Oral appliance and craniofacial problems of obstructive sleep apnea syndrome

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Chapter 11 Oral appliance and craniofacial problems of obstructive sleep apnea syndrome

Soichiro Miyazaki, Makoto Kikuchi

1 INTRODUCTION

Pierre Robin (1934) used the monoblock mandible advancement appliance for the purpose of treating patients with obstructive sleep apnea for the first time.¹ Following this, Boraz treated pediatric OSA patients.² Cartwright and Samelson (1982)³ reported the effectiveness of the tongue retaining device (TRD) which retains the tongue in the bulb of the device. Meier-Ewert (1984)⁴ used Esmarch–Heiberg manipulation, which opens the airway of a general anesthetized patient, and developed the Esmarch appliance. The tongue retaining appliance represented by the TRD, and the mandible advancing type represented by the Esmarch, are the two main types of oral appliance. Thereafter, other oral appliances were developed such as the adjustable type, which can adjust the amount of mandible advancement. Currently, more than 55 oral appliances (OAs) are on the market.⁵

2 PATIENT SELECTION

In 2006, the Standards of Practice Committee of the American Academy of Sleep Medicine published the reports Oral Appliance for Snoring and Obstructive Sleep Apnea: A Review⁶ and Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005.⁷ Oral appliances are indicated for use with patients with primary snoring and with mild to moderate OSA, who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who have failed treatment attempts with CPAP.

3 PROCEDURES FOR ORAL APPLIANCE THERAPY

The procedures for oral appliance therapy are as follows.

1. Written referral and diagnostic polysomnographic (PSG) report by the physician or sleep specialist sent to the dentist or dental specialist.

2. Oral examination:

• number of teeth

• periodontal evaluation (including dental x-ray and/or panorama x-ray)

• temporomandibular joints evaluation

• dental arch and curve of Spee evaluation.

3. Craniofacial skeletal diagnosis:

• cephalometric radiograph

• computed tomography

• magnetic resonance imaging.

4. Taking the impression of both arches.

5. Titration of the mandible position:

• George gauge: This was developed by Peter George of Hawaii to take the bite registration of the upper and lower incisors in the respective notches.⁸

• Snoring sound test: Kazuhisa Esaki developed the snoring sound test to calculate the distance of mandibular advancement that works effectively for oral appliances for OSA. The patient should be placed in the supine position, and while snoring the mandible is gradually moved anteriorly; the site at which the sound of snoring diminishes is then used as the mandible position for the oral appliance.⁹

• Initial bite registrations: These are taken at 70% of maximum protrusion.¹⁰

6. Appliance determination. This is influenced by the characteristics of the patient, such as number of teeth, periodontal factors, dental arch, curve of Spee evaluations and craniofacial skeletal diagnosis.

7. Setting the oral appliance for treatment: there should be no pain and a comfortable feeling.

8. Home monitoring to check if the appliance works well.

9. Refer patient back to the physician or sleep specialist for assessment by PSG.

4 ORAL APPLIANCE VARIATIONS

With so many different oral appliances available, selection of a specific appliance may appear somewhat difficult, but they are designed around a few major themes. Oral appliances can be classified by mode of action or design variation. Nearly all appliances fall into one of two categories: the tongue retaining type and the mandibular advancing type.

4.1 TONGUE RETAINING DEVICE (TRD)

(See Fig. 11.1A&B.)

Fig. 11.1

The TRD functions by holding the tongue in a forward position by means of a suction bulb. When the tongue is in this position, the device keeps the tongue from collapsing during sleep and obstructing the airway in the throat.

4.2 MANDIBULAR ADVANCING TYPE

The mandibular advancing type functions by repositioning and maintaining the mandible in a protruded position during sleep. This serves to open the airway by indirectly pulling the tongue forward, keeping the soft palate attached to the tongue (oral seal) by the negative pressure occurring in the mouth and making it more rigid. It also holds the lower jaw and other structures in a stable position to prevent opening of the mouth.

4.2.1 NON-TITRATABLE TYPE

The mandibular advancing and non-titratable type of oral appliance is a custom-made monoblock device connected by two separate arches (maxillary and mandibular) without an advancing mechanism. Several versions are listed below.

1. Esmarch appliance (Fig. 11.2A&B). Meier-Ewert developed this mandibular advancing and non-titratable type of oral appliance, using the Esmarch–Heiberg manipulation method, which opens the airway of the general anesthetized patient.

2. Nocturnal airway patency appliance (NAPA) (Fig. 11.3A &B). With this appliance, the mandible is in a protruded position during sleep. This serves to open the airway by indirectly pulling the tongue forward and keeping the soft palate attached to the tongue. This device has a hole in the front extended portion, to enable inhaling from the mouth.

3. Mandibular repositioner (Fig. 11.4A&B). This appliance also has a hole in the front to enable inhaling from the mouth.

4. Snore guard (Fig. 11.5A&B). This appliance is made of heat-activated resin.

Fig. 11.2

Fig. 11.3

Fig. 11.4

Fig. 11.5

4.2.2 TITRATABLE TYPE

The mandibular advancing and titratable type of oral appliance is a custom-made two-piece appliance composed of two separate arches (maxillary and mandibular) containing an advancing mechanism. Examples are listed below.

1. Klearway (Fig. 11.6A&B). This custom-made two-piece appliance is composed of two separate arches (maxillary and mandibular) to advance the mandible with a screw (0.25 mm/1 turn) to determine the ideal forward position of the mandible required to adequately open the airway. A total of 44 forward positions are available in increments of 0.25 mm, which covers a full 11.0 mm range of anterior–posterior movement.

2. Thornton adjustable positioner (TAP)

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