A small presentation for orthodontists

1. Welcome to the 1st CAO webinar
on Obstructive Sleep Apnea
Today’s presentation will be animated by
Dr Jean-Marc Retrouvey, the Director of the
Division of Orthodontics at McGill University.
Today, we will :
• Define OSA
• Discuss the manifestations of OSA.
• Describe the typical type(s) of patients affected by OSA
• Recognize the difference between OSA and snoring
• Suggest different therapeutic approaches for the treatment of
OSA

2. Obstructive Sleep Apnea
The Role of the Orthodontist:
The role of orthodontics in improving breathing in children, teenagers
and adults who suffer from sleep apnea
Dr Jean Marc Retrouvey
Director of Orthodontics
McGill University

3. Objectives
Define OSA
Discuss the manifestations of OSA.
Describe the typical type(s) of patients
affected by OSA
Recognize the difference between OSA
and snoring
Suggest different therapeutic approaches
for the treatment of OSA

4. Apnea–hypopnea index
WIKIPEDIA
• The apnea–hypopnea index (AHI) is an
index of sleep apnea severity that
combines apneas and hypopneas.
• AHI values are typically categorized as 5–
15/hr = mild;
• 15–30/hr = moderate;
• > 30/h = severe.)

5. Apnea–hypopnea index
WIKIPEDIA
• The apnea–hypopnea index (AHI) is an index of
sleep apnea severity that combines apneas and
hypopneas.
AHI values are typically
categorized as:
• 5–15/hr = mild
• 15–30/hr = moderate
• > 30/h = severe

6. Obstructive Sleep Apnea
27 % of
Snoring patients may
exhibit snoring
Upper Airway
UARS Resistance
Syndrome
4%
Obstructive
OSA Sleep Apnea
2-3%
Snoring and obstructive sleep apnea
By David N. F. Fairbanks, Samuel A. Mickelson, B. Tucker Woodson, p 243

7. Snoring: Benign condition
(annoying but not
dangerous)
UARS: Sleep disturbances
but no severe oxygen
desaturation (No cardiac
sequellae)
OSA: Oxygen desaturation
and sleep disturbances
(Cardiac disturbances:
Strokes, hypertension
arrhythmias)
Collpo N. Semin Respir Crit Care Med 2005; 26(1): 13-24
Pediatric Care Med 2005; 26(1): 13-24

8. 1. Excessive daytime
somnolence
Daytime
symptoms in 2. Abnormal daytime
children with behavior
obstructive
sleep apnea 3. Learning problems
4. Bizarre behavior
5. Morning headaches
6. Failure to thrive or
obesity
7. Repetitive upper
airway infections
8. Acute cardiac
failure Guilleminault C,
Korobkin R, and R
Winkle. A Review of
9. Cor pulmonale 50 Children with
Obstructive Sleep
Apnea
Syndrome. Lung
10. Hypertension 1981.

9. Most common
contributing factors
Obesity Allergies
and Combinations
Genetics (ex: Skeletal
malocclusions)

10. 1. Obesity
 A fairly direct correlation has been established between obesity
and OSA in children1 and adolescents2
 Apnea Hypoxia Index (AHI) scores are higher in obese than in
normal-weight children with OSA3
1 - The Correlation Among Obesity, Apnea-Hypopnea Index, and Tonsil Size in Children
Yuen-yu Lam, FHKAM(Paed), et al. Chest 2006: 1751-1756
2 - Obesity increases the risk for persisting obstructive sleep apnea after treatment in children
Louise M. O’Brien et al . International Journal of Pediatric Otorhinolaryngology (2006) 70, 1555—1560
3 - Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children
Ron B. Mitchell, MD, and James Kelly, PhD, St Louis, MO; Albuquerque, NM . Otolaryngology–Head and
Neck Surgery (2007) 137, 43-48

11. 1. Obesity
What about treating OSA in obese kids?
 Both groups show a dramatic improvement in AHI
after adenotonsillectomy, but persistent OSA is more
common in obese children.
Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children
Ron B. Mitchell, MD, and James Kelly, PhD, St Louis, MO; Albuquerque, NM . Otolaryngology–
Head and Neck Surgery (2007) 137, 43-48

12. 1. Obesity
With treatment, improvement in OSA but…..
 Weight gain!
Recommendation : Lose weight and improve physical
condition before starting OSA treatment.
Soultan, Z., et al., Effect of treating obstructive sleep apnea by tonsillectomy and/or adenoidectomy on
obesity in children. Archives of Pediatrics and Adolescent Medicine, 1999. 153(1): p. 33.

13. Treatment of OSA or UARS in
non-obese children
Impact of Orthodontic treatment

14. Common Contributing
Observations
 Severely enlarged
tonsils and adenoids in
the young patient
presenting either
UARS or OSA
http://kidshealth.org.nz/index.php/ps_pagename/content
page/pi_id/303

15. Consequence of
Enlarged Tonsils and Adenoids
Dr Harvold, from the University of Toronto, performed studies on Monkeys which showed
that:
 If you block nasal respiration, mouth breathing follows and
a severe malocclusion is observed (variable response)
Harvold EP et al. Primate experiments on oral respiration. Am J Orthod 79(4):359-72, 1981
Harvold EP et al. Experiments on the development of dental malocclusion. Am J Orthod 61:38-44, 1972.

16. Recognize early!
OSA will have an impact on normal growth
and development (early treatment must be
seriously considered)
• Growth hormone is mainly released during the
stage 3 of NREM sleep.
• http://youtu.be/HiNaJhO2Ht4

17. Importance of Early Detection
and Treatment
Such changes are also influenced by genetic factors. Facial growth is nearly complete between the ages
of 15
and 16 years in girls and between 18 and 19 years in boys, but the largest increments of growth occur
during the earliest years of life: By the age of 4 years, the craniofacial
skeleton has attained 60% of adult size, and by the age of 12
years it is 90% of adult size. Thus both genetic and environmental factors play a role in
teenage facial determination.
Our findings suggest that specific morphometric features may have been present in certain children ot
tonsilectomy and adenoectomy, some aspect of facial growth may even
have been modified by the early airway obstruction.
Morphometric facial changes and obstructive sleep apnea in adolescents
Christian Guilleminault, MD, Markku Partinen, MD, Jean Paul Praud, MD,
Maria-Antonia Quera-Salva, MD, Nelson Powell, MD, and
Robert Riley, DDS, MD
From Stanford University Medical Center, Stanford, California, Ullanlinnan Sleep Disorders
Clinic, Helsinki, Finland, Laboratoire d'Explorations Fonctionelles, Hopital Antoine Beclere,
Clamart, France, and Hopital Raymond Poincarré, Garches, France A, Jand ournal of Pediatrics 1989

18. Examination of a Patient Suffering
from OSA or UARS
1 • Reference to pneumologist for polysomnography
2 • Extra oral findings
3 • Intra oral findings
4 • Cephalometric or Cone Beam assessment
5 • Final diagnosis
6 • Treatment options

19. Examination of a Patient Suffering
from OSA or UARS
2 Extra oral findings
• Facial features
• ―Pockets‖ under the eyes
• Evidence of mouth
breathing
• Retrusive mandible (Cl II
malocclusion)
• Retrusive maxilla?

20. Examination of a Patient
Suffering
from OSA or UARS
3 Intra oral findings
• Openbite
• Narrow palate
• Curve of Spee
• Lower arch form
• Severe malocclusion
• Usually Cl II

21. Examination of a Patient
Suffering
from OSA or UARS
3 Intra oral findings
Compared with 48 asymptomatic children from the
same cohort, the obstructed children had a
narrower maxilla, a deeper palatal height, and a
shorter lower dental arch. In addition, the
prevalence of lateral crossbite was significantly
higher among the obstructed children.
Breathing obstruction in relation to craniofacial and dental arch morphology in 4-year-old
children
B Löfstrand-Tideström European Journal of Orthodontics
Volume 21, Issue 4 , 1999 Pp. 323-332

22. Examination of a Patient Suffering
from OSA or UARS
4 Cephalometric or Cone Beam assessment
• Consistent for a large number of OSA pediatric
patients

23. • Retrognathic mandible
• Steep mandibular plane angle
• Long anterior face height
• Short posterior face height

24. Examination of a Patient Suffering
from OSA or UARS
6
5 Treatment options
1. Tonsillectomy
2. Rapid Palatal Expansion
3. Mandibular Advancement

25. 1. Tonsillectomy?
Children, who were tonsillectomized because of sleep apnea
were examined with respect to facial growth and dental arch
morphology.
The findings were compared to data from children without
tonsillary obstruction. A higher proportion of malocclusion
than normal, especially openbite and crossbite, was noticed
before surgery.
Two years after surgery, 77% of the open bites were normalized
and 50-65% of the buccal and anterior crossbites. The best
results were seen in children operated before the age of 6.
E. Hultcrantz E., Larson M. , Hellquist R. , Ahlquist-Rastad J. , Svanholm H. and Jakobsson
O.P. : The influence of tonsillar obstruction and tonsillectomy on facial growth and dental arch
morphology
International Journal of Pediatric Otorhinolaryngology 22,2: 125-134 1991

26. 2. Rapid Palatal expansion
• Multiple articles point
towards an improvement
in the sleep apnea
condition.
• Expansion is done via
RPE and averages
4.5mm to 6 mm at the
palatal suture.
• On sleep apnea
patients, the earlier the
better.

27. Selection Criteria for RPE patients
• High narrow palate
• Deep bite
• Retrusive mandible
Villa, M.P., et al., Rapid maxillary
expansion in children with obstructive
sleep apnea syndrome: 12-month
follow-up. Sleep medicine, 2007. 8(2):
p. 128-134.

28. 3. Mandibular advancement
Has the same effect in growing children as
rapid palatal expansion
Randomized Controlled Study of an Oral Jaw-Positioning Appliance for the Treatment of Obstructive Sleep Apnea in
Children with Malocclusion. MARIA P. Villa, edoardo bernkopf, jacopo pagani, vanna broia, Marilisa montesano and
roberto ronchetti.

29. Impact of Orthodontics on Pediatric
OSA Management
Treatment will depend on the severity of the OSA, its
influence on the degree of malocclusion and the age of
the patient.
Take Home Message :
 Early recognition (before age 7)
• Educate parents and dentists
 Constant collaboration with the treating physician
(Respirologist, Plastics, ENT), the Orthodontist and
the Dentist.
 Treat early and aggressively
• Through RPE; Mandibulat advancement and Maxillary
Vertical Control

30. OSA Treatment in the adult
Role of the orthodontist?
Therapy Provider
CPAP Pneumologist or
Sleep center
Soft tissue surgery ENT
MADs Sleep center
Dentist – TMJ
specialist
Orthodontist?
MMA surgery OMFS
SARPE Orthodontist

31. Mandibular advancement
devices
• May be efficient for moderate OSA
• Do not replace the CPAP in severe cases

32. Future: CAD-CAM Manufactured Appliance
Slide from Dr Arcache

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

34. Maxillary Mandibular Advancement.
Surgical goal: Improvement of the
pharyngeal airway along its entire length

35. 43 yr male with snoring and
witnessed apneas.
• Sleep study
– RDI 67/hr, LSAT 83%
• Sleep study with CPAP
– RDI 15/hr, LSAT 86%
• Does not tolerate CPAP

36. Pre-operative Cephalogram
• Bimaxillary retrusion
• Cl II bimaxillary
retrusion
malocclusion
• Blocked airway

37. Surgical Procedure
• Maxillary advancement 8mm
• Mandibular advancement 8mm
• Advancement genioplasty 4mm
• Hyoid suspension 10mm

38. Post-operative Cephalogram

39. Results
Pre- operative sleep study:
- RDI 67/hr
6 month post- operative sleep study
– RDI 9/hr, (was down to 15 with CPAP)
RDI : Respiratory Disturbance Index
LSAT: Saturation in oxygen

40. Long Term Follow up of a
TMJ- OSA Patient
Patient presenting with Long face
syndrome :
– Narrow palate
– Retrusive mandible
– Anterior tongue posture
– Severe to moderate crowding of dental arches
– Painful bilateral TMJ clicks
– Moderate OSA ( No C Pap used)

41. Treatments
1. Maxillary expansion at 8 years old (failed)
2. Dental alignment (camouflage failed)
3. Extractions were contemplated by
previous orthodontist (failed to recognize
OSA)
4. Mandibular protraction appliance contra-
indicated (High MP angle)

42. Long term Follow up of TMJ and
OSA Patient
In 2004, after
first rapid palatal
expansion
attempt

43. 2009: Ready for Ortho-Surgery
Orthodontics: 3 piece maxilla preparation
Uprighting of lower arch

45. Immediately Post Surgery
(4 weeks)

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

47. Conclusions
OSA is a medical condition and may be
potentially lethal
A positive diagnosis of OSA should be
obtained before starting any treatment
The dental profession has an important role
in screening young patients
Orthodontists have a greater role to play
(back to the future: treat early and
aggressively)

48. Conclusions
Tonsillectomy is making a comeback in preventive
therapy for this type of patients (OSA-UARS)
CPAP machine is still standard of care in adults
Growth modification may play an important aspect
of OSA treatment
Maxillary expansion
Mandibular protraction seem to have a positive effect
on OSA
Must start as early as possible ( do not allow upper
molars descent)