A method of studying adaptive changes of the oropharynx to variation in mandibular position in patients with obstructive sleep apnoea

Abstract

Obstructive sleep apnoea may present with a wide range of symptoms resulting in a variety of referral pathways. A multidisciplinary approach to examination and diagnosis helps to determine the most appropriate treatment plan for each individual. The subject is seen by each member of the team, appropriate investigations undertaken and a further meeting arranged at which all opinions are discussed. A reasoned treatment regime is produced, taking into consideration the patient's wishes and overall medical condition. This paper describes the team approach currently employed in the Department of Thoracic Medicine at The Prince Charles Hospital, Brisbane, Australia. The thoracic physician and ENT surgeon work in close collaboration with their dental colleagues: an orthodontist, prosthodontist and a maxillofacial surgeon. An outline of the examination and investigations made by each is described and the multidisciplinary approach is illustrated by a description of the management of five subjects with suspected obstructive sleep apnoea.

Current principles in the management of obstructive sleep apnoea with mandibular advancement appliances

“…As a consequence of poor longterm compliance with CPAP, estimated at between 60 and 70%, 9 the use of mandibular advancement splints (MAS) as an alternative treatment strategy has been increasingly recognised. 4,5,7,10 It is however, important to stress that dental practitioners should only undertake the management of patients with OSA after their diagnosis has been confirmed by polysomnography and on the advise of an ENT surgeon or chest physician.…”

Supine cephalometric analyses of an adjustable oral appliance used in the treatment of obstructive sleep apnea

“…Marklund et al 2~ evaluated the effect of a mandibular advancement device in patients with supinedependent sleep apnea and patients with non-supinedependent sleep apnea, and found that successful apnea reduction with a mandibular advancement device best correlated with supine-dependent sleep apnea. L'Estrange et al 22 used fluoroscopic recordings to investigate the effects of mandibular advancement on oropharyngeal airway dimensions in the sagittal plane in conscious, supine patients. They suggested that where mandibular advancement is considered beneficial, jaw opening should be kept to a minimum.…”

The effect of a mandibular advancement splint in subjects with sleep-related breathing disorders

“…The risk of exacerbating the sleep-related breathing disorder by mandibular advancement splint therapy has been previously reported and indeed is the reasoning behind undertaking a follow-up objective assessment. 23,32,33 Mandibular advancement splints are thought to act by increasing the size and/or reducing the collapsibility of the pharyngeal airway. 15 Cephalometric predictors have been suggested where a favourable response to MAS therapy can be expected 15 but the technique at best only provides a two-dimensional image.…”

“…Studies of the effects of mandibular protrusion on the airway have also shed some light on the variability of response to MAS therapy. 32 Mandibular opening has been shown to occlude the oropharyngeal airway in subjects with increased vertical facial proportions and retrognathic mandible. 32 Ryan et al 35 found the lateral diameter of the velopharynx was the airway site that changed the most with mandibular advancement splints.…”

“…32 Mandibular opening has been shown to occlude the oropharyngeal airway in subjects with increased vertical facial proportions and retrognathic mandible. 32 Ryan et al 35 found the lateral diameter of the velopharynx was the airway site that changed the most with mandibular advancement splints. It may be that the nonresponders in this study had obstruction, either high in the nasopharynx or very low in the pharynx beyond the therapeutic range of the splint.…”