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CONTINUING EDUCATION Course Number: 188 Correction of Severe Obstructive Sleep Apnea With Interdisciplinary Treatment Authored by Joseph Yousefian, DMD, MS, MA; Kate Weaver, DDS; Douglas Trimble, DMD, MD; Robert William DePaso, MD; and Robert Gottlieb, DDS Upon successful completion of this CE activity, 2 CE credit hours may be awarded A Peer-Reviewed CE Activity by Dentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in indentifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp. Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. June 1, 2015 to May 31, 2018 AGD PACE approval number: 309062 Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements. CONTINUING EDUCATION D Correction of Severe Obstructive Sleep Apnea With Interdisciplinary Treatment ental practitioners frequently treat patients who may have dentofacial aesthetic concerns but also suffer from other medical problems such as obstructive sleep apnea syndrome (OSAS). OSAS can be debilitating and if not treated properly can lead to more dangerous health issues including high blood pressure, diabetes, and cancer. The patient presented in this article was mainly concerned about simple dentofacial aesthetic issues but also suffered from a severe and complex OSAS, high blood pressure, prostrate cancer, and developing diabetes. OSAS is one of the more severe forms of sleep-disordered breathing (SDB). It can be a debilitating, even life-threatening, condition. Potential health risk factors associated with OSAS include tooth grinding, temporomandibular disorders, facial deformities, attention deficit hyperactivity disorder,1 gastroesophageal reflux disease, premature aging, depression, hypertension, sexual impotence, Alzheimer’s disease, metabolic syndrome, diabetes, obesity, and more dangerous illnesses such as Effective Date: 08/01/2015 Expiration Date: 08/01/2018 Learning Objectives: After reading this article the individual will learn: (1) definition and complications of obstructive sleep apnea syndrome (OSAS), and (2) interdisciplinary treatment, dentofacial aesthetic concerns, and other health issues involving OSAS. About the Authors Dr. Yousefian obtained his DMD degree from Washington University, in St. Louis, in 1987, and completed 3 years of post-graduate training in orthodontics at The Ohio State University in 1991. He also received the master of science degree in orthodontics and master of arts degree in physical anthropology. He is a Diplomate of the American Board of Orthodontics and has been in private practice in Bellevue, Wash, since 1991. He has served as a clinical assistant professor and orthodontic research associate at The Ohio State University and the University of Washington in the department of orthodontics. He is an active international lecturer and has contributed as a main author to numerous publications in orthodontics as well as dental journals and textbooks. He can be reached via email at [email protected]. Disclosure: Dr. Yousefian reports no disclosures. Dr. Weaver graduated from the University of Washington School of Dentistry in 2001. While there, she received multiple awards in comprehensive patient care and outstanding clinical performance in aesthetic and cosmetic dentistry. She is a graduate of the Kois Center, which provides a didactic and clinical program with the latest advances in aesthetics, implant, and restorative dentistry. Dr. Weaver and her team are participants in national “Give Kids a Smile Day” in which 100 kids from low-income families are given free dental services. She also volunteers overseas and thus far has helped many people in India and Ethiopia. She maintains a private practice in Kirkland, Wash, and can be reached via email at [email protected]. Disclosure: Dr. Weaver reports no disclosures. Dr. Trimble graduated from the University of Manitoba, earning his DMD degree in 1973 and his MD degree in 1976. He completed his residency in oral and maxillofacial surgery at the University of Washington from 1979 to 1982. His experience includes a general surgery internship in 1977, emergency room staff in 1978, and an aesthetic surgery fellowship in 1997. He has been in private practice in Bellevue, Wash, for 32 years. He can be reached via email at [email protected]. Disclosure: Dr. Trimble reports no disclosures. Dr. DePaso received his MD degree from the University of Chicago, Pritzker School of Medicine, in 1981, and currently serves as medical director of the Virginia Mason Sleep Disorders Center. He is a Diplomate of the American Board of Internal Medicine, the American Board of Sleep Medicine, and the American Board of Internal Medicine, Sleep Disorders. He can be reached via email at [email protected]. Disclosure: Dr. DePaso reports no disclosures. Dr. Gottlieb received his DDS degree from from the University of Illinois in 1975, and his certificate in periodontics from the University of Washington in 1977. He has taught at the University of Illinois and the University of the Pacific, and served as president of the Washington State Society of Periodontics. He has lectured throughout the United States on periodontal therapy. He can be reached via email at [email protected]. Disclosure: Dr. Gottlieb reports no disclosures. 1 CONTINUING EDUCATION Correction of Severe Obstructive Sleep Apnea With Interdisciplinary Treatment Before After Figure 1. Pretreatment extraoral and intraoral photographs. Figure 2. Post-treatment extraoral and intraoral photographs. cancer,2,3 heart disease, and stroke.4 Health issues related to OSAS contribute to many of the complex socioeconomic problems endemic to our industrial societies such as poor job performance, academic failure, a sevenfold increase in the incidence of accidents both at home and work, and severe nighttime snoring, which can have a major negative influence on family relationships.4 OSAS is a multifactorial disease. Constriction of the upper airway is recognized as one of the most important factors in the development of OSAS. Variables that affect the upper airway luminal size include the relative sizes of the jaw and tongue and the enlarged adenoid and tonsillar bulk in children. Craniofacial abnormalities (eg, retrognathia) also are associated with SDB and OSAS.5 Case reports correlate the development of OSAS in individuals with various craniofacial abnormalities.6 Other risk factors include aging and weight gain.7,8 Developments in the science of sleep medicine, along with education and media coverage of the subject, especially sleep apnea, are making the public aware of the consequential impact of jaw and dental problems as potential causes of airway insufficiencies during sleep. With increased public awareness and greater clinical recognition, this trend is likely to escalate. The field of dentistry and its involvement with the PharyngOroFacial environment provides the dental practitioner with an opportunity in screening for the presence of OSAS as a complex health condition or participation in its treatment.9 A report by the Institute of Medicine suggests that dental practitioners should work closely with other health professionals when pa- tients have complex health conditions.10 The ADA also emphasizes the importance of interdisciplinary professional and patient collaboration in its strategic plan, which includes a goal to “improve public health outcomes through a strong collaboration across the spectrum of our external stakeholders.”11 The case presented in this paper demonstrates the effective participation of the dental practitioner as a member of an interdisciplinary dental/medical team collaborating in the treatment of SDB and OSAS. CASE REPORT A 58-year-old male patient visited a new general dentist for potential Invisalign (Align Technology) treatment to improve his nonaesthetic smile. In the past he had received multidisciplinary oral care provided by a number of reputable dental specialists in the area. A review of the patient’s medical history indicated a healthy lifestyle including healthy diet, routine exercise, and no history of smoking or alcohol abuse. The patient reported a history of severe OSAS (an apnea/hypopnea index [AHI] of 53 [below 5 is normal]) diagnosed by a sleep specialist and polysomnography at a sleep center. His initial clinical symptoms included high blood pressure, excessive daytime sleepiness affecting his job performance, and falling asleep while driving. For treatment of his OSAS, he was using a continuous positive airway pressure device (CPAP) with H2O pressure of 18 cm. Although his CPAP compliance effort was good, it was ineffective in reducing his symptoms due to air leakage around the facial mask. As a result, he was taking 2 CONTINUING EDUCATION Correction of Severe Obstructive Sleep Apnea With Interdisciplinary Treatment a b Figures 3a and 3b. (a) Pretreatment and (b) post-treatment cephalometric radiographs. Provigil (Teva Pharmaceuticals) medication as a wakefulness promoting agent. The patient had not proceeded with the previously proposed surgical protocol for treatment of his OSAS. Phase one of this protocol included hyoid suspension, midline glossectomy, nasal valve stabilization, and septoplasty, followed by phase 2 consisting of maxillomandibular advancement surgery. A clinical examination showed that the patient had a Class III skeletal and dental relationship with a moderate retrognathic position of the maxilla and retrusive position of the dentition in the mandible (Figure 1). His oral hygiene was excellent. There was no presence of decay or gingival inflammation, but he had generalized type one periodontitis, with horizontal bone loss and gingival recession. He was missing teeth Nos. 1, 2, 16, 23, and 32; teeth Nos. 3, 30, and 31 had been replaced with implant-supported restorations. Tooth No. 23 was extracted at childhood. The anterior cross-bite was the patient’s main aesthetic dissatisfaction with his smile and had never been addressed properly. Based on the complexity of the patient’s oral and medical health issues including his narrow oropharyngeal airway, the general dentist referred the patient to a new interdisciplinary dental/medical team. Treatment began with a combination of orthodontic and telegnathic surgery for correction of the maxillary/mandibular vertical, sagittal, and transverse deficiencies. When orthognathic surgery is used to treat OSAS, it is referred to as telegnathic surgery. An 8-mm surgically assisted mandibular expansion (SAME) as an outpatient technique was performed to create a recipient site for future replacement of missing tooth No. 23 by an implant-supported restoration. During this stage of treatment, the patient reported a recent diagnosis of elevated blood sugar and prostate cancer. The interdisciplinary medical/dental team—based on the severity of patient’s OSAS and his intolerance of CPAP—recommended postponing the surgical protocol for treatment of prostate cancer until after the second stage surgery for treatment of his OSAS. The second stage of telegnathic surgery was performed to provide definitive OSAS relief. The procedure included a 10mm maxillary advancement, a 6-mm maxillary expansion, and a 5-mm mandibular advancement combined with counterclockwise rotation of the maxillomandibular complex. The patient proceeded with the surgery and treatment protocol for his prostate cancer 3 months later with complete remission. The postsurgical orthodontic treatment was completed within 15 months. The implant for the future replacement of missing tooth No. 23 was installed. The patient received partial connective tissue grafting to restore the excessive gingival recession. Treatment Results A well intercuspated Class I molar and canine relationship was attained. The general dentist provided a comprehensive equilibration followed by the restoration of the implant replacing missing tooth No. 23. A balanced facial profile with improved chin protrusion was obtained (Figure 2), but most importantly, the patient reported a significant improvement in night sleep 3 CONTINUING EDUCATION Correction of Severe Obstructive Sleep Apnea With Interdisciplinary Treatment and daytime level of alertness. Later tests demonstrated that his high blood pressure and high blood sugar normalized. His spouse reported almost no disturbances during sleep, and the postsurgical polysomnography performed at the sleep lab by his sleep specialist showed an AHI of 2.1 (below 5 is normal). An increase in the retropalatal, retroglossal, and hypoglossal airway spaces concomitant with maxillary and mandibular advancement was evident on the cephalometric radiograph (Figure 3). It also could cause deterioration in facial and dental aesthetics by retracting the lower lip and magnifying the chin protrusion.16-20 Ideally, a treatment plan involving expansion of the oral environment in all 3 dimensions would be a more effective treatment for these patients. SAME procedure as an outpatient protocol produced a proper recipient site for the installation of an implant to replace tooth No. 23,21 and combined with the subsequent bimaxillary advancement surgery provided adequate oral volume to accommodate the tongue, thus opening the oropharynx.9 Maxillomandibular counterclockwise rotation and advancement by expansion of the posterior nasopharyngeal openings also augment the nasal cavity. A nasal cavity volume increase should reduce the resistance to nasal airflow.22 If the airway is considered a simple tube, as the radius of the tube increases, the resistance to flow decreases exponentially to the fourth power (resistance = 8 L η/π r 4).23 Therefore, even small increases in the diameter of the tube (the nasal cavity) can dramatically decrease the resistance to nasal air flow.23 DISCUSSION The most favorable treatment for patients with OSAS is treatment provided by an interdisciplinary team that includes members from the appropriate dental and medical disciplines. Prescribed therapies might include weight loss, behavior modification, oral appliances, soft-tissue surgery, telegnathic surgery, or a combination of the above.12 In the majority of telegnathic cases, only the anteroposterior jaw dimension is addressed, and due to the complexity in incorporating the transverse dimension, this opportunity is overlooked. Based on this concern, usually a maxillomandibular advancement of 10 mm has been considered as one of the most effective surgical treatments for OSAS.13,14 However, not all patients diagnosed with OSAS are affected by severe sagittal discrepancies of maxillary or mandibular skeletal structures. Therefore, a routine cookbook approach of a 10-mm bimaxillary advancement just to treat OSAS could create a very unaesthetic facial result for this category of patients. For this reason, the literature describes few attempts to incorporate a transverse expansion in addition to sagittal skeletal corrections for treatment of OSAS patients.9,12,15 In an article entitled, “Correction of Severe Obstructive Sleep Apnea With Bimaxillary Transverse Distraction Osteogenesis and Maxillomandibular Advancement” published in the American Journal of Orthodontics and Dentofacial Orthopedics, Conley and Legan12 discussed the role of increased transverse dimension by means of mandibular symphyseal distraction osteogenesis in resolving dentoalveolar crowding in treatment of OSAS patients. To the authors’ knowledge, currently there are no reports describing the role of SAME in the development of implant sites for replacement of missing teeth and the subsequent effectiveness in the treatment of OSAS. A nonsurgical treatment approach, including the extraction of one lower incisor or 2 lower first bicuspids, would have addressed the orthodontic aspects of this patient’s malocclusion. However, correction of the malocclusion was only one of the objectives of treatment. The need for treatment of the patient’s OSAS, which was a more health-threatening condition, overshadowed the need for treatment of the patient’s malocclusion. CONCLUSION Many patients see their dentists more often than their physicians. Some patients may stay with the same dentist throughout their lifetime.24 Therefore, dentists may have the opportunity to evaluate their patients for medical conditions and refer these patients to appropriate physicians for further diagnosis and therapy. SDB and OSAS are conditions for which dentists may assist with both diagnosis and therapy, and make a positive contribution to the health of these patients. The general dentist can effectively monitor the lifetime stability of the PharyngOroFacial rehabilitation through prophylactic maintenance of supportive dental and periodontal structures. It has been the authors’ experience that treating this category of patients is both a challenging and rewarding aspect of interprofessional collaboration. An added benefit of this collaboration is that the cost of treating these patients, including the use of oral appliances and telegnathic surgeries, is being partially or fully covered by medical insurance policies more frequently. It seems likely that this trend will continue in the future.25! References 1. Youssef NA, Ege M, Angly SS, et al. Is obstructive sleep apnea associated with ADHD? Ann Clin Psychiatry. 2011;23:213-224. 2. Martínez-García MA, Campos-Rodriguez F, Durán-Cantolla J, et al. Obstructive sleep apnea is associated with cancer mortality in younger patients. Sleep Med. 2014;15:742-748. 3. Chen JC, Hwang JH. Sleep apnea increased incidence of primary central nervous system cancers: a nationwide cohort study. Sleep Med. 2014;15:749-754. 4. Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230-1235. 5. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 4 CONTINUING EDUCATION Correction of Severe Obstructive Sleep Apnea With Interdisciplinary Treatment 1998;102(3 pt 1):616-620. 6. Cistulli PA, Sullivan CE. Sleep-disordered breathing in Marfan’s syndrome. Am Rev Respir Dis. 1993;147:645-648. 7. Iguchi A, Yamakage H, Tochiya M, et al. Effects of weight reduction therapy on obstructive sleep apnea syndrome and arterial stiffness in patients with obesity and metabolic syndrome. J Atheroscler Thromb. 2013;20:807-820. 8. Morong S, Benoist LB, Ravesloot MJ, et al. The effect of weight loss on OSA severity and position dependence in the bariatric population. Sleep Breath. 2014;18:851856. 9. Yousefian J, Moghadam B. The role of contemporary orthodontics in the diagnosis and treatment of sleep-disordered breathing. In: Girardot RA, Ribbens KA, eds. Goaldirected Orthodontics. Los Gatos, CA: Roth Williams International Society of Orthodontists; 2013:601-655. 10. Field MJ, Jeffcoat MK. Dental education at the crossroads: a report by the Institute of Medicine. J Am Dent Assoc. 1995;126:191-195. 11. Jakush J. Board adopts 2011-2014 ADA Strategic Plan. arkansasdentistry.org/2010/06/board-adopts-2011-2014-ada-strategic-plan. Accessed April 17, 2015. 12. Conley RS, Legan HL. Correction of severe obstructive sleep apnea with bimaxillary transverse distraction osteogenesis and maxillomandibular advancement. Am J Orthod Dentofacial Orthop. 2006;129:283-292. 13. Waite PD, Shettar SM. Maxillomandibular advancement (a cure for obstructive sleep apnea). Oral Maxillofac Surg Clin North Am. 1995;7:327-336. 14. Hochban W, Brandenburg U, Peter JH. Surgical treatment of obstructive sleep apnea by maxillomandibular advancement. Sleep. 1994;17:624-629. 15. Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27:761-766. 16. Yousefian J, Trimble D, Folkman G. A new look at the treatment of Class II Division 2 malocclusions. Am J Orthod Dentofacial Orthop. 2006;130:771-778. 17. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop. 2001;120:98-111. 18. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part 2. Smile analysis and treatment strategies. Am J Orthod Dentofacial Orthop. 2003;124:116-127. 19. Peck S, Peck L. Selected aspects of the art and science of facial esthetics. Semin Orthod. 1995;1:105-126. 20. Zachrisson BU. Esthetic factors involved in anterior tooth display and the smile: vertical dimension. J Clin Orthod. 1998;32:432-445. 21. Yousefian J. A simple technique for mandibular symphyseal distraction osteogenesis. J Clin Orthod. 2010;44:731-737. 22. Kunkel M, Hochban W. The influence of maxillary osteotomy on nasal airway patency and geometry. Mund Kiefer Gesichtschir. 1997;1:194-198. 23. Courtiss EH, Goldwyn RM. The effects of nasal surgery on airflow. Plast Reconstr Surg. 1983;72:9-21. 24. Dworkin SF. The dentist as biobehavioral clinician. J Dent Educ. 2001;65:14171429. 25. Nierman R. Dentists become durable medical equipment suppliers for sleep apnea oral appliances. dentistryiq.com/articles/2013/10/dentists-become-durable-medical-equipment-suppliers-for-sleep-apnea-oral-appliances.html. Accessed April 17, 2015. 5 CONTINUING EDUCATION Correction of Severe Obstructive Sleep Apnea With Interdisciplinary Treatment POST EXAMINATION INFORMATION To receive continuing education credit for participation in this educational activity you must complete the program post examination and receive a score of 70% or better. Traditional Completion Option: You may fax or mail your answers with payment to Dentistry Today (see Traditional Completion Information on following page). All information requested must be provided in order to process the program for credit. Be sure to complete your “Payment,” “Personal Certification Information,” “Answers,” and “Evaluation” forms. Your exam will be graded within 72 hours of receipt. Upon successful completion of the post-exam (70% or higher), a letter of completion will be mailed to the address provided. Online Completion Option: Use this page to review the questions and mark your answers. Return to dentalcetoday.com and sign in. If you have not previously purchased the program, select it from the “Online Courses” listing and complete the online purchase process. Once purchased, the program will be added to your User History page where a Take Exam link will be provided directly across from the program title. Select the Take Exam link, complete all the program questions and Submit your answers. An immediate grade report will be provided. Upon receiving a passing grade, complete the online evaluation form. Upon submitting the form, your Letter of Completion will be provided immediately for printing. General Program Information: Online users may log in to dentalcetoday.com any time in the future to access previously purchased programs and view or print letters of completion and results. POST EXAMINATION QUESTIONS 4. Case reports correlate the development of OSAS in individuals with various craniofacial abnormalities. Other risk factors for OSAS include aging and weight gain. a. The first statement is true, the second is false. b. The first statement is false, the second is true. c. Both statements are true. d. Both statements are false. 1. Obstructive sleep apnea syndrome (OSAS), if not treated properly, can lead to: a. High blood pressure. b. Diabetes. c. Cancer. d. All of the above. 5. What is considered a normal apnea/hypopnea index (AHI)? a. < 5. b. 5 to 10. c. 10 to 20. d. 20 to 30. 2. OSAS is a multifactorial disease. Constriction of the upper airway is recognized as one of the most important factors in the development of OSAS. a. The first statement is true, the second is false. b. The first statement is false, the second is true. c. Both statements are true. d. Both statements are false. 6. When orthognathic surgery is used to treat OSAS, it is referred to as: a. Transverse surgery. b. Distraction osteogenesis. c. Telegnathic surgery. d. Septoplasty. 3. A threefold increase in the incidence of accidents both at home and at work can be attributed to OSAS. a. True. b. False. 7. Prescribed therapies for OSAS may include: a. Behavior modification. b. Oral appliances. c. Weight loss. d. All of the above. 6 CONTINUING EDUCATION Correction of Severe Obstructive Sleep Apnea With Interdisciplinary Treatment 8. Usually, a maxillomandibular advancement of _____ has been considered as one of the most effective surgical treatments for OSAS. a. 5 mm. b. 8 mm. c. 10 mm. d. 15 mm. 9. In the case report presented, the patient’s AHI showed the following change as a result of interdisciplinary treatment: a. 35 (pretreatment) to 5.0 (post-treatment). b. 46 (pretreatment) to 4.3 (post-treatment). c. 49 (pretreatment) to 4.0 (post-treatment). d. 53 (pretreatment) to 2.1 (post-treatment). 10. Even small increases in the diameter of the nasal cavity can dramatically decrease resistance to nasal airflow. a. True. b. False. 7 CONTINUING EDUCATION Correction of Severe Obstructive Sleep Apnea With Interdisciplinary Treatment PROGRAM COMPLETION INFORMATION PERSONAL CERTIFICATION INFORMATION: If you wish to purchase and complete this activity traditionally (mail or fax) rather than online, you must provide the information requested below. 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