Interdisciplinary treatment of obstructive sleep apnea
Cooperation with orthodontist and maxillofacial surgeon
Abstract
Obstructive sleep apnea, known as OSA, is a chronic disorder of breathing characterized by frequent episodes of partial or complete obstruction of upper airway during the non-REM phase of sleep. It can be graded as mild, moderate and severe. We know numerous morphological and functional predisposing factors as well as risk factors which contribute to OSA. Among many particularities of stomatognathic system are mandibular microgenia and rethrognatia, bigger base of tongue and longer soft palate and as a consequence the narrowing of upper respiratory tract. The gold standard for the diagnosis is polysomnography. Its primary consequences hypoxemia and recurrent arousals from sleep can show numerous and harmful effects on health, neurophysiological development and quality of life. Today OSA is recognized also as a public health problem. Treatment of OSA is multidisciplinary and very diverse. The article presents the basic facts about the disease with the emphasis on the craniofacial morphology and the role of a dentist, orthodontist and maxillofacial surgeon in its prevention, recognition and treatment.
Downloads
References
Guilleminault C, Tilkian A, Dement WC. The sleep apnea syndromes. Annu Rev Med. 1976;27(1):465–84. https://doi.org/10.1146/annurev.me.27.020176.002341 PMID:180875
Brown LK. Sleep apnea syndromes: overview and diagnostic approach. Mt Sinai J Med. 1994 Mar;61(2):99–112. PMID:8022435
American Academy of Sleep Medicine. International classification of sleep disorders: diagnostic and coding manual. 2nd ed. Westchester (IL): American Academy of Sleep Medicine; 2005.
Guilleminault C, Korobkin R, Winkle R. A review of 50 children with obstructive sleep apnea syndrome. Hai. 1981;159(5):275–87. https://doi.org/10.1007/BF02713925 PMID:7300438
Prabhat KC, Goyal L, Bey A, Maheshwari S. Recent advances in the management of obstructive sleep apnea: the dental perspective. J Nat Sci Biol Med. 2012 Jul;3(2):113–7. https://doi.org/10.4103/0976-9668.101877 PMID:23225971
Rosen CL. Clinical features of obstructive sleep apnea hypoventilation syndrome in otherwise healthy children. Pediatr Pulmonol. 1999 Jun;27(6):403–9. https://doi.org/10.1002/(SICI)1099-0496(199906)27:63.0.CO;2-8 PMID:10380092
Guilleminault C, Eldridge FL, Tilkian A, Simmons FB, Dement WC. Sleep apnea syndrome due to upper airway obstruction: a review of 25 cases. Arch Intern Med. 1977 Mar;137(3):296–300. https://doi.org/10.1001/archinte.1977.03630150020008 PMID:557314
Bearpark H, Elliott L, Grunstein R, Cullen S, Schneider H, Althaus W, et al. Snoring and sleep apnea. A population study in Australian men. Am J Respir Crit Care Med. 1995 May;151(5):1459–65. https://doi.org/10.1164/ajrccm.151.5.7735600 PMID:7735600
Udwadia ZF, Doshi AV, Lonkar SG, Singh CI. Prevalence of sleep-disordered breathing and sleep apnea in middle-aged urban Indian men. Am J Respir Crit Care Med. 2004 Jan;169(2):168–73. https://doi.org/10.1164/rccm.200302-265OC PMID:14604837
Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Rein J, Vela-Bueno A, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001 Mar;163(3 Pt 1):608–13. https://doi.org/10.1164/ajrccm.163.3.9911064 PMID:11254512
Brunetti L, Rana S, Lospalluti ML, Pietrafesa A, Francavilla R, Fanelli M, et al. Prevalence of obstructive sleep apnea syndrome in a cohort of 1,207 children of southern Italy. Chest. 2001 Dec;120(6):1930–5. https://doi.org/10.1378/chest.120.6.1930 PMID:11742924
Kaditis AG, Finder J, Alexopoulos EI, Starantzis K, Tanou K, Gampeta S, et al. Sleep-disordered breathing in 3,680 Greek children. Pediatr Pulmonol. 2004 Jun;37(6):499–509. https://doi.org/10.1002/ppul.20002 PMID:15114550
Kapur VK. Obstructive sleep apnea: diagnosis, epidemiology, and economics. Respir Care. 2010 Sep;55(9):1155–67. PMID:20799998
Battagel JM, L’Estrange PR. The cephalometric morphology of patients with obstructive sleep apnoea (OSA). Eur J Orthod. 1996 Dec;18(6):557–69. https://doi.org/10.1093/ejo/18.6.557 PMID:9009420
Solow B, Skov S, Ovesen J, Norup PW, Wildschiødtz G. Airway dimensions and head posture in obstructive sleep apnoea. Eur J Orthod. 1996 Dec;18(6):571–9. https://doi.org/10.1093/ejo/18.6.571 PMID:9009421
Schwab RJ, Gupta KB, Gefter WB, Metzger LJ, Hoffman EA, Pack AI. Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of the lateral pharyngeal walls. Am J Respir Crit Care Med. 1995 Nov;152(5 Pt 1):1673–89. https://doi.org/10.1164/ajrccm.152.5.7582313 PMID:7582313
Kushida CA. Obstructive sleep apnea. Informa Health Care; 2007.
Hudgel DW. Mechanisms of obstructive sleep apnea. Chest. 1992 Feb;101(2):541–9. https://doi.org/10.1378/chest.101.2.541 PMID:1735286
Strobel RJ, Rosen RC. Obesity and weight loss in obstructive sleep apnea: a critical review. Sleep. 1996 Feb;19(2):104–15. https://doi.org/10.1093/sleep/19.2.104 PMID:8855032
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993 Apr;328(17):1230–5. https://doi.org/10.1056/NEJM199304293281704 PMID:8464434
Liu Y, Lowe AA, Zeng X, Fu M, Fleetham JA. Cephalometric comparisons between Chinese and Caucasian patients with obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 2000 Apr;117(4):479–85. https://doi.org/10.1016/S0889-5406(00)70169-7 PMID:10756275
Scrima L, Broudy M, Nay KN, Cohn MA. Increased severity of obstructive sleep apnea after bedtime alcohol ingestion: diagnostic potential and proposed mechanism of action. Sleep. 1982;5(4):318–28. https://doi.org/10.1093/sleep/5.4.318 PMID:7163721
Wetter DW, Young TB. The relation between cigarette smoking and sleep disturbance. Prev Med. 1994 May;23(3):328–34. https://doi.org/10.1006/pmed.1994.1046 PMID:8078854
Wolk R, Shamsuzzaman AS, Somers VK. Obesity, sleep apnea, and hypertension. Hypertension. 2003 Dec;42(6):1067–74. https://doi.org/10.1161/01.HYP.0000101686.98973.A3 PMID:14610096
Albajalan OB, Samsudin AR, Hassan R. Craniofacial morphology of Malay patients with obstructive sleep apnoea. Eur J Orthod. 2011 Oct;33(5):509–14. https://doi.org/10.1093/ejo/cjq108 PMID:21118908
Hochban W, Brandenburg U. Morphology of the viscerocranium in obstructive sleep apnoea syndrome—cephalometric evaluation of 400 patients. J Craniomaxillofac Surg. 1994 Aug;22(4):205–13. https://doi.org/10.1016/S1010-5182(05)80559-1 PMID:7962567
Tangugsorn V, Krogstad O, Espeland L, Lyberg T. Obstructive sleep apnoea: multiple comparisons of cephalometric variables of obese and non-obese patients. J Craniomaxillofac Surg. 2000 Aug;28(4):204–12. https://doi.org/10.1054/jcms.2000.0147 PMID:11110151
Mandell DL, Yellon RF, Bradley JP, Izadi K, Gordon CB. Mandibular distraction for micrognathia and severe upper airway obstruction. Arch Otolaryngol Head Neck Surg. 2004 Mar;130(3):344–8. https://doi.org/10.1001/archotol.130.3.344 PMID:15023845
Imes NK, Orr WC, Smith RO, Rogers RM. Retrognathia and sleep. JAMA1977;237:1596–7.
Rivlin J, Hoffstein V, Kalbfleisch J, McNicholas W, Zamel N, Bryan AC. Upper airway morphology in patients with idiopathic obstructive sleep apnea. Am Rev Respir Dis. 1984 Mar;129(3):355–60. PMID:6703493
Hui DS, Ko FW, Chu AS, Fok JP, Chan MC, Li TS, et al. Cephalometric assessment of craniofacial morphology in Chinese patients with obstructive sleep apnoea. Respir Med. 2003 Jun;97(6):640–6. https://doi.org/10.1053/rmed.2003.1494 PMID:12814148
Rojewski TE, Schuller DE, Clark RW, Schmidt HS, Potts RE. Synchronous video recording of the pharyngeal airway and polysomnograph in patients with obstructive sleep apnea. Laryngoscope. 1982 Mar;92(3):246–50. https://doi.org/10.1288/00005537-198203000-00005 PMID:7070167
Riley R, Guilleminault C, Herran J, Powell N. Cephalometric analyses and flow-volume loops in obstructive sleep apnea patients. Sleep. 1983;6(4):303–11. https://doi.org/10.1093/sleep/6.4.303 PMID:6665392
Tangugsorn V, Skatvedt O, Krogstad O, Lyberg T. Obstructive sleep apnoea: a cephalometric study. Part II. Uvulo-glossopharyngeal morphology. Eur J Orthod. 1995 Feb;17(1):57–67. https://doi.org/10.1093/ejo/17.1.57 PMID:7737346
Tangugsorn V, Skatvedt O, Krogstad O, Lyberg T. Obstructive sleep apnoea: a cephalometric study. Part I. Cervico-craniofacial skeletal morphology. Eur J Orthod. 1995 Feb;17(1):45–56. https://doi.org/10.1093/ejo/17.1.45 PMID:7737345
Zettergren-Wijk L, Forsberg CM, Linder-Aronson S. Changes in dentofacial morphology after adeno-/tonsillectomy in young children with obstructive sleep apnoea—a 5-year follow-up study. Eur J Orthod. 2006 Aug;28(4):319–26. https://doi.org/10.1093/ejo/cji119 PMID:16648209
Pirilä-Parkkinen K, Pirttiniemi P, Nieminen P, Tolonen U, Pelttari U, Löppönen H. Dental arch morphology in children with sleep-disordered breathing. Eur J Orthod. 2008;11:160–7. https://doi.org/10.1093/ejo/cjn061 PMID:19028674
Vos WG, De Backer WA, Verhulst SL. Correlation between the severity of sleep apnea and upper airway morphology in pediatric and adult patients. Curr Opin Allergy Clin Immunol. 2010 Feb;10(1):26–33. https://doi.org/10.1097/ACI.0b013e328334f659 PMID:19996963
Douglas NJ, Thomas S, Jan MA. Clinical value of polysomnography. Lancet. 1992 Feb;339(8789):347–50. https://doi.org/10.1016/0140-6736(92)91660-Z PMID:1346422
Marcus CL, Omlin KJ, Basinki DJ, Bailey SL, Rachal AB, Von Pechmann WS, et al. Normal polysomnographic values for children and adolescents. Am Rev Respir Dis. 1992 Nov;146(5 Pt 1):1235–9. https://doi.org/10.1164/ajrccm/146.5_Pt_1.1235 PMID:1443877
Carli E, Hočevar Boltežar I. Sindrom obstrukcijske apneje v spanju pri odraslih in otrocih. Zobozdrav Vestn. 2015;70:60–7.
Partinen M, Guilleminault C, Quera-Salva MA, Jamieson A. Obstructive sleep apnea and cephalometric roentgenograms. The role of anatomic upper airway abnormalities in the definition of abnormal breathing during sleep. Chest. 1988 Jun;93(6):1199–205. https://doi.org/10.1378/chest.93.6.1199 PMID:3371099
Gami AS, Olson EJ, Shen WK, Wright RS, Ballman KV, Hodge DO, et al. Obstructive sleep apnea and the risk of sudden cardiac death: a longitudinal study of 10,701 adults. J Am Coll Cardiol. 2013 Aug;62(7):610–6. https://doi.org/10.1016/j.jacc.2013.04.080 PMID:23770166
Benninger M, Walner D. Obstructive sleep-disordered breathing in children. Clin Cornerstone. 2007;9 Suppl 1:S6–12. https://doi.org/10.1016/S1098-3597(07)80004-4 PMID:17584620
Grote L, Hedner J, Grunstein R, Kraiczi H. Therapy with nCPAP: incomplete elimination of Sleep Related Breathing Disorder. Eur Respir J. 2000 Nov;16(5):921–7. https://doi.org/10.1183/09031936.00.16592100 PMID:11153593
Flemons WW. Measuring quality of life in patients with sleep apnoea: whose life is it anyway? Thorax. 2004 Jun;59(6):457–8. https://doi.org/10.1136/thx.2003.016774 PMID:15170022
Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, et al.; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009 Jun;5(3):263–76. PMID:19960649
Ohayon MM, Li KK, Guilleminault C. Risk factors for sleep bruxism in the general population. Chest. 2001 Jan;119(1):53–61. https://doi.org/10.1378/chest.119.1.53 PMID:11157584
Behlfelt K, Linder-Aronson S, McWilliam J, Neander P, Laage-Hellman J. Cranio-facial morphology in children with and without enlarged tonsils. Eur J Orthod. 1990 Aug;12(3):233–43. https://doi.org/10.1093/ejo/12.3.233 PMID:2401330
Pirilä-Parkkinen K, Löppönen H, Nieminen P, Tolonen U, Pirttiniemi P. Cephalometric evaluation of children with nocturnal sleep-disordered breathing. Eur J Orthod. 2010 Dec;32(6):662–71. https://doi.org/10.1093/ejo/cjp162 PMID:20305055
Oksenberg A, Khamaysi I, Silverberg DS. Apnoea characteristics across the night in severe obstructive sleep apnoea: influence of body posture. Eur Respir J. 2001 Aug;18(2):340–6. https://doi.org/10.1183/09031936.01.00038101 PMID:11529294
Alsufyani NA, Al-Saleh MA, Major PW. CBCT assessment of upper airway changes and treatment outcomes of obstructive sleep apnoea: a systematic review. Sleep Breath. 2013 Sep;17(3):911–23. https://doi.org/10.1007/s11325-012-0799-7 PMID:23344828
Momany SM, AlJamal G, Shugaa-Addin B, Khader YS. Cone Beam Computed Tomography Analysis of Upper Airway Measurements in Patients With Obstructive Sleep Apnea. Am J Med Sci. 2016 Oct;352(4):376–84. https://doi.org/10.1016/j.amjms.2016.07.014 PMID:27776719
Ahrens A, McGrath C, Hägg U. A systematic review of the efficacy of oral appliance design in the management of obstructive sleep apnoea. Eur J Orthod. 2011 Jun;33(3):318–24. https://doi.org/10.1093/ejo/cjq079 PMID:21239397
Gale DJ, Sawyer RH, Woodcock A, Stone P, Thompson R, O’Brien K. Do oral appliances enlarge the airway in patients with obstructive sleep apnoea? A prospective computerized tomographic study. Eur J Orthod. 2000 Apr;22(2):159–68. https://doi.org/10.1093/ejo/22.2.159 PMID:10822889
American Academy of Dental Sleep Medicine. Oral Appliances Therapy for Sleep Disordered Breathing, 2009.
Johnston CD, Gleadhill IC, Cinnamond MJ, Gabbey J, Burden DJ. Mandibular advancement appliances and obstructive sleep apnoea: a randomized clinical trial. Eur J Orthod. 2002 Jun;24(3):251–62. https://doi.org/10.1093/ejo/24.3.251 PMID:12143089
Robertson C, Herbison P, Harkness M. Dental and occlusal changes during mandibular advancement splint therapy in sleep disordered patients. Eur J Orthod. 2003 Aug;25(4):371–6. https://doi.org/10.1093/ejo/25.4.371 PMID:12938843
Adachi S, Lowe AA, Tsuchiya M, Ryan CF, Fleetham JA. Genioglossus muscle activity and inspiratory timing in obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 1993 Aug;104(2):138–45. https://doi.org/10.1016/S0889-5406(05)81003-0 PMID:8338066
Kyung SH, Park YC, Pae EK. Obstructive sleep apnea patients with the oral appliance experience pharyngeal size and shape changes in three dimensions. Angle Orthod. 2005 Jan;75(1):15–22. PMID:15747810
Tan YK, L’Estrange PR, Luo YM, Smith C, Grant HR, Simonds AK, et al. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial. Eur J Orthod. 2002 Jun;24(3):239–49. https://doi.org/10.1093/ejo/24.3.239 PMID:12143088
Lazard DS, Blumen M, Lévy P, Chauvin P, Fragny D, Buchet I, et al. The tongue-retaining device: efficacy and side effects in obstructive sleep apnea syndrome. J Clin Sleep Med. 2009 Oct;5(5):431–8. PMID:19961027
Ronchi P, Novelli G, Colombo L, Valsecchi S, Oldani A, Zucconi M, et al. Effectiveness of maxillo-mandibular advancement in obstructive sleep apnea patients with and without skeletal anomalies. Int J Oral Maxillofac Surg. 2010 Jun;39(6):541–7. https://doi.org/10.1016/j.ijom.2010.03.006 PMID:20434311
Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, Pack AI. Dynamic upper airway imaging during awake respiration in normal subjects and patients with sleep disordered breathing. Am Rev Respir Dis. 1993 Nov;148(5):1385–400. https://doi.org/10.1164/ajrccm/148.5.1385 PMID:8239180
Abramson Z, Susarla SM, Lawler M, Bouchard C, Troulis M, Kaban LB. Three-dimensional computed tomographic airway analysis of patients with obstructive sleep apnea treated by maxillomandibular advancement. J Oral Maxillofac Surg. 2011 Mar;69(3):677–86. https://doi.org/10.1016/j.joms.2010.11.037 PMID:21353929
Holty JE, Guilleminault C. Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2010 Oct;14(5):287–97. https://doi.org/10.1016/j.smrv.2009.11.003 PMID:20189852
Islam S, Uwadiae N, Ormiston IW. Orthognathic surgery in the management of obstructive sleep apnoea: experience from maxillofacial surgery unit in the United Kingdom. Br J Oral Maxillofac Surg. 2014 Jul;52(6):496–500. https://doi.org/10.1016/j.bjoms.2014.04.002 PMID:24793413
The Author transfers to the Publisher (Zdravniški vestnik/Slovenian Medical Journal) all economic copyrights following form Article 22 of the Slovene Copyright and Related Rights Act (ZASP), including the right of reproduction, the right of distribution, the rental right, the right of public performance, the right of public transmission, the right of public communication by means of phonograms and videograms, the right of public presentation, the right of broadcasting, the right of rebroadcasting, the right of secondary broadcasting, the right of communication to the public, the right of transformation, the right of audiovisual adaptation and all other rights of the author according to ZASP.
The aforementioned rights are transferred non-exclusively, for an unlimited number of editions, for the term of the statutory
The Author can make use of his work himself or transfer subjective rights to others only after 3 months from date of first publishing in the journal Zdravniški vestnik/Slovenian Medical Journal.
The Publisher (Zdravniški vestnik/Slovenian Medical Journal) has the right to transfer the rights, acquired parties without explicit consent of the Author.
The Author consents that the Article be published under the Creative Commons BY-NC 4.0 (attribution-non-commercial) or comparable licence.
