Supine Cephalometric Analyses of an Adjustable Oral Appliance Used in the Treatment of Obstructive Sleep Apnea

Yuehua Liu; Young-Chel Park; Alan A. Lowe; John A. Fleetham

doi:10.1055/s-2000-9838

Sleep and Breathing, Table of Contents

Sleep Breath 2000; 04(2): 059-066
DOI: 10.1055/s-2000-9838

Supine Cephalometric Analyses of an Adjustable Oral Appliance Used in the Treatment of Obstructive Sleep Apnea

Yuehua Liu¹ , Young-Chel Park² , Alan A. Lowe¹ , John A. Fleetham³

¹Department of Oral Health Sciences Faculty of Dentistry; The University of British Columbia Vancouver, Canada;
²Department of Orthodontics, Dental College, Yonsei University, Seoul, Korea; and
³Department of Medicine, Vancouver Hospital and Health Sciences Centre, The University of British Columbia, Vancouver, Canada

Abstract

ABSTRACT

Objective: To investigate the effects of the Klearway^TM appliance on the upper airway in patients with obstructive sleep apnea (OSA) in the supine position. Methods: Sixteen subjects (12 males and 4 females) were recruited on the basis of baseline polysomnography with a documented Apnea and Hypopnea Index (AHI) >15 per hour. A second overnight sleep study was performed for each subject with the appliance in place. Baseline supine cephalometry was performed for each subject before the initial insertion of the appliance, and follow-up supine cephalometry was undertaken with the appliance in place. Results: The polysomnographic variables improved significantly, and the mean changes in overbite and overjet were 5.15 mm and 6.26 mm after insertion of the Klearway^TM appliance. The supine sagittal cross-sectional areas of the pharynx and the tongue significantly increased, while the linear distance from the hyoid position to the mandibular plane or the RGN-C3 line significantly decreased after insertion of the appliance. The ratio of the vertical pharyngeal length to the sagittal cross-sectional area of nasopharynx or tongue decreased significantly. When the subjects were evaluated on the basis of the after-insertion AHI, the group with good response (n = 11) was found to be significantly younger than the group with the poor response (n = 5). Similarly, the good responders revealed less prominent chins, larger tongue heights, and an increase in hypopharyngeal sagittal cross-sectional area after insertion of the appliance. There was a significant correlation between the improvement in AHI (%) and the supine middle airway space (r = -0.52, p < 0.05). Conclusion: The mechanical effect of the Klearway^TM appliance on the upper airway and the stabilization of jaw posture may be important determinants of the efficacy of the appliance.

KEYWORD

obstructive sleep apnea (OSA) - oral appliance (OA) - supine cephalometry

Full Text

References

REFERENCES

1 Remmers J E, De Groot J W, Sauerland E K, Anch A M. Pathogenesis of upper airway occlusion during sleep. J Appl Physiol . 1978; 44 931-938
2 Guilleminault C. Clinical features and evaluation of obstructive sleep apnea. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine, 2nd ed Philadelphia: WB Saunders, 1994: 667-677
3 Mayer P, Pépin J-L, Bettega G. Relationship between body mass index, age and upper airway measurements in snorers and sleep apnoea patients. Eur Respir J . 1996; 9 1801-1809
4 Lowe A A, Ono T, Ferguson K A, Pae E-K, Ryan F, Fleetham J A. Cephalometric comparisons of craniofacial and upper airway structure by skeletal subtype and gender in patients with obstructive sleep apnea. Am J Orthod Dentofac Orthop . 1996; 110 653-664
5 Battagel J M, L'Estrange P R. The cephalometric morphology of patients with obstructive sleep apnoea (OSA). Eur J Orthod . 1996; 18 557-569
6 Lowe A A, Özbek M M, Miyamoto K, Pae E-K, Fleetham J A. Cephalometric and demographic characteristics of obstructive sleep apnea: an evaluation with partial least squares analysis. Angle Orthod . 1997; 67 143-154
7 Tangugsorn V, Skatvedt O, Krogstad O, Lyberg T. Obstructive sleep apnoea: a cephalometric study. Part I. Cervico-craniofacial skeletal morphology. Eur J Orthod . 1995; 17 45-56
8 Tangugsorn V, Skatvedt O, Krogstad O, Lyberg T. Obstructive sleep apnoea: a cephalometric study. Part II. Uvuloglossopharyngeal morphology. Eur J Orthod . 1995; 17 57-67
9 Menn S, Loube D, Morgan T, Milter M, Berger J, Erman M K. The mandibular repositioning device: role in the treatment of obstructive sleep apnea. Sleep . 1996; 19 794-800
10 Eveloff S E, Rosenberg C L, Carlisle C C, Millman R P. Efficacy of a Herbst mandibular advancement device in obstructive sleep apnea. Am J Resp Crit Care Med . 1994; 149 905-909
11 Mayer G, Meier-Ewert K. Cephalometric predictors for orthopaedic mandibular advancement in obstructive sleep apnea. Eur J Orthod . 1995; 17 35-43
12 Cartwright R D. Effects of sleep position on sleep apnea severity. Sleep . 1984; 7 110-114
13 McEvoy R D, Sharp D J, Thornton A T. The effects of posture on obstructive sleep apnea. Am Rev Respir Dis . 1986; 133 662-666
14 Brown I B, McClean P A, Boucher R, Zamel N, Hoffstein V. Changes in pharyngeal cross-sectional area with posture and application of continuous positive airway pressure in patients with obstructive sleep apnea. Am Rev Respir Dis . 1987; 136 628-632
15 Jan M A, Marshall I, Douglas N J. Effect of posture on upper airway dimensions in normal human. Am J Respir Crit Care Med . 1994; 149 145-149
16 Yildirim N, Fitzpatric M F, Whyte K F, Jalleh R, Wightman A JA, Douglas N J. The effect of posture on upper airway dimensions in normal subjects and in patients with the sleep apnea/hypopnea syndrome. Am Rev Respir Dis . 1991; 144 845-847
17 Pae E K, Lowe A A, Sasaki K, Price C, Tsuchiya, Fleetham J A. A cephalometric and electromyographic study of upper airway structures in the upright and supine positions. Am J Orthod Dentofac Orthop . 1994; 106 52-59
18 Pracharktam N, Hans M G, Stohl K P, Redline S. Upright and supine cephalometric evaluation of obstructive sleep apnea syndrome and snoring subjects. Angle Orthod . 1994; 64 63-74
19 Martin S E, Marshall I, Douglas N J. The effect of posture on airway caliber with the sleep-apnea/hypopnea syndrome. Am J Respir Crit Care Med . 1995; 152 721-724
20 Miyamoto K, Özbek M M, Lowe A A, Fleetham J A. Effects of body position on tongue posture in awake patients with obstructive sleep. Thorax . 1997; 52 255-259
21 Marklund M, Persson M, Franklin K A. Treatment success with a mandibular advancement device is related to supine-dependent sleep apnea. Chest . 1998; 114 1630-1635
22 L'Estrange P R, Battagel J M, Harkness B. A method of studying adaptive changes of the oropharynx to variation in mandibular position in patients with obstructive sleep apnoea. J Oral Rehabil . 1996; 23 699-711
23 Ryan C F, Love L L, Peat D, Fleetham J A, Lowe A A. Mandibular advancement oral appliance therapy for obstructive sleep apnoea: Effect on awake calibre of the velopharynx. Thorax . 1999; 54 972-977
24 Ryan F C, Love L L. Mechanical properties of the velopharynx in obese patients with obstructive sleep apnea. Am J Respir Crit Care Med . 1996; 154 806-812
25 Bonham P E, Currier G F, Orr W C, Othman J, Nanda R S. The effect of a modified functional appliance on obstructive sleep apnea. Am J Orthod Dentofacial Orthop . 1988; 94 384-392
26 Schmidt-Nowara W W, Meade T E, Hays M B. Treatment of snoring and obstructive sleep apnea with a dental orthosis. Chest . 1991; 99 1378-1385
27 Johnson L M, Arnett G W, Tanborello J A, Binder A. Airway changes in relationship to mandibular posturing. Otolaryngol Head Neck Surg . 1992; 106 143-148
28 Lowe A A, Sjöholm T T, Ryan C F, Fleetham J A, Ferguson K, Remmers J. Treatment, airway and compliance effects of a titratable oral appliance. Sleep . 2000; 23(supp 4) 172-178
29 Ferguson K A, Love L I, Ryan C F. Effect of mandibular and tongue protrusion on upper airway size during wakefulness. Am Rev Respir Dis . 1997; 155 1748-1754
30 Schmidt-Nowara W W, Williamson M S, Olivera D L, Meade T E. The effect of a dental appliance for snoring on upper airway anatomy. Am Rev Respir Dis . 1993; 147 682A
31 Schwab R J, Gupta K B, Duong D. Upper airway soft tissue structural changes with dental appliances in apneics. Am J Respir Crit Care Med . 1996; 153 A719
32 Miyamoto K, Özbek M M, Lowe A A. Mandibular posture during sleep in patients with obstructive sleep apnoea. Arch Oral Biol . 1999; 44 657-664
33 Douglas N J, Jan M A, Yildirim N, Warren P M, Drummond G B. Effect of posture and breathing route on genioglossal electromyogram activity in normal subjects and in patients with the sleep apnea/hypopnea syndrome. Am Rev Respir Dis . 1993; 148 1341-1345
34 Martin S E, Mathur R, Marshall I, Douglas N J. The effect of age, sex, obesity and posture on upper airway size. Eur Respir J . 1997; 10 2087-2090
35 Burger C D, Stanson A W, Sheedy P F, Daniels B K, Shepard Jr W J. Fast-computed tomography evaluation of age-related changes in upper airway structure and function in normal men. Am Rev Respir Dis . 1992; 145 846-852
36 Leither J C. Upper airway shape. Is it important in the pathogenesis of obstructive sleep apnea?. Am J Respir Crit Care Med . 1996; 153 894-898