Prosthodontics

Principles of Prosthodontic Management of

Sleep Apnea Syndrome
Dr. Aparna S Barabde
BDS, MDS
Prof. & PG Teacher
Dept. of Prosthetic Dentistry
V.Y.W.S. Dental College & Hospital, Amravati, India
Dr. Barabde Dental Clinic, Badnera Road Rajkamal Sq
Amravati, India 444 602

Dr. Mradul Gupta

PG Student
Dept. of Prosthetic Dentistry
V.Y.W.S. Dental College & Hospital
Amravati

Dr. R.U.Thombare
MDS,Professor,Dean
Dept of Prosthetic Dentistry
V.Y.W.S. Dental College & Hospital
Amravati
Abstract: Dr. Shailesh M Barabde
Obstructive sleep apnea is a sleep disorder of airflow at the nose and mouth during sleep. It is a MBBS, MD
potentially hazardous condition and appropriate treatment should be strongly advised to all OSA patients. P.D.M.Medical College
Amravati,india
Dentist are becoming increasingly aware of the importance of detection and management of obstructive sleep
apnea. Mandibular repositioning appliance plays an important role in management of OSA. This articles Dr. B.R.Thombare
reviews etiology, clinical features, diagnosis and various treatment options with special reference to oral BDS,MDS
Senior Lecture
appliances how snoring can be controlled prosthodontically by different modalities of scientifically defensible Dept. of Prosthetic Dentistry
Key words: Dental implications, obstructive sleep apnea, AHI, oral appliances approaches. V.Y.W.S. Dental College & Hospital
Amravati, India.

Introduction: problem, as the aim of the prosthodontic

W e spend one third of our lives

asleep and the quality of that sleep
has a real impact on our quality of
life.The understanding of the complex link
between healthy sleep and brain and body
specialty is to
restore, rehabilitate and maintain oral and
stomatognathic health and function, and this
disorder seems to affect the harmony of the oral-
stomatognathic region and challenges the
function is relatively new.1 Sleep apnea is a general health of the individual.7
potentially life-threatening sleep disorder The purpose of this article is to review the
characterized by repeated pauses in breathing anatomic features and etiologic factors of upper
during sleep. The term sleep apnea is derived airway sleep disorders and medical and dental
from the Greek etymology meaning ‘without treatment options.
breath’. Breathing Epidemiology:
pauses can last anywhere from several seconds to Fig. 1: Upper airway space of patient with It is a major medical problem affecting 4% of
minutes, and happen as often as 30 times or more normal anatomy, with unrestricted passage of air the total elderly population. The prevalence
per hour. Ongoing disrupted breathing causes an through upper airway ( Courtesy : Ivanhoe JR, increases dramatically with the increasing age.5
imbalance between the carbon dioxide and Treatment of It has been reported that 10% of men and 5% of
oxygen levels in the bloodstream, as not enough upper airway sleep disorder patients with dental women in the 30-40 year age-group are habitual
carbon dioxide is exiting and not enough oxygen devices, Quintessence 2000:215-31) snorers; prevalence of snoring increases with
is entering the body. 2 age, reaching at least 20% for men and 15% for
Sleep apnea is probably the most prevalent of women in the 50-60 year age-group. Day time
all the sleep disorders and is classi? ed as central, sleepiness is reported by at least 5% of men and
obstructive, or mixed; it may be mild, moderate, 8% of women in the general population. The
or severe. In central sleep apnea (CSA) there is a prevalence of OSAS is around 4% for men and
diminution of oxygen entry into the lungs due to 2% for women in the age-group of 30-60 years.6
the respiratory (chest) muscles failing to act as a Obese and overweight individuals have much
result of a central nervous system disorder. OSA, higher chance of snoring or having obstructive
the most prevalent of all the apneas, is a sleep apnea.2
disturbance in normal sleep patterns and when Etiology and pathogenesis:
combined with excessive day time sleepiness is OSA is characterized by a collapsing of the
termed obstructive sleep apnea syndrome Fig. 2: Upper airway space of snoring patient tongue back out the pharynx during sleep.
(OSAS).3 demonstrates partial closure of airway space Typically, this is because of large tongue, small
Snoring is a common disorder caused by between tongue and posterior wall of pharynx air pathway or abnormal throat anatomy. This
narrowing of the airway producing turbulence of and simulated vibration of uvula ( Courtesy : blockage restricts breathing, lowering the
the inspired or the expired air, causing the palate Ivanhoe JR, Treatment of upper airway sleep concentration of oxygen in the blood until
and other soft structures of the air lumen to disorder patients with dental devices, receptors in carotid sinus are altered to higher
flutter. Light intermittent snoring is ubiquitous in Quintessence 2000:215-31) CO2 levels in the body causing the patient to
adult men and most women and although it could It is evident from the uniqueness, high wake up and normal breathing is restored.
be a nuisance, it is not medically significant. On prevalence and multisystem involvement that the When a patient falls asleep in the supine
the other hand habitual snoring (continuous, upper airway resistance syndrome cries for position, the muscle relaxation causes the base of
every night) usually indicates the onset of OSA attention from the scienti? c sorority. the tongue to approach the posterior wall of the
particularly in overweight men and requires Prosthodontists are more concerned with the pharynx. With the consequent reduced air ? ow,
medical attention.4 management and resolution of this menacing

16 Heal Talk // July-August 2015 // Vol 07 // Issue 06

 Prosthodontics
Barabde, et al.: Principles Of Prosthodontic Management of Sleep Apnea Syndrome
the patient the patient must increase the speed of obstruction.7 Disorder Association as an appropriate treatment
the air? ow to maintain the required oxygen modality for OSA patient.
supply to the lungs. This increase in air? ow Mechanism of oral appliances:
velocity causes vibration of soft tissues, which Oral appliances function by repositioning the
produces snoring.3 tongue and mandible forward and downwards to
The anatomical defects that contribute to the reduce airway collapse.The upper airway is
obstruction are adenotonsillar hypertrophy, divided in three regions:Velopharynx(hard palate
retrognathia and macroglossia. Obesity to tip of uvula),Oropharynx(tip of uvula to tip of
frequently contributes to decrease in size of upper epiglottis) and hypopharynx (tip of epiglottis to
airway by increasing fat deposition or Fig 3:Mallampati Score vocal cords).The velopharynx is the most
compressing the pharynx by superficial fat mass Lateral cephalometric radiographs reveal the common site of primary pharyngeal collapse in
in the tongue.2 diversion of airway column, position of hyoid OSA.The oral appliances has a lateral wall
Clinical feature: bone and craniofacial skeleton for any widening effect on the velopharyngeal and
Sleep apnea is a chronic health problem and is maxillomandibular deficiencies. 9 Fibro-optic oropharyngeal space.1
also a progressive condition which means it can nasopharygoscopy to examine three-dimensional Types of oral appliances:
potentially structure of the airway revealing any anatomic Broadly classified as Mandibular Repositioning
worsen overtime. The signs and symptoms of site of obstruction.2 a p p l i a n c e s ( M R A ) , To n g u e r e t a i n i n g
OSA are as follows: Management of patient with OSA: devices(TRD), and soft palatal lifters.
Characteristic sign and symptoms of OSA: 1 OSA should be treated as a chronic disease MRA are further classified as custom made and
requiring long term, multidisciplinary prefabricated appliances.
management.There are medical,dental Some of the prefabricated oral appliances are as
behavioural and surgical treatment options. follows:1,11
Options for treatment:1
1. Conservative approach: Positive airway
pressure(PAP)
Pharmacologic treatment
Behavioural modification: Weight loss,
Alteration in sleeping position
Oral appliance therapy
2 Surgical invasive
approach:Genioglossus and tongue
advancement
Maxillomandibular advancement
Diagnosis: Laser assisted uvuloplasty (LAUP)
The diagnosis of OSA syndrome typically is Tracheostomy
Uvulopalatopharyngoplasty (UPPP) Fig 5:Aveo-TSD
formed by a comprehensive sleep history,
presence of PAP is highly efficacious in terms of reduction of
characteristic clinical feature , together with the AHI and producing positive outcome,there has
objective demonstration of Sleep disorder.1 It is been significant criticism with regards to its
not solely based on the above parameters but also expense, and local side effect at the nose or
requires demonstration of abnormal respiratory face,or discomfort due to the mask. Oral
events with polysomnography(PSG) which is a appliances has emerged as an alternative to CPAP
gold standard. Some of widely used .
questionnaire are the Berlin Questionnaire,
Epworth Questionnaire and STOP-Bang
questionnaire. Fig 6:TAP (Thornton Adjustable Positioner)
The PSG yields AHI (Apnea Hypopnea
index) that is apnea, hypopnea events divided by
total sleep
time in hours,which is use to determine The
severity of OSA.1,2
Grading of OSA: 1

Fig 7:Silent nite

Fig 4:Continuous positive airway pressure

(CPAP)
The multiple sleep latency test (MSLT) is used to Oral appliance therapy:
establish how rapidly the patients falls asleep to Oral appliances find their greatest success
distinguish it from narcoleps when utilized for simple snoring, upper airway
The mallampati score (grade 1-4). There are 4 resistance syndrome and mild-to-moderate
'grades', and the higher the grade, the smaller the obstructive sleep apnea. A large literature review
air passage, which is another indicator of sleep by Lowe showed that, as group’s oral appliances
disordered breathing, can be used as a predictor of were effective in mild-to-moderate OSA with Fig 8:EMA
sleep apnea particularly in cases where an 75% compliance rate.10 Oral appliance therapy
enlarged tongue seems to be the cause for airway has been accepted by the American Sleep It is found that there is superior treatment

Heal Talk // July-August 2015 // Vol 07 // Issue 06 17

 Prosthodontics
Barabde, et al.: Principles Of Prosthodontic Management of Sleep Apnea Syndrome

response with custom made appliances over aperture guard and soft palate lift appliance and a
prefabricated appliances.1,2,3 The custom made conventional mandibular advancement
appliances includes: appliance. He concluded that nasopharyngeal
aperture guard appliances was the best among the
For dentulous patients: Maxillary and five types of appliances.7
mandibular vacuum-formed splints
Heat polymerized and latched 2-part splint
Twin block appliance
Herbst appliances Fig 12:1. Cephalogram of edentulous state
For edentulous patients: Maxillary and 2. With acceptable VD
mandibular vacuum-formed splints. 3. With increased VD
Dentures with and without increased vertical Suresh Nayar, Jeremy Knox 5 given a simple
dimension Loss or absence of teeth produces technique for fabrication of mandibular
prominent anatomical changes that may advancement appliance for edentulous patient
influence upper airway size and function, such as without increase of vertical dimension
loss of the vertical dimension of occlusion which is simple and easy to use.
resulting into reduction of height of the lower Fig 16: 1.Uvula lift appliance
face and mandibular rotation. Rehabilitation of
edentulous patients with complete dentures is an
integral part of prosthodontic treatment. A
denture not only provides esthetics and improves
the phonetics but also restores the desired
function of mastication and also provides
adequate support to orofacial structures by Fig 13:Mandibular advancement appliance for
restoring altered vertical dimension of face. edentulous patient 5
Besides, it also improves OSA/hypopnea.9
The Cephalometric Evaluation of the Effect
of Complete Dentures on Retropharyngeal Space
and Its Effect on Spirometric Values in Altered 2.Velopharynx and Uvula lift appliance
Vertical Dimension using occlusal jig and
concluded that there was marked increase in the
values more than the values observed in same
subjects wearing complete dentures with
acceptable vertical dimension of occlusion.9

Fig 14:Twin Block appliance

3.Nasopharyngeal aperture guard appliance

Fig 9:Occlusal jig

4.Soft palate lift appliance

Fig 15:Herbst appliance
Advantages of oral appliances: 12
Nonintrusive
Lack of noise
Fig 10:Occlusal surface registered with putty Simplicity
Reversible treatment modality
Smaller and more portable than PAP
No need for power source
Comfortable: fits inside mouth
Lower cost

Soft Palate Lift Appliances:

Those that lift the soft palate are rarely used
because of gag, discomfort and success of laser
and radiofrequency soft palate procedures. A 5.Mandibular advancement and tongue
recent study be Venket R et al describes the use, positioning appliance
four new prosthodontic appliances for managing Discussion:
sleep apnea namely uvula lift appliance, uvula The indication for use of MRA is to treat
Fig 11:Increased vertical dimension using jig and velopharynx lift appliances, nasopharyngeal snoring. MRA is effective in a substantial number

18 Heal Talk // July-August 2015 // Vol 07 // Issue 06

 Prosthodontics
Barabde, et al.: Principles Of Prosthodontic Management of Sleep Apnea Syndrome
of patient with mild to moderate OSA and to a commoncondition but a large number of of Complete Dentures on
much lesser degree in those with severe OSA. A patients remain undiagnosed. In spite of Retropharyngeal Space and Its Effect on
referral is needed from the physician to the dentist significant advances its management in adults Spirometric Values in Altered Vertical
based on clinical history and findings and PSG remains challenging. State of the art treatment Dimension. Indian Journal of Sleep Medicine
.Response to the treatment can be somewhat requires a multidisciplinary approach. The team 2010;5(4).
predicted based on patient preexisting conditions, of experts should be headed by a physician 10. Lowe AA. Dental appliances for treatment of
severity and protrusive capacity of the specializing in Sleep Medicine and should snoring and sleep apnea. In: Kruyger M, Roth
mandible.Protrusion is necessary to make MRA include an Otolaryngologist, an Oral- T,
effective. The most common mandibular Maxillofacial Surgeon, and a Prosthodontist. C- Dement W (Eds). Principles and practice of
repositioning dimension quoted is 50 to 75% of Pap is the primary mode of treatment and is sleep medicine (2nd ed). Philidelphia: WB
maximal protrusion (Approximately 5-7 mm).7 universally successful. Patient compliance, Saunders Co 1994;722-
The advantage of using dentures in however, is low. Weight loss and life-style 11. D Saee S, S Sarin P, Pravin S. Obstructive
edentulous patient during sleep resulted in changes can be curative in cases of mild apnea.4 sleep apnoea: Dental implications and
reducing apnea-hypopnea events in edentulous Because of the established training in TMD treatment
obstructive sleep apnea patient. This occurred ,removable appliance therapy and occlusion, strategies. The Internet Journal of Dental
due to the fact that wearing dentures induces prosthosontic is uniquely suited to educating Sciences 2009;7:1.
modi? cations in the position of the jaw, tongue, dental students in sleep disorder and oral 12. Epstein LJ et al.Clinical guideline for the
soft tissue, and pharyngeal airway space that appliance therapy. Prosthodontist can set new evaluation,management and long term care
may contribute to the reduction of apnea events. standard in developing more in depth dental sleep of OSA
Moreover, since wearing complete dentures medicine training with access to adults.J clin Sleep Med 2009;5(3):263-76
might not change multidisciplinary teams and to ensuring that 13. F. Erovigni,A. Graziano,P.Ceruti, G.
the horizontal mandibular position as oral dental sleep medicine continues to strive for Gassino,A. De Lillo,and S. Carossa,
appliance do, it might help to restore the vertical excellence in management of sleep apnea with “Cephalometric
mandibular position. Thus, the denture itself can oral appliances.1 evaluation of the upper airway
act as an oral appliance and provides esthetic look References: inpatients with complete dentures,”
to the patient.13 1. Barewall,Hagen .Management of Minerva Stomatologica, vol. 54, no. 5,pp.
The disadvantages of wearing dentures snoring 293–301, 2005.
during sleep are due to the fact that they are and obstructive sleep apnea with 14. P. A. Marcus, A. Joshi, J. A. Jones, and
associated with chronic in? ammatory changes, mandibular S. M. Morgano, “Complete edentulism
leading to irritation and alveolar bone resorption positioning and denture use for
in the denture-supporting area. In addition, in- appliances:A prosthodontic approach. elders in New England,” Journal of
creasing the vertical dimension of occlusion can DCNA 58(2014) 159-180 Prosthetic Dentistry, vol. 76, no. 3, pp.
cause strain on temporomandibular joint, and 2. S Meenakshi, N Raghunath. Sleep Apnea: 260–266, 1996.
patient may need more time for adaptation to the More than Just a Noise. J Orofac Res 15. Marklund M, Franklin KA, Sahlin C,
same.14,9 2012;2(2): 76-81. Lundgren R. The effect of a mandibu-
Johal and Battagel 17 stated that increased 3. Padma A, Ramakrishnan N, Narayan V. lar advancement device
vertical dimension decreases the Management of obstructive sleep apnea: A on apneas and sleep in patients with
posteropharyngeal space but mandibular dental obstructive sleep apnea. Chest
advancement appliance bring the forward and perspective. Indian J Dent Res 2007;18:201- 1998;113:707-13.
downward movement of mandible with posterior 09 16. Powell NB, Riley RW, Robinson A.
movement of tongue and soft palate. 4. George Katsantonis. The Management of Surgical management of obstructive
Marklund et al 15 found MADs satisfactorily Obstructive Sleep Apnea in Adults. Missouri sleep apnea syndrome.
treated patients with mild and moderate sleep Medicine Clin Chest Med 1998;19:77-86.
apnea but had poor results with those classified as May/June 2008 Vol. 105 No. 3;262-266 17.Johal A,Battagel JM.Current
severe. They have suggested that oral devices 5. Suresh Nayar, Jeremy Knox. Management of perspective in management of OSA
may not address larger obstructions in the upper obstructive sleep apnea in an edentulous with mandibular advancement
airway, perhaps extending to the epiglottis, and patient with a appliances. Br Dent J 2001; 190:532-6
this may account for their decreased success in mandibular advancement splint: A clinical 18. Knudson RC, Meyer JB Jr, Montalvo R.
these patients. Powell et al 16 believe this may report. J Prosthet Dent 2005;94:108-111 Sleep apnea prosthesis for dentate
also account for the low success rate in treatment 6. Swedish medical research council .Diagnosis patients. J Prosthet Dent
with UPPP. and management of OSA.A state of art 1992;68:109-11.
Oral devices are not a panacea; many patients conference in 19. Sadan A, Novoselsky A, Rogers WA. An
may not achieve satisfactory results and oral Stockholm 1994. alternative technique for mandibular
devices can cause dental complications, 7. Venkat R, Gopichander N, Vasantkumar M. advancement
including TMJ sensitivity, loss of posterior Four novel prosthodontics method for prosthesis fabrication. J Prosthodont
occlusion, tooth movement, tooth managing upper 1998;7:40-4.
sensitivity, and loss of existing restorations. It is airway resitance syndrome: An investigative 20. Lyons MF, Cameron DA, Banham SW.
even possible that an oral device may exacerbate analysis revealing the efficacy of the new Snoring, sleep apnoea and the role of
an existing OSA. Fortunately, most of these nasopharyngeal dental appliances.
conditions are transient with the newer adjustable aperture guard appliance, Indina J Dent Res Dent Update 2001;28:254-6
oral devices. An informed consent (Fig. 9) 2010;21:44-48
describing these possibilities is absolutely 8. Freidman M, Tanyeri H, LaRosa M,
necessary for all patients, including the Landsberg R, Vaidyanathan K, Pieri S, et al.
recommendation that an overnight Clinical predictors of obstructive sleep
polysomnography study be completed. apnea. Laryngoscope 1999;109:1901-07.
Conclusion: 9. Gupta Prachi, Thombare Ram, Singhal
OSA is a serious disease with significant Sameer, Pakhan AJ. Cephalometric
morbidity and should be treated aggressively. It is Evaluation of the Effect

Heal Talk // July-August 2015 // Vol 07 // Issue 06 19