Upper Airway, Cranial Morphology, and Sleep Apnea

The adenoid facies craniofacial characteristics include

1. Open-mouth posture,
2. Hypotonia,
3. Narrow maxilla,
4. High palate,
5. Narrow base in the area of the ala of the nose,
6. Proclined maxillary incisors,
7. Proclined lower lip,
8. Increased lower facial height,
9. High mandibular angle,
10. Anterior tongue position,
11. Frequent mandibular retrognathia, and
12. A vacant facial expression.
Another adaptation of mouth breathing is that the upper lips muscular tonicity is
lost.
A short and flaccid upper lip may be unable to cover the anterior teeth, thereby
displaying more maxillary anterior teeth when at rest.
Additionally, gingival display is increased and the potential of a gummy smile
appearance increases.
As a result of lip incompetence, salivary flow to the area is decreased, resulting
in reduced effects of salivary cleaning mechanisms. The incidence of caries is
increased, and maxillary anterior teeth are most affected.
The gingiva also repeatedly alternates from wet (with saliva from the tongue and
lip) to dry (as the short incompetent lip returns to its open rest position). This
repeated wet-dry cycle results in a histologically incomplete keratinization of the
gingiva. Clinically, the gingiva has a red color, rolled gingival margins, and
bulbous papilla. Inflammation may occur alone or with hyperplasia.
Mouth breathing, increased lip separation, and decreased upper lip coverage at
rest have all been associated with higher levels of plaque and gingival
inflammation. As a result of long-term plaque accumulation and poor oral
hygiene, a mouth breathers gingivitis can progress to pocket formation and bone
loss.

IMPORTANCE OF NASAL BREATHING: Another consequence of mouth

breathing is that air brought into the body through the nose is different from air
brought in through the mouth.
1.

Only the nose is able to

Filter,
Warm,
Moisturize, and
Dehumidify air.

2. Small amounts of nitric oxide are made by the nose and sinus mucous
membranes. Nitric oxide is lethal to bacteria and viruses and is also
known to increase oxygen absorption in the lungs from 10% to 25%.
3.

Breathing through the nose

Increases blood circulation and blood oxygen and carbon dioxide levels,
Slows the breathing rate, and
Improves overall lung volumes as a consequence to providing almost
double the resistance than when breathing through the mouth.
The nasal resistance is crucial to maintain adequate elasticity of the lungs.
There are reports of hypoxemia (low levels of oxygen in the blood),
hypercarbia (high levels of carbon dioxide in the blood), and
hypoventilation after only 24 hours of nasal obstruction, forcing the
individual to breathe through the mouth.

Adults who habitually breathe through the mouth, attributable to nasal

obstruction, are more likely to have sleep disorders and attentiondeficit/hyperactivity dis- order (ADHD).
Patients with obstructive sleep apnea (OSA) are noted to have high blood
pressure as a result of overactivation of the sympathetic nervous system.
Exaggerated negative intrathoracic pressure during obstructive apneas further
increases left ventricular afterload, reduces cardiac output, and may promote the
progression of heart failure.
Intermittent hypoxia and postapneic reoxygenation cause vascular endothelial
damage, which can progress to atherosclerosis and, consequently, to coronary
artery disease and ischemic cardiomyopathy, although the mechanisms of
progression have not yet been fully explained.
Chronic OSA is also characterized by apnea, hypoxia, and increased
sympathetic nervous activity and, when present in heart failure, is associated
with increased risk of death.

ANATOMY AND GROWTH

Overview
The respiratory tract is the complete path that air takes through the nose or
mouth, ending at the lungs.
The respiratory tract can be divided into the upper respiratory tract (UA) and
lower respiratory tract (LA).
The LA comprises the trachea, bronchi, and lungs.
The UA, which is more relevant to orthodontics, includes the nasal cavity, the
pharynx, and the larynx.
The pharyngeal airway can be divided into the following three regions of interest,
with one subdivision very relevant to orthodontics:
1. Nasopharynx: Is located between the nares and hard palate.
2. Oropharynx: Is located from the soft palate to the upper border of the
epiglottis. The velopharynx or retropalatal oropharynx is located between
the soft palate and the posterior pharyngeal wall and is found within the
oropharynx. The minimum caliber of the UA in the wake state is primarily
in the velopharynx, which makes it a site of interest as the potential
location of collapse during sleep.
The anterior wall of the oropharynx primarily comprises the soft palate,
tongue, and lingual tonsils.
The posterior wall is bounded by a muscular wall made up of the
superior, middle, and inferior constrictor muscles that lie in front of the
cervical spine.
The lateral pharyngeal walls are a complex structure made up of
muscles (hypoglossus, styloglossus, stylohyoid, stylopharyngeus,
palatoglossus, palatopharyngeus, and pharyngeal constrictors),
lymphoid tissue, and pharyngeal mucosa.
3. Laryngopharynx or hypopharynx: Is located from the base of the tongue to
the inferior border of the cricoid cartilage.
The UA forms the passage for movement of air from the nose to the lungs and
also participates in other physiologic functions such as phonation and deglutition.

The muscles surrounding the airway that actively constrict and dilate the UA
lumen interact in a complex fashion to determine the patency of the airway.
They can be classified into four groups:
1. Muscles regulating the position of the soft palate: ala nasi, tensor palatini,
and levator palatine
2. Tongue: genioglossus, geniohyoid, hyoglossus, and styloglossus
3. Hyoid apparatus: hyoglossus, genioglossus, digastric, genio hyoid, and
sternohyoid
4. Posterolateral
constrictors

pharyngeal

walls:

palatoglossus

and

pharyngeal

Soft tissue structures form the walls of the UA and include the tonsils, soft palate,
uvula, tongue, and lateral pharyngeal walls
Pharyngeal soft tissues exhibited two periods of accelerated change

Ages 6 to 9 years and

12 to 15 years

And two periods of quiescence

Ages 9 to 12 years and

15 to 18 years.

The increase in airway size that occurs from ages 6 to 9 years is thought to occur
because of

The continued growth of the pharyngeal region,

The surgical removal of adenoid tissue, and
The natural involution of adenoid tissue, either alone or in combination
with one another.

These three mechanisms are suspected to play a role in the increase of the
airway during the 12- to 15-year-old period.
The primary craniofacial bony structures that determine the airway size are the
mandible and the hyoid bone ; these presumably act by providing the anchoring
structures to which muscles and soft tissue attach.

Hyoid Bone Position and Morphologic Features

The hyoid bone is the only bone in the head and neck region without a bony
articulation.
Its muscle attachments can be described as belonging either to the suprahyoid
group or the infrahyoid group. The position of the hyoid bone is determined by
the combined activity of the suprahyoid and infrahyoid muscle groups, with the
UA dilator muscles being of great importance.
Arising from the cartilages of the second and third branchial arches, the hyoid
bone consists of a central body that posteriorly projects as a left and right greater
horn. Attaching to the superior surface of the hyoid bone are the left and right
lesser horns.
Anterior movement of the hyoid bone is believed to be related to the forward
translation of the mandible that occurs during cephalocaudal skeletal growth.
The descent of the hyoid bone may be explained by the growth of the cervical
vertebrae.
The combined anterior and downward displacement results from the hyoid bone
being suspended between the cervical vertebrae and the mandible.
Enlarged tonsils can impinge on the UA, leading to a restricted passage and
smaller airway volumes. They observed that children with enlarged tonsils had a
more caudally positioned hyoid bone with respect to the mandibular plane (hyoid
to mandibular plane [H-MP]).
Excessive submental fat deposition in obese patients could be responsible for
inferiorly moving the hyoid bone further.
Pharyngeal critical (Pcrit) pressure, which represents the airway pressure above
which airflow can pass through the UA, is a measure of pharyngeal collapsibility.
A lower hyoid position was theorized to predispose a subject to pharyngeal
collapse by influencing the Pcrit pressure, thus contributing to an anatomic deficit
in patients with OSA.
Studies have proved H-MP distance is increased due to lower hyoid position and
H-Ph (hyoid bone to the posterior pharyngeal wall) is also more due to anterior
hyoid positioning in patients with OSA when compared to normal individuals.

Relationship of Different Skeletal Patterns to Airway Morphologic Structure

Mandibular retrognathia and vertical excess (class II and III) are often
associated with airway problems.
Class III mandibular protrusion groupthe highest oropharyngeal volume, nasal
airway volume, and minimum axial cross-sectional areas.
Class III skeletal pattern present a more vertical orientation of the airway in the
sagittal plane, compared with Class I and Class II subjects, whereas a Class II
skeletal pattern is associated with a more forward orientation of the airway.
Patients with a vertical growth pattern have shown a narrower airway, both
anteroposteriorly and coronally, when compared with patients showing more
horizontal growth. Most vertical growers may also have a skeletal anteroposterior
(AP) malocclusion (Class II or Class III)
Smaller dimensions in the hyperdivergent group can be due to retrusion of the
maxilla and mandible and a low-set hyoid position.

AIRWAY MEASUREMENTS AND IMAGING

Overview
A number of techniques have been used to study the airway, including
1.
2.
3.
4.
5.
6.
7.

Nasal pharyngoscopy/ endoscopy,

Cephalometric radiographs,
Fluoroscopy,
Conventional CT
Electron-beam CT,
Acoustic reflection, and
MRI.

Cephalograms have been found useful in identifying airway obstruction, adenoid

hypertrophy, and very constricted airways. However, the cephalogram is an
image with incomplete information as it attempts to represent a 3D structure in
2D. Since many of the airway deficiencies and changes have been shown to
occur in a mediolateral direction, the use of cephalograms for airway assessment
is limited.
Nasoendoscopy presently holds the position of gold standard diagnosis for UA
obstruction. However, nasoendoscopy has drawbacks as well; primarily, it allows
little opportunity for objective measurement but relies, instead, on professional
opinion, often causing low interobserver agreement.
Acoustic rhinometry (AR) or acoustic pharyngometry and cone-beam computed
tomography (CBCT) are more widely used in otolaryngology and orthodontics,
respectively.
Experiments have found using fast cardiovascular CT (cine CT), that airway size
stays fairly constant during inspiration and reaches a minimum during end
expiration, suggesting that muscular stabilization of the airway lumen during
inspiration against the negative intraluminal pressure is more important than
actual dilation.
It have been confirmed that normal UA has a longer lateral (coronal) than AP
(sagittal) dimension using MRI techniques.
And studies have found that most respiratory-related changes (e.g., endexpiratory loss of diameter) are predominantly in the lateral dimension

Cone-Beam Computed Tomography

The axial plane, which is not visualized on a lateral cephalogram, is the most
physiologically relevant plane because it is perpendicular to the airflow.
The airway can be accurately assessed through segmentation. In medical
imaging, segmentation is defined as the construction of 3D virtual surface models
to match the volumetric data.
UA segmentation can be performed either manually or semiautomatically.
In the manual approach, the user identifies the airway in each slice through the
length of the airway. The software then combines all slices to form a 3D volume.
This method is time-consuming and almost impractical for clinical application.
In contrast, semi- automatic segmentation of the airway is significantly faster. In
the semiautomatic approach, the computer automatically differentiates the air
and the surrounding soft tissues by using the differences in density values (gray
levels) of these structures.
In some programs, the semiautomatic segmentation includes two user-guided
interactive steps:
(1) Placement of initial seed regions in the axial, coronal, and sagittal slices, and
(2) Selection of an initial threshold
Proper analysis of the airway starts with the orientation of the 3D image,
adjusting all three planes of space.
Calculating the volume is relatively easy; however, the volume alone is not
descriptive enough to describe all of the changes that may have occurred.
Using anatomic limits when measuring the airway is very important to ensure that
the same segmented volume is being compared among patients and groups.
Unfortunately, no consensus has been reached at this point on which planes or
landmarks to use as anatomic limits.
The minimum axial area, also known as the area of maximum constriction (mm2)
is probably more useful than the airway volume.

Acoustic Rhinometry
This technique is based on the principle that a sound pulse propagating in the
nasal cavity is reflected by local changes in acoustic impedance.
AR is a simple, fast (approximately 30 seconds), and noninvasive technique that
became widely accepted in a short period.
Most previous investigations of living human subjects have demonstrated
reasonably good agreement between the cross-sectional areas in the anterior
part of the nasal cavity determined by AR and those determined by imaging
techniques such as MRI and CT.
However, this does not hold true for the posterior part of the nasal cavity and the
epipharynx, in which AR significantly overestimates cross-sectional areas
compared with MRI and CT scans.
Pharyngometry
The acoustic reflection technique may also assess the pharyngeal crosssectional area.
Unlike the nose, the oropharyngeal airway is geometrically more complex and
variable and includes mobile structures (soft palate and tongue); therefore
establishing a standard operating protocol and an understanding of the possible
sources of artifacts is of great importance in obtaining reliable results.
Pharyngometry provides a noninvasive assessment of the dimensions, structure,
and physiologic behavior of the UA from the oral cavity to the hypopharnyx while
the patient breathes.
Computer processing of the incident and reflected sound waves from the airways
provide an area distance curve that represents the lumen from which minimal
cross-sectional area and volume can be derived. This dynamic test measures the
dimensions of the airway through the oral cavity and 25 cm down the pharynx.
When attempting to maintain good reliability and obtain accurate results, posture
may play an important role in determining the pharyngeal area. Flexion of the
neck and back, as well as raising the shoulders (which occurs near residual
volume), may compress the pharynx and decrease its cross-sectional area.
Pharyngometry is often marketed as a screening method to assess quickly a
patient for potential sites of sleep-related UA obstruction and to better determine
whether an OA or continuous positive airway pressure (CPAP) device may be
appropriate for the patient.

INFLUENCE OF ORTHODONTIC TREATMENT ON THE AIRWAY

Treatment Including Extractions
Tongue position is considered to be an important factor for the UA since the root
and posterior part of the tongue form the anterior wall of the oropharynx, and its
position can be changed by extractions.
Existing evidence suggests that extraction treatment with maximum anchorage
mechanics may cause the tongues length and height to decrease slightly and
move to a more retracted position against the soft palate. This movement results
in an adaptation and may lead to the narrowing of the UA.
Another possible explanation for UA reduction after incisor retraction is the
movement of the hyoid bone in a posterior and inferior direction
Closure of extraction sites with mesial movement carries the molar to a narrower
part of the arch, which could potentially have an effect on the tongue position.
Mesial movement of the molars in to extraction spaces seems to enlarge the
space behind the tongue, which is considered to play a vigorous role in improving
UA dimensions.
Minimum anchorage and vertical control mechanics are also preferred in
vertically growing patients to obtain a counterclockwise rotation of the mandible.
Rapid Maxillary Expansion
Nasal resistance to airflow is an important factor in determining the nasal
breathing pattern.
Rapid maxillary expansion (RME) is commonly used to correct maxillary
constriction. Because of the nature of the procedure, an increase in the nasal
cavity width and posterior nasal airway is anticipated, not only attributable to the
opening of the median palatal suture but also to an increase in the sagittal and
vertical dimensions.
As a result, an improvement in nasal respiration is expected, along with
expansion in patients with a transverse arch discrepancy.
Surgically assisted rapid palatal expansion (SARPE), on the other hand, is a
frequently used surgical modality of RME preferred in skeletally mature
individuals to overcome the resistance of the closed sutures. Studies have
documented nasal resistance reduction and intranasal capacity increase with
both RME and SARPE treatments.

Research have shown twofold increase in the nasal passage volume of patients
who underwent RME treatment compared with controls even at the end of
approximately a 2-year treatment.
Functional Orthopedic Appliances
The position of the mandible, relative to the anterior cranial base and mandibular
length, seems to have an impact over the oropharyngeal airway.
Several studies have shown weak negative correlation between oropharyngeal
dimensions and the skeletal configuration according to the A point nasionB
point (ANB) angle. In addition, mandibular corpus length and oropharyngeal
airway volume, along with minimum axial area, have shown a positive
correlation.
When the mandible is protruded, a different posture of the tongue caused by
increased genioglossus muscle activity and/or other soft tissue activity may play
an important role over airway dimensions. The majority of the airway
enlargement occurs in the mediolateral dimensionin other words, in the width
of the airway.
On the other hand, when fixed functional appliances are used in the later stages
of growth, when most dental changes take place, no significant posterior airway
changes are usually seen after treatment is completed.
Other extensively used orthopedic appliances are headgears, to inhibit the
forward maxillary growth, and the facemask for maxillary protraction.
Cervical headgear treatment increased the velopharyngeal airway space but did
not significantly affect the rest of the oropharynx or hypopharynx.
Facemask with or without RME seems not to create a significant change for the
oropharyngeal or nasopharyngeal sagittal airway dimensions when compared
with subjects with untreated Class III malocclusions.
Orthognathic Surgery
When mandibular setback osteotomy is performed, the hyoid bone tends to move
to a more posterior and inferior position, and the tongue is carried to a more
posterior position, regardless of whether using bilateral intraoral vertical ramus
osteotomy or sagittal split ramus osteotomy.
As a result, narrowing in the width and depth of the hypopharyngeal and
oropharyngeal areas has been reported. However, there seems to be an
adaptation of the airway in the oropharyngeal and hypopharyngeal levels after

surgery.
On the contrary, mandibular advancement surgery results in an increase in the
dimensions of the oropharyngeal airway. Maxillary advancement, on the other
hand, creates a significant increase in the nasopharyngeal and oropharyngeal
airway dimensions.
Therefore performing bimaxillary orthognathic surgery rather than only
mandibular setback surgery would be advisable, even if the patient exhibits
mandibular prognathia.
Additionally, when maxillomandibular advancement surgery is performed in
conjunction with genial tubercle advancement, which pulls the geniohyoid and
genioglossus muscles forward, the gain in the UA is even better.
Craniofacial anomalies involving the midface (Crouzon, Apert, and Pfeiffer
syndromes), the ones primarily involving the mandible (Nager and Stickler
syndromes and Pierre Robin sequence), and those affecting the midface along
with the mandible (Treacher Collins syndrome and hemifacial microsomia) can
lead to a decrease in the size of the oropharyngeal and nasopharyngeal airways.
In these disorders, the reduced size of the mandible and its retruded position
cause retrodisplacement of the tongue and concomitant reduction of the
oropharyngeal airway, which may lead to UA obstruction. Distraction
osteogenesis (DO) has become an accepted method of treatment for patients
requiring reconstruction of a hypoplastic mandible and a severely retruded
maxilla to increase airway dimensions.
Different types of distraction devices are used for the treatment of craniofacial
anomalies. These are primarily classified as external and internal distraction
devices.
External distractors, although bulky and having a negative impact on a patients
psychosocial life, appear to provide more extended bone osteogenesis
advancement when compared with internal devices. Therefore a greater gain is
obtained in the UA
Similarly, mandibular DO has been proposed as a useful method to resolve
oropharynx airway obstruction. This effect is primarily due to the displacement of
the hyoid bone away from the posterior pharyngeal wall. Furthermore, the small
size of the mandible and its retruded position causes a corresponding
retrodisplacement of the tongue, which also contributes to a reduction in the
airway. Mandibular DO also creates a change in the position of the tongue and is
believed to aid in increasing the airway

Summary of Orthodontic Treatment Effects on the Airway

Final recommendations in light of current literature can be as follows:

Extraction treatment does not seem to affect the airways size, but caution
may be taken in patients who have respiratory problems or already
constricted airways, possibly avoiding maximum anchorage approaches, if
possible.

RME may be able to help solve the nasal resistance to air- flow if the
problem originates from the anterior nasal cavity. Therefore in a possible
relationship with an ear, nose, and throat (ENT) specialist, the clinician
must be aware of the limitations of the procedure.

Functional appliances are most useful in patients with a horizontal growth

pattern of the mandible. If so, using fixed or removable appliances in a
timely fashion may increase the dimensions of the airway. On the
contrary, vertical-growing patients may not benefit from such a treatment
since it is not the sagittal correction but rather a counterclockwise rotation
that may increase the airway space.

When planning surgical treatments, consideration should be given to

avoiding large amounts of mandibular setback even if the patients
diagnostic records indicate mandibular prognathia. Bimaxillary surgeries
are probably better choices for such patients.

SLEEP-DISORDERED
MANAGEMENT

BREATHING:

AIRWAY

DISORDERS

AND

Getting enough quality sleep can help protect mental health, physical health,
quality of life, and safety.
Inadequate sleep contributes to

Heart disease,
Diabetes, depression,
Falls,
Accidents,
Impaired cognition, and
A poor quality of life.
In children and teenagers, sleep also supports growth and development.

OSA, which the orthodontist will most frequently encounter, is considered part of
a group of disorders called sleep- disordered breathing (SDB). This class of
disorders refers to abnormal respiratory patterning during sleep; but ironically its
presence or a suspicion of disease is made when the patient is awake.
It can result in decrease in oxygen and increase in carbon dioxide levels, and
arousals during sleep. Sleepiness by itself is not specific for SDB.
OSA is estimated to affect approximately 8% of men and 2% of women,
averaging 5% of the general population.
The orthodontist who treats many patients a day probably encounters several
people daily with OSA. Although the role of the orthodontist is not to diagnose
SDB, an opportunity to screen for SDB exists. It is important for the orthodontist
to recognize the signs and symptoms of SDB and refer the patient to a sleep
medicine physician for proper diagnosis. An otorhinolaryngologist (also known as
ENT physician) may also be consulted in suspected cases of chronic nasal
obstruction or adenotonsillar hypertrophy.
Proper diagnosis can only be done through polysomnography (PSG) or home
testing with portable monitors, with PSG being the gold standard.

Definitions and Testing Reports

Breathing abnormalities detected during sleep are classified as apnea,
hypopnea, respiratory effortrelated arousals, and hypoventilation.
Apnea is the cessation, or near cessation, of airflow. It exists when airflow is less
than 20% of baseline for at least 10 seconds in adults. In children, the duration
criteria are shorter.
Apnea is most commonly detected using airflow sensors placed at the nose and
mouth of the sleeping patient. Inspiratory airflow is typically used to identify an
apnea, although both inspiratory and expiratory airflows are usually abnormal.
Some laboratories use alternate measures instead, such as inspiratory chest wall
expansion.
Three types of apneas may be observed during sleep:
1. OSA occurs when airflow is absent or nearly absent but ventilatory effort
persists. It is caused by complete, or nearly complete, UA obstruction.
2. Central apnea occurs when both airflow and ventilatory effort are absent.

3. Mixed apnea is mix of intervals during which no respiratory efforts occur

(i.e., central apnea pattern) and intervals during which obstructed
respiratory efforts occur.
The most common breathing abnormality scored in a sleep study is called
hypopnea, which is an abnormal reduction of airflow to a degree that is
insufficient to meet the criteria for an apnea.
Although the criteria for hypopnea vary among sleep laboratories, a common
definition is 30% reduction of breathing movements or airflow for at least 10
seconds, with 3% or 4% oxyhemoglobin desaturation.
Similarly to apnea, hypopnea is detected using airflow sensors or surrogate
measures, such as chest wall expansion. Airflow is typically used to identify
hypopnea, and both inspiratory and expiratory airflows are usually abnormal.
Further classified,
1. Obstructive hypopneas are due to partial UA obstruction, which can be
heard as snoring.

2. Central hypopneas are due to reduced inspiratory effort.

Another class of breathing abnormalities, respiratory effort related arousals
(RERAs), which are episodes during which breathing and oxygenation are
maintained at the expense of a great increase in respiratory efforts, results from
increased UA resistance.
RERAs are terminated by an arousal, which is often characterized by a
resuscitative snore or an abrupt change in respiratory measures with arousal and
a change in breathing sounds.
Patients with RERAs tend to have frequent microarousals of 3 seconds or less
during sleep.
Repetitive RERAs associated with daytime sleepiness was previously called UA
resistance syndrome, a subtype of OSA. These patients may exhibit abnormal
sleep and cardiorespiratory changes that are typical of OSA.
Sleep hypoventilation is expressed by a reduction in only the oxygen level or
an increase in the carbon dioxide level without measurable changes in breathing
patterns evident in the air- flow monitor. Sleep hypoventilation is usually
presumed when persistent oxyhemoglobin desaturation is detected without an
alternative explanation.

Assess the severity of suspected sleep apnea

Apnea-Hypopnea Index (AHI)
The AHI is the total number of apneas and hypopneas per hour of sleep. The AHI
is most commonly calculated per hour of total sleep and is the current defining
measure of disease and disease risk.
However, an AHI is occasionally calculated per hour of non- REM sleep, per hour
of REM sleep, or per hour of sleep in a certain position to provide insight into the
sleep-stage dependency or sleep-position dependency.
If AHI values are 4 or less, then the patient is within normal limits.
OSA is

Mild when the AHI reflects 5 to 15 episodes per hour of sleep,

Moderate when the AHI reflects 15 to 29 episodes per hour of sleep, and
Severe when the AHI reflects 30 and higher episodes per hour of sleep.

Respiratory Disturbance Index (RDI)

The RDI is the total number of events (apneas, hypopneas, and RERAs) per
hour of sleep.
The RDI is generally larger than the AHI, because the RDI considers the
frequency of RERAs, whereas the AHI does not.
OSA severity is defined as

Mild when the RDI reflects 5 to 15 episodes per hour of sleep,

Moderate when the RDI reflects 15 to 30 episodes per hour of sleep, and
Severe when the RDI reflects 30 or more episodes per hour of sleep.

Reporting oxygen saturation.

Oxygen desaturation is a consequence of SDB.
The oxygen desaturation index (ODI) is the number of times that the oxygen
saturation falls by more than 3% to 4% per hour of sleep.
The percent of sleep time during which oxygen saturation is <90% quantifies the
exposure to hypoxemia.
This measure and mean oxygen saturation are associated with a risk for
cardiovascular disorders and glucose intolerance.

Minimum levels (i.e., troughs) of oxygen saturation are important because

severe hypoxemia is considered a risk for cardiac arrhythmias.
One measure of interrupted sleep is the arousal index, calculated as arousals
per hour of sleep. The arousal index score is generally lower than the AHI or RDI
score because approximately 20% of apneas or hypopneas are not accompanied
by arousals.
However, the arousal index score can be greater than the AHI or RDI score if
arousals that occur are due to causes other than apneas or hypopneas. As
examples, arousals can be caused by

Periodic limb movements,

Noise, and
Sleep state transitions.

Indexes determined by PSG define the number of events per hour of

electroencephalographically documented sleep, whereas indexes determined by
portable monitoring define the number of events per hour of recording time,
subjectively estimated sleep time, or time in bed. In portable monitoring, the
tendency is to overestimate the sleep time and thus underestimate the index.

Classifications of Sleep-Disordered Breathing

The syndromic classification of SDB results from a combination of testing results
and symptom presentations.
Obstructive Sleep Apnea
OSA is defined as either

More than 15 apneas, hypopneas, or RERAs per hour of sleep (i.e., an

AHI or RDI >15 events per hour) in an asymptomatic patient, OR

More than 5 apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI
or RDI >5 events per hour) in a patient with symptoms (e.g., sleepiness,
fatigue, inattention) or signs of disturbed sleep (e.g., snoring, restless
sleep, respiratory pauses).

OSA syndrome applies only to the latter definition. In both situations, more than
75% of the apneas or hypopneas must have an obstructive pattern.

Upper Airway Resistance Syndrome

Individuals previously diagnosed with upper airway resistance syndrome (UARS)
are now classified as having OSA. UARS refers to RERAs accompanied by
symptoms or signs of disturbed sleep.
Central Sleep Apnea Syndrome
Central sleep apnea syndrome (CSAS) exists when symptoms or signs of
disturbed sleep are accompanied by more than five central apneas plus
hypopneas per hour of sleep and normocarbia during wakefulness.
The UA has little or no involvement in CSAS.
A special case of recurrent central apneas is called Cheyne-Stokes respiration
and refers to a cyclic pattern of central apneas and crescendo-decrescendo tidal
volumes.
Cheyne- Stokes respiration is considered a type of CSA and is commonly
associated with heart failure or stroke.
Sleep Hypoventilation Syndromes
Patients with one of the hypoventilation syndromes generally have mild
hypercarbia when awake, which worsens during sleep.
The two-hypoventilation syndromes are

Congenital central hypoventilation syndrome (CCHS) and

Obesity hypoventilation syndrome (OHS).

Epidemiologic Factors
In OSA, the most common form of sleep apnea, episodes of apnea occur during
sleep as a result of airway obstruction at the level of the oropharynx and
velopharynx
OSA in children is a special case for several reasons. The presenting symptoms
are more likely to be behavioral problems during the day and below expected
performance in school.
Sleepiness during the day is less common than hyperactivity, and a
consideration of OSA is warranted in those with ADHD.
Adenotonsillar hypertrophy by itself or in the presence of obesity, the prevalence
of which is increasing, is a major cause for OSA in children.
The scoring rules for diagnosis are different in children, with less emphasis on
the number of apnea episodes or hypoxemia and more emphasis on the number
of hypopneas, RERAs, and arousals from sleep
Adenotonsillary surgery plays a greater role in children
In young women and in women before menopause, OSA is accompanied with
more complaints of fatigue and depression than with snoring or sleepiness, and a
workup for hypothyroidism is more often negative. The results of a PSG may be
dominated by arousals, RERAs, and hypopneas.
The special case of pregnancy is also a time when a woman is more vulnerable
to OSA because of edema, nasal congestion, progesterone and small lung
volumes, resulting in increased oscillation from hyperventilation to apnea

Pathophysiologic Factors
Pharynx is abnormal in size and/or is capable of collapsing or being collapsed in
patients with OSA.
The pharynx must be collapsible because, as an organ for speech and
deglutition, it must be able to change shape and close. However, as a conduit for
airflow, it must also resist collapsing. The solution to this design problem involves
a group of muscles that can alter the shape of the pharynx when an individual
swallows or speaks but will hold it open when he or she inhales.
With sleep,

There is a reduced tonic input to the UA muscles,

Diminished reflexes that protect the pharynx from collapsing,
Reduced compensation for resistive loading, and
An increased chemoreceptor set point during nonrapid eye movement
(non-REM) sleep, which reveals a sensitive hypocapnia-induced apneic
threshold.

An abnormal pharynx can be kept open in wakefulness by an appropriate

compensatory increase in dilator muscle activity, but this compensation fails
during sleep and the airway collapses. Partial collapse results in snoring,
hypopneas, and, in some cases, prolonged obstructive hypoventilation. Complete
closure results in an apnea.
The anatomic location of a UA obstruction may be anywhere from the nose to the
glottis, with the most frequent site of primary obstruction being the velopharynx at
the level of the soft palate and the oropharynx.
Besides anatomic vulnerability, the physiologic causes for recurrent apneas
during sleep are three-fold:

Ventilation transitions from waking to sleeping and back

A reduced UA activation in response to an apnea or hypopneas, and
A high arousal threshold that awakens the patient with a ventilatory
overshoot before a compensatory response occurs during sleep.

Clinical Presentation
The most recognized manifestations of the OSA are

Loud snoring
Severe sleepiness;
Insomnia or
Fatigue or
Inattention.

In adults, some other common reports include:

1. Physically restless sleep and reports of insomnia
2. Morning dry mouth or sore throat from mouth breathing upon recovery
from apnea and/or hypopnea
3. Morning confusion and headache from increases in carbon dioxide levels
4. Personality changes (irritability and distracted demeanor) and judgment
changes resulting from sleepiness
5. Night sweats, secondary to increased work of breathing
6. Erectile dysfunction, especially in the setting of hyperlipidemia

Physical Characteristics
The patient with OSA exhibits
1. Hypertension,
2. Obesity,
3. Large neck, neck size is an important predictor of sleep apnea and, in
some cases, is a better predictor than body mass index (BMI), and
4. Structurally abnormal or crowded UA.
The orthodontist can detect
5. Nasal obstruction,
6. Low hanging soft palate and
7. Large uvula,
8. Enlarged tonsils and adenoids, and
9. Retrognathia or micrognathia.
10. Nasopharyngeal tumors are rare but must be ruled out.
Other disorders that can crowd or affect the pharynx include
11. Hypothyroidism,
12. Acromegaly,
13. Amyloidosis,
14. Neuromuscular disease, and
15. Vocal cord paralysis.

Clinical Prediction of Significant Sleep-Disordered Breathing

Clinical features may not reliably predict sleep apnea in all patients suspected of
having the disorder. Several models have been developed that can help the
clinician decide which patients could be referred for more definitive testing. The
most useful models use the following clinical domains:
1. Presence of hypertension (or hypertension treatment)
2. BMI 30 or higher
3. Neck circumference (or collar size) of >17 inches for men and >16 inches
for women
4. History of habitual snoring, snorts, observed apneas, and restless sleep
5. Observed reports of nocturnal choking or gasping
6. Reported or observed sleepiness, inattention, and nocturnal changes in
energy
A patient with a low clinical score will have a low or very low posttest probability
of having important sleep apnea and does not need further evaluation.
A patient with a high probability of having clinically important sleep apnea
requires further testing.
Patients with a clinical score that is intermediate can be potential candidates, but
further evaluation is needed.
Clinical severity profiles are being developed and range from
Severe (very high sleepiness and profiles for abnormal breathing during sleep) to
Mild (loud snoring without cardiovascular or behavioral indications for immediate
treatment).
Moderate severity may be initially managed by weight loss or the treatment of an
anatomic problem, such as a nasal polyp or rhinitis, leaving the use of a CPAP
device or an OA and surgery for consideration after appropriate diagnostic
testing.

Tests and Questionnaires

The presence or absence and predicting the severity of OSA must be determined
before initiating any kind of treatment.
The gold standard of OSA diagnosis is

Clinical examination,
Daytime sleepiness, and
Overnight PSG.

Other clinical tools that are more time efficient and clinically feasible are available
and include

Screening questionnaires,
Indexes, and
Cephalometric analyses.

Examples of some screening methods are the

1.
2.
3.
4.
5.
6.
7.

Berlin Questionnaire,
The Epworth Sleepiness Scale (ESS),
The Sleep Disorders Questionnaire (SDQ),
The STOP Bang Questionnaire,
The Kushida Index,
Apnea prediction score, and
The Friedman classification that includes the modified Mallampati (MMP)
score.

Friedman Classification
Friedman showed that the combination of many factors such as tonsil size, MMP
score, and BMI plays an important role in clinically predicting OSA
The tonsil size can be graded from 0 to 4
MMP scoring was initially developed to help clinically predict the ease versus
difficulty of laryngeal intubation.
This scoring system is based on the direct visualization of the soft palate, uvula,
faucial pillar, and hard palate and on the concept of examining the tongue size
relative to the oral cavity.
Because measuring the size of the tongue relative to the oropharyngeal cavity is
not possible, the MMP score is considered an indirect way of assessing the size

of the base of the tongue.

The original classification was divided into three classes, Classes I, II, and III,
that, respectively, coincide with the severity and difficulty of intubation.
Later a modified Mallampati test (MMT), adding a fourth class.
Although it was initially designed for predicting the difficulty of tracheal intubation,
today, this clinical tool is used to assess patients with OSA and to detect those
who have breathing
problems
attributable
to UA obstruction.
CHAPTER
12 Upper
Airway, Cranial
Morphology, and Sleep Apnea

Surgically removed tonsils

Tonsils hidden within tonsil pillars

Tonsils extending to the pillars

3
Tonsils are beyond the pillars

337

4
Tonsils extend to midline

FIGURE 12-10 Tonsil classification. 0: surgically removed tonsils; 1: tonsils hidden within pillars;
2: tonsils extended to the pillars; 3: tonsils beyond the pillars; 4: tonsils extended to the midline.

the tongue relative to the oropharyngeal cavity is not possible,

the MMP score is considered an indirect way of assessing the
size of the base of the tongue.182 The original classification was
divided into three classes, Classes I, II, and III, that, respectively,
coincide with the severity and difficulty of intubation. In 1987,
Samsoon and Young suggested a modified Mallampati test
(MMT), adding a fourth class (Fig. 12-11).183 Although it was

It is important to note that the MMP score increases in certain conditions such as pregnancy; therefore it is important
that clinicians not confuse high scores when they are caused by
pathologic versus physiologic reasons.186
Mallampati Score Method
Three steps are followed to determine the MMP score:

338

CHAPTER 12 Upper Airway, Cranial Morphology, and Sleep Apnea

STOPBang Questionnaire
The STOPBang questionnaire was developed
on the Berlin Questionnaire by anesthetist Ch
sleep specialists in Canada to screen patients
OSA preoperatively. It was first identified as
tionnaire, which stands for yes or no question
tiredness (T), observed events (O), and blood
was later modified to STOPBang, adding BMI (
circumference (N), and gender (G) (Table 12
ification improved the questionnaires sensit
study reports that the STOPBang Questionnair
sensitivity to diagnose the patient with modera
when compared with other screening tests su
Questionnaire, the original STOP questionna
Their result showed that with AHI of 5 even
of 15 events per hour, and AHI 30 events per
the sensitivities of the STOPBang Questionna
92.9%, and 100%, and the specificities were 5
37%, respectively.192

Epworth Sleepiness Scale

The ESS was introduced by Dr. Murray Joh
is a tool for assessing daytime sleepiness.193
situations with a likelihood of falling asleep an
from 0 to 3, giving a total scale of 0 to 24. E
play a relatively small role in screening patie
of OSA and cannot be used to predict or scr
OSA.194

Cephalometric Analysis
Although cephalometrics has an inherent lim
a 2D representation of a 3D structure, cephal
FIGURE 12-11 The modified Mallampati test (MMT) classificais still common in orthodontic offices. The sa
tions. I: Soft palate, fauces, uvula, and pillars are visible. II: Soft
cal position of different structures such as sof
palate, fauces, and uvula are visible. III: Soft palate and base of
airway, and hyoid position measurements cou
uvula are visible. IV: Soft palate is not visible.
airway problem. In 1984, McNamara describ
metric technique,195 which included assessmen
suggested taking two measurements, one for
Kushida Index
ynx and the other for the lower pharynx dimen
Mallampati Score Method
The Kushida index was developed in 1997 through a mathematpharynx dimension was described as the mi
ical formula and is considered to have high levels of sensitivity
between the upper soft palate and the nearest
188,189
Three steps and
arespecificity.
followed
to determine
the MMP
score: with
It combines different
measurements
terior pharynx wall. This distance was determ
BMI and neck circumference, creating a morphometric mathewith age, with its norm established at 17.4 3.4
matical
model
to
predict
OSA.
After
the
calculations
are
made,
dimension
is the minimum distance b
Step 1. Patients are asked to take a seated or supine position.pharynx
A study
showed
if the result is 70 or above, then it indicates a high risk of OSA.
terior wall of the pharynx and a point seen in t
that the accuracy
of predicting
the intubation
observed
more
The Kushida
index is calculated
as follows: using the MMT was
as the
intersection
between the posterior conto
with
the
lower
border
in the sitting position; however, both positions are reliable. If seated in an upright of the mandible. The
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dimension was not seen to change with age, a
position, the{1head
is in neutral position.
determined to be 11.3 3.3 mm for females an
where P, palatal height; Mx, maxillary intermolar distance; Mn,
for males (Fig. 12-12).195 The anteroposterior a
Step 2. Patients
are intermolar
asked todistance;
protrude
their tongue
asmass
far forward
mandibular
OJ, overjet;
BMI, body
tions ofas
the they
hyoid can
bone can also be seen in th
index;
and
NC,
neck
circumference.
but
a
3D
modality
such
without emitting a sound. In the Friedman classification, the patient opens his or as the CBCT allows a fa
The first part of the formula reflects the contribution of the
hensive analysis, including axial and mediolate
her mouth wide
without
protruding
tongue.
craniofacial
dysmorphism
to the
predict
OSA through measureSleep Disorders Questionnaire
ments from the oral cavity, whereas the second part reflects the
contribution
of obesity.
SDQ was
developed
Step 3. Through
visual
observation, a Class I to Class IVTheMMP
score
is from the sleep qu
assessment of wakefulness in 1993 by retrievin
determined. Berlin Questionnaire
tions, creating a multivariate scoring scale (T
The Berlin questionnaire was developed in 1996 at the Conferfour clinical diagnostic scales are sleep apnea
ence on Sleep in Primary Care that took place in Berlin, Ger(NAR), psychiatric sleep disorder (PSY), an
many. This 10-question questionnaire is considered to be a very
movement (PLM) disorder.196 In a 2003 study
accurate method of predicting OSA.190 The complete method is
questions proved to be valid and useful in scre
explained in Table 12-1.
a good degree of sensitivity and specificity.197 I

http://dentalebooks.com

from 0 to 3, giving a total scale of 0 to 24. ES

play a relatively small role in screening patie
of OSA and cannot be used to predict or scr
OSA.194

Cephalometric Analysis
Although cephalometrics has an inherent lim
a 2D representation of a 3D structure, cephal
Kushida Index
FIGURE 12-11 The modified Mallampati test (MMT) classificais still common in orthodontic offices. The sa
tions. I: Soft palate, fauces, uvula, and pillars are visible. II: Soft
cal position of different structures such as sof
The Kushida
index
through
a are
mathematical
formula
andof is considered
to have
palate,
fauces,
and uvula
visible. III: Soft palate
and base
airway, and hyoid
position measurements coul
uvula
are visible. IV:
Soft
palate is not visible.
high levels of
sensitivity
and
specificity.
airway problem. In 1984, McNamara describ
metric technique,195 which included assessmen
suggested taking
two measurements,
one for
It combinesKushida
different
measurements with BMI and neck circumference,
creating
a
Index
ynx and the other for the lower pharynx dimen
morphometric
toinpredict
OSA.
The mathematical
Kushida index wasmodel
developed
1997 through
a mathematpharynx dimension was described as the min
ical formula and is considered to have high levels of sensitivity
between the upper soft palate and the nearest p
188,189 It combines different measurements with
and specificity.are
terior pharynx
wall. This
After the calculations
made, if the result is 70 or above, then
it indicates
a distance was determ
BMI
and
neck
circumference,
creating
a
morphometric
mathewith
age,
with
its
norm
established at 17.4 3.4
high risk of OSA.
matical model to predict OSA. After the calculations are made,
pharynx dimension is the minimum distance b
if the result is 70 or above, then it indicates a high risk of OSA.
terior wall of the pharynx and a point seen in th
The Kushida
is index
calculated
as follows:
Theindex
Kushida
is calculated
as follows:
as the intersection between the posterior conto
with the lower border of the mandible. The
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dimension was not seen to change with age, a
determined to be 11.3 3.3 mm for females an
where P, palatal height; Mx, maxillary intermolar distance; Mn,
for males (Fig. 12-12).195 The anteroposterior a
Where P, mandibular
palatal height;
Mx,
maxillary
intermolar
distance;
Mn,
mandibular
intermolar distance; OJ, overjet; BMI, body mass
tions
of the
hyoid bone can also be seen in th
intermolar index;
distance;
overjet; BMI, body mass index;butand
NC, neck
and NC,OJ,
neck circumference.
a 3D modality
such as the CBCT allows a fa
The first part of the formula reflects the contribution of the
hensive analysis, including axial and mediolate
circumference.
craniofacial dysmorphism to predict OSA through measureSleep Disorders Questionnaire
ments from the oral cavity, whereas the second part reflects the
The first part
of
the
formula
reflects
the
contribution
of
theSDQcraniofacial
contribution of obesity.
The
was developed from the sleep qu
dysmorphism to predict OSA through measurements fromassessment
the oral
cavity, in 1993 by retrievin
of wakefulness
Questionnaire
tions, creating a multivariate scoring scale (T
whereas theBerlin
second
part reflects the contribution of obesity.
The Berlin questionnaire was developed in 1996 at the Conferfour clinical diagnostic scales are sleep apnea (
ence on Sleep in Primary Care that took place in Berlin, Ger(NAR), psychiatric sleep disorder (PSY), an
Berlin Questionnaire
many. This 10-question questionnaire is considered to be a very
movement (PLM) disorder.196 In a 2003 study
190
accurate method of predicting OSA. The complete method is
questions proved to be valid and useful in scre
explained in Table 12-1.
a good degree
The Berlin questionnaire
10-question questionnaire is considered
to beofasensitivity
very and specificity.197 I

accurate method of predicting OSA.

http://dentalebooks.com

STOPBang Questionnaire
It was first identified as the STOP Questionnaire, which stands for yes or no
questions on snoring (S), tiredness (T), observed events (O), and blood pressure
(P). It was later modified to STOPBang, adding BMI (B), age (A), neck
circumference (N), and gender (G)
STOPBang Questionnaire has the highest sensitivity to diagnose the patient with
moderate to severe OSA when compared with other screening tests such as the
Berlin Questionnaire, the original STOP questionnaire, and the ESS.

Epworth Sleepiness Scale

The ESS was introduced for assessing daytime sleepiness.
It assesses eight situations with a likelihood of falling asleep and assigns scores
from 0 to 3, giving a total scale of 0 to 24.
ESS was found to play a relatively small role in screening patients at high risk of
OSA and cannot be used to predict or screen patients for OSA.
Cephalometric Analysis
Although cephalometrics has an inherent limitation of being a 2D representation
of a 3D structure, cephalometric analysis is still common in orthodontic offices.
The sagittal and vertical position of different structures such as soft palate,
tongue, airway, and hyoid position measurements could help detect an airway
problem.
The anteroposterior and vertical positions of the hyoid bone can be seen in the
cephalograms.
McNamara described his cephalometric technique, and suggested taking two
measurements, one for the upper pharynx and the other for the lower pharynx
dimension.
The upper pharynx dimension was described as the minimum distance between
the upper soft palate and the nearest point of the posterior pharynx wall.
This distance was determined to increase with age, with its norm established at
17.4 3.4 mm.
The lower pharynx dimension is the minimum distance between the posterior wall
of the pharynx and a point seen in the cephalograms as the intersection between
the posterior contour of the tongue with the lower border of the mandible.
The lower pharynx dimension was not seen to change with age, and its norm
was determined to be 11.3 3.3 mm for females and 13.5 4.3 mm for males.
Sleep Disorders Questionnaire
The four clinical diagnostic scales are sleep apnea (SA), narcolepsy (NAR),
psychiatric sleep disorder (PSY), and periodic limb movement (PLM) disorder.

Diagnostic Testing of Obstructive Sleep Apnea

Diagnosis of OSA requires that the patient be examined during sleep, and the
gold standard is to diagnose through PSG.
PSG can be performed as an in-laboratory full-night or split- night test that
includes the analysis of the following tests:
1.
2.
3.
4.
5.
6.
7.
8.

Electroencephalogram,
Electrooculogram,
Chin electromyogram,
Airflow analysis,
Oxygen saturation,
Respiratory effort, and
Electrocardiogram, sometimes replaced by heart rate.
Body position and excessive movements are also observed during this
test.

Treatment Modalities

CPAP therapy
OAs
Surgery. Bariatric surgery is indicated for eligible men and women and can
reduce OSA to low levels in 85% of patients.

New forms of therapy include

Expiratory nasal valves,

Unilateral hypoglossal stimulation, and
Muscle exercises.

Treatment Options
The desired outcome of treatment includes the resolution of the clinical signs and
symptoms, and the normalization of the AHI and oxyhemoglobin saturation.
No treatment should be rendered without proper diagnosis through PSG.
Positive airway pressure (PAP) is the treatment of choice for mild, moderate, and
severe OSA and should be offered as an option to all patients; however,
depending on the severity of the OSA, the patients anatomy, risks factors, and
patient preferences, other options such as OAs and surgery may be adequate.

Lifestyle and Behavioral Modification

Loss of weight to a BMI of 25 kg/m2 or less

Exercise
Positional therapy during sleep. Sleeping in a supine position can affect
the airway size and patency, helping the collapse of all structures.
Positional therapy consists of a method that keeps the patient sleeping in
a nonsupine position. Positional therapy will not always have a positive
effect; consequently, PSG should be performed in both the supine and
nonsupine positions before deciding if it will be a primary or secondary
therapy for a patient. To prevent the patient from sleeping in a supine
position, using objects such as tennis balls, pillows, or a backpack is
recommended.
Avoidance of alcohol or sedatives before going to sleep.

Positive Airway Pressure

PAP is the treatment of choice for all levels of OSA; it provides pneumatic
splinting of the UA and shows positive outcomes in reducing the AHI.
PAP may be delivered as continuous (CPAP), bilevel (BPAP), or autotitrating
(APAP) modes.
The airway pressure can be applied through nasal, oral, or oronasal mask.
PAP therapy is also indicated for

Improving sleepiness and

Quality of life and
As an adjunctive therapy to lowering blood pressure in patients with OSA
who also have hypertension.

Oral Appliances
When the OSA is diagnosed as mild to moderate, OAs are considered a viable
option.
Patients often prefer OAs instead of a CPAP device because of their portability,
ease of use, and comfort.
OAs are also helpful with patients who snore or have UA resistance syndrome.
As a general rule, patients with severe OSA are not treated with OAs because of
the concern that failed treatment or partial treatment may lead to respiratory
failure. Overall, two-thirds of patients will experience improvement in OSA

symptoms with OA therapy.

Better treatment responses have been found in

Younger patients,
Patients with smaller neck circumferences,
Women,
Supine-dependent patients with OSA.

Cephalometric variables associated with better treatment responses have

included

Longer maxilla,
Shorter facial heights and soft palate,

Reduced overjet, and

Shorter distances between mandibular plane and hyoid bone.

These variables are consistent with less severe OSA.

OAs appears to enlarge the pharynx to a greater degree in the lateral plane than
in the sagittal plane at the velopharynx.
The three general groups of OAs that are available include

Soft palate lift devices,

Tongue retention devices, and
Mandibular advancement splints (MAS)

MAS are the predominant type of OA used in clinical practice and have shown
the best results. MAS effects include:

1. Enlargement of velopharyngeal airway caliber in the lateral dimension

2. Increasing UA neuromuscular tone
3. Stimulation of UA dilator muscles
MAS can be

One piece (monobloc) or two pieces (bibloc) in design,

Custom-made or prefabricated, and
Titratable or nontitratable.

Titratable appliances have shown greater reductions in obstructive events than

nontitratable OAs, especially in patients with moderate to severe OSA.

The use of a dental implant retained MAS and mini-implants have been
reported in edentulous and partially dentate patients.
Tongue-retaining and tongue-stabilizing devices, which protrude and hold the
tongue forward by using suction, have also been suggested as a treatment
alternative for edentulous patients.
Contraindications to the use of OA therapy include:

1. Multiple comorbid conditions such as heart failure and respiratory failure,

2.
3.
4.
5.

as well as when the possibility of central apnea and/or central

hypoventilation exists
Severe periodontal disease, when the risk for teeth mobility and loss is
significant
Severe temporomandibular disorder (TMD), in which the pain and
dysfunction are aggravated with mandibular protrusion
Severe gag reflex
Poor coordination or dexterity as required for the placement and removal
of OAs

Side effects of wearing an OA include

1.
2.
3.
4.
5.
6.
7.
8.
9.

Excessive salivation,
Dry mouth,
Tooth discomfort,
Gingival irritation,
Masticatory muscle tenderness, and
Temporomandibular joint (TMJ) discomfort.
Increases in facial height,
Occlusal changes,
Incisor inclination, and molar positional changes.

Surgical Treatment
Surgical procedures may be considered as a secondary option when the patient
is intolerant of CPAP or OAs or when CPAP therapy is unable to eliminate OSA
Surgical treatment alternatives for OSA treatment include:
UA bypass procedure or tracheostomy: This procedure creates an opening in
the trachea to bypass the UA where obstruction is causing OSA. A tube or stoma
is placed for ventilation.
Nasal procedures: The objective of procedures such as

Septoplasty,
Functional rhinoplasty,
Inferior turbinate reduction, and
Nasal polypectomy

is to eliminate the obstruction that is preventing nasal breathing.

Tonsillectomy and/or adenoidectomy: When OSA is prop erly diagnosed, as
previously described in this chapter, such procedures can provide significant
improvements in the treatment of OSA in children and young adults. Surgical
treatment of pediatric SDB with tonsillectomy and adenoidectomy is the
recommended first-line treatment.
Uvulopalatopharyngoplasty: The purpose of this procedure is to enlarge the
velopharyngeal area, including trimming and reorienting the tonsillar pillars and
excising both the uvula and the posterior part of the palate.
This procedure can also be performed using a laser-assisted method, during
which incisions are placed along both sides of the uvula, followed by laser
ablation of the uvula rather than excision.
Radiofrequency ablation: This technique consists of placing a temperaturecontrolled probe in the base of the tongue and/or soft palate with the objective
of stiffening the area. Soft palatal implanting of malleable plastic rods is also
used with the same objective.
Orthognathic surgery: Simultaneous advancement of both the maxilla and
mandible has shown to provide significant enlargement of the velopharyngeal
and overall oropharyngeal airway.
Bariatric surgery as an adjunctive surgery is an effective means to achieve

major weight loss and is indicated in individuals with a BMI of 40 kg/m2 or those
with a BMI of 35 kg/m2 with important comorbidities and in whom dietary
attempts at weight control have been ineffective
Oropharyngeal Exercises
A less invasive option for the treatment of snoring and/or OSA includes exercises
One of the reasons why OSA could occur in some patients is the larger size and
hypotonicity of the oropharyngeal muscles.
Oropharyngeal hypotonia may be linked to the pathogenesis of an individual and
predispose him or her to OSA.
To treat patients with OSA, the muscles responsible for blocking the UA need to
be exercised to prevent airway collapse.
The goal of the exercise is to strengthen the muscles located around the airway
and to increase their tonicity, especially during sleep when muscles tend to relax.
Oropharyngeal exercises can also improve stomatognathic function and reduce
neuromuscular impairment.
The oropharyngeal muscles are the tongue, soft palate, neck muscles, and
pharyngeal muscles. UA dilator muscles are very important to the maintenance
of the pharyngeal opening and may contribute to the beginning of OSA.
In addition, if the neck muscles are flabby and weak, then they can exert
pressure on the airway, which may lead to its collapse and obstruction of airway
flow.
The oropharyngeal exercises target the soft palate, tongue, and facial muscle, as
well as stomatognathic function. They are frequently performed during the day for
few minutes in

An isotonic (intermittent) and

An isometric (continuous) way.

Some examples of possible exercises include:

Soft palate:
1. An oral vowel is intermittently and continuously pronounced.
The palatopharyngeus, palatoglossus, uvula, and tensor veli palatini and levator

veli palatini muscles are recruited in this exercise.

The intermittent exercise recruits the pharyngeal lateral wall as well.
2. A blowing exercise is also performed, whether blowing a balloon or
inhaling through the nose and exhaling through the mouth while keeping
the lips together.
Tongue:
1. Exercises that target the tongue include brushing the superior and lateral
surfaces of the tongue while the tongue is positioned in the floor of the
mouth;
2. Placing the tip of the tongue against the front of the palate and sliding the
tongue backward, which forces tongue sucking upward against the palate;
3. Pressing the entire tongue against the palate; and
4. Forcing the back of the tongue against the floor of the mouth while
keeping the tip of the tongue in contact with the inferior incisive teeth.
Facial:
The exercises of the facial musculature use facial imitations to recruit the
orbicularis oris, buccinator, major zygomaticus, minor zygomaticus, levator labii
superioris, levator anguli oris, lateral pterygoid, and medial pterygoid muscles.
1. Muscle pressure of the orbicularis oris with the mouth closed
2. Suction movements contracting only the buccinators (These exercises are
performed with repetitions and holding position.)
3. Recruitment of the buccinator muscle against the finger that is introduced
in the oral cavity, pressing the buccinator muscle outward
4. Alternating elevation of the mouth angle muscle
5. Lateral jaw movements with alternating elevation of the mouth angle
muscle
Stomatognathic functions:
1. Breathing and speech: Forced nasal inspiration and oral expiration in
conjunction with phonation of open vowels, while sitting; balloon inflation
with prolonged nasal inspiration and then forced blowing
2. Swallowing and chewing: Alternate bilateral chewing and deglutition, using
the tongue in the palate, closed teeth, without perioral contraction,
whenever feeding
Other types of exercises, such as wind instrument playing and singing, have
been studied in the literature and show mixed results

Upper Airway Electrical Neurostimulation

UA stimulation using a unilateral implantable neurostimulator for the hypoglossal
nerve for the treatment of patients with moderate to severe OSA who are
intolerant to CPAP therapy.
Contraindications

Patients with AHI >65 and/or BMI >32 are not good candidates for this
therapy, attributable to a decreased likelihood of response to treatment.
This therapy is also contraindicated when central and mixed apneas
represent 25% or more of the AHI and
When neurologic problems in the UA are due to a condition or previous
procedures.

The device is implanted in the chest and has a small generator, a breathing
sensor lead, and a stimulation lead. The patient can turn on the therapy before
bedtime and turn it off in the morning through a remote control. When the device
is activated, it senses the persons breathing patterns and delivers a mild
stimulation to keep the airway open, acting in a similar fashion as a pacemaker.
The hypoglossal nerve is accessed through a horizontal incision in the upper
neck at the inferior border of the submandibular gland. The median time for
surgical implantation has been reported as 140 minutes (65 to 360 minutes), with
most patients spending the night at the hospital.