causes:
- Parkinsonism disease
- Certain medication like narcotic pain killer
- Heart failure
- Obesity

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Dr. Mohammed Alruby
Management of OSA
1- Non dental treatment:
a- Removing the aggravating factors:
Therapeutic control for the chronic airway obstruction disease as asthma
Avoid intake CNS depressant, alcohol, sleeping pills
Reduction of weight
Avoid smoking
Avoid of supine sleep position
ENT assessment and correction of nasal polyps or tonsillar enlargement
b- Continuous positive airway pressure: CPAP:
Continuous stream of air under pressure is filtered and delivered to pharynx, via a nasal mask,
this constant flow is sufficient to prevent the airway from collapsing
CPAP: should be in place for 6 hour / night ------ 7 day / week
Advantages:
1- Improvement individual quality life
2- Improvement of memory and safety in driving
3- Reduction in blood pressure
4- Less strain on heart
Disadvantage:
1- Presence of constant, humming noise
2- Possibility of dislodgement of the mask during sleep
2-Dental treatment:
a- Mandibular advancement:
Mandibular advancement splints are non-invasive appliance; this appliance is made in a
protrusive working bite
criteria of appliance:
- Good retention in both upper and lower teeth
- Sufficient protrusion to prevent pharyngeal collapse in supine position
- Little vertical opening as possible
b- Tongue retaining device: TRD
TRD described by Cartwright and Samelson in 1982
Custom made appliance with an anterior bulb by means of negative pressure, holds the tongue
forward during sleep
For patient with blocked nasal passage, a modified TRD with lateral airway tubes is available
Advantages:
1- Can be used in edentulous patients
2- Will not loosen restoration as they do not require retention
3- Minimal or no adjustment and no sensitivity to teeth
Disadvantages:
1- Tongue is not always held in forward position
2- Esthetic intolerable
3- Tongue may get irritated due to lack of blood supply
TRD and genioglossus activity:
Altered muscle activity of genioglossus muscle improved TRD ------ cartwright et al 1982
Ono et al 1996: 2 tongue retaining device

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Dr. Mohammed Alruby
- TRDA: no anterior bulb
- TRDB: has bulb
Anterior tongue position with TRD alleviation narrowing of upper airway the produce more
positive pressure during inspiration
N: B: adverse effect of oral appliance:
Short term:
- Mouth dryness
- Tooth pain
- Headache
- Excessive salivation
- Gum irritation
- TMJ discomfort
Long term:
- Reduce overjet
- Increase facial height
- Increase degree of mouth opening
- Change inclination of incisors
- Increase mandibular plane angle
c- Snore guard appliance:
Therapeutic intra-oral appliance fitted to upper dentition and mandible positioned to an edge to
edge incisor position
This removable appliance was designed to enlarge the pharyngeal airway
d- Klear way appliance:
Is a fully- adjustable oral appliance used for treatment or snoring and mild to moderate OSA
Fabricated for therapeutic acrylic
e- Removable Herbst appliance:
Ernest 1988 introduced the removable Herbst appliance is treatment of OSA
It is plunger mechanism advances the mandible and tongue to a predetermined position whether
mouth is open or closed
The mandible is usually brought forward to an initial edge to edge position. On the other hand,
four bicuspid extractions in an already hypoplastic skeletal pattern could further reduce tongue
space and increase the possibility of sleep disorder later in life
f- Nocturnal airway patency appliance: NSPA: Loy George 1987
Was designed to keep the airway open during sleep by:
- Posturing the tongue more anteriorly
- Inhibit wide jaw opening
- Assuring adequate air intake through the mouth
The appliance protrudes the mandible three quarter of the distance between centric occlusion and
full protrusion
The mandible is opened vertically just enough to permit an airway between the incisors
==Liu et al 2000: concluded the mandibular re-positioner may be an effective treatment
alternative for obstructive sleep apnea

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Dr. Mohammed Alruby
== Hiyama et al 2001: cervical headgear significantly reduces the dimension of upper airway
during sleep
g- Magnetic appliance:
Maximal alternative force between magnets was 8.5n
Inter-magnetic distance 0.6 -1mm which reduce force magnitude for mandibular advancement to
5.6 -5n, Clasps for additional retention, No effect on TMJ
Studies: Anette et al 2002 evaluate the influence of mandibular protruding device MPD after 2
years of nocturnal use on upper airway and its surrounding structure.
Lateral cephalogram taken before and after use of the device of OSA and snoring, they concluded
that after 2 years’ device there is an increase in airway passage in both OSA and snoring patient
Adjustment
Initially 70 – 75% of maximum forward position of mandible
Recalls at every 2 weeks, 1 month, 6 months
Problems:
- Distocclusion of posterior teeth
- Forward movement of lower teeth
- Excessive salivation
- Feeling of fullness
- TMJ sensitivity and teeth also
Efficiency:
- Slow good prognosis in mild to moderate cases
- Base of tongue was advanced and dorsal surface appeared more superior
- Hyoid bone positional anteriorly and cross-section of oro-pharyngeal increased from 41.6
to 92.3mm
- Airway volume increased by 27% and tongue volume decreased by 17% due to forward and
superior tongue posture
Anti-snoring device:
Clark and Nakanos 1989
Described 2 devices:
1- Labial shield: prevent mouth breathing and force nasal breathing, maintain patency
between soft palate and pharynx
2- Palatal lift: stop soft palate vibration so reduce snoring
Surgical treatment of OSA
Surgical technique used:
- Tracheotomy
- Uvulo-palato-pharyngeo plasty
- Osteomy and sagittal with hyoid myotomy and suspension
- Maxillary, mandibular and hyoid advancement
- Partial glossectomy
- Tongue base suspension suture

9. 9
Dr. Mohammed Alruby
1- Tracheotomy:
An operative procedure that create surgical way in the cervical trachea
Most reliable surgical solution because it allows patient to cork the airway to allow speech during
the day and cork at night to provide patent airway
It is not favorably accepted by most patient
Reported as treatment of OSA in 1969 by Guillem et al
2- Uvulo-palato-pharyngeo-plasty:
Proposed by Ikematsu in 1964
Introduced by Fugita et al 1981
Surgical procedure or sleep surgery used to remove tissue in the throat like: tonsils, adenoid,
uvula, soft palate and pharynx
Complications:
- Pharyngeal dryness
- Loss of taste
- Noso-pharyngeal stenosis
N: B: tonsils and adenoids
Tonsils:
= Paired
= Situated in oropharynx
= Covering epithelium is stratified squamous
= tonsils crypt is at medial
= tonsils capsule is at lateral surface
= are right up at old age
Adenoids:
= single
= situated in the roof and posterior wall of naso-pharynx
= covering epithelium is ciliated columner
= has no capsule
= disappear at or before age of 12 year
3- Kamami technique:
Laser assisted uvulo-palato-plasty
Carbon-dioxide laser at 20 watts
Report success rate and better the UPPP
4- Inferior sagittal osteotomy of mandible with hyoid myotomy and suspension:
1st
reported by Riley et al 1984
They treat 55 patients: 67% has good response, and 33% has no response
5- Maxillary, mandibular and hyoid advancement:
= give more predictable results
= best alternative to tracheotomy
= highly successful
Indications:
- Patients with normal skeletal development and severe OSA
- Obese patients - Severe skeletal deficiency