describes sleep apnea and prosthodontic management

1. Preceptor- Dr Siddhi Tripathi Presenter-Dr Megha Sabharwal
Barewal RM,Hagen CC. Management of Snoring and Obstructive Sleep Apnea with
Mandibular Repositioning Appliances: A Prosthodontic Approach.Dent Clin N Am 2014;58:
159–180
Date- 4th June 2020

2. 2

3. INTRODUCTION
• Dentists are becoming increasingly aware of the importance of detection
and management of obstructive sleep apnea.
• Obstructive sleep apnea (OSA) is a sleep-related breathing disorder that
involves a decrease or complete halt in airflow despite an ongoing effort
to breathe.
• It occurs when the muscles relax during sleep, causing soft tissue in the
back of the throat to collapse and block the upper airway.
3

4. 4

5. 5

6. • OSA1 is defined as the occurrence of 5 or more episodes of complete (apnea) or partial
(hypopnea) upper airway obstruction per hour of sleep (apnea-hypopnea index [AHI])
and is estimated to occur in around 24% of middle aged men and 9% of women.
• Obstructive sleep apnea (OSA) results in sleep fragmentation and oxygen desaturation
1.Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep disordered
breathing among middle-aged adults. N Engl J Med 1993;328:1230-5.
Definitions
6

7. • Apnea is defined as a cessation of airflow (breathing) lasting for at least
10 seconds.
• Hypopnea is a 50% reduction in airflow for 10 seconds or more, usually
associated with a fall in blood oxygen saturation.
• The Apnea Index (AI) is the number of apneic episodes per hour of sleep.
• The total number of apneic and hypopneic episodes per hour of sleep is
referred to as the Apnea-Hypopnea Index (AHI) or the Respiratory-
Disturbance Index (RDI).
7

8. SLEEP ARCHITECTURE
The two main divisions of a normal cycle are non-rapid eye movement (non-
REM) and rapid eye movement (REM)2
• Non-REM consists of four stages.
1. Transitional stage. This is the time when one is falling asleep, and it
usually represents only 5 percent of sleep time.
2. Light sleep stage. This stage accounts for 50 percent of normal sleep
time.
3. The delta and slow-wave stages. These stages represent about 20
percent of sleep time and are the stages in which one experiences a
deep and relaxing state of rest.
2.Weaver and Millman, Broken sleep. Am J Nurse 1986;88:146-50
8

9. • After the non-REM cycle is complete, one usually enters into REM sleep. Restful
sleep continues during this cycle. It is also the period in which one dreams. This
stage accounts for the final 25 percent of a normal sleep cycle.
• To experience a restful night sleep, one must spend sufficient time in deep sleep
A person suffering from sleep apnea cannot do this because they are constantly
awakened throughout the night.
9

10. CLASSIFICATION3
• Sleep apnea is classifed as :
 Central- Although the airway remains open, the chest wall muscles
make no effort to create airflow
 Obstructive-This is the cessation of airflow due to a total airway
collapse despite a persistent effort to breathe.
 Mixed -This term is used when both central and obstructive episodes
are observed during a sleep study.
3. Tsara V, Amfilochiou A.Definition and classification of sleep related breathing
disorders in adults. Different types and indications for sleep studies (Part 1)
HIPPOKRATIA 2009; 13(3): 187-191 10

11. 4. Barewal RM,Hagen CC.Management of Snoring and Obstructive Sleep Apnea with
Mandibular Repositioning Appliances: A Prosthodontic Approach Dent Clin N Am2014:
159–180
CLASSIFICATION OF SDB. UARS,UPPER AIRWAY RESISTANCE SYNDROME
11

12. OBJECTIVES
• To review the diagnosis,risk factors,treatment approach,indications and
contraindications for treatment,appliance design of obstructive sleep
apnea.
• To emphasize the role of a prosthodontist because of established training
in TMD, removable appliance therapy, and occlusion & the management
of sleep apnea with oral appliances
12

13. WHO ALL ARE AT RISK?
13

14. PREVALENCE
• OSA can occur in any age group, but prevalence increases between middle
and older age.
• OSA with resulting daytime sleepiness occurs in at least 4 percent of men
and 2 percent of women
• About 24 percent of men and 9 percent of women have the breathing
symptoms of OSA with or without daytime sleepiness.
14

15. INDIA
Vijayan & Patial(2006)-
males-4.4%
Females-2.5%
Reddy et al (2009)
Males- 13.5%
Females- 5.6%
Obese
individuals -4
times higher
risk than non
obese
individuals
5.Karl OE. Obstructive sleep apnea is a common disorder in the population—a review on the
epidemiology of sleep apnea J Thorac Dis 2015; 7(8):1311–1322 15

16. • People who are overweight (Body Mass Index of 25 to 29.9) and obese
(Body Mass Index of 30 and above)
• Men and women with large neck sizes: 17 inches or more for men, 16
inches or more for women
• Middle-aged and older men, and post-menopausal women
• Ethnic minorities
16

17. • Down Syndrome
• large tonsils and adenoids
• Anyone who has a family member with OSA
• Endocrine disorders such as Acromegaly and Hypothyroidism
• Smokers and alcoholics
• nocturnal nasal congestion due to abnormal morphology, rhinitis or both.
17

18. OBSTRUCTIVE SLEEP APNEA AND OBESITY:
• Obese individuals (BMI >30 kg/m(2)) are at higher risk for OSA compared with
non-obese individuals and up to 75% of OSA patients are obese.
• It is hypothesized that obese individuals have large deposits of fat in the neck that
cause the upper airway to collapse in the supine position during sleep.
• The observations reported from several studies support the hypothesis that AHIs
(or RDIs) are significantly reduced with weight loss in obese individuals.
18

19. WHY INTERVENTION IS NECESSARY?
19

20. Why intervention is needed??
Reccurent ecurrent episodes affects organs systems, mainly the
brain and the cardiovascular system, and alter the body metabolic
balance6
clinical sequelae accepted as the OSA syndrome.Daytime
sleepiness,due to nocturnal sleep fragmentation.
causing impaired performance at work and major work-related and
road accidents.
patients develop cognitive and neurobehavioral dysfunction,
inability to concentrate, memory impairment and mood changes.
if left untreated
insulin resistance,type II diabetes and altered serum lipid
profile,can represent a further risk of cardiovascular morbidity4&
mortality
6.Guilleminault C., Quo S. Sleep-disordered breathing. A view at the beginning of the new Millennium. Dent Clin
North Am 2001 ;13(3): 643–656.
20

21. • The clinical history should document the
following:
1. Presence and severity of snoring
2. Presence and severity of witnessed apneic
events
3. Presence and severity of excessive daytime
sleepiness
4. Energy level during day
5. Quality of sleep (provide a scale of 1–10)
6. Quantity of sleep (number of hours of sleep
per night)
7. Number of awakenings per night
8. Sleep position: side, back, stomach
21

22. 9. Presence of other symptoms
a. Recent weight gain
b. Bruxism
c. Morning headache
d. Gastroesophageal reflux disease
e. Depression
f. Impotence
g. Nasal congestion
DETAILED DENTAL HISTORY & EXAMINATION
22

23. HISTORY
• A complete dental history is required, which includes any
orthodontic or periodontal treatment rendered. A complete
intra-oral examination will provide an assessment of risks to
treatment .
• Caries assessment, a periodontal examination, and TMJ
evaluation including the muscles of mastication, occlusal
analysis, and parafunctional habits.
• Current dental radiographs ,cephalometric evaluation ,MRI
and computed tomography to assess the efficacy of oral
appliances.
23

24. POLYSOMNOGRAPHY7 –Gold Standard
• Polysomnography is essential to yield a clear diagnosis of OSA.
• It combines electrophysiologic indices of sleep stage,electromechanical
parameters contrasting respiratory effort with actual ventilation and
measurements reflecting the consequences of abnormal respiratory
events.
• A tracing is produced showing the duration and number of obstructive
and hypoxic events during six to eight hours of sleep.
24

25. • The average number of desaturation episodes per hour can be measured
using PSG and is called the oxygen desaturation index (ODI). Desaturation
episodes are generally described as a decrease in the mean oxygen
saturation of ≥4% (over the last 120 seconds) that lasts for at least 10
seconds.
• Respiratory Effort Related Arousal-An event that causes an arousal or a
decrease in oxygen saturation, without qualifying as an apnea or
hypopnea.
• Respiratory Disturbance Index-This is your combined number of apneas,
hypopneas, and RERAs per hour of sleep.
• Arousal index- number of arousals per night
7. Billings ME. Interpreting Sleep Study Reports: A Primer for Pulmonary Fellows.
AASM SCORE2014;2(1)
25

26. GRADING OF OSA
26

27. HOME SLEEP APNEA TESTING DEVICES
• New generations of portable sleep apnea testing devices have
become increasingly accurate with better sensitivity and better
specificity.
• allow the application of sensors by patients themselves at home &
the patient can perform the recording themselves at home.
• the recorded data are downloaded from the device and are scored
by the sleep technician in order to check for sleep time.
27

28. QUESTIONNAIRE
28

29. • Berlin Questionnaire
29

30. UPDATED STOP
BANG
QUESTIONNAIRE
•The dentist should ideally
apply specific questionnaires
for all “patients with
suspected OSA”; the most
recommended ones are:
EPWORTH questionnaire / or
STOPBANG questionnaire7
30

31. 31

32. 32

33. The Epworth Sleepiness Scale (ESS)
How likely are you to doze off or fall asleep in the following
situations, in contrast to feeling just tired? This refers to your
usual way of life in recent times. Even if you have not done
some of these things recently try to work out how they would
have affected you. Use the following scale to choose the most
appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
33

34. SITUATION CHANCE OF DOZING (0–3)
Sitting and reading
Watching television
Sitting inactive in a public place (e.g. a theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in the traffic
34

35. TOTAL SCORE
Score Results :
1-6 Congratulations, you are getting enough sleep!
7-8 Your score is average
9 and up Very sleepy and should seek medical advice
35

36. Modified Mallampati score. Class 1, complete visualization of the soft palate;
class 2, complete visualization of the uvula; class 3, visualization of only the
base of the uvula; class 4, soft palate is not visible at all. Ginapp T. Ask the
clinical instructor.Cath Lab Digest 2012;20(7)
36

37. Oral anatomic variables potentially directly or indirectly affecting
airway space15
• Mallampati score - Score of 3 or 4, probability of OSA is 58%–82%.
• Tonsillar size
Mandibular tori Macroglossia
Impingement of oral space for the
tongue
Obstructive size effect
37

38. Serrations on lateral border of tongue Steep soft palate drape
Indications of tongue size/arch size
discrepancy, and possible nocturnal
clenching 38
In combination with a large tongue, the
soft palate can reduce airway dimension
especially in the supine position

39. 39
Retrognathia and micrognathia
Negative effect on pharyngeal airway dimension

40. Loss of vertical dimension of occlusion V-shaped arch forms
Overall reduction of oral volume Reduction of tongue space and
reduction of pharyngeal airway
dimension
40

41. TREATMENT OPTIONS
1.Behavioral modification: weight loss, alcohol avoidance,
alteration of sleeping position
2. Positive airway pressure (PAP)
3.Upper airway surgical procedure
4. Pharmacologic treatment
5. Oral appliances
41

42. BEHAVIOURAL CHANGES
-- Weight loss- Remains a highly effective method 10 – 15 % reduction in weight
can lead to an approximately 50 % reduction in sleep apnea severity in moderately
obese male patients
– Avoid alcohol and sedatives
– Avoid sleep deprivation
– Avoid supine sleep position
– Stop smoking
42

43. Positive airway pressure (PAP)8
• Nasal continuous positive airway pressure
(nCPAP) is considered the “gold standard” for
treatment of OSA .
• It helps keep the airway open during sleep
through a continuous stream of air under light
pressure, applied to the pharynx through a
nasal mask.
• It should be used for a minimum six hours
everynight and is virtually always effective if
used regularly .
8.Beecroft J, Zanon S, Lukic D. Oral continuous positive airway pressure for sleep apnea:
effectiveness, patient preference, and adherence. Chest 2003; 124:2200–8.
43

44. Drawbacks -
1. Noisy
2. Tolerance
3. The application of a face mask can be a hindrance to patients may find it
suffocating.
4. Drying of the airway mucosa often occurs which can be overcome by the
inclusion of a humidifier.
5. Bulky
44

45. Reconstruct upper airway
Uvulopalatopharyngoplasty (UPPP)-is a surgical procedure to
enlarge the airspace of the oropharynx of OSA patients This
enlargement is accomplished by excising redundant soft tissue
of the palate, uvula, tonsils, and posteriorand lateral
pharyngeal walls.
Laser-assisted uvulopalatopharyngoplasty (LAUP)
Radiofrequency Mandibular advancement & tissue volume
reduction ( somnoplasty)
Genioglossal advancement
Mandibular advancement
Nasal reconstruction
Tonsillectomy
SURGICAL INTERVENTION9
9. Jack B,Meyer JR .The sleep apnea syndrome. Part II. Treatment March 1990;63(3):883-9
45

46. Bypass upper airway
Tracheostomy- Tracheostomy is one of the most effective
surgical measures because it provides an airway below the
level of obstruction.Even though a tracheostomy often
results in immediate relief of symptoms, it is poorly accepted
by patients because of long-term morbidity
9. Jack B,Meyer JR .The sleep apnea syndrome. Part II. Treatment March 1990;63(3):883-9
46

47. PROGETERONE
Respiratory
stimulant to
airway,diaphragm
and intercostal
muscles.
More than 50%
response
Expensive and
feminizing side
effects
PROTRIPTOLINE
Non sedating
antidepressant
Related to
reduction of REM
sleep
60% to 100%
patients showed
urinary retention
and anticholinergic
effects
SUPPLEMENTALOXYGEN
Conflicting results
Side effects-
bradycardia,arryth
mias,hypertension
and CHF
DRUG THERAPY9
9. Jack B,Meyer JR .The sleep apnea syndrome. Part II. Treatment March 1990;63(3):883-9
47

48. ORAL APPLIANCE THERAPY
• Oral appliance therapy has emerged as an alternative to CPAP for snoring, and mild
to moderate OSA in patients who refuse or fail to adhere to the use of the CPAP
device.
• Although mandibular repositioning appliances (MRAs) seem to be less efficacious
than CPAP, in instances when both treatments are effective, patients usually prefer
oral appliances over CPAP.
48

49. OBJECTIVES of APPLIANCE THERAPY
• Reduce snoring to a subjectively acceptable level
• Resolution of clinical signs and symptoms of OSA
• Normalization of the AHI and oxyhemoglobin saturation levels
49

50. MECHANISM OF ACTION
• Oral appliance therapy functions by repositioning the tongue and
mandible forward and downwards to reduce airway collapse.
• The treatment aims to widen the lateral aspects of the upper airways to
improve the upper airway patency and reduce snoring and OSA.
• The upper airway can be defined by 3 regions:
• the velopharynx
• oropharynx
• hypopharynx
50

51. TYPES OF ORAL APPLIANCES
• 3 broad classes –
1.MRA
2.Tongue retaining devices ( TRD)
3.Soft palate lifters
51

52. SNORE-AIDE PLUS
SILENCER SYSTEMTHORNTON ADJUSTABLE POSITIONER
ELASTIC MANDIBULAR ADVANCEMENT
(EMA) APPLIANCE
52

53. 53

54. • MRAs are further subdivided into –
 Titratable ( 2 piece appliance )
 Non titratable ( 1 piece appliance )
• Also as
 Custom made appliance
 Pre fabricated
• there is a superior treatment response with MRAs that are custom-
made over prefabricated designs.
54

55. • The requirements of an MRA are as follows:
1. Good retention form to 1 or 2 arches
2. Sufficient protrusion of the mandible at an increased vertical dimension
3. Appliances that do not restrict jaw movement laterally or vertically are optimal for
temporomandibular joint (TMJ) comfort.
55

56. CHOOSING AN APPROPRIATE DESIGN10
Various aspects should be considered
when choosing the appropriate oral
appliance:
• oral condition (number, location and
health of remaining teeth, periodontal
tissues status etc.)
• anticipated dental restorative needs;
cranio-facial structures; the presence of
allergies and / or sensitivities; patient’s
manual dexterity, visual acuity and
cognitive ability; patient’s comfort;
financial considerations .
56

57. • There are more than 100 models of oral appliances available
on the medical market (Monoblock, Klearway; IST – Intraoral
Snoring Appliance; TAP-T Thornton Adjustable Positioner;
Erkodent – Silensor; Somnodent; boil and bite – ready-made
splints), therefore the dentist must select the proper oral
appliances for specific clinical cases.
• It is advisable, however, that a custom, titratable appliance
be used over non-custom oral devices
10.Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, et al. Clinical practice
guideline for the treatment of obstructive sleep apnea and snoring with oral appliance
therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773–827
57

58. 58

59. ADVANTAGES OF ORAL APPLIANCES
1. Nonintrusive
2. Lack of noise
3. Simplicity
4. Reversible treatment modality
5. Smaller and more portable than CPAP devices
6. No need for power source
7. Comfortable: fits inside the mouth
8. Potentially lower cost of treatment
59

60. ADVERSE EFFECTS
• Side effects can be grouped into 2 broad categories :
1. Minor in severity and temporary: tend to resolve during a short adaptive
period of 6 to 8 weeks or are tolerable and do not resolve. Frequency
reported from 6% to
86%.64
2. Moderate to severe and continuous: these side effects can occur at any
stage during treatment and might lead to intolerance and discontinuation
of the appliance
60

61. 11. Ferguson KA, Cartwright R, Rogers R. Oral appliances for snoring and obstructive sleep
apnea: a review. Sleep 2006;29:244–62. 61

62. DEGREE OF PROTRUSION12
• Protrusion of the mandible is required to make the MRA effective unless it
is being used as a stabilizing appliance in conjunction with CPAP when the
requirement is more reduction of pressure.
• Reports of effective degrees of advancement range from 6 to 10 mm, or
from 65% to 70% of maximum protrusive potential
12. Mehta A, Qian J, Petocz P. A randomized controlled study of a mandibular advancement
splint for obstructive sleep apnea. Am J Respir Crit Care Med 2001;163:1457–61 62

63. • The value of a titratable appliance is the opportunity to initiate therapy at
a mandibular position that is no more than 50% of maximum protrusion,
which although may be below optimal level, would allow for slow
advancement thereby reducing negative side effects such as muscular
tension or TMD.
• Patients can remain at this level during an adaptive period of 1 to 8 weeks
during which period most if not all of the transient negative side effects
resolve.
RAPID ADVANCEMENT
SIDE EFFECTS
REJECTION
63

64. TIME LINE BY VISIT NUMBER
64

65. HIGH RISK OF OSA PT COMPLAINS OF
SYMPTOMS
SELF REPORTING
QUESTIONNAIRES
POSITIVE FOR SLEEP
DISORDERS
SYMPTOMS
OSA SLEEP
EVALUATION (SLEEP
SPECIALIST)
SLEEP STUDY
•PSG
•PORTABLE MONITOR
AHI>5 WITH
SYMPTOMS
AHI> 15
EVALUATION FOR
OTHER DISEASES
TREATMENT
OPTIONS
CPAP
OFFERED
ALTERNATIVE
THERAPIES
CPAP
GIVEN
LIFESTYLE
CHANGES
ORAL
APPLIANCE
BEHAVIOURAL
/POSITIONAL
THERAPY
SURGERY
Flow chart for evaluation and treatment of patients suspected of having OSA. pt,
patient
65

66. Critical Analysis
• Comparision of efficacy of oral appliance therapy with other treatment modalities
was absent.
• No mention of the fabrication techniques for dentulous and edentulous patients
• No comparison of different customized appliances.
• No affirmation about measurement of mandibular advancement and vertical
opening.
66

67. 67

68. ORAL APPLIANCES COMPARED TO CPAP
• 11 published
randomized
controlled trials
which compare
efficacy of OA
treatment with
CPAP with
polysomnography
that evaluate
aspects of clinical
effectiveness .
Complete resolution with CPAP
With success defined as
AHI < 10 events/h, success rates for OAm
are 30% to 85% and 62% to 100% for
CPAP
Only one parallel trial has found an Equal
improvement in minimum arterial
oxygen saturation.
All other studies report only CPAP
Improves oxygen saturation.
68

69. Overall, studies comparing OAm with
surgical treatment are extremely limited.
Surgery, as an irreversible intervention,
whereas device therapy is dependent on
patient adherence
Symptoms- both treatments reduced
subjective daytime sleepiness,More
reduction in sleepiness was initially
observed with OAtreatment at 6 months,
but this was not sustained at 12 months
Hoekema and colleagues suggested
response to OAm therapy may be a
predictor of success of MMA surgery for
OSA.
Only one clinical trial says at 12 months
the OAm group showed a greater
reduction in AHI. Complete treatment
response (AHI ≥ 10 events/h) also
occurred in a greater proportion of
patients using OA compared to the UPPP
group (78% vs. 51%). At 4-year follow-
up, AHI remained lower in the OA group
SURGERY VERSUS ORAL
APPIANCE THERAPY
69

70. Oral appliances- Customized versus
Thermoplastic
• In a crossover study of 35 patients over 4 months of each device found post-
treatment AHI was reduced only with the custom-made OA.
• The thermoplastic device showed a much lower rate of treatment success (60% vs.
31%).
• Lower adherence to the thermoplastic appliance was also due to insufficient
retention of the appliance during sleep.
• Majority of patients (82%) preferred the customized OAm at the end of the study.
• Hence customization to a patient’s dentition is a key component of
treatment success.
Vanderveken OM, Devolder A, Marklund M. Comparison of Custom-made and
Thermoplastic Oral Appliance. Am J Respir Crit Care Med2008;178(2):197-202.
70

71. • Objective: To compare three different oral appliances: a mandibular advancement device
(Snoreguard), a tongue retaining device, and a soft palate lift, for treatment of OSAS.
• Methods: Eight patients with a mean apnea hypopnea index (AHI) of 72.1 (SD+/-39.9) were studied.
Polysomnographic measures during each of the treatment nights were compared to baseline.
• Results: Eight out of 8 patients completed the mandibular advancement device (MAD) night; 5/8
tolerated the tongue retaining device (TRD); only 2/8 could sleep with the soft palate lift (SPL) in
place. Improvement using the MAD reached significance: overall AHI (mean+/-SD) decreased from
72.1+/-39.9 at baseline to 35.5+/-39.4 with the appliance in place (P<0.02).
• Conclusions: A mandibular advancement device is an effective treatment alternative in some
patients with severe OSAS. In comparison, the tongue retaining device and the soft palate lift do not
achieve satisfactory results.
71

72. • A 49-year-old man was referred from the Ear, Nose and Throat Department with a
history of intrusive snoring and obstruction. Sleep endoscopy showed evidence of
a retrognathic mandible with marked obstruction to 68%. There was obvious
tongue base collapse at rest, with an associated component from the lateral
pharyngeal wall and uvula.
• In view of the retrognathic mandible, it was determined that a mandibular
advancement splint should be fabricated to bring the mandible forward, which in
turn would enlarge the posterior pharyngeal space
72

73. STEPS
• Preliminary Impressions
• Definitive impressions
• Wax rims
• Maxillomandibular relation was recorded maintaining the patient’s existing vertical
dimension of occlusion. Vertical marks were made bilaterally on both of the wax
occlusion rims in the canine region at the CR position. The patient was then asked
to protrude maximally, and another line was marked on the maxillary rim
corresponding to the centric relation line in the mandibular rim
73

74. • relation was recorded at that
position with occlusal
registration paste.
• After articulation, the casts were
duplicated with duplicating
silicone & vacuum formed clear
bases were fabricated on the
duplicated casts.
• these were then placed on the
articulated casts, and 2 wax
blocks were adapted on either
side, in the position of the wax
rims.
• they were processed with heat-
polymerized clear acrylic resin
74
Protrusion achieved with no
increase in vertica dimension

75. • they were processed with heat
polymerized clear acrylic resin.
• vent holes were placed in the middle of
the heat-polymerized acrylic resin blocks,
which were then adapted onto the
vacuum-formed bases and sealed
with autopolymerizing acrylic resin.
75

76. •Instructions- 1-3 hours a day for first week ,after
followup visit regulary at night.
•At the first monthly review, the patient reported
his sleep had improved at night and his daytime
somnolence had diminished.
76

77. • Conservative treatment of obstructive sleep apnea (OSA) includes weight loss,
changes in sleep posture, drug therapy, nasal continuous positive airway pressure
(CPAP),and placement of an intraoral prosthesis.
• This article describes a technique for fabrication of sleep apnea prosthesis for
dentate patients.
77

78. Fig. 1. Blocked out master casts with outline of design.
Pig. 2. Blocked out master casts mounted with wax interocclusal record.
Pig. 3. Occlusal view of wax-up on duplicated casts.
Pig. 4. Anterior view of wax4rp on duplicated casts. 78

79. Fig. 5. Sleep apnea prosthesis polished and fitted to mounted master casts.
Fig. 6. Maxillary and mandibular segments joined with visible light-cured resin.
Fig. 7. Sleep apnea prosthesis in place.
Fig. 8. Sleep apnea prosthesis with clasps.
79

80. • Approach for treating the soft palate in those patients diagnosed with
mild to moderate OSA.
• Palatal implantsare made of polyethylene terephthalate (PET), a linear,
aromatic polyester. Shows the following characteristics:
 biostability,
 promotion of tissue in-growth,
 a well-characterized fibrotic response.
• Each soft palate implant is cylindrical in shape, measures 18 mm -1.8
mm, and is made of porous and braided PET.
80

81. • Three palatal implants are placed in the upper portion of the soft
palate under local anesthesia in a single office visit.
• Placement of the implants increases the rigidity of the soft palate.
• Increased rigidity has a substantial impact on pharyngeal closing
pressure.
• A more negative value implies a less collapsible airway.
81

82. 82
DO YOU KNOW?
•Pillows to
encourage side
sleeping(with
ridges)
•Wedge pillows.
•CPAP Mask
pillows
•Realignment
pillows(cervical
repositioning to
avoid airway
compression)
•Smart Pillows

83. CONCLUSION
• Because of established training in TMD, removable appliance
therapy, and occlusion, prosthodontics is uniquely suited to
educating dental students in sleep disorders and oral
appliance therapy.
• Prosthodontists can set a new standard by developing more
in-depth dental sleep medicine training within prosthodontic
residency programs with access to multidisciplinary teams
and to ensuring that dental sleep medicine continues to strive
for excellence in the management of sleep apnea with oral
appliances
83

84. References
1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence
of sleep disordered breathing among middle-aged adults. N Engl J Med
1993;328:1230-5.
2. Weaver and Millman, Broken sleep. Am J Nurse 1986;88:146-50
3. Tsara V, Amfilochiou A.Definition and classification of sleep related
breathing disorders in adults. Different types and indications for sleep
studies (Part 1) HIPPOKRATIA 2009; 13(3): 187-191
4. Barewal RM,Hagen CC.Management of Snoring and Obstructive Sleep
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