Sleep 2020 - Sleep Professionals of Arkansas

Sleep 2020

• Stephen Deal DDS
• Diplomate, The Facial
  Beauty Institute
• Fellow, American Academy of
  Craniofacial Pain
• Fellow, International Association for
  Orthodontics
• Fellow, Academy of General Dentistry
• Fellow, American Orthodontic Society
• Editorial Review Board; International
  Journal for Orthodontics

Facial Growth and Development as
        a 3 Option for OSA
           rd

Facial Growth

 Modern Orthodontics
          and
Dento-Facial Orthopedics

Sleep Apnea
     2013
Proper Craniofacial
Growth is the best
way to possibly
prevent OSA

Facial Growth

Displacement + Remodeling

Facial Growth
• Our DNA is programmed to allow growth to take place in a
  specific way.....

• Adaptation
     Our environment and situations influence the change
     from normal balanced growth to altered growth

              EPIGENETICS

• EPIGENETIC influence:

• Allergies: dairy, seasonal, living indoors, pets, gluten

• Soft Diet: we are thick enamel primates designed to eat things that
  are very hard.

• Early Weening: only mammal that weens their young prior to
  eruption of the first deciduous molar

How does EPIGENETICS alter a Normal Growth Pattern?

   Airway Constriction
    Causes a vertical growth pattern due to mouth breathing

   Soft Diet
    Soft food doesn’t allow for the proper development of our jaws that
    is required to house our teeth

• The change in mode of breathing from nasal to mouth
  breathing is the single biggest contributing factor to
  altered facial growth

• Mouthbreathing and Soft Diet = Malocclusion and Crooked Teeth

Vertical Growth

• Altered Vertical Growth of the
  Nasomaxillary Complex is the cause of
  Mid-facial Deficiency

• This is the problem in which modern
  treatment seeks to address

What VERTICAL GROWTH
                                       looks like:

                         Normal Growth               Vertical Growth

          This obstructs the airway and so the ramus remodels posteriorly creating an
          anti-gonial notch.
Slide Courtesy of Dr. John Mew

Orthodontics

Treatment must be focused on more than just straight teeth

Traditional Orthodontics
Traditional diagnosis and mechanics fails to take into
consideration basic tenets of proper growth and
development and more importantly fails to address
the……

               AIRWAY

Speaking of Failure…..

                               22%

• Long-term orthodontic success is gauged by the degree of incisor crowding

The Why….
• The reason that traditional orthodontics only experiences a 22%
  success rate is because the SYSTEM was left unchanged
• The Big 3
   • Lip Seal
   • Nasal Breathing
   • Tongue Habits/Problems

   • A compromise in the Big 3 is a compromise in long term treatment results
     EVERYTIME.

Can there be any doubt that there is an underdeveloped nasal airway
                    in the patient on the left?

The Proof is in the Literature

The Proof is in the Literature

The Proof is in the Literature

The Big 3
          • Lip Seal
      • Nasal Breathing
• No Tongue Habits/Problems

Traditional Orthodontics

• Predominantly RETRACTIVE Forces

• Moves teeth toward back of the mouth

• Complicates already Compromised Airway

• Decreases Tongue Space

Why we can’t simply retract teeth…….

2012

Maxillary Protraction Mechanics

• Uses PROTRACTIVE forces

• Moves teeth away from the airway

• Positive affects on airway

• Creates more room for the tongue

Treatment for Naso-Maxillary
        Deficiency

• Sagittal appliances
• Protraction mechanics
• Myofunctional Therapy

Maxillary protraction appliance
effect on the size of the upper
airway passage.
Oktay H1, Ulukaya E.
Angle Orthod. 2008 Mar;78(2):209-14.

• Effects of maxillary protraction
 and fixed appliance therapy on the
 pharyngeal airway.
• Kaygisiz E1, Tuncer BB, Yüksel S, Tuncer C, Yildiz C.

Assessment of the effect of
maxillary protraction appliance on
pharyngeal airway dimensions in
relation to changes in tongue
posture.
Danaei SM1, Ajami S1, Etemadi H2, Azadeh N2
Dent Res J (Isfahan). 2018 May-Jun;15(3):208-214.

• Correlation between skeletal changes by
  maxillary protraction and upper airway
  dimensions.
Lee, Ji-Won & Park, Ki-Ho & Kim, Seong-Hun & Park, Young-Guk & Kim,
Su-Jung. (2011). The Angle orthodontist. 81. 426-32. 10.2319/082610-
499.1.

Treatment for OSA
Maxillary growth guidance and remodeling/Airway Orthodontics
     Positively affect the airway
     More tongue space
     Room to straighten the teeth
     Healthy TMJ’s

Oral Sleep Appliance
     Hold airway open with mandibular protrusion

All Oral Sleep Apnea Appliances:

1. Advance the mandible and open vertical

1. Have a tendency to cause jaw pain and tooth
   movement

How do we find the best of both worlds?

Clinical success with advancement and vertical

AND…..

keep jaw pain and tooth movement to a minimum

Clinical Procedure
Pharyngometry & Biometric Equipment

Clinical Baseline
• 40 consecutive patients
• Initial AHI range from 1.5(snoring only) to 89.8
  events/hr
• Initial Pharyngometry assessment range 1.37 to 3.97
  square centimeters (Avg.2.48)
• All patients had attempted CPAP with unsatisfactory
  results

Clinical Results

• Final AHI range decreased to 2 to 8
  events/hr (snoring pt 0) Avg. reduction
  in AHI 75%

• Final Pharyngometry range increased to
  3.20-5.77 square centimeters ( Avg.
  3.98) Overall increase in airway cross
  section 62%

Clinical Results

     • One severe OSA patient had no change
       in AHI but reported dramatic
       improvement in sleep quantity and
       quality
     • One patient discontinued due to pre-
       existing TM Joint Osteoarthritis and
       increase in joint pain

Thank You!!!!