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OSA MANAGEMENT: DENTAL OPTIONSMimi Yow
Senior Consultant in Orthodontics, National Dental Centre SingaporeDirector (Clinical Services), SingHealth Duke-NUS Sleep Centre
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ROOF OF MOUTH IS FLOOR OF NOSE
FRONT OF AIRWAY
MAXILLA / MANDIBLE
SOFT PALATE / TONGUE
BACKGROUND
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EPIDEMIOLOGY
SLEEP-DISORDERED BREATHING IN ASIA
SINGAPORE / HK CHILDREN
SNORING 28.1%; OSA 2%
HABITUAL SNORING 6.0% [SLEEP BRUXISM 94%] [OSA 20%] More prevalent among Chinese
Atopy is the strongest risk factor
Chng SY et al., 2008
Ng D et al., 2002
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BACKGROUND
PIERRE ROBIN SEQUENCE
“A fall of the base of the tongueconsidered as a new cause ofnasopharyngeal respiratory impairment.Pierre Robin Sequence, a translation.”
Robin, 1994
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BACKGROUND
OSA
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MULTIFACTORIAL
KEY CONTRIBUTORS
• HIGH COLLAPSIBILTY
• LOW MUSCLE RESPONSIVENESS
• HIGH LOOP GAIN
• LOW AROUSAL THRESHOLD
OSA is a heterogeneous disorder Pcrit-anatomy is an important determinantNonanatomic traits are also present in most patients with OSA (56%)Eckert et al., 2013. Am J Respir Crit Care Med. 15; 188(8): 996–1004
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BACKGROUND
OSA
POISEUILLE’S LAW
FLOW RATE
SMALL AIRWAY WIDTH STRONGLY ASSOCIATED WITH OSA
LOW EVIDENCE OF CRANIOFACIAL STRUCTURE & OSA. Katyal 2013
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SMALL AIRWAY IS VULNERABLE
TONGUE
TONSILS
UVULA
Airway caliber
9mm ADVANCEMENT
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SMALL AIRWAY IS VULNERABLE
OSASNORING NEUROPATHY
• Soft tissue oedema• Progressive nerve lesion • OSA progression • Swallowing dysfunction
Friburg, 1999
• Disorganized desmin (p<0.0001) • Less Schwann cells (p=0.001) • Lower density of axons within nerve
fascicles (p<0.02)
Shah et al., 2018
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RISK FACTOR
OSA
OBESITY
60% IN AHI VARIANCE
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THE SUSPECTS
Chay OM, et al. OSAS in obese Singapore children. Pediatr Pulmonol. 2000 ; 29(4):284-90.
Ng DK, et al. OSA in children with Down Syndrome.Singapore Med J. 2006 Sep;47(9):774-9.
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THE SUSPECTSAT RISK
NARROW AIRWAY [NASOPHARYNGEAL & OROPHARYNGEAL]NARROW MAXILLANARROW MANDIBLE
NO ANTEROPOSTERIOR OR VERTICAL PREDICTORS
SHORT TERM RAPID MAXILLARY EXPANSION • REDUCES MOUTHBREATHING• NEED BOTH TONSILLECTOMY AND RME Guilleminault, 2011
ORTHODONTIC APPLIANCES MAY PERMANENTLY MODIFY BREATHINGVilla et al., 2012
RME EFFECTIVE IN REDUCING AHI (6.9) Machado Jr et al., 2016
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Airway shape changes after orthodontic treatment
Airway compressed in A-P dimension
Untreated matched controls compared with extraction orthodontic treatment
Zhang J et al.
Upper Airway Changes after Orthodontic Extraction Treatment in Adults: A Preliminary Study using Cone Beam Computed Tomography.
PLOS ONE DOI:10.1371/journal.pone.0143233 Nov 20, 2015
INCREASED RISK
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Airway shape changes after orthodontic treatment
Retraction of lower incisors and airway reduction in
velopharynx, glossopharynx and hypopharynx
Hyoid moved posteroinferiorly
Wang Q et al. Changes of pharyngeal airway size and hyoid bone
position following orthodontic treatment of Class I bimaxillary protrusion.
Angle Orthodontist. 2012; 82:115-21.
INCREASED RISK
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Airway shape changes after orthodontic treatment INCREASED RISK
Reduced volume of oral cavity and oropharynxDownward backward mandibular rotationReduced retroglossal airway 28% AP and 12.8% in volume
Effect of orthognathic surgery
on the posterior airway space (PAS). Lye KW.
Ann Acad Med Singapore. 2008; 37:677-82.
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MYOFUNCTIONAL THERAPY
REDUCES AHI IN 62% CHILDREN [AHI - 14.3]IMPROVED OXYGEN SATURATION [+ 4.2%]SNORING REDUCED [- 10% TST]
MYOFUNCTIONAL THERAPY IS AN ADJUNCT TO OTHER OSA TREATMENTCamacho et al., 2015
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OSA
• IMPROVE CHILDHOOD OSA DETECTION - SCREENING
• PSG OR HST
• ADENOTONSILLECTOMY
• MONITOR POST-OP
• RE-EVALUATE FOR FURTHER TREATMENT
WEIGHT LOSS, NASAL STEROIDS, CPAP, ADJUNCTS
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IT TAKES A TEAM TO GET IT RIGHT
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Team Management
SCREEN FOR SNORINGPSG
CPAPMANAGE WEIGHT & RHINITISEXCISE ADENOIDS & TONSILS
JAW EXPANSION JAW GROWTH
STEPWISE APPROACH
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