OBSTRUCTIVE SLEEP
APNEA DIAGNOSIS,
MANIFESTATIONS AND
MANAGEMENT
1
Contents
■ Introduction
■ Terminology
■ Pathophysiology of Obstructive sleep apnea
■ Diagnosis & Investigations
■ Dentofacial characteristics in OSA Patients
■ Treatment Modalities for OSA
■ Conclusion
■ References
2
INTRODUCTION
3
History (Edition of ResMedica)
■ In 1918 Sir William Osler coined the term
"Pickwickian" to refer to obese, Apneic symptoms.
■ In1965 the first polysomnograph recorded apneas
during sleep.
■ Made the important observation that "Pickwickian"
patients had repetitive apnea events while asleep.
4
■ In 1978, Dr. John Remmers described the
interaction between sleep, the breathing muscles.
■ Explained why the upper airway collapses during
sleep, leading to obstructive sleep apnea.
5
What is Obstructive sleep
Apnea?
6
Joseph R Deatherage (Semin in orthodontics
2009)
■ Obstructive Sleep Apnea syndrome (OSA) is a
serious condition that afflicts a substantial number
of individuals.
■ It is characterized by disruption of normal sleep
architecture by complete or partial obstruction of
respiratory airflow.
7
■ Schwab( Am J Respir Med 2003) suggests that
sleep apnea is a anatomic compromise that allows
reduction in motor activity of airway dilator muscles
that occurs during sleep.
■ State- Dependent condition occurring only during
sleep. ( Graber Vanarsdall fourth edition)
8
Magini et al AJODO 2010
■ Obstructive Sleep Apnea (OSA) is a public health
problem and potentially life-threatening condition.
■ It is characterized by the repeated collapse or
narrowing of the pharyngeal walls during sleep,
interrupting normal sleep.
■ The impact of OSA on a patient’s life is sometimes
irreversible
9
■ OSA affects sleep of the bed partner
■ Interrupted sleep at night can cause problems
during the day, including sleepiness, loss of
concentration, memory malfunction, and impaired
performance of common skills such as driving.
■ These factors add up to a decrease in quality of life
10
■ The definitive diagnosis and treatment plan should
formulated
■ Progress of certain diseases, such as
hypertension, cardiovascular disorders, brain
stroke.
11
Fujita et al (Ear Nose Throat J 1993)
■ Simply categorized the upper airway obstruction as
either retropalatal or retroglossal.
■ The retropalatal level involves the soft palate,
uvula, and palatine tonsils. ( Type I obstruction)
■ The retroglossal level involves the tongue base
and supraglottic structures.
(Type II Obstruction)
12
OSA is related to upper airway obstruction
that develops during sleep with manifestations
that include snoring, apneas and hypopneas.
TERMINOLOGY
13
Apnea (Earle.F.Cote Angle orthodontics 1988)
■ Cessations of breathing for ten seconds or
longer are termed Apneas.
■ Types of Apnea
1.Obstructive- Cessation of airflow
2. Central- Inability of brain to send signals to
breathing muscles.
3. Mixed- episode of central apnea lasts
10seconds followed by obstructive apnea
14
■ When thirty or more Apneic episodes occur in
the course of seven hours of sleep
■ Described as Sleep Apnea Syndrome
15
Hypopnea ( Under breathing)
■ Involves episodes of overly shallow breathing
■ This differs from apnea in that there remains
some flow of air.
SNORING:
The snoring sound is produced by the vibration of
the soft palate or other oropharyngeal tissues.
16
Earle.F.Cote Angle orthodontics 1988
■ Key symptom of Obstructive Sleep Apnea(OSA)
■ Snoring in some patients without apnea has been
associated with significant sleep disturbance and
sleepiness.
■ This so-called "upper airway resistance
syndrome“ (Schmidt-Nowara et al Graber vanarsdall)
17
Factors related to Snoring
■ Anatomical obstruction of the Nasal passages
■ Large Tonsils
■ Large tongue
■ Retrognathic mandible
■ Low position of the hyoid bone
■ Sedative medication
■ Allergies
■ Loss of muscle tone
18
PATHOPHYSIOLOGY OF OSA
19
■ Narrowing of the upper airway is commonly
observed, especially at the level of the soft palate
and the base of the tongue ?
■ Excessive relaxation or loss of compensatory
excitation of upper airway muscles explains the
propensity to collapse during sleep.
20
■ More negative inspiratory pressure resulting in
improper exchange of air leads cardiovascular
problems.
21
Signs & Symptoms
■ Excessive day time sleepiness.
■ Irritability & depression
■ Snoring
■ Some times cardiac involvement.
■ Apnea
■ Morning headaches
■ Waking up tired & thirsty
■ Obesity
22
Predisposing Factors
■ Age due to loss of muscle mass is common and
replacement with fat, leaving the airway narrow
and soft.
■ Men have a greater risk for OSA.
■ Retropositioned maxilla
and mandible
23
■ Obese & Non obese
■ Enlarged tonsils and adenoids, the main
causes of OSA in children
■ Habitual snoring
■ Family Inheritance
24
■ Drugs – Alcohol, Sedative drugs, Sleeping
pills, Narcotics (codeine, morphine)
■ Smoking, which can cause swelling of the
upper airway
■ Nasal congestion
■ Hypothyroidism.
25
Obstructive Sleep Apnea in Children (JAMES
CHAN Am Fam Physician. 2004)
■ OSA affects 1 percent to 10 percent of children.
■ The finding suggests that the etiology of OSA in
children may result from a complex interplay
between adenotonsillar hypertrophy and loss of
neuromuscular tone.
26
■ Children with craniofacial syndromes have fixed
anatomic variations that predispose them to airway
obstruction like Downs Syndrome
■ Relatively large tongue, and hypertrophy of adenoid
and tonsillar tissues.
■ Increased upper airway infections and nasal
secretions, and higher incidence of obesity. 27
■ In patients with cleft palate, the incidence is 30%
(Maclean Cleft Palate Craniofac J 2009)
■ Schendel et al (AJODO 1976) airway obstruction
and enlarged tonsils and adenoids are commonly
associated with long-face syndrome.
28
Miller JJ et al (Ann Plast Surg 2006)
■ Mandibular micrognathia associated with
congenital malformations such as Pierre Robin,
Treacher Collins which causes of OSA in infants
and young children.
■ Mandibular distraction has been shown to be a
safe and effective means of relieving the airway
obstruction in these micrognathic infants.
29
DIAGNOSIS &
INVESTIGATIONS
30
Physical Examination (Kok Weng Lye et al
Semin Orthod 2009)
■ Includes the weight and body mass index (BMI-
>28 kg/m2) of the patient and neck circumference
>43.2 cm is also a positive risk factor for OSA.
ORAL EXAMINATION
■ Focus on the length of the soft palate, the size of
the palatine tonsils, and the width of the palatal
vault and dental arches.
31
■ In addition, the association of the structures can be
determined by the use of some available scales
like the Mallampati.
■ The Mallampati scale (1985) is used to evaluate
the oropharyngeal soft tissues and airway
obstruction.
■ Scores of 3 and 4 are at a greater risk of sleep
apnea.
32
Sleep Monitoring
POLYSOMNOGRAPHY
■ Simultaneous recording of a number of physiologic
variables during sleep.
■ Electroencephalogram,electromyogram,electro-
oculogram to determine sleep stages.
■ Cardiopulmonary measures that are recorded
include airflow at nose & mouth, oxygen saturation
via oximetry, ECG. (Haskell et al Semin Orthod 2009)
33
34
■ These measures allows to record airflow at
various states of sleep.
■ When thirty or more Apneic episodes, oxygen
saturation (<90%) occur in the course of seven
hours of sleep can be described as Obstructive
Sleep Apnea Syndrome.
35
American Academy of Sleep Medicine
■ A common measurement of sleep apnea is the
apnea-hypopnea index (AHI).
■ This is an average that represents the combined
number of apneas and hypopneas that occur per
hours of sleep.
■ Types
Mild OSA- AHI of 5-15
Moderate OSA- AHI of 15-30
severe OSA- AHI of >30
36
Sleep Architecture ( Joseph R. Deatherage et
al Semin Orthod 2009)
■ Normal sleep architecture is characterized
by two forms.
1. Non-rapid eye movement (NREM)
2. Rapid eye movement (REM)
Stage1- (5-20 minutes)
Stage2 – Deeper Sleep
Stage3,4- Deepest sleep
37
In OSA Patients
■ Spending a majority of their sleeping time in Stage 1
and 2 Non-REM sleep and much less in Stage 3-4
and REM sleep.
■ The result is that many people complain of a very
unrefreshing sleep.
■ Apneas tend to be more common and more severe
during REM compared with Non-REM sleep
38
EMG Activity (Takashi Ono et al AJODO 1996)
■ The GG muscle is active during the inspiratory
phase of quiet breathing with the jaw closed or
slightly open.
■ Evidence has shown that a smaller airway size is
associated with a hypotonic GG muscle in
subjects with OSA.
39
■ Mark et al ( AO 1994) the posterio superior
pharyngeal airway space in OSA & Snoring
patients reduced when changing from upright to
supine posture.
40
INVESTIGATIONS
41
MC NAMARA’S ANALYSIS (Jacobson Second Edition)
Measurement Mean
Upper airway 15-20mm
Lower airway 11-14mm
Adenoid Hypertrophy
Tonsillar Hypertrophy
43
Hou et al ( AO 2006)
■ MP-H is the distance between the mandibular
plane and the hyoid bone. The reference range is
11-19 mm.
■ The longer the distance, the higher the possibility
of the patient having OSA 44
Computed Tomography (CT) (Graber
vanarsdall)
45
CBCT (Haskell et al Semin Orthod 2009)
46
■ CBCT images can be used to make accurate 2D
simulations of lateral cephalometrics, AP
cephalometrics.
■ The resulting images are more accurate than those
traditionally made using lateral cephalometric
radiographs.
■ CBCT technology, which does not show clear
delineations between soft tissues, but clearly
shows the airway space and related skeletal
structures. 47
Coscarelli et al Dental press J orthod 2010
48
Conventional CT Versus CBCT (Hatcher
AJODO 2002).
■ CBCT can collect a much greater amount of
information from the subject in a single rotation
than the conventional CT
■ The spatial resolution is also much greater than
conventional CT
49
MRI (Sanner et al Eur Respir J 2002)
■ MRI may be more useful in understanding the role
of soft-tissue in OSA than computed tomography
(CT).
■ Did not measure, cross-sectional airway area,
airway volume, or soft-tissue dimensions
■ It may be unwarranted because of the extremely
high cost. 50
Pharyngometer (Rev Bras Otorrinolaringol 2007)
51
DENTOFACIAL
CHARACTERISTICS IN OSA
PATIENTS
52
■ In addition to changes in upper airway soft tissue
structures, alterations in craniofacial structures
also have been shown to predispose to OSA.
■ Previous studies of different samples have shown
an association between craniofacial skeletal
morphology & upper airway dimension in OSA
patients.
Zhe Zhong et al Angle orthodontics 2010 53
■ Numerous studies using cephalometrics have
demonstrated craniofacial abnormalities in patients
with OSA.
■ These studies in general have demonstrated that
patients with sleep apnea have small, repositioned
mandible, narrow posterior airway space, Inferior
position of hyoid bone, retroposition of maxilla.
54
■ According to Mergen & Jacobs (Nasopharynx.
1970) reported that midsagittal nasopharyngeal
area & depth are significantly larger in subjects with
normal occlusion than in those with classII
malocclusion.
■ De Freitas et al ( AJODO 2006) class II & class III
patients with vertical growth patterns had
significantly narrower upper pharyngeal airways
than those with a normal growth pattern.
55
■ Lam et al found that retroposition of the mandible
was associated with severe OSA in Chinese
subjects. (Respir Med. 2004)
■ Liu et al demonstrated that OSA patients with more
retrognathic mandibles showed a significantly
higher apnea(AJODO 2000)
■ They also reported that OSA patients showed a
Class II and hypodivergent skeletal pattern
compared with a normal population
56
Mirja Kirjavainen Angle Orthodontics 2007
■ Class II division 1 malocclusion is associated with
a narrower upper airway structure even without
retrognathia.
■ According to Yoshihiko Takemoto (Angle
Orthodontics 2011) mandible in prognathic
patients tends to be positioned more anteriorly,
resulting in a wider lower pharyngeal airway.
57
Cephalometric Characteristics in OSA (Un Bong
Baik AO 2002)
■ Abnormal cephalometric dentofacial morphologies
have been extensively reported in patients with
OSAS.
■ Tendencies toward retrognathia, micrognathia,long
face, inferior positioning of the hyoid bone, reduced
cranial base length, large ANB angle, steep
mandibular plane, large soft palate & tongue.
58
Relation of hyoid bone position in patients with
obstructive sleep apnea (Stella R Minerva Stomatol.
2004)
■ In OSA patients hyoid bone is, on average, in a
lower and in a more posterior position than in
control group patients.
■ Due to the tongue’s increasing in bulk and
becoming larger in relation to the intermaxillary
space
59
Mandibular Morphology Vs Naso pharyngeal Airway
(Faye et al AO 1973)
■ Decreased nasopharyngeal airway size with
increased gonial angle.
■ No significant change in airways with change in
height of ramus, length of body of mandible, height
of antegonial notch.
60
Dentofacial Characteristics of Chinese Obstructive Sleep
Apnea Patient in Relation to Obesity (Hou et al AO 2006)
■ Longer soft palate, Inferior position of tongue base
& hyoid bone, longer Lower Posterior Face Height.
■ Increased mandibular length & body length,
Craniocervical extension was significantly
increased in the severe OSA group.
61
Zhe Zhong et al Angle orthodontics 2010
■ A total of 370 subjects, ages 11 to 16 years, was
selected.
■ The sagittal dimension of the inferior part of the
upper airway decreased from Class III to Class I to
Class II.
■ The superior part of the upper airway dimension
decreased with an increasing FH-MP angle.
62
63
■ Joseph et al (J Oral Maxillofac Surg
1998)suggested that the difference occurred
because of the relative bimaxillary retrusion
exhibited by the hyperdivergent group.
64
■ De Freitas et al (AJODO 2006) may be a result of
deficient development of the craniomaxillary
complex.
■ Hou et al (AO 2006) suggested that normal-weight
OSA patients had a significantly shorter anterior
cranial base and maxillary length. 65
TREATMENT MODALITIES FOR
OSA
66
Various Treatment Modalities
■ Continous Positive Airway Pressure (CPAP)
■ Tongue stabilizing device
■ Mandibular Advancement Device ( MAD)
■ Surgical
■ Combined oral appliance & Continous Positive
Airway Pressure
■ Drugs
■ Expiratory Positive Airway Pressure (EPAP)
67
Continuous Positive Airway Pressure (CPAP)
■ The general aim of all treatment modalities in
sleep-breathing disorders is to facilitate breathing
■ As there can be many causes of OSA, there are
also several different treatment types.
■ All focus on preventing collapse of the lumen of
the pharynx during sleep.
68
■ The gold standard for initial treatment is home use
of a device called CPAP.
■ In this treatment method, the patient wears a mask
at night that is attached to a machine that
continuously forces air through the entire airway.
■ This keeps the pharynx patent due to air pressure.
69
Zozula et al (Curr Opin Pulm Med
2001)
Disadvantages:
■ Many patients cannot tolerate the treatment.
■ Many complain of not being able to sleep
with a mask on their face.
■ Feels unnatural to have air blown down their
throat.
■ Nasal dryness and congestion
70
Tongue stabilizing Device
■ Tongue Retaining Devices
■ Posterior Tongue Restrainers
71
Tongue Retaining Devices (TRD) Takashi et al
AJODO 1996
■ The TRD 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.
■ This pulls the tongue forward to enlarge the
volume of the upper airway and to reduce airflow
resistance.
72
The Genioglossus EMG activity was greater with
the Tongue Retaining Device
73
Posterior Tongue Restrainers (Bryan Keropian)
■ Posterior tongue restrainer is small, very
comfortable, and one-arched.
■ Full Breath Solution Sleep Appliance (FBS) was
introduced to the dental profession at the end of
2006.
74
Fabrication
75
Mandibular Advancement Device (Haskell et al
Semin Orthod 2009)
■ Indicated in mild-to-moderate OSA who cannot
tolerate CPAP treatment, orthognathic surgery may
be too aggressive a form of treatment.
■ An option for these patients is a removable oral
appliance that repositions the mandible forward.
76
■ These devices have their effect because of the
attachment of the mandible to the tongue,
pharyngeal dilator muscles, and indirectly the soft
palate.
■ By moving the mandible forward, it brings these
structures that make up the lumen of the
oropharynx forward as well, thereby increasing the
airway space 77
Haskell et al Semin Orthod 2009
■ The removable Herbst appliance is one type
used for mandibular advancement in patients
with OSA.
78
Flexible connectors Thermoflex
Coupling Mechanics Screw mechanics
79
Twin Block Monoblock
Coscarelli Dental Press J Orthod 2010 Marklund AJODO 2006
80
Microimplant-based mandibular advancement
therapy ( Joachim et al AO 2012)
81
■ An alternative treatment modality for OSA
patients who cannot tolerate continuous positive
airway pressure and oral appliance therapy.
■ Highly significant reductions in the apnea-
hypopnea index & snoring.
82
Effects of a mandibular repositioner on
obstructive sleep apnea (Liuet al AJODO 2000)
■ Concluded that a mandibular repositioner may be
an effective treatment alternative for obstructive
sleep apnea.
■ Reduction in the frequency of apneic episodes is
mainly attributed to the effects of the appliance
on oropharyngeal structures.
83
Oral appliance treatment for obstructive sleep apnea in a
partly edentulous patient (Magini AJODO 2010)
■ 74-year-old man with a body mass index of
28kg per square meter.
84
■ Partly edentulous patients who refuse surgery
or CPAP therapy can be candidates for oral
appliance therapy.
85
■ Fransson et al (AJODO 2004) developed a lateral
open bite during treatment, and experienced
subjective symptoms related to the altered
occlusion.
■ Rose et al (AJODO 2001) bite was raised and
there was a Class I relationship with a lateral open
bite in the molar and premolar region
86
Surgical Treatment
■ Rachmiel et al (Int J Oral Maxillofac Surg 2005)
The guidelines for OSA surgery state that a
prerequisite for surgery candidates is that they
must be nonresponsive to CPAP or other
nonsurgical OSA treatments.
■ They are often more severe OSA sufferers.
87
■ There are many different types of surgery that
have been used to treat OSA.
■ They range from soft tissue to osteotomy
surgeries.
■ The older of the 2 is soft-tissue surgery.
■ The uvulopalatopharyngoplasty (UPPP) was
introduced in 1981
88
■ In this type of surgery part of the soft palate and
surrounding oropharyngeal tissues are surgically
resected.
■ The most common surgical treatment for OSA in
childern is Adenoidectomy or tonsillectomy.
■ Tonsils & adenoids are present at birth & grow until
the age of 5-7 years.
■ They become symptomatic at age of 18-24 months
(Graber Vanarsdall fourth edition) 89
■ Lee et al 60% of children with airway obstruction
have adenoid and tonsillar hypertrophy.
■ Affected persons tended to have a dolichocephalic
skeletal pattern with mandibular retrognathia.
90
Tonsillectomy
Adenoidectomy uvulopharyngoplasty
91
■ Disadvantage – higher intraoperative blood
loss.
Laser Harmonic scalpel
92
Graber Vanarsdall (fourth edition)
■ (Nasal septum deviation) Septoplasty is acceptable
in adults & adolescents, who reached end of facial
growth.
93
■ Sher et al (1996) concluded that a low
success rate with reduction of the soft palate
alone.
■ Because lead to relapse after several years
when the soft tissue has grown back.
■ However, a tonsillectomy and adenoidectomy
alone do not resolve the obstruction
94
■ Limitations of soft-tissue surgery in the treatment
of OSA, orthognathic treatments have been used.
■ Placing the anterior aspect of the mandible more
anteriorly pulls the tongue forward and away from
the posterior wall of the oropharynx. (Conley et al
AJODO 2006).
95
■ Procedures like inferior sagittal mandibular
osteotomy and maxillomandibular osteotomy
and advancement.
■ Much more recently, maxillary and mandibular
expansion has also been found to be effective in
the treatment of sleep apnea.
96
■ Dental occlusion can be controlled in the surgically
bimaxillary advancement because both jaws are
being moved.( MAD vs Bimaxillary surgery).
■ This procedure prevents the immediate
postoperative period of worsening OSA that is
found in soft-tissue pharyngeal surgeries.
■ Because this area has not been operated upon,
there is no edema that can cause further
obstruction.
97
■ Another surgical treatment that has been found to
coincidentally improve OSA mandibular and
maxillary transverse Distraction Osteogenesis.
■ When used in conjunction with bimaxillary
advancement, this treatment can result in a
significant increase effect on the dimensions of the
oropharynx. (Conley et al AJODO 2006).
98
Conley et al AJODO 2006
Pre
99
■ The first stage of surgery included mandibular
symphyseal distraction osteogenesis to widen the
mandible and maxillary transverse distraction
osteogenesis to widen the maxilla.
■ The second stage of surgery includes Bimaxillary
advancement.
100
101
post
102
Pre Post
103
■ Surgeons should always work with orthodontists
trained in sleep medicine. (Jacobson et al AJODO
2012)
■ Since their combined treatment expertise,
optimally exercised, yields superior short-term and
long-term results.
104
■ Lye et al (Semin Orthod 2009) minor complications
reported for the MMA procedure.
■ As the advancement of the mandible is often 10
mm or greater, the incidence of permanent
hypesthesia of the lower lip.
■ Esthetic alterations like widening of the alar base
of the nose and superior movement of the nasal tip
and a more acute nasolabial angle.
105
■ Another complication that may arise is temporo-
mandibular disorder (TMD).
■ The TMD is caused by the alteration in the
condylar position and increased joint pressure from
the large mandibular advancement.
106
Lafornara et al sleep Medicine 2011
■ A combination of nasal CPAP and MAD may
provide another option for CPAP-intolerant
patients with incomplete response to MAD.
■ Combination therapy is effective in normalizing
respiratory disturbances of sleep apnea in
selected OSA patients who are intolerant to
CPAP 107
Drugs
108
Nasal expiratory positive airway pressure(EPAP)
device Walsh et al sleep medicine 2011
The valves are open when
inhaling to allow for nearly
unobstructive airflow, but
close when exhaling
■ The nasal EPAP device significantly reduced
the AHI and improved subjective daytime
sleepiness.
109
Harry et al (2008)
■ The guideline for treating mild cases of OSA
include increasing the hours of night sleep to eight,
weight reduction, sleep posture training.
■ Oral appliances, which can be very effective in
treating mild cases
110
■ The treatment of moderate to severe cases is
done with CPAP, which is considered the gold
standard.
■ The other main treatment option is orthognathic
surgery.
■ The last treatment option for moderate to
severe cases of OSA is the use of oral
appliances.
111
CONCLUSION
112
References
113
■ Graber Vanarsdall fourth edition
■ Oral Pathology – Shafers fifth edition
■ Treating obstructive sleep apnea: The case for
surgery (Jacobson AJODO 2012)
■ Oral appliance treatment for obstructive sleep
apnea in a partly edentulous patient (MaginiJODO
2010)
■ Effects of a mandibular repositioner on obstructive
sleep apnea (Liu AJODO 2000)
■ Influence on the masticatory system in treatment of
obstructive sleep apnea and snoring with a MAD
(Fransson AJODO 2004) 114
■ Dentofacial Characteristics of Chinese
Obstructive Sleep Apnea Patients in Relation to
Obesity and Severity (Hou AO 2006)
■ OSA –A Orthodontic Concern (Earle.F.Cote Angle
orthodontics 1988)
■ Increase in upper airway volume in patients with
obstructive sleep apnea using a mandibular
advancement device (Coscarelli Dental Press J
orthod 2010)
■ Correction of severe obstructive sleep apnea with
bimaxillary transverse distraction osteogenesis and
maxillomandibular advancement (Conley AJODO
2006)
115
■ The effect of the tongue retaining device on awake
genioglossus muscle activity in patients with
obstructive sleep apnea (Takashi Ono AJODO
1996)
■ Microimplant-based mandibular advancement
therapy for the treatment of snoring and
obstructive sleep apnea (Joachim Ao 2012)
■ Acoustic pharyngometry: clinical and instrumental
correlations in sleep disorders (Rev Bras
Otorrinolaringol 2007)
■ Relationship Between Cephalometric
Characteristics and Obstructive Sites in OSA Un
Bong Baik AO 2002
116
■ Effects of Mandibular Advancement Device (MAD)
on Airway Dimensions (Haskell Semin Orthod
2009)
■ Surgical Procedures for the Treatment of
Obstructive Sleep Apnea (Kok Weng Lye Semin
Orthod 2009)
■ Normal Sleep Architecture (Deatherage Semin
Orthod 2009)
■ An Overview of Oral Appliances and Managing
the Airway in Obstructive Sleep Apnea (Mimi Yow
Semin Orthod 2009)
117
■ Occlusal Side Effects Caused by a Mandibular
Advancement Appliance in Patients with
Obstructive Sleep Apnea (Rose AO 2001)
■ An Orthodontic Update on Treating Obstructive
Sleep Apnea in Children and Adults (Harry et al
2008)
■ A Comparison Study of Upper Airway among
Different Skeletal Craniofacial Patterns in
Nonsnoring Chinese Children Zhe Zhong (AO
2010)
■ Combined oral appliance and positive airway
pressure therapy for obstructive sleep apnea: a
pilot study (Lafornara et al sleep Medicine 2011)
118
119
