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 oral breathing, 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 potential sleep 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 are the documentations available through the "Anatek Software Imaging Program", developed by David Roberts, Ph.D., as used at the Graduate Hospital Imaging Centers / Health System in Philadelphia.
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 II-Thornton Adjustable Positioner®, which allows for progressive ¼ mm advancements of the jaw via an anterior screw mechanism at the labial aspect of the upper splint. |
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4. The EMA II® Elastic Mandibular Advancement : This appliance design uses bands of varying elasticity to reach the desired position with considerable freedom of movement. |
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5. The Klearway TM oral appliance, which useses a maxillary orthodontic expander to sequentially move the mandible forward. |
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6. 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 ¼ mm increments as the jaw/airway is titrated. The appliance is very comfortable for patient adaptation. |
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7. 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: Smith, S.D.: "A Three Dimensional Airway Assessment for the Treatment of Snoring and/or Sleep Apnea with Jaw Repositioning Intraoral Appliances: A Case Study" in: CRANIO, The Journal of Craniomandibular Practice, October 1996, vol 14, #4, pp 332-343.