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Snoring and Sleep apnea
Removable apparatus s that used for snoring and sleep apnea were originally developed for treatment of glossoptosis. Pierre Robin described the syndrome known by his name. Patients with this syndrome have a small chin and a tongue that sits far back in the mouth and it obstructs the airway. He produced an apparatus to breathe easy. The apparatus was holding the lower jaw forward to release tongue and it was removing the soft palate from the posterior pharyngeal wall by muscle attachments. Patients used this apparatus while sleeping and they were taking it off after sleep. Pierre Robin realized that the apparatus strengthened position of the lower jaw permanently. Therefore, he put forward the idea of using apparatus for Mandibular Retrognathia. Mandibular Retrognathia is a type of skeletal anomaly characterized by abnormal posterior positioning of the mandible. He gave it the name of functional orthopedic treatment. For sleep apnea, prophylaxis is the basic principle as treatment of any medical condition. Studies have shown that airway size is decreased in the patients with snoring and sleep apnea. One of the reasons of the decreased airway size is posteriorly positioned mandible. Mandibular Retrognathia is characterized by abnormal posterior positioning of the mandible. Tongue and connected tissues are also closer to the posterior pharyngeal wall and so airway size is decrease. Mandibular retrognathia can be diagnosed by lateral cephalometric radiography. In the cephalometric measurements, SBN is the measurement of the lower jaw according to the head and SBN angle is decreased. ANB is measurement of the difference between upper and lower jaws and ANB angle is increased (ANB > 4°). These are most important measurements. Photograph analysis can be used for diagnosis. There are various causes of posteriorly positioned mandible. Causes can be inherited or acquired. Pacifier and thumb sucking habits in the age of growth and development, early dental contact and respiratory problems may cause posteriorly positioned mandible in time. Respiratory problems cause nasal congestion and mouth breathing. Posterior positioned mandible is known as ‘toothy’ and patients present to dentists with the complaint of upper teeth positioned in forward. However, problem is usually mandibular retrognathia. Children with mandibular retrognathia have increased risk of sleep apnea and so best way is to treat the disease in childhood. An ENT clinician can diagnose the Mandibular retrognathia easily.Upper teeth are significantly in forward, tip of mentum is not certain and patients have dolichocephalic face type. Lower first molars are behind the upper first molars in intraoral examination. Usually, patients have recurrent respiratory tract infection and mouth breathing. Some patients have habits such as thumb sucking and nail biting. Treatment is age-related. The first step is elimination of the cause in patients who are in the age of growth and development. Growth of the mandible is slower than the other structures and this is an advantage for treatment. When the cause is removed, mandible growth will continue and skeletal disorder will be corrected. If the mandibular retrognatia cannot be treated in the age of growth and development, mandible growth can be stimulated by orthodontic treatment. This treatment is called functional orthopedic treatment. Functional orthopedic treatment can be combined with fixed orthodontic treatment and fixed and removable apparatus s can be used. Patients’ growth is controlled with wrist radiograph. Before peak of the growth and development, the lower jaw can be placed in forward morphologically by medical interventions. Functional orthopedic treatment is not possible in adults, because growth and development ends in adults. In this case, removable apparatus s can be used for apnea. However, these apparatus s have adverse effects on condyle and long-term treatment is not suitable. In these patients, another treatment is orthognatic surgery for sleep apnea. The lower jaw is usually taken forward by the surgery. The lower and upper jaws can be taken forward together to increase the airway size. Procedure of the orthognatic surgery is: first plans are done with patients’ initial radiographs and orthodontic models and so treatment gets started. Orthodontist and surgeon plan the surgical limit together. Position of the teeth is adjusted according to the skeletal position and radiographs are evaluated again. And other step is orthognatic surgery. After surgery, orthognatic treatment is continued for a while. Usage of oral apparatus s for obstructive sleep apnea and snoring is: Medical examination – Polysomnogram examination – Dental checkup (soft tissue, periodontal tissue, TME, tooth examination) – Producing test apparatus – Producing final apparatus – 2-3 months use and follow-up-. Control oral apparatus is used in patients who are in early stages of the obstructive sleep apnea. The apparatus should be proper for the patients (patients should be non-allergic to material of the apparatus etc.); there must be no acute disease in mandibular condyle, muscles, teeth and mouth. Compared to other alternative treatments, advantages of the oral apparatus are: usage is easy and tolerance of the body is good, it is a reversible method, it can be modified, it is cheap. And disadvantages are: It leads TME problems – Pain in masticatory muscles can occur – It may cause soft palate reactions – It may cause increased saliva and nausea – It cannot be used in patients who have total prosthesis. In the following table, apparatus used in clinics for apnea and snoring are shown:
- Apparatus for Treatment of Snoring, OSA Treatment Snore Guard™
- Tongue Retaining Device ™
- Klearway ™
- PM Positioner ™
- Equalizer ™
- Nocturnal Airway Patency Appliance (NAPA) ™
- Sleep and Nocturnal Obstruction Patency Appliance (SNOAR)™ • TAP ™
- Tongue Locking Device ™
- Herbst Appliance™
- Adjustable Soft Palate Lifter ™
- Silencer ™
- Silent Night ™
Appliances used for OSAS are:
1- Mandibular advancement appliance
2- Tongue retainer
3- Soft palate lifter
MANDİBULAR ADVANCEMENT APPLİANCE
These appliances put the lower jaw in forward to enlarge the pharynx size. Some of these appliances are: in the production of appliance mandibular is brought forward as 50-75% of the maximum protraction amount and occlusal closing remains 3-5 mm opened and so record is fixed. Appliances with this closing may be in different forms: Mono block, Twin block (inclined plane appliance, magnet activated appliance, herbst appliance, jasper jumper) etc. The appliances are used for one night. The other day patient is checked by the dentist and then patient will be followed. It is seen that long-term usage of the mandibular advancement appliances has negative effects on the mandibular condyle. Studies performed have shown that; night usage of the appliance for 2 years causes forward-lower positioned mandible. Even if the difference is less than 1 mm, it is significant statistically. Also, during MAA usage, occlusion may be changed, TME problems and open bite in the posterior teeth may occur, lower face height may increase.
This appliance helps the tongue to place passively in forward during sleep. In front of the appliance, there is acrylic piece. This piece helps the movement of the tongue by creating space. During sleep, tongue moves to this space by force absorption and pharynx area enlarges. In the production of this appliance, occlusal closing remains 5-8 mm opened and then appliance is produced according to fixed record.
EMG measurements have shown that the tongue retainer appliance increases the activity of genioglossus muscle to place the tongue in forward.
SOFT PALATE LİFTERS
Wire extensions and acrylic cushions are added to the intraoral appliances to uphold soft palate. This appliance can be added to a simple night plate or it can be used with other apnea appliances. Studies performed have shown that, use of the appliance itself treats snoring. However, it cannot treat apnea as well as the mandibular advancement appliance. It is difficult to use this appliance due to the appliance-soft palate contact; it may require time to be used.