introduction to sleep apnea for orthodontists

Welcome to the 1st CAO webinar on Obstructive Sleep Apnea

Today’s presentation will be animated by Dr Jean-Marc Retrouvey, the Director of the

Division of Orthodontics at McGill University.

Today, we will :• Define OSA• Discuss the manifestations of OSA.• Describe the typical type(s) of patients affected by OSA• Recognize the difference between OSA and snoring• Suggest different therapeutic approaches for the treatment of

OSA

Obstructive Sleep Apnea The Role of the Orthodontist:

The role of orthodontics in improving breathing in children,

teenagersand adults who suffer from sleep apnea

Dr Jean Marc RetrouveyDirector of Orthodontics

McGill University

Objectives

Define OSADiscuss the manifestations of OSA.Describe the typical type(s) of patients affected by OSARecognize the difference between OSA and snoringSuggest different therapeutic approaches for the treatment of OSA

Apnea–hypopnea indexWIKIPEDIA

• The apnea–hypopnea index (AHI) is an index of sleep apnea severity that combines apneas and hypopneas.

• AHI values are typically categorized as 5–15/hr = mild;

• 15–30/hr = moderate; • > 30/h = severe.)

Apnea–hypopnea indexWIKIPEDIA

• The apnea–hypopnea index (AHI) is an index of sleep apnea severity that combines apneas and hypopneas.

AHI values are typically categorized as:• 5–15/hr = mild• 15–30/hr = moderate• > 30/h = severe

Snoring

27 % of patients

may exhibit snoring

UARSUpper Airway

Resistance Syndrome

4 %

OSA Obstructive Sleep Apnea 2-3%

Snoring and obstructive sleep apnea By David N. F. Fairbanks, Samuel A. Mickelson, B. Tucker Woodson, p 243

Obstructive Sleep Apnea

Snoring: Benign condition (annoying but not dangerous)

UARS: Sleep disturbances but no severe oxygen desaturation (No cardiac sequellae)

OSA: Oxygen desaturation and sleep disturbances (Cardiac disturbances: Strokes, hypertension arrhythmias)

Collpo N. Semin Respir Crit Care Med 2005; 26(1): 13-24Pediatric Care Med 2005; 26(1): 13-24

Daytime symptoms in children

with obstructive

sleep apnea

1. Excessive daytime

somnolence 2. Abnormal

daytime behavior

3. Learning problems

4. Bizarre behavior

5. Morning headaches

6. Failure to thrive or obesity

7. Repetitive upper airway infections

8. Acute cardiac failure

9. Cor pulmonale

10. Hypertension

Guilleminault C, Korobkin R, and R Winkle. A Review

of 50 Children with Obstructive Sleep

ApneaSyndrome. Lung

1981.

Obesity Allergies

Genetics (ex: Skeletal malocclusions)

Most common contributing factors

and Combinations

A fairly direct correlation has been established between obesity and OSA in children1 and adolescents2

Apnea Hypoxia Index (AHI) scores are higher in obese than in normal-weight children with OSA3

1 - The Correlation Among Obesity, Apnea-Hypopnea Index, and Tonsil Size in ChildrenYuen-yu Lam, FHKAM(Paed), et al. Chest 2006: 1751-17562 - Obesity increases the risk for persisting obstructive sleep apnea after treatment in childrenLouise M. O’Brien et al . International Journal of Pediatric Otorhinolaryngology (2006) 70, 1555—15603 - Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight childrenRon B. Mitchell, MD, and James Kelly, PhD, St Louis, MO; Albuquerque, NM . Otolaryngology–Head and Neck Surgery (2007) 137, 43-48

1. Obesity

Both groups show a dramatic improvement in AHI after adenotonsillectomy, but persistent OSA is more common in obese children.

Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight childrenRon B. Mitchell, MD, and James Kelly, PhD, St Louis, MO; Albuquerque, NM . Otolaryngology–Head and Neck Surgery (2007) 137, 43-48

1. Obesity

What about treating OSA in obese kids?

Weight gain!

Recommendation : Lose weight and improve physical condition before starting OSA treatment.

Soultan, Z., et al., Effect of treating obstructive sleep apnea by tonsillectomy and/or adenoidectomy on obesity in children. Archives of Pediatrics and Adolescent Medicine, 1999. 153(1): p. 33.

1. Obesity

With treatment, improvement in OSA but…..

Treatment of OSA or UARS in non-obese children

Impact of Orthodontic treatment

Common Contributing Observations

Severely enlarged tonsils and adenoids in the young patient presenting either UARS or OSA

http://kidshealth.org.nz/index.php/ps_pagename/contentpage/pi_id/303

Dr Harvold, from the University of Toronto, performed studies on Monkeys which showed that:

If you block nasal respiration, mouth breathing follows and a severe malocclusion is observed (variable response)

Harvold EP et al. Primate experiments on oral respiration. Am J Orthod 79(4):359-72, 1981 Harvold EP et al. Experiments on the development of dental malocclusion. Am J Orthod 61:38-44, 1972.

Consequence of Enlarged Tonsils and Adenoids

Recognize early!

OSA will have an impact on normal growth and development (early treatment must be seriously considered)• Growth hormone is mainly released

during the stage 3 of NREM sleep.• http://youtu.be/HiNaJhO2Ht4

Such changes are also influenced by genetic factors. Facial growth is nearly complete between the ages of 15

and 16 years in girls and between 18 and 19 years in boys, but the largest increments of growth occur

during the earliest years of life: By the age of 4 years, the craniofacial skeleton has attained 60% of adult size, and by the age of 12 years it is 90% of adult size. Thus both genetic and environmental factors play a role in teenage facial determination.

Our findings suggest that specific morphometric features may have been present in certain children ot

tonsilectomy and adenoectomy, some aspect of facial growth may even have been modified by the early airway obstruction.

Morphometric facial changes and obstructive sleep apnea in adolescentsChristian Guilleminault, MD, Markku Partinen, MD, Jean Paul Praud, MD,

Maria-Antonia Quera-Salva, MD, Nelson Powell, MD, andRobert Riley, DDS, MD

From Stanford University Medical Center, Stanford, California, Ullanlinnan Sleep DisordersClinic, Helsinki, Finland, Laboratoire d'Explorations Fonctionelles, Hopital Antoine Beclere,

Clamart, France, and Hopital Raymond Poincarré, Garches, France A, Jand ournal of Pediatrics 1989

Importance of Early Detection and Treatment

Examination of a Patient Sufferingfrom OSA or UARS

1 • Reference to pneumologist for

polysomnography

2 • Extra oral findings

3• Intra oral findings

4 • Cephalometric or Cone Beam assessment

5 • Final diagnosis

6 • Treatment options

Examination of a Patient Sufferingfrom OSA or UARS

• Facial features• “Pockets” under the

eyes• Evidence of mouth

breathing• Retrusive mandible (Cl

II malocclusion)• Retrusive maxilla?

2 Extra oral findings

Examination of a Patient Sufferingfrom OSA or UARS

• Openbite• Narrow palate• Curve of Spee• Lower arch form• Severe malocclusion• Usually Cl II

3 Intra oral findings

Examination of a Patient Sufferingfrom OSA or UARS

3 Intra oral findings

Compared with 48 asymptomatic children from the same cohort, the obstructed children had a narrower maxilla, a deeper palatal height, and a shorter lower dental arch. In addition, the prevalence of lateral crossbite was significantly higher among the obstructed children.

Breathing obstruction in relation to craniofacial and dental arch morphology in 4-year-old children

B Löfstrand-Tideström European Journal of OrthodonticsVolume 21, Issue 4 , 1999 Pp. 323-332

Examination of a Patient Sufferingfrom OSA or UARS

• Consistent for a large number of OSA pediatric patients

4 Cephalometric or Cone Beam assessment

• Retrognathic mandible• Steep mandibular plane

angle• Long anterior face height• Short posterior face

height

Examination of a Patient Sufferingfrom OSA or UARS

1. Tonsillectomy2. Rapid Palatal Expansion3. Mandibular Advancement

5 6 Treatment options

1. Tonsillectomy?

Children, who were tonsillectomized because of sleep apnea were examined with respect to facial growth and dental arch morphology. The findings were compared to data from children without tonsillary obstruction. A higher proportion of malocclusion than normal, especially openbite and crossbite, was noticed before surgery. Two years after surgery, 77% of the open bites were normalized and 50-65% of the buccal and anterior crossbites. The best results were seen in children operated before the age of 6.

E. Hultcrantz E., Larson M. , Hellquist R. , Ahlquist-Rastad J. , Svanholm H. and Jakobsson O.P. : The influence of tonsillar obstruction and tonsillectomy on facial growth and dental arch morphology International Journal of Pediatric Otorhinolaryngology 22,2: 125-134 1991

2. Rapid Palatal expansion

• Multiple articles point towards an improvement in the sleep apnea condition.

• Expansion is done via RPE and averages 4.5mm to 6 mm at the palatal suture.

• On sleep apnea patients, the earlier the better.

Selection Criteria for RPE patients

• High narrow palate• Deep bite• Retrusive mandible

Villa, M.P., et al., Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep medicine, 2007. 8(2): p. 128-134.

3. Mandibular advancement

Has the same effect in growing children as rapid palatal expansion

Randomized Controlled Study of an Oral Jaw-Positioning Appliance for the Treatment of Obstructive Sleep Apnea in Children with Malocclusion. MARIA P. Villa, edoardo bernkopf, jacopo pagani, vanna broia, Marilisa montesano and roberto ronchetti.

Impact of Orthodontics on Pediatric OSA Management

Treatment will depend on the severity of the OSA, its influence on the degree of malocclusion and the age of the patient.

Take Home Message : Early recognition (before age 7)

• Educate parents and dentists Constant collaboration with the treating physician

(Respirologist, Plastics, ENT), the Orthodontist and the Dentist.

Treat early and aggressively• Through RPE; Mandibulat advancement and Maxillary Vertical

Control

OSA Treatment in the adultRole of the orthodontist?

Therapy Provider

CPAP Pneumologist or Sleep center

Soft tissue surgery ENT

MADs Sleep centerDentist – TMJ specialistOrthodontist?

MMA surgerySARPE

OMFSOrthodontist

Mandibular advancement devices

• May be efficient for moderate OSA• Do not replace the CPAP in severe

cases

Slide from Dr Arcache

Future: CAD-CAM Manufactured Appliance

What about SARPE?

Dr Fiore (Fiore et al., U de Montreal, 2012) testing 9 patients treated with Sarpe and comprehensive orthodontics.Showed a small but not significant reduction in respiratoy index.Significant change in snoring index.

Maxillary Mandibular Advancement.

Surgical goal: Improvement of the pharyngeal airway along its entire length

43 yr male with snoring and witnessed apneas.

• Sleep study– RDI 67/hr, LSAT 83%

• Sleep study with CPAP– RDI 15/hr, LSAT 86%

• Does not tolerate CPAP

Pre-operative Cephalogram

• Bimaxillary retrusion

• Cl II bimaxillary retrusion malocclusion

• Blocked airway

Surgical Procedure

• Maxillary advancement 8mm• Mandibular advancement 8mm• Advancement genioplasty 4mm• Hyoid suspension 10mm

Post-operative Cephalogram

Results

Pre- operative sleep study:- RDI 67/hr

6 month post- operative sleep study– RDI 9/hr, (was down to 15 with CPAP)

RDI : Respiratory Disturbance IndexLSAT: Saturation in oxygen

Long Term Follow up of aTMJ- OSA Patient

Patient presenting with Long face syndrome :– Narrow palate– Retrusive mandible– Anterior tongue posture– Severe to moderate crowding of dental

arches– Painful bilateral TMJ clicks–Moderate OSA ( No C Pap used)

Treatments

1. Maxillary expansion at 8 years old (failed)

2. Dental alignment (camouflage failed)3. Extractions were contemplated by

previous orthodontist (failed to recognize OSA)

4. Mandibular protraction appliance contra- indicated (High MP angle)

Long term Follow up of TMJ and OSA Patient

In 2004, after first rapid

palatal expansion attempt

2009: Ready for Ortho-Surgery

Orthodontics: 3 piece maxilla preparation Uprighting of lower arch

Immediately Post Surgery (4 weeks)

Results:TMJ pain is resolved ( no splint worn)Snoring and symptoms of OSA have subsidedPatient is satisfied with aesthetic result.

Conclusions

OSA is a medical condition and may be potentially lethalA positive diagnosis of OSA should be obtained before starting any treatmentThe dental profession has an important role in screening young patientsOrthodontists have a greater role to play (back to the future: treat early and aggressively)

Conclusions

Tonsillectomy is making a comeback in preventive therapy for this type of patients (OSA-UARS)CPAP machine is still standard of care in adultsGrowth modification may play an important aspect of OSA treatment

Maxillary expansionMandibular protraction seem to have a positive effect on OSA Must start as early as possible ( do not allow upper molars descent)