A small lecture on the potential correlation between sleep apnea and TMJ dysfunction

1. “Diagnosis and treatment of sleep
apnea in dentistry: the relationship
with the TMJ dysfunction”
A dentist’s perspective
Dr Jean-Marc Retrouvey
Director of the Division of Orthodontics
McGill University

2. Objectives of the Presentation
• Discuss the dental therapeutic approaches for
TMJ dysfunction and Sleep Apnea from a
dental perspective
• Describe the different oral appliances used in
the treatment of these conditions
• Discuss the possible correlations between
sleep apnea, TMJ disorders and bruxism

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

4. Most common contributing factors of OSA
1. Environment
1. Diet = Obesity
2. Allergies
2. Genetics
1. Skeletal malocclusions
3. Combination
http://www.saberycuidar.or
http://www.crystalinks.com/overweight g/allergies-in-children.html
kids.html

5. Correlation between Obesity and OSA
Fairly direct correlation has been established between obesity
and OSA in children* and teens**
*The Correlation Among Obesity, Apnea-Hypopnea Index, and Tonsil Size in Children*
Yuen-yu Lam, FHKAM(Paed), et al. Chest 2006: 1751-1756
**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

6. Dentist’s approach of OSA
Dental Appliances
Mandibular advancement devices (MADs)
– Bring mandible forward to open airway
– Basically same type of appliances as the
mandibular protractors used for growth
modifications
– Over 75 types of appliances are described in the
literature.

7. Clear Way Appliance: Dr Lowe UBC

8. CAD-CAM Manufactured Appliance
Slide from Dr Arcache

9. 2.TMJ dysfunction and the dental
profession approach

10. Temporo-Mandibular Dysfunction?
Myofascial 3 to 6%
pains (10%)
Intra-
Painfull
capsular 5 to 8% or not
problems
Type?
bruxism 5 to 95%!
Transient
Snoring and obstructive sleep apnea
By David N. F. Fairbanks, Samuel A. Mickelson, B. Tucker Woodson, p 243

11. Myofascial pain: Flat Occlusal Splint
• Reported to be efficient
to relieve myo-fascial
pains
– Variable response
probably caused by poor
differential diagnosis
• Multiple designs
– None seems to be
consistently better than
others
Same design is also used in nocturnal
bruxers

12. Disk Displacement:
Mandibular Advancement Splints
« Disk recapture »

14. What about OSA and bruxism?
Sleep apnea (i.e., cessation of breathing in sleep
with hypoxemia and risk of
hypertension, daytime sleepiness) is a health
hazard found twice as often in the general
population reporting tooth-grinding than in the
normal population (Krieger, 2000; Ohayon et
al., 2001).
Quantitative Polygraphic Controlled Study on Efficacy and Safety of
Oral Splint Devices in Tooth-grinding Subjects
C. Dubé, P.H. Rompré, C. Manzini, F. Guitard, P. de Grandmont and G.J.
Lavigne
J DENT RES 2004 83: 398

15. ‘’The use an occlusal splint in an OSA patient may
trigger more episodes of bruxism in 50% of cases’’
(Gagnon et al, Int J Prostho 2004)

16. More TMJ dysfunction in OSA patients?
No difference in
dysfunction between
‘’normal ‘’ population
and OSA population

17. Contraindications to MADs in OSA
Patients
• Active TMJ dysfunction is a contraindication to
the use mandibular advancement devices
• 6 mm of protrusive movement is the
minimum to consider a MAD

18. Association or
correlation?

21. Herbst type MAD

22. Study of MAD use
24 patients 12 drop out
3 for TMJ pain reasons
( no exact diagnosis given)

23. Picture from Dr Arcache

25. Interesting case of interdisciplinary
treatment of an UARS-TMJ patient

26. 17 year old female patient
• Presents with severe
malocclusion and
temporo-mandibular
pains and clicking in both
joints
– Physiotherapy helps
alleviate pain but does not
eliminate it

27. Treatment options
Continue physiotherapy
Orthodontics-orthognathic surgery
Physiotherapy after surgery
Potential for occlusal splint after surgery

28. Pre Orthodontics-Orthognathic surgery
2004

29. 2009

30. Orthodontic preparation

31. Maxillo-Mandibular Advancement
(MMA)

32. Post Surgery
Patient reports an improvement in her sleep apnea (subjective as no somnography
is available)
Significant improvement in TMJ symptoms and mandibular excursions.
Has stopped physiotherapy for now but advised to return if symptoms reappear.
No occlusal splint worn at night.

33. OSA is a potentially life threatening medical
condition
TMJ dysfunctions can dramatically affect
quality of life (non lethal)
Cranio-mandibular disorders (OSA included)
will benefit from interdisciplinary care
jean-marc.retrouvey@mcgill.ca