OBSTRUCTIVE SLEEP APNEA

OBSTRUCTIVE SLEEP APNEA

DEFINITION:
• It takes its name from the Greek word apnea, which means
"without breath."
• Sleep apnea means "cessation of breath." It is characterized by
repetitive episodes of upper airway obstruction that occur
during sleep, usually associated with a reduction in blood
oxygen saturation.
INCIDENCE:
• 2% of middle-aged women and 4% of middle-aged men.
PREVALENCE:
• OSA commonly is thought to involve 14% of men and 5% of
women
 ETIOLOGY
• The complexity of obstructive sleep apnea is exemplified by
its multifactorial etiology.
• Such etiologies involve the craniofacial structures,
neuromuscular tone, and other related factors.
• Collapsibility of the upper airway is influenced further by
hormonal fluctuation (e.g., pregnancy or menopause),
obesity, rostral fluid shifts, and genetic predisposition that
influences craniofacial anatomy.
• OSA severity is heterogeneous among patients with the
disorder.
 RISK FACTORS
• Individuals with certain characteristics appear to be
predisposed to OSA.
• Conditions that may be risk factors for the development of
OSA in adults include obesity, menopause, gender , and
increasing age.
• Craniofacial morphologies that may predispose to OSA include
retrognathia, long and narrow faces, dolichocephalic facial
type, narrow and deep palate, steep mandibular plane angle,
anterior open bite, midface deficiency, and lower hyoid
position.
• It should be noted, however, that the strength of the
relationship between these craniofacial morphologies and the
development of OSA is not well established.
 SYMPTOMS
• Patients with obstructive sleep apnea often have a history of
snoring, gasping respiration or choking, and witnessed pauses
in breathing (apneas) during sleep.
• Common clinical symptoms of untreated obstructive sleep
apnea include frequent nocturnal awakenings, non-restorative
sleep, morning headaches, and excessive daytime sleepiness.
• Patients with OSA often describe difficulty with attention and
concentration, mood disturbance, and difficulty controlling
other medical comorbidities such as diabetes mellitus,
hypertension, and obesity.
 DIAGNOSIS
Diagnostic confirmation of OSA

In -centre polysomnography Out- of centre sleep testing

PSG OCST

Home sleep apnea

testing
HSAT
Attended PSG includes at least 7 channels of recording,
including
• electroencephalography (EEG),
• monitoring of sleep,
• airflow through the nose and mouth,
• pulse oximetry,
• respiratory effort,
• Electrocardiography and
• leg movement.
 DIAGNOSTIC CRITERIA
According to the International Classification of Sleep Disorders1
obstructive sleep apnea can be diagnosed by either of two sets of
criteria:

• The first set of diagnostic criteria for OSA includes the presence of at least one of the
following:
(1) the patient has sleepiness, Nonrestorative sleep, fatigue or insomnia symptoms,
(2) the patient wakes with breath holding, gasping or choking,
(3) a bed partner or other observer reports habitual snoring, breathing interruptions,
or both, during the patient’s sleep,
(4) the patient has been diagnosed with hypertension, a mood disorder, cognitive
dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or
type 2 diabetes mellitus AND polysomnography or OCST shows 5 or more predominantly
obstructive events (obstructive or mixed apneas, hypopneas, or respiratory effort related
arousals (RERAs) per hour of sleep during a PSG or per hour of monitoring on OCST.

• Secondly, obstructive sleep apnea can be diagnosed if PSG or OCST shows 15 or more
predominantly obstructive events (obstructive or mixed apneas, hypopneas, or
respiratory effort related arousals (RERAs) per hour of sleep during a PSG or per hour of
monitoring on OCST).
 SEVERITY

• Severity of obstructive sleep apnea is

classified based on the RDI; categories are
• mild (RDI ≥5 and <15),
• moderate (RDI ≥15 and ≤30)
• severe (RDI >30).
 The Role of Orthodontics in Adult OSA
MEDICAL AND DENTAL HISTORY
 Screening tool- STOP-Bang questionnaire
• STOP-Bang questionnaire which asks yes or no questions based on its acronym:
• snoring (S),
• tiredness (T),
• observed pauses in breathing (O),
• high blood pressure (P),
• BMI (B),
• age (A),
• neck circumference (N),
• gender (G).
• A patient is considered to be at low risk for OSA if the questionnaire has 2 or less
“yes” answers, at intermediate risk if 3 to 4 “yes” answers, and at high risk if there
are more than 5 “yes” answers.
• The STOP-Bang Questionnaire has a high sensitivity for identifying patients with
moderate-to-severe OSA.
• This sensitivity gives the practitioner an excellent tool for identifying patients who
have the condition. This questionnaire can be completed in a few minutes when
incorporated into an orthodontist’s workflow
 CLINICAL EXAMINATION
• Three steps are followed to determine the MM Class
• Step 1. Patients are asked to take a seated or supine position.
• Step 2. Patients are asked to protrude their tongue as far
forward as they can without emitting a sound.
• Step 3. The examiner observes the relationship between the
palate, tongue base and other soft tissue structures to
determine the MM Classification defined as
• Class Ι: Soft palate, fauces (the arched opening at the back of
the mouth leading to the pharynx), uvula, and tonsillar pillars
are visible;
• Class ΙΙ: Soft palate, fauces, and uvula are visible;
• Class ΙΙΙ: Soft palate and base of uvula are visible;
• Class ΙV: Soft palate is not visible.
EPWORTH SLEEPINESS SCALE
 Epworth Sleepiness Scale
• Epworth Sleepiness Scale
• The EES is a subjective measure of a patient's sleepiness. The test is a list of
eight situations
• where you rate your tendency to become sleepy on a scale of 0, no chance of
dozing, to 3, high
• chance of dozing.
• Interpretation:
• 0-7 It is unlikely that the patient is abnormally sleepy.
• 8-9 Average amount of daytime sleepiness.
• 10-15 The patient may be excessively sleepy depending on the situation. The
patient
• may want to consider seeking medical attention.
• 16-24 The patient is excessively sleepy and should consider seeking medical
attention.
Friedman Tongue Classification System
 FRIEDMAN TONGUE POSITION (FTP).
• The Friedman Tongue Position (FTP) is a grading system used to assess
the relationship of the palate to the tongue and is frequently utilized
in the preoperative evaluation of patients with OSA. The tongue is
evaluated in a neutral position within the oral cavity. The procedure
for assigning an FTP grade involves having a patient open their mouth
widely without tongue protrusion or phonation. The tongue position
is then graded; Friedman suggests repeating the process five times
and the most consistent grade be assigned as the FTP.
• FTP I visualizes the uvula and tonsils/pillar.
• FTP IIa visualizes most of the uvula but not the tonsils/pillar.
• FTP IIb visualizes the entire soft palate to the uvular base.
• FTP III shows some of the soft palate with the distal end absent.
• FTP IV visualizes only the hard palate.
• FTP has also been found to correlate strongly with OSA severity
UPPER AIRWAY IMAGING
 OPTICAL COHERENCE TOMOGRAPHY

• Armstrong et al utilized an endoscopic optical technique (optical

coherence tomography) that generates quantitative, real-time
images of the upper airway that enables accurate determination
of shape and size.
• Optical coherence tomography involves the insertion into the
nares of an optical probe (3 mm diameter) that is housed in a
catheter.
• Rotation of this probe within the catheter provides a 360-degree
profile of surrounding tissue, and longitudinal movement allows
the upper airway to be scanned at multiple sites without irritation
of the airway mucosa thereby avoiding waking a potentially
sleeping subject.
• This imaging modality examines the airway lumen; it cannot
evaluate craniofacial or soft tissue structures that are not adjacent
to the airway.
 MAGNETIC RESONANCE IMAGING
• MRI may be the best current mode of imaging for assessment of
the upper airway and surrounding soft tissue and craniofacial
structures. Advantages of MRI include the following.
(i) achieves high resolution images of the upper airway and soft
tissue;
(ii) provides precise and accurate measurements of the upper
airway and surrounding tissue;
(iii) obtains multiplanar images in the axial, sagittal, and coronal
planes;
(iv) permits volumetric data analysis including three-dimensional
reconstruction images of the upper airway and surrounding
structures;
(v) avoids radiation exposure allowing for repeat measurements.
The shortcomings of MRI include that it:

(i) is costly and not widely available;

(ii) cannot be performed on patients with metallic
implants such as pacemakers;
(iii) has noise related to the machine that can be
disturbing to sleep;
(iv) difficult to perform in patients with claustrophobia
and morbid obesity.
 COMPUTED TOMOGRAPHY

• CT is a noninvasive technique that permits a thorough evaluation of the

entire upper airway.
• Most of the studies using CT have evaluated airway dimension during states
of wakefulness and sleep and have shown narrowing predominantly in the
retropalatal region in patients with OSA .
• Volumetric CT studies have demonstrated smaller airway caliber and larger
tongue volume in obese patients with OSA.
• Three-dimensional CT has shown that the most important parameter
associated with sleep-disordered breathing appears to be narrowing at the
retropalatal area .
• CT studies have also been employed to try to identify favorable surgical
candidates for uvulopalatopharyngoplasty (UPPP) and to examine dynamic
changes of the upper airway and surrounding soft tissue structures during
respiration. These dynamic CT imaging studies have shown that the upper
airway is narrowest at end-expiration and early-inspiration in both normal
and apneic subjects
 RADIOGRAPHIC CEPHALOMETRY
• Lateral cephalometry is a simple and well-standardized
technique involving radiographs of the head and neck with
focus on bony and soft tissue structures.
• An upright lateral cephalograph is obtained while the subject
is seated with gaze parallel to the floor and teeth together.
• The cephalometric technique has highlighted important
differences between sleep apneics and normal subjects, sleep
apneics and snorers, and obese and nonobese subjects.
• OSA patients have been shown to have a small posteriorly-
placed mandible, a narrow posterior airway space, an enlarged
tongue and soft palate, and an inferiorly located hyoid.
• OSA patients compared with snorers have been demonstrated
to have a longer soft palate in addition to an inferiorly
positioned hyoid bone and posteriorly displaced mandible
• When subdivided for age or body mass index (BMI), it was
found that the significant differences between upper airway
dimensions of OSA patients and snorers in the overall
population were almost exclusively derived from the younger
(age < 52 years) and leaner (BMI < 27 kg/m2) subgroups.
• The upper airway measurements studied in obese or older
OSA patients were not different from obese or older snorers.
• More recent work with supine cephalometry has shown that
the transition from upright to supine position in sleep apneics
is associated with a significant narrowing of the
oropharyngeal sagittal dimension.
• Cephalometry has also been employed to assess and optimize
the efficacy of mandibular advancement oral appliances
based on the anatomical changes in supine imaging.
 ACOUSTIC REFLECTION
• Acoustic reflection is an imaging technique that
employs analysis of the phase and amplitude of sound
waves reflected from surrounding airway structures.
• The information derived is used to calculate the upper
airway cross-sectional area at defined distances from
the mouth.
• Subjects hold a device in their mouth that is connected
to the acoustic reflection apparatus. Using this
modality, reproducible measurements can be obtained
to assess the airway with a noninvasive and radiation-
free technique.
• The effect of posture (sitting versus supine position) on
the upper airway can be studied with this technique.
• Acoustic reflection has demonstrated that sleep apnea
subjects have a smaller cross-sectional airway area
when compared to normal subjects.
• It has also shed light on differences in airway dimension
between genders, confirming that men have a larger
upper airway than women when seated.
• The use of a mouthpiece (which requires opening of the
mouth) alters upper airway morphology: the soft palate
is no longer contiguous with the posterior tongue and
the craniofacial structures alter their position.
 NASOPHARYNGOSCOPY
• Otolaryngologists employ this technique to assess the upper airway
beginning from the nasal passage.
• Nasopharyngoscopy is a relatively inexpensive method that allows a direct
real-time view of the upper airway without radiation. Although it is invasive,
it is well-tolerated and safely performed in the outpatient setting.
• It allows static and dynamic anatomical assessment, when coupled with a
Müller maneuver. A Müller maneuver is performed in awake subjects and
involves voluntary inspiration against a closed mouth and obstructed nares.
• It is thought to simulate the upper airway collapse that occurs during the
negative airway pressure of apneic episodes although it is a voluntary
maneuver.
• The limitation of extrapolation from an awake subject attempting to
simulate a negative pressure-induced apnea to a sleep-induced apnea is well
recognized.
• Nonetheless, valuable information on the intrinsic soft tissue tone and
collapsibility can be derived from nasopharyngoscopy with a Müller
maneuver.
 CPAP- CONTINUOUS POSITIVE AIRWAY PRESSURE

• Continuous positive airway pressure (CPAP), usually

nasally applied, is the established treatment for
moderate-to-severe obstructive sleep apnea (OSA).
• Nasal CPAP therapy for sleep apnea was first
described in 1981.
• CPAP is currently the “gold standard” treatment for
moderate-to-severe OSA because of its
demonstrated efficacy
• In the first description of CPAP use for treatment of OSA in 1981,
it was suggested that nasal CPAP acts as a pneumatic splint to
prevent collapse of the pharyngeal airway, by elevating the
pressure in the oropharyngeal airway and reversing the
transmural pressure gradient across the pharyngeal airway.
• CPAP increases airway volume and airway area, and reduces
lateral pharyngeal wall thickness and upper airway edema
secondary to chronic vibration and occlusion of the airway.
• PAP is delivered through a mask interface as either continuous
positive airway pressure (CPAP), bi-level positive airway pressure
(BPAP) or auto-titrating positive airway pressure (APAP).
• CPAP use can decrease OSA-related cognitive impairment
along with improving objective and subjective measures of
sleepiness, particularly in patients with severe OSA (AHI ≥
30/hour).
• BPAP may be used for patients with OSA who are intolerant to
CPAP or those who have other forms of sleep-related
breathing disorders (e.g., sleep-related hypoventilation).
• APAP may be considered for patients with OSA patients who
do not have contraindications to APAP use (e.g., congestive
heart failure, lung disease such as chronic obstructive
pulmonary disease, obesity hypoventilation syndrome, or
central sleep apnea).
 PHARMACOLOGICAL AGENTS

PROGESTATIONAL AGENTS-Estrogen has shown to be used in central sleep

apnea and obesity hypoventilation syndrome. not used in obstructive type.
OPIOD ANTAGONISTS AND NICOTINE-shown to improve oxygenation. not
clinically useful as these are short acting and disrupt sleep cycle.
ACETAZOLAMIDE-produces metabolic acidosis and stimulates ventilatory
control centrally. very useful in periodic breathing and central sleep apnea.
may be helpful in OSA
• Tricyclic antidepressants -- Protriptyline has been used in people with mild
apnea and snoring with mild success. It increases upper airway neuromuscular
activity and decreases REM sleep. Protriptyline is not considered primary
therapy for OSA. Consider use in a person with mild apnea who does not want
CPAP or an oral appliance.

• Modafinil -- May exert stimulant effects by decreasing GABA-mediated

neurotransmission. Improves wakefulness in patients with excessive daytime
hypersomnolence.

• NON AMPHETAMINE -- Used for treatment of fatigue without interfering with

normal sleep architecture. They promote wakefulness.

• THEOPHYLLINE-Evidence exists to support its use in central sleep apnea. Also

reduces obstructive events but causes severe sleep disruption

• The search for a pharmacological agent to treat OSA has been disappointing
though some patients respond to treatment.
 MANDIBULAR ADVANCEMENT APPLIANCES

• Originally, MAAs were derived from an orthodontic functional appliance, the

Esmarch appliance as proposed by Meyer-Ewert and Brosik (1987), which
has been variously modified with the aim of increased effectiveness and
patient compliance.
• There are main appliance groups: tongue repositioning devices, such as the
tongue retaining device, mandibular advancement devices which work by
holding the lower jaw and the tongue forward during sleep and devices
designed to lift the soft palate or reposition the uvula .Uvula lifters are not
in use now due to discomfort.
• MAAs enlarge and stabilize the oro- and hypo-pharyngeal airway space by
advancing the mandible, and stretching the attached soft tissue, and in
particular the tongue (American Sleep Disorders Association, 1995; Lavigne
et al.,1999). A tooth-borne device and a modified activator have been
reported to reduce snoring and to improve the incidence of OSA (Clark et
al., 1993; Rose et al., 2000).
 LITERATURE REVIEW

Airway changes:
• PAS (Posterior Air Space) did not always increase on cephalometric studies with
the MRD device in place .Rick Schwab's work shows lateral increase of up to 25%
retroglossally and 16% retropalatally.
• Awake Fiberoptic videoendoscopy showed no alteration in hypopharynx or
oropharynx, but a significant increase in x-sect. of velopharynx. MRI evaluation
with appliance in place showed 32% total increase in volume with the largest
improvement in the airway behind the mid-soft palate and uvula/ nasopharynx
area

Sleep changes:
• A 39% relative decrease in stage 1 sleep (Clark / Herbst) and Increase in stage 2, 3,
4 and REM sleep (Clark / Herbst)
• REM sleep increased 50%. The average total sleep time increased by 23 minutes
Total sleep time was unchanged. Arousal Index decreased significantly
• Sleep efficiency improved from 80% to 86% .
 DENTAL EFFECTS
• Significant retroclination of the maxillary incisors and proclination of the
mandibular incisors were accompanied by reductions in maxillary arch
length, overbite and overjet. The SNA, ANB angles, ANS–PNS length and
face height increased, and the mandibular first molars and the maxillary
first premolars significantly over-erupted. The appliance used produced
small, changes in the occlusion that tended to occur after 24 months wear.
It is postulated that the changes in overbite might be lessened by keeping
the bite opening to a minimum.(Christopher Robertson, Peter Herbison
EJO2003)
• Minor dental changes might be an acceptable side effect, if associated
with significant treatment efficacy. In cases of unacceptable, progressive
occlusal alterations, the indication for therapy with an OA has to be re-
evaluated, and, in severe cases, therapy might have to be changed to
CPAP.
This appliance uses tongue displacement technology to address the primary cause
of snoring in a noninvasive way. By gently pulling the tongue forward and keeping it
in place, the mouthpiece clears blocked airways.

The appliance is a “one size fits most” mouthpiece and requires no special
fitting by a sleep specialist. The mouthpiece fits comfortably between the lips
and teeth and has an aperture with a bulb for holding the tongue. Once the
bulb is squeezed to reduce the air volume, a vacuum is formed that keeps the
tongue comfortably retained within the bulb.
• USES OF TRD

• Found to be most useful in patients with very large tongues, poor dental
health, no teeth, chronic joint pain, or if their sleep apnea is worse when lying
on their backs than when they lie on their sides at night.

• CANNOT BE USED IN

People who are tongue-tied, so overweight that they are more than 50 percent
above their ideal body weight, grind their teeth at night, or have chronically
stuffy nose.Patients complain most often about irritation on the tip of their
tongue (which can be painful, or cause irritation to spicy and salty foods).
Patients also require practice in swallowing with the appliance in-place,
because the tongue cannot move in its normal pattern. This appliance also
forces nasal breathing and can be difficult to use if the patient has a stuffy nose
or allergies.

• One form of this appliance comes with "breathing tubes" on either side of the
front bubble, but no research has been done using this form of the appliance
• 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.
• Unlike the previous four appliances, this appliance cannot be
adjusted by the patient, but must be adjusted in the dental
office.
• It is made of elastomeric plastic and is the only appliance that
allows adjustment in not only a front to back' position, but in an
'open and close' position.
• Because it includes a very expensive titanium metal hinge
device, this appliance is one of the most expensive available
Airway patency achieved through incremental advancement
combined with vertical adjustability and lateral movement.
Advancement through a range of 10 mm, adjustable in 1
mm increments. Vertically adjustable through changing
connecting stylus pin .
• 4.The TAP-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. This is an appliance
which has a separate section for them
mandible and maxilla. Each portion of
the appliance is placed the mouth
separately and then the patient sticks
out his/her chin until the ' hook and
bar' hardware can be connected. The
hardware is located at the tip of the
tongue, and may take some getting
used to. The adjustment knob sticks
out through the lips and is visible
when sleeping. This appliance is
easily retained by tooth grinders,
even those who have worn away
much of their tooth structure.
The Klearway oral appliance, which utilizes a
maxillary orthodontic expander to sequentially
move the mandible forward. Klearway is a fully-
adjustable oral appliance used for the treatment or
snoring and mild to moderate Obstructive Sleep
Apnea. Fabricated of thermoactive acrylic,
KlearwayTM becomes pliable for easy insertion and
confirms securely to the dentition for an excellent
fit while significantly decreasing soft tissue and
tooth discomfort. Small increments(25 mm) of
forward lower jaw advancement are initiated by the
patient under the direction of a dentist and this
helps avoid rapid jaw movements that can cause
significant patient discomfort. Once warmed under
hot water and inserted, the acrylic resin hardens as
it cools to body temperature and firmly affixes itself
to both arches. Lateral and vertical jaw movement is
permitted which enables the patent to yawn,
swallow, and drink water without dislodging the
appliance
• Upper and lower splints are immersed in boiling water for 1-2 minutes until
the thermoplastic material becomes soft and clear.
• Removed from water to cool for 1 minute before fitting separately to upper
and lower arches.
• After cooling and setting on the teeth for 4 minutes, the splints are
removed and finished by trimming any excess thermoplastic material.
• Upper and lower splints are connected to form the finished appliance
before re-inserting in the mouth to find the optimal level of mandibular
protrusion.
• A comfortable starting position can be found under
the supervision of the operator by inserting the
device unlocked into the mouth and moving the
lower jaw.
• When the optimal protrusion is found, the device is
removed and locked in position.
• A titration protocol is recommended whereby the
lower jaw is advanced 1 mm per week if required
until symptoms are relieved.
The Adjustable TheraSnore is worn on the maxillary arch and
gently holds the mandible in a protrusive position. The mandible
has complete vertical and lateral freedom of movement, thereby
eliminating any TMJ discomfort.
• Available in different arch sizes providing a more
comfortable fit and adjustable with precise settings.

• Easily adjusted by separating the halves of the

appliance and following the number guide along the
side of the appliance to the appropriate protrusion
setting. Appliance is snapped back together at the
desired setting via a locking mechanism.
6.The EMA Elastic Mandibular
Advancement : This appliance
design uses specially designed,
patented elastic bands to reach
the desired position with
considerable freedom of
movement. The E.M.A. is the
thinnest and least bulky of all
the appliances. It is similar to
clear acrylic orthodontic
retainers, and moves the jaw
forward in fairly significant steps,
and can be difficult to tolerate
The device opens the patient’s airway through advancement of the mandible using an
adjustable telescopic Herbst mechanism. Like the Oravan device, Oravan Herbst has a
truly open anterior design, encouraging natural protrusion of the tongue and
maximum patient comfort . The Oravan Herbst can be adjusted by inserting the key
into the adjustment mechanism that is located on the anterior mandibular component
of the device. Can be advanced in very small increments, up to 5 mm.
ProSomnus [IA] utilizes vertically mated buccal posts to advance and hold the
mandible forward to open the airway . To adjust, remove an arch and insert the
next arch in the series of advancement arches. Combinations of arches add up
to a new titration increment. No screws, mechanisms, or elastics required.
ProSomnus offers Unlimited Advancement Arches that can be ordered one at a
time until satisfied that the patient is in the treatment position desired
Narval is a computer-aided design and computer-aided manufacturing (CAD/CAM)
MRD device, and each device is fitted specifically to the patient by their dentist.
The dentist will take a digital or traditional impression—just like they would for any
dental procedure—and will define the initial amount of protrusion required. The
lateral flexibility allows patients to talk and drink while wearing the device.

Narval CC is easy to titrate and highly adjustable with connecting rods that allow
for 15 mm of protrusive range at 0.5 mm increments.
The SomnoDent Fusion is advanced in 1 mm increments by changing the wings
on the lower device or more precisely by adjusting the screw in 0.1 mm
increments using the screw on the top device. The SomnoDent Fusion offers a
custom 8.5 mm range of calibration, reducing the need for device resets.
 OPAP : 'Oral Pressure Appliance'

• It is a "combination" therapy which combines a

nonadjustable MRD with continuous positive airway pressure
(nCPAP). Instead of using nasal nCPAP, which delivers air
pressure through a mask over the nose or the nose and
mouth, the air pressure is delivered through a small conduit
that fits across the roof of the patients mouth. Thus, the
more effective nCPAP can be used by patient without the
need to wear a nasal mask, have elastic straps around the
head, or sleep on one's back.
• Pressures necessary to control snoring and obstructive sleep
apnea are much lower when delivered through OPAP than
when using nasal delivery
 SURGICAL MANAGEMENT

• Proper screening and selection of patients for surgery is paramount to achieve

successful outcomes and to minimize postoperative complications.
• Surgical Indications
• Apnea-hypopnea index ≥ 20a events per hour of sleep
• Oxygen desaturation nadir < 90%
• Esophageal pressure (Pes) more negative than −10 cm H2O
• Cardiovascular derangements (arrhythmia, hypertension)
• Neurobehavioral symptoms (excessive daytime sleepiness)
• Failure of medical management
• Anatomical sites of obstruction (nose, palate, tongue base)
• Surgery may be indicated with an AHI < 20 if accompanied by excessive
daytime fatigue
 SURGICAL MANAGEMENT

Poor Surgical Candidates

• Severe pulmonary disease
• Unstable cardiovascular disease
• Morbid obesity
• Alcohol or drug abuse
• Psychiatric instability
• Unrealistic expectations
 SURGICAL MANAGEMENT

• Various surgical procedures are now available to increase the

posterior airspace and treat OSA in CPAP intolerant patients.
• The anatomy of the upper airway is classified into 3 general
obstructive types (Fujita classification):
• type 1: narrow oropharynx (eg, large tonsils, enlarged uvula,
pillar webbing) with normal palatal arch position;
• type 2: low arched palate with relatively large tongue; further
subdivide into 2a (predominantly oropharyngeal abnormality)
and 2b (abnormality involves oro- and hypopharynx);
• type 3: hypopharyngeal obstruction (eg, retrognathia, floppy
epiglottis, enlarged linguinal tonsils) with normal oropharynx.
• Surgical procedures address specific upper-airway
abnormalities (eg uvulopalatopharyngoplasty for type 1,
genioglossus advancement for type 3, maxillomandibular
advancement for combined type 1, 2 and 3).

• Preoperative pharyngeal anatomy, OSA severity, and patient

preference (eg, recovery time, prolonged facial paresthesias,
and malocclusion) are all contributing factors influencing the
surgical decision.
 Powell-Riley Protocol Surgical Procedures
• Phase I
• Nasal surgery (septoplasty, turbinate reduction, nasal valve grafting)
• Tonsillectomy
• Uvulopalatopharyngoplasty or uvulopalatal flap
• Mandibular osteotomy with genioglossus advancement
• Hyoid myotomy and suspension
• Temperature-controlled radiofrequencya—turbinates, palate, tongue
base
• Phase II
• Maxillomandibular advancement osteotomy
• Temperature-controlled radiofrequencya—tongue base
Tonsillectomy. The primary treatment of OSA in children with tonsillar
enlargement is tonsillectomy usually with concurrent adenoidectomy. To
prevent collapse and improve OSA success, it is preferable that the lateral
pharyngeal walls are sutured.
Uvulopalatopharyngoplasty. This operation enlarges the oropharyngeal airway
lumen by excising redundant tissues from the soft palate, tonsillar pillars, and uvula.
Shown is Friedman’s submucosal uvulopalatopharyngoplasty technique
 POSSIBLE SITES OF OBSTRUCTION
Nose:
• Deviated septum
• Enlarged turbinates
• Polyps
Nasopharynx:
• Enlarged adenoids
Pharynx:
• Enlarged tonsils
• Enlarged uvula or soft palate
• Enlarged base of the tongue
• Tongue base falling into pharyngeal airway
• Submucosal fat or redundant mucosa
Larynx (voice box):
• Laryngopharyngeal reflux changes with severe posterior
commissure swelling.
 CONCLUSION
Sleep-breathing disorders are potentially life threatening;
therefore, the diagnosis and treatment of these diseases are
the domain of the medical profession. The prevailing opinion
is that patients should be treated only with a referral by a
physician. As orthodontists we have a significant role in the
diagnosis of sleep apnea and the oral appliance therapy to
improve the quality of life to the apneic patients.