Treatment of Snoring/Sleep Apnea with
Jaw Repositioning
Intraoral Appliances
Obstructive Sleep Apnea (OSA) is a serious respiratory disorder affecting a significant portion of the population. Estimates run from 9% to 40% of the male population between the ages of 40 and 60 and 4% to 25% of the Female population in the same age group. Sleep apnea (OSA) is defined as a cessation of all nasal and oralbreathing, despite diaphragm activity, for periods of ten seconds or longer; "central" apnea is cessation of breathing with no diaphragm activity, vs. "mixed", a combination of both. A significant concern about a potentialsleep apnea problem is suggested from the following symptoms:
With these presenting symptoms, referral for a Sleep
study/polysomnography may be justified after clinical evaluation by the
Dentist/Physician. The definitive diagnosis of this disorder is done through
sleep laboratory studies with an overnight Sleep Polysomnography. Sleep
polysomnography features electrocardiography/EKG, brainwave
electroencephalography/ EEG measurements, motor activity extremity
measurements, diaphragmatic/chest movement, eye movement, pulse oximetry for
oxygen desaturation measurement, and inhalational/exhalational oro-nasal flow
characteristics. Complications from Sleep Apnea include: falling asleep while
driving a motor vehicle, cardiac arrythmia, increased cerebrovascular
accidents, high blood pressure, and complete cessation of breathing from
occlusion of the airway.
Symptoms related to Sleep Apnea (obstructive
sleep apnnea /OSA) include the following: Loud snoring, witnessed apnea events,
daytime sleepiness/narcolepsy, disturbed sleep, daytime irritability, poor
memory, morning headaches, decreased cognative functions, nocturea/ night- time
awakening arousals, extreme anxiety, and fatique.
One of the cardinal
signs on patient evaluation and questioning includes the presence of snoring.
While snoring itself may be a noxious habit affecting family/those around the
snorer, snoring in and of itself may not be a major health hazard. The problem
exists however, that there is a high correlation between snoring and
obstructive sleep apnea symptomatology and its progressive developement into
obstructive sleep apnea patterns. The standard protocol for diagnosis has been
referral with the patients'physician and a sleep laboratory polysomnography
study.
There has been a significant increase in interest within the
medical community of dentistry's potential role in aiding patients with mild to
moderate obstructive sleep apnea. The July 1995 publication of the American
Sleep Disorders Society of their protocol for treatment of sleep apnea has been
a major step forward in dental therapy of this major health problem The use of
oral repositioning appliances has become an accepted part of conservative
treatment of such patients.
Other considerations for treatment of sleep
apnea include: CPAP- Continuous Positive Airway pressure, and surgical
approaches to soft tissue/oropharynx modification. Surgical techniques have
involved mandibular advancement, tonque resection, tonsillar and adenoid tissue
removal, nasal obstruction surgery, deviated septal modification, nasal polyp
removal and UPPP(uvulopalatopharyngoplasty) and more recently, LAUP- Laser
-assisted uvulopalatal-plasty. Any one of these procedures or a combination of
them may be applicable to each patient on an individual basis. Proper
assessment of such patients is essential, who may have complicated medical
histories. Medical factors need to be considered which include: emergency
status of patients'respiratory system; trachestomy has been done in the past
for acute obstruction. Obesity of patient is a significant factor and weight
control has been done as an initial conservative step. Proper medical/dental
team management is essential!
The use of jaw repositioning appliances
has been in the dental literature since the early 1980's and an increasing
awareness by the dental profession has been evident with the growth of the
International Snoring Association and the Sleep Disorders Dental Society. A
wide assortment of designs of intraoral orthotic repositioning appliances have
published, and are being taught at postgraduate courses. The efficacy in design
of these appliances is based on ability to position the jaw, bring the tonque
forward and open up the occluded airway or narrowed airway space. Measurement
of changes with and without the appliance have been discussed from lateral
skull/ cephalometric measurement techniques, CAT Scan and M.R.I., magnetic
resonance imaging techniques. Most recently , the use of magnetic resonance
imaging/ M.R.I. software for airway views with and without the appliance, can
establish a baseline and a potential increase in the patients' airway
opening/volume. Lateral airway view of MRI is seen in film:
The most-likely obstructed areas in
snoring and sleep apnea are the 3 divisions of the upper airway and throat: the
oropharynx, nasopharynx and hypopharynx. The areas that particularly relate to
jaw repositioning are the nasopharynx and hypopharynx. The documentation of
dimensional changes in the airway structures by 3- D M.R.I. computerized
analysis, including cone beam I-CAT technology imaging of the airway.
Diagnosis: Level of severity will be indicated from such a
study, with recommendations . The findings may indicate no snoring, mild to
moderate obstructive sleep apnea, or severe apnea with cessation of breathing
of critical significance.
Treatment of choice may be weight
loss, medication, Respiratory nasal CPAP (continuous positive airway pressure)
device worn all night, ENT/ palatal surgery, or dental jaw repositioning
appliances worn intraorally. The choice of therapy would depend upon the
objective findings of the sleep study, in addition to the patients' presenting
complaints, physical examination, and Doctor's preferences.
If a jaw
appliance is to be done, the affect of such repositioning on the airway is
tested with a jaw positioning temporary device, such as this waxup bite form,
shown interposed between upper and lower jaw plaster dental models. A temporary
appliance may be made at this position.
This positions the jaw further down and forward, increasing the total volume/space in the mouth and base of the tongue. The patient is sent with this, for MRI scan, with and without the appliance in place.The purpose of the 3-D M.R.I. is to verify with objective findings, specific areas in the airway which do change and which areas are still restrictive, necessitating a team approach in the management of this type of potentially serious clinical case pattern.*
Design of the long-term appliance can then be done, correlated to sleep study findings. One such positioning device is seen in this photo, repositioning the jaw and opening up the airway. MRI measurements indicated a 32% total increase in airway breathing volume on this case in comparison to baseline.
A properly designed dental snoring / sleep apnea appliance can go far in rehabilitating the patient with sleep deprivation. One particular appliance design, the "Halstrom Hinge Appliance"TM, utilizes a custom fitted upper and lower splint with a titanium precision attachment. This allows the jaw to move slightly while the patient is in different sleeping positions, still keeping it forward to clear the airway. The system design (see photo) also provides posterior molar area pivoting to support the TMJ-Temporomandibular Joints.
Appliances / Oral Airway Dilator Designs:
All Snoring/Obstructive Sleep Apnea Intraoral Appliances are
designed to advance the mandible and dilate the airway.
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1.The Silencer® System: This appliance incorporates the Halstrom Hinge Titanium Precision Attachment at the incisor level, allowing sequential 2 mm advancements up to 8mm, lateral movement 6 mm, 3 mm bilaterally, and vertical pin height replacements. A flat posterior bite plane is provided for the biting surfaces. |
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Other adjustable intraoral appliances besides the Silencer® also allow lateral jaw movement and some vertical change, as well as a variable forward progressive movement. The following appliances, which have had extensive published clinical research include:
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2.The OASYS TM Oral Nasal Airway System allows mandibular advancement with a combination upper and lower splint with locking orthodontic slide wire attachment. The system features nasal pads which engage the inner lip surfaces to improve airflow through the nose. |
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3.The TAP III-Thornton Adjustable Positioner®, which allows for progressive 1/10 mm advancements of the jaw via an anterior screw mechanism at the labial aspect of the upper splint. |
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4. The SommoMed MAS Mandibular Advancement Splint allows for opening and closing. Jaw advancement comes from a lateral in on the sides of the lower splint as it engages a moveable wedge of the upper. The upper screw-plate component can be sequentially moved in 1/10 mm increments as the jaw/airway is titrated. The appliance is very comfortable for patient adaptation. |
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5. The Homeoblock TM appliance system is used to expand the dental arch and level mis-aligned teeth. It is used in adult cases to widen the maxilla to provide more room for the tongue. With upper and lower dental arch expansion, the mandible can come forward, allowing more airway space in many cases. It can be a first stage of treatment via orthodontic intervention, for obstructive sleep apnea situations. The appliance is worn primarily at night only. The amount of expansion is 1/4 mm per week. It has been used to improve facial esthetic and growth. |
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| With all patients with sleep apnea, titration/adjustment and follow-ups are needed. Evaluating the patient response and effectiveness of oral appliance involves subjective improvement (spouse assessment, Epworth Sleepiness Scale, comfort, compliance, symptom review). It also involves the use of objective overnight home monitoring such as pulse oximetry, and other sleep/nasal recording devises. Follow-up polysomnography referral with laboratory and sleep medicine specialist is part of the dentist/physician team approach protocol. | |
A sleep apnea dental anti-snoring device can be an equal benefit to one's sleeping partner, allowing two to sleep better by treating one! Extensive research* has gone into treating this disorder by clinicians familiar with its medical/dental benefits.
Many insurance plans will cover such appliances under the medical coverage benefit, where proper documentation of medical necessity has been established.
*For a detailed scientific paper on this subject
refer to:
Atlas of Oral Surgery Clinics of North America, Vol. 15, #2,Sept.
2007:
Oral Appliances in the Treatment of Obstructive Sleep
Apnea,
Elsevier-Saunders Publishers.