CLINICAL EBOOK SERIES POWERED BY

CURRENT TOPICS IN DENTISTRY:

SLEEP MEDICINE
DECEMBER 2018

2 C E C R E D I T S

SLEEP DISORDERS

CBCT Images and

Early OSA Detection
Thomas M. Bilski, DDS

C L I N I C A L R E V I E W

SLEEP THERAPY

Diagnostic, Evaluation, and Treatment

Approaches Used in Dental Sleep Medicine
Stephen Poss, DDS

SUPPORTED BY AN UNRESTRICTED GRANT FROM THE AMERICAN ACADEMY OF DENTAL SLEEP MEDICINE • Published by AEGIS Publications, LLC © 2018
Good Night, Patients!

T
his special Compendium eBook provides
two articles featuring topics in dental sleep
medicine. The first is a continuing educa-
tion (CE) article on how cone-beam com-
puted tomography (CBCT) can be used to
detect possible sleep disorders, with specific case examples.
The second article is a clinical review that provides further
of Continuing Education in Dentistry
DECEMBER 2018 | www.compendiumlive.com
PUBLISHER
AEGIS Publications, LLC
of Continuing Education in Dentistry
SPECIAL PROJECTS MANAGER
Justin Romano
SPECIAL PROJECTS EDITOR
Cindy Spielvogel of Continuing Education in Dentistry

background on diagnosing and evaluating sleep disorders and SPECIAL PROJECTS COORDINATOR
June Portnoy
offers an overview of treatment options. BRAND DIRECTOR
The CE article explains how CBCT imaging can aid in eval- Matthew T. Ingram
MANAGING EDITOR
uating patients for disorders such as obstructive sleep apnea Bill Noone
(OSA). CBCT imaging can be used to investigate the dimen- CREATIVE
Claire Novo
sions of upper airways, contributing to the diagnosis of pos-
EBOOK DESIGN
sible upper-airway obstruction. As the author explains, CBCT Jennifer Barlow

imaging can provide the clinician with measurements and

COVER
quantifying information regarding congenital dental agen- © AEGIS Publications,, LLC

esis, premature dental extraction, tongue position, mandible
position, and relative hyoid position, information needed to
diagnose OSA and other sleep disorders.
For a more in-depth look at some of the topics discussed
in the CE article, this eBook also includes an article that re-
views methods for diagnosing and treating sleep-disordered
breathing. Several screening, diagnostic, and treatment
advancements have become available in recent years, sup-
ported by published literature regarding their efficacy and
appropriateness for identifying and resolving different types
of obstructions. These resources provide dentists and their
sleep physician colleagues with tools to help make decisions
on how best to treat patients. As the author asserts, dentists
working with patients with sleep-disordered breathing will
do well to pursue quality ongoing education and training, as
well as strong collaborative relationships with sleep physi-
cian colleagues.
Compendium provides dental education in many forms,
both as CE and other informational articles. For more infor-
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CONTINUING EDUCATION 1 SLEEP DISORDERS

CBCT Images and Early OSA

Detection
Thomas M. Bilski, DDS

ABSTRACT: Sleep disturbances in general and obstructive sleep apnea (OSA) in particu-
lar are related to other health conditions, such as cardiovascular disease, type 1 and type
2 diabetes, hyperinsulinemia, dementia, hypertension, migraines, and weight gain. Cone-
beam computed tomography (CBCT) examinations can be used to evaluate patients for
potential OSA when they are still adolescents. CBCT images allow a focus on airway vol-
ume, soft-palate area, and soft-tissue thicknesses that can be measured before and after
rapid maxillary expansion. This article explains the use of CBCT for evaluating possible
sleep disorders and describes dental conditions that can lead to early OSA, as illustrated
by a familial case.

LEARNING OBJECTIVES

• Define obstructive sleep • Describe how cone-beam • Discuss how dentistry can
apnea (OSA) and its computed tomography can contribute to the treatment
ramifications. help detect OSA, particularly of patients with OSA.
in young patients.

S
cientific literature on sleep dis-
orders suggests that patients may
be diagnosed when they are young,
as early as adolescence.1 However,
dental professionals are not al-
ways in agreement regarding the tools to
implement for diagnosis, such as cone-beam
computed tomography (CBCT). Opinions are
divided regarding the reliability of detecting
sleep disorders by using CBCT to conduct
upper-airway analysis, diagnosis, and treat-
ment planning. Accepting the use of CBCT
depends on the knowledge of the individual
clinician. CBCT scans provide accurate static
images of airways; however, clinicians should
also include dynamic assessments. The stat-
ic CBCT images focus on the well-defined
bony and soft-tissue relationships; they also
DISCLOSURE: The author had no disclosures to report.
quantify tongue position, mandibular con-
figuration, hyoid-to-mandible relationship,
and airway obstruction/narrowing. Upper-
airway analysis with CBCT images may
also reveal missing adult dentition, airway
morphology, smaller pharyngeal volume
with smaller cross-sectional area, tongue
position relative to the palate, shorter man-
dibular length, and flatter mandibles. Hence,
CBCT, a radiographic imaging method that
allows 3-dimensional (3D) imaging of hard-
tissue structures, has been introduced as an
effective diagnosis method to evaluate upper
airways.2-5
Missing Teeth and Sleep Apnea
Missing teeth in early childhood can result in
abnormal facial morphology with a narrow

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 3

 CONTINUING EDUCATION 1
upper airway.6 Dental agenesis, which is the
manifestation of missing permanent teeth, is
the most prevalent craniofacial anomaly in hu-
mans.7 The potential association between den-
tal agenesis or early dental extractions and the
presence of OSA has been investigated.6 OSA
causes breathing to repeatedly stop and start
during sleep; this type of apnea occurs when
the throat muscles intermittently relax and
block the airway. A noticeable sign of OSA is
snoring. OSA is characterized by upper airway
collapsibility, repetitive pharyngeal collapse
during sleep. Therefore, one variable used in
describing the mechanics of the upper airway
is to measure its propensity for collapse.8
A study was conducted of 31 children with
dental agenesis and 11 children with early den-
tal extractions who had at least two perma-
nent teeth missing.6 All children with missing
teeth had identifiable clinical signs of OSA.
There was a significant difference in mean
apnea-hypopnea indices (AHI) in the agen-
esis, dental extraction, and tonsillo-adenoid
studied groups, with mean abnormal AHI
lowest in the pediatric dental agenesis group.
In the children with missing teeth, aging was
associated with the presence of a higher AHI.
When a child has dental agenesis or early ex-
tractions, over time a breathing pattern devel-
ops due to alveolar bone growth in the absence
of teeth. Alveolar bone growth is dependent
on the presence of the teeth that it supports.
Children with permanent teeth missing due
to congenital agenesis or permanent teeth ex-
traction have smaller oral cavities. Patients
with smaller oral cavities are predisposed to
collapse of the upper airway during sleep and
present with OSA symptoms as they mature.9
Parents of these children often do not recog-
nize these symptoms due to the low-grade ini-
tial symptomatology. Daytime mouth breath-
ing and sleep-disordered breathing, if left
untreated for a prolonged period, suggest that
worsening symptoms will occur over time.6
Sleep disturbances in general and OSA in
4 COMPENDIUM EBOOK SERIES December 2018
SLEEP DISORDERS
Fig 1. Fig 2.
Fig 1 and Fig 2. Airway morphology.
particular are related to other health condi-
tions, such as cardiovascular disease, type 1
and type 2 diabetes, hyperinsulinemia, de-
mentia, hypertension, migraines, and weight
gain, the latter due to increases in cortisol and
insulin hormone levels and decreases in hu-
man growth hormone (reducing lean muscle
mass and forcing fat to be stored as energy,
resulting in weight gain).10 To identify poten-
tial OSA patients during adolescence, CBCT
examinations can help evaluate airway vol-
ume, soft-palate area, and soft-tissue thick-
nesses that can be measured before and after
rapid maxillary expansion. Rapid maxillary
expansion causes significant increases in nasal
cavity volume, nasopharynx volume, anterior
and posterior (A-P) facial heights, and palatal
and mandibular planes.11
CBCT Images and Diagnostic
Information
The morphology of the airway can be evalu-
ated with CBCT images. Understanding the
length and width of the upper airway is impor-
tant to assess the pathology and the physiology
of OSA and deliver the appropriate treatment
therapies that best fit the patient’s needs and
predict effectiveness of the treatment. Wider
and shorter upper airways display less airway
resistance than narrow and long upper air-
ways, which have an increase in airway resis-
tance. Increase in airway resistance evokes
inflammation of the airway, creating more
inflammation and, therefore, increasing the
severity of OSA. Figure 1 and Figure 2 display
different morphologies in airways, as shown
through CBCT imaging.9
CONTINUING EDUCATION 1
Fig 3.
Using CBCT with a patient in a sitting posi-
tion has been a topic of discussion because
changes in posture can create an obstructed
airway that differs from the position of the
airway when the patient is in a sleeping posi-
tion. Because a CBCT image is static, when
obtaining the image, the teeth should remain
in occlusion to prevent posterior movement
of the mandible and surrounding soft tissues
(tongue, nasopharynx, oropharynx, and hy-
popharynx). Figure 3 shows a narrow upper
airway of a patient in a sitting position dem-
onstrating an airway obstruction. When the
patient is in a sleeping position, the obstruc-
tion is more pronounced (Figure 4).
Additional information gathered from the
CBCT images shows the distinct airway divi-
sions, tongue size/position, and relative hyoid
position, all critical in developing a diagno-
sis and a decision to refer to a physician to
begin the process of either clinical or home
sleep studies. The sleep study provides the
physician with information regarding sleep
disturbances and how these disturbances may
potentially lead to overall diminishing health,
fatigue, and metabolic disturbances. After a
diagnosis has been confirmed, the physician
is able to discuss therapies that best suit the
needs and compliance considerations of the
patient. If the physician determines that the
patient will not benefit from continuous posi-
tive airway pressure (CPAP) or bilevel positive
Fig 4.
www.compendiumlive.com
SLEEP DISORDERS
Fig 4.
Fig 3. Open and obstructed airway, sitting posi-
tion. Fig 4. Open and obstructed airway, sleeping
position.
airway pressure (BiPAP) due to lack of com-
pliance or claustrophobia, then the patient
has an option to be referred to a dentist who
is well versed and trained in providing OSA
oral appliance therapy (OAT).12
Finally, the patient is evaluated face to face
in the dental practice for medical history re-
view, dynamic evaluations within the temporo-
mandibular joint (TMJ) assemblies, thorough
periodontal review, caries risk assessment, and
overall satisfactory condition that allows for a
stable sleep oral appliance. Scheduled follow-
ups should be discussed after the seating of the
OAT in the following intervals for the first year:
1 week, 3 weeks, 6 weeks, 3 months, 6 months,
and 1 year.13 The patient should return to the
referring physician for evaluation of sleep pat-
tern and well checks.
Familial Case of Dental Agenesis
Four brothers with dental agenesis are currently
being evaluated and treated by the author with
CBCT imaging and digital treatment planning to
regain their dentition. Developing arch form and
palatal positioning by using CBCT imaging and
digital software is critical. Much is learned from
evaluating CBCT images and the advancement
of virtual implant therapies. Combined with
durable medical equipment and orthopedic/
mandibular repositioning appliances, normal
daytime breathing and normal sleep breathing
patterns can be achieved through surgical dental
December 2018 COMPENDIUM EBOOK SERIES 5
 CONTINUING EDUCATION 1 SLEEP DISORDERS

Fig 5.
Fig 6.

Fig 7.

Fig 8.

Fig 9

Fig 10.

Fig 11

Fig 5. Panoramic radiograph, 18-year-old brother.

Fig 6. Photograph, 18-year-old brother.
Fig 7. Panoramic radiograph, 14-year-old brother.
Fig 8. Photograph, 14-year-old brother.
Fig 9. Panoramic radiograph, 25-year-old brother.
Fig 10. Photograph, 25-year-old brother.
Fig 11. Panoramic radiograph, 27-year-old brother.
Fig 12.
Fig 12. Photograph, 27-year-old brother.

implant services, orthodontic services, and long-
term dental restorations that reposition the
mandible and create a comfortable tongue
position within the oral cavity. In the author’s
experience, CBCT in these situations provides
a considerable amount of diagnostic informa-
tion, improves quality of life, and improves the
opportunity to enjoy a healthier lifestyle without
the previously mentioned diseases of civilization.
Figure 5 through Figure 12 exemplify what
currently may present in private dental prac-
tices with these types of patients. Four brothers
aged 14 years to 27 years all suffered from ob-
structed airways; high incidence of caries of
dentin, enamel, and cementum; moderate
periodontal disease; collapsed vertical; undi-
agnosed OSA; and the potential for increase in
comorbidities such as diabetes, cardiovascu-
lar disease, dementia, cancer, high blood pres-
sure, and others. Symptomology was presented
throughout the young lives of the brothers in
this family. The parents were unaware that
the dental agenesis and premature permanent
tooth extraction could have led their sons into

6 COMPENDIUM EBOOK SERIES December 2018

CONTINUING EDUCATION 1 SLEEP DISORDERS

severe health issues as they matured. ABOUT THE AUTHOR

Swift intervention took place with caries Thomas M. Bilski, DDS
control, periodontal care, orthodontic evalu- Co-Director, Midwest Implant Institute
Columbus, Ohio
ation for arch form development to aid in the Private Practice
development of facial bones and creating an Independence, Ohio
improved upper airway with nasal patency. REFERENCES
These interventions were followed up with 1. Young T, Peppard PE, Gottlieb DJ. Epidemiology of
definitive implant therapies and rapidly ad- obstructive sleep apnea: a population health perspec-
tive. Am J Respir Crit Care Med. 2002;165(9):1217-
vancing restorative technology and materials. 1239.
Thus, not only were these young men’s smiles 2. Kumar M, Shanavas M, Sidappa A, Kiran M. Cone
restored, they also were provided with the op- beam computed tomography - know its secrets. J Int
portunity to regain their dignity when they Oral Health. 2015;7(2):64-68.
3. Aboudara C, Nielsen I, Huang JC, et al. Comparison
become confident with their new smiles. of airway space with conventional lateral headfilms
and 3-dimensional reconstruction from cone-beam
Conclusion computed tomography. Am J Orthod Dentofacial Or-
thop. 2009;135(4):468-479.
CBCT imaging is a tool that is recommended for 4. Hatcher DC. Cone beam computed tomography:
use in investigating the dimensions of upper air- craniofacial and airway analysis. Dent Clin North Am.
ways and contributing to the diagnosis of possible 2012;56(2):343-357.
upper-airway obstructions.2-5 The 3D scan mea- 5. Lenza MG, Lenza MM, Dalstra M, et al. An analysis
surements of CBCT can be helpful in evaluating of different approaches to the assessment of upper
airway morphology: a CBCT study. Orthod Craniofac
upper-airway patency in patients suspected to be Res. 2010;13(2):96-105.
suffering with sleep disorders. The upper airway 6. Guilleminault C, Abad VC, Chiu HY, et al. Missing
is the final common pathway for abnormalities teeth and pediatric obstructive sleep apnea. Sleep
Breath. 2016;20(2):561-568.
in respiratory control and neuromuscular func- 7. Shimizu T, Maeda T. Prevalence and genetic basis of
tion leading to sleep apnea. Patients with OSA tooth agenesis. Jpn Dent Sci Rev. 2009:52-58.
have a smaller upper airway compared with other 8. Malhotra A, Pillar G, Fogel R, et al. Upper-airway
individuals, with the exception of airway length.4 collapsibility: measurements and sleep effects. Chest.
2001;120(1):156-161.
The lack of a significant difference in the aver- 9. Rivlin J, Hoffstein V, Kalbfleisch J, et al. Upper airway
age A-P distance indicates that patient position morphology in patients with idiopathic obstructive
during imaging (vertical versus horizontal) can sleep apnea. Am Rev Respir Dis. 1984;129(3):355-360.
10. Mesarwi O, Polak J, Jun J, Polotsky VY. Sleep
affect this measurement. However, if there is a
disorders and the development of insulin resis-
visible decrease in upper airway with the patient tance and obesity. Endocrinol Metab Clin North Am.
in a sitting position during imaging, then one 2013;42(3):617-634.
can be certain there is a high potential for this 11. Smith T, Ghoneima A, Stewart K. Three-dimension-
al computed tomography analysis of airway volume
patient to show signs of OSA while in a sleeping changes after rapid maxillary expansion. Am J Orthod
position.14 CBCT imaging is rapidly evolving to Dentofacial Orthop. 2012;141(5):618-626.
the point where it is difficult to keep up with the 12. Mohsenin N, Mostofi MT, Mohsenin V. The role of
technological advancements. CBCT imaging oral appliances in treating obstructive sleep apnea. J
Am Dent Assoc. 2003;134(4):442-449.
provides the clinician with many measurements 13. Silverman L, Razavi M. Seven appointment protocol
and quantifying information regarding congeni- for OSA treatment. Sleep 101 dental sleep medical
tal dental agenesis, premature dental extraction, model. June 24-25, 2013.
14. Baik UB, Suzuki M, Ikeda K, et al. Relationship be-
tongue position, mandible position, and relative tween cephalometric characteristics and obstructive
hyoid position, ultimately providing the informa- sites in obstructive sleep apnea syndrome. Angle Or-
tion required for diagnosis. thod. 2002;72(2):124-134.

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 7

 CONTINUING EDUCATION QUIZ
1 QUIZ 2 Hours CE Credit

CBCT Images and Early OSA Detection

Thomas M. Bilski, DDS

TAKE THIS FREE CE QUIZ BY CLICKING HERE: compendiumlive.com/go/ccedsleepdec

ENTER PROMO CODE: SLEEPDEC

1. The static CBCT image can quantify: 6. Sleep disturbances in general and OSA in par-
A. tongue position. ticular are related to:
B. mandibular configuration. A. cardiovascular disease.
C. airway obstruction/narrowing. B. type 1 diabetes.
D. all of the above C. dementia.
D. all of the above
2. What type of analysis may reveal missing
adult dentition, airway morphology, and small- 7. R
 apid maxillary expansion causes:
er pharyngeal volume, among other details? A. significant increases in nasal cavity volume.
A. upper-airway analysis with CBCT B. significant decreases in nasal cavity volume.
B. lower-airway analysis with CBCT C. significant decreases in anterior and posterior
C. nephrologic analysis with MRI (A-P) facial heights.
D. pneumatic volume assessment D. significant increases in snoring.

3. W
 hat is the most prevalent craniofacial anomaly 8. Wider and shorter upper airways display:
in humans? A. more airway resistance.
A. dens indente B. less airway resistance.
B. dental agenesis C. more inflammation.
C. tryptic occulus D. worse OSA.
D. impacted third molars
9. S
 leep disturbances may lead to:
4. A noticeable sign of OSA is: A. overall diminishing health.
A. obesity. B. fatigue.
B. snoring. C. decreased metabolic disturbances.
C. gasping. D. Both A and B
D. cardiac arrhythmia.
10. A patient who will not benefit from CPAP or
5. Patients with what type of oral cavities are BiPAP may be a candidate for:
predisposed to collapse of the upper airway A. GOAT.
during sleep and present with OSA symptoms B. MOAT.
as they mature? C. OAT.
A. smaller D. COAT.
B. larger
C. edentulous
D. prognathous

Fig 6.

Fig 11.
Course is valid from 12/1/2018 to 12/31/2021. Participants
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8 COMPENDIUM EBOOK SERIES December 2018

CLINICAL REVIEW SLEEP THERAPY

Diagnostic, Evaluation, and

Treatment Approaches Used in Dental
Sleep Medicine
Stephen Poss, DDS

ABSTRACT: While some causes or symptoms of sleep-disordered breathing can be

identified visually upon oral examination or by observing radiographic images, es-
tablishing a diagnosis of this disorder and determining its severity requires the use of
specific diagnostic testing. This article reviews diagnostic and evaluation technologies,
as well as surgical and nonsurgical treatments, currently available for dentists collabo-
rating in the treatment of patients with sleep breathing disorders, including snoring

S
and obstructive sleep apnea.

leep-disordered breathing (eg, most of their patients every 6 to 12 months,

snoring, obstructive sleep apnea)
affects an estimated 24% or more
of adults and contributes to such
life-threatening conditions as
hypertension and high blood pressure, heart
failure, diabetes, stroke, depression, and
obesity.1,2 It is also associated with serious
motor vehicle, work-related, and at-home
accidents.3 Characterized by recurring ces-
sations or reductions in breathing during
sleep, sleep-disordered breathing involves
loss of the normal “awake” or “upright” tone
and position of the oral cavity and oropha-
ryngeal musculature. In some instances, the
tongue falls back into the oropharynx, or the
airway narrows, collapses, or otherwise be-
comes obstructed. Sleep-disordered breath-
ing results from obstructions and/or upper
airway collapse, some of the causes or symp-
toms of which can be identified visually upon
oral examination and others by examining
radiographic images.4,5
Among the anatomical characteristics that
may contribute to sleep-disordered breathing
that could be observed during a dental exami-
nation are macroglosia, narrow mandibular
arch, high palatal vault, large uvula, and en-
larged tonsils. Considering that dentists see
they may be the first healthcare professionals
to suspect a patient is suffering from sleep-
disordered breathing. Other contributing an-
atomical characteristics that can be observed
radiographically include a larger distance
between the mandibular plane and hyoid
bone,6 posterior displacement of the sym-
physis,7 and other disproportionate relation-
ships between the tongue base, soft palate,
cranial base, pterygoid processes, cervical
spine, and others.8
Visual examination and radiographic ap-
proaches are helpful for identifying the signs
of, and anatomical characteristics potentially
contributing to, sleep-disordered breathing.
However, establishing a diagnosis of sleep-
disordered breathing and determining the se-
verity of the disorder (ie, snoring, obstructive
sleep apnea, mild-moderate-severe) require
the use of specific diagnostic testing (eg, poly-
somnography, portable home sleep study).
Depending upon the state in which dentists
practice, they may be limited to screening for
the condition or administering a sleep apnea
test, and prohibited from rendering a diagno-
sis or prescribing a specific treatment because
the tests must be interpreted—and a correct
diagnosis rendered—by a physician.9,10

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 9

 CLINICAL REVIEW SLEEP THERAPY

Fig 1.C
A

Fig 1.
Fig 1. Portable home sleep studies are increasingly being utilized based on their ease of at-home use by
patients compared to polysomnography. These systems typically include: (A) a nasal cannula to measure
airflow; (B) a pulse oximeter to measure oxygen saturation levels and heart rate; and (C) a respiratory
effort sensor belt for measuring respiratory effort.

Fortunately, since dental sleep medicine
began gaining greater attention more than 20
years ago, dentists and sleep physicians are in-
creasingly collaborating to enhance the timeli-
ness of sleep-disordered breathing diagnoses
and appropriateness of treatment. Further, a
variety of diagnostic/evaluation technologies
and treatment approaches have been studied
and reviewed in recent years to enable dentists
and their sleep physician colleagues to deter-
mine the most appropriate treatment options
for individual patients, based on the cause of
their sleep-disordered breathing and the extent
of the problem. This article briefly reviews diag-
nostic and evaluation technologies and surgical
and nonsurgical treatments currently available
for dentists collaborating in the treatment of
patients with sleep breathing disorders.
training in dental sleep medicine can identify pa-
tients with the signs and symptoms of this condi-
tion. When signs of sleep-disordered breathing
are discovered, asking questions about the pa-
tient’s sleep habits and sleep quality can confirm
the need for diagnostic testing and referral to a
board-certified sleep medicine physician.
Polysomnography
Polysomnography was originally the “go-to”
method for diagnosing sleep apnea and sleep-
disordered breathing. Although considered
the most accurate approach for diagnosing
patients with this condition, simpler and less
complicated methods were needed to over-
come the expense, labor intensity, and poorly
tolerated instrumentation inherent with
polysomnography.11

Diagnostic Technologies Portable Home Sleep Study

Because some of the anatomic features that con- Portable home sleep studies gained in popu-
tribute to sleep-disordered breathing can be ob- larity as an alternative, largely because they
served during an oral examination, dentists with can be performed at home and involve a less

10 COMPENDIUM EBOOK SERIES December 2018

CONTINUING
CLINICAL EDUCATION 1
REVIEW
complicated procedure (Figure 1). Requiring
less monitoring and well-tolerated by patients,
portable home sleep studies have been shown
to demonstrate high specificity and sensitivity
for identifying patients with sleep apnea.11
When the diagnosis reveals moderate to
severe sleep apnea and/or obstructive sleep
apnea, further diagnostics and evaluation of
maxillofacial, oropharyngeal, and upper air-
way anatomy are required. These additional
diagnostics and evaluations help to identify
the anatomical cause and extent of the ob-
struction, and guide dentists and sleep physi-
cians in their decisions regarding the most ap-
propriate treatment approach for the patient.
Radiographs and CBCT
Dental radiographs and cone-beam computed
tomography (CBCT) play significant roles in as-
sessing patients with sleep-disordered breath-
ing, enabling more precise identification of the
areas and extent of airway obstructions.8 In
particular, 3-dimensional (3-D) CBCT images
allow analysis of the airways and specific maxil-
lofacial, oropharyngeal, and other anatomy that
may be involved with sleep-disordered breath-
ing. Considering that years of research have
identified radiographically visible anatomical
characteristics and obstructions in patients
with sleep-disordered breathing, CBCTs in the
dental practice can be a valuable screening and
treatment planning tool.8
For example, attempts were made to identify
upper airway abnormalities in patients with
idiopathic obstructive sleep apnea. Cross-
sectional analysis of cephalometric roent-
genograms revealed that the patients studied
had smaller mandibles and overall posterior
displacement of the mandibular symphysis,
and that there was a correlation between
the number of apnea episodes and posterior
displacement. This suggested a correlation
between idiopathic obstructive sleep apnea
and upper airway occlusion that is not visible
www.compendiumlive.com
SLEEP THERAPY
SLEEP DISORDERS
during an oral examination.7
Similarly, cephalometric roentgenograms
have been studied and shown to indicate
the presence of small posterior airway
space and inferiorly placed hyoid bone in
patients with obstructive sleep apnea who
required palatopharyngoplasty (PPP) in
order to better identify the soft-tissue ob-
struction location.12 Additionally, other
dentofacial features (eg, retrognathia, mi-
crognathia, skeletal Class II, long soft pal-
ate, tonsillar hypertrophy, inferior hyoid
bone position) of patients with obstructive
sleep apnea have been identified and cat-
egorized through cephalometric evaluation
and found to correspond to specific types of
obstructive sleep apnea.13
In more recent years, studies have fo-
cused on the manner in which the use of
CBCT scans could potentially lend greater
precision to analyzing the maxillofacial
and airway characteristics of patients with
sleep-disordered breathing. However, more
research and discussion are needed to con-
firm the full extent to which CBCTs can ben-
efit dentists when collaborating with sleep
physicians in the diagnosis, screening, and
treatment planning of patients with sleep-
disordered breathing.
Among the relevant research conducted, a
2009 study compared imaging information
about nasopharyngeal airway size between
lateral cephalometric headfilms and 3-D
CBCT scans and found considerable vari-
ability in the airway volumes of patients with
similar airways among the lateral headfilms,
whereas the 3-D CBCT scans were found to
be simple and effective for accurately analyz-
ing the airway.5 Subsequently, CBCTs have
been used to determine linear, volumetric,
and cross-sectional airway area measure-
ments in patients with sleep-disordered
breathing, ultimately determining that the
areas where most airway constriction occurs
December 2018 COMPENDIUM EBOOK SERIES 11
 CLINICAL REVIEW
Fig 2.
Fig 2. These CBCT images demonstrate the airway space before an oral appliance is placed (left, pre-
treatment: total volume 2.2 cc; minimum area 41.1 mm2) and the increased volume of airway space with
an oral appliance (right, post-treatment: total volume 12.6 cc; minimum area 306.8 mm2).
can vary, with the variation correlating in part
to age and gender.14
Other research has also suggested that CBCT
airway analysis could be useful in assessing
the presence and severity of obstructive sleep
apnea, noting that these parameters are asso-
ciated with a narrow lateral dimension of the
airway, among other individual traits.15 What’s
interesting to note, however, is that what may
affect the accuracy and utility of CBCT scans
in dental sleep medicine is the position in
which the patient is situated at the time the
scans are taken. Whereas images taken with
the patient in an upright position (eg, cepha-
lometric views) do not realistically reflect a
patient’s airway during sleeping, the supine
position required for CBCTs may enable more
accurate assessment of airway, soft palate, and
volumetric measurements and identification
of obstruction locations.15
Treatments for Sleep-Disordered
Breathing
The results of these radiographic-based in-
vestigations suggest that using CBCTs in
screening, diagnosing, and treatment plan-
ning patients with sleep-disordered breath-
ing—and particularly obstructive sleep
12 COMPENDIUM EBOOK SERIES December 2018
SLEEP THERAPY
apnea—can be beneficial, especially prior to
planning surgical interventions. They also
underscore the need to consider the location
of the obstruction along the airway to ensure
treatment efficacy.16 For example, the further
down the airway an obstruction is located,
the less likely that an oral appliance will be
effective in treating the sleep-disordered
breathing condition.16
Continuous Positive Airway Pressure
(CPAP)
The most prescribed and recommended treat-
ment for moderate to severe obstructive sleep
apnea is continuous positive airway pressure
(CPAP). With a 70% acceptance rate, CPAP
machines require patients to wear a mask dur-
ing nighttime sleep. The unit introduces air
into a person’s nasal passage and exerts posi-
tive pressure to open the upper airway, which
enables him or her to breathe.11
Appliance Therapy
Oral appliances have been widely used to treat
sleep-disordered breathing and have been shown
to lessen the severity of the condition by 60%;
additionally, like CPAP machines, they have
an acceptance rate of approximately 70%.17,18
CLINICAL REVIEW SLEEP THERAPY

Currently, there are more than 40 types of oral that reduce soft-palate redundancy (ie, uvu-
appliances available, all categorized according to lopalatopharyngoplasty [UPPP], uvulopala-
their design or mechanism of action (eg, tongue- tal flap, laser-assisted uvulopalatoplasty, and
retaining or mandibular advancement). soft-palate radiofrequency ablation with ad-
Mandibular advancement oral appliances enotonsillectomy). 21
More drastic procedures
(either fixed or adjustable) have been the non- for more severe cases of obstructive sleep ap-
surgical method of choice and shown to be suc- nea include genioglossal advancement, hyoid
cessful in the treatment of sleep-disordered suspension, distraction osteogenesis, tongue
breathing when patients cannot tolerate CPAP radiofrequency ablation, lingualplasty, and
machines and have mild to moderate sleep maxillomandibular advancement.21
apnea (Figure 2).1,9-11,16-18 In fact, mandibular Nasal surgeries—Nasal surgeries address
advancement devices have been shown to re- obstructions created by hypertrophied, car-
duce both systolic and diastolic blood pressure tilaginous, or bony tissues in the nasal airway.21
among patients with obstructive sleep apnea,16 Although they cannot significantly improve
as well as improve blood oxygen saturation sleep breathing in patients with moderate
levels and reduce the apnea-hypopnea index to severe sleep-disordered breathing, nasal
(AHI).11 However, these devices may present surgeries do help to enhance CPAP compli-
complications, including occlusal changes, ance, as well as prevent or minimize the mouth
temporomandibular joint discomfort, fabri- breathing that can ultimately force the tongue
cation issues, and high cost.19 into the posterior pharyngeal area, thereby
Additionally, despite the relatively high ac- exacerbating sleep breathing conditions.
ceptance rate associated with oral applianc- Mandibular osteotomy with genioglossus ad-
es, consistent patient compliance in terms vancement—When upper airway obstruction
of nightly wear remains an issue. However, occurs at the base of the tongue, moving the
oral devices such as SomnoDent® with CR geniotubercle or the hyoid complex forward
(SomnoMed, somnomed.com) incorporate will stabilize the tongue base as well as the re-
some of the compliance features used with a lated pharyngeal dilators.21 With mandibular
CPAP. Designed specifically to objectively re- osteotomy with genioglossus advancement, a
cord compliance measurements when patients limited parasagittal mandibular osteotomy is
use the oral appliance to treat obstructive sleep used to advance the geniotubercle of the man-
apnea, SomnoDent contains a thermal sensor dible forward, force an anterior advancement
and accelerometer “chip” (DentiTrac®) embed- of the tongue base, and enlarge the retrolingual
ded and sealed within it to measure hours worn airway. Depending on the severity of the sleep-
and record head position.20 disordered breathing, success rates for this pro-
cedure have ranged from 35% to 60%, with the
Surgical Interventions most serious complications being mandibular
Upper airway surgery is considered the last fracture, infection, permanent anesthesia, and
resort and reserved for patients who have not seroma.21 However, it is usually performed with
responded to other available treatment op- UPPP to enhance the upper airway space and
tions (eg, CPAP, oral appliance). The variety eliminate the need for additional procedures,
of surgeries performed to reduce upper airway such as hyoid myotomy suspension.
obstructions range from those focused on na- Hyoid myotomy suspension—Considered part
sal obstructions (ie, septoplasty, turbinectomy, of phase I treatment, although not necessar-
turbinate radiofrequency ablation) to those ily performed simultaneously with mandibular

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 13

 CLINICAL REVIEW
osteotomy with genioglossus advancement,
hyoid myotomy suspension focuses on moving
the hyoid complex forward to enhance the air-
way space behind the tongue.21 Many patients,
however, find this procedure difficult to tolerate,
which is why alternative approaches (eg, man-
dibular osteotomy with genioglossus advance-
ment combined with UPPP) are undertaken.21
Uvulopalatopharyngoplasty (UPPP)—This
surgical approach excises the uvula and pos-
terior palatal area and trims and reorients
the posterior and anterior lateral pharyngeal
pillars in order to enlarge the retropalatal
airway, and is also considered part of phase
I treatment.21,22 In recent years, lasers have
been used for tissue incisions and vaporiza-
tion when shortening the uvula and modifying
the soft palatal tissue.23 Usually performed in
combination with other procedures (eg, ad-
enotonsillectomy, advancement), UPPP has
only been 41% successful in treating sleep-
disordered breathing, particularly obstructive
sleep apnea syndrome; is quite comfortable;
and is only 5% effective if retrolingual nar-
rowing exists.22 Complications have included
dysphagia, persistent dryness, and nasopha-
ryngeal stenosis,21 and, overall, inconsistent
outcomes and adverse effects have been re-
ported as a result of pharyngeal surgeries.23
Further, the success of such surgical inter-
ventions is predicated on precisely locating
the soft tissue and obstruction,12 which un-
derscores the need for appropriate techniques
when analyzing cephalometric and/or radio-
graphic images. UPPP is not recommended
when imaging has confirmed a retrolingual
narrowing or retrolingual collapse during ap-
neas.22 Instead, maxillofacial surgery is rec-
ommended for patients suspected of having
hypopharyngeal collapse.22
Maxillomandibular advancement osteotomy
(MMA)—In MMA surgery, the velo-orohypopha-
ryngeal airway is enlarged by advancing the soft
palate, tongue base, and suprahyoid musculature
14 COMPENDIUM EBOOK SERIES December 2018
SLEEP THERAPY
(ie, anterior pharyngeal tissues) that are attached
to the maxilla, mandible, and hyoid bone.23 The
multilevel skeletal surgery also involves LeFort I
and bilateral sagittal split rami osteotomies and
stabilization using bone grafts, plates, or screws.23
Considered part of phase II treatment, MMA has
been shown to produce substantial and consis-
tent reductions in the AHI.23
Although MMA surgery can help to reduce the
health risks associated with obstructive sleep
apnea,24 the efficacy of surgical interventions
overall for the treatment and management of
sleep-disordered breathing remains a topic of
debate and study, particularly when the condi-
tion cannot be attributed to specific anatomic
attributes of the upper airway.8 Nevertheless,
advancing the mandibular arch through MMA
has proven more successful than other surgical
techniques in reducing AHI, but more research
is still needed in the areas of morbidity, patient
selection, and long-term efficacy.23
Conclusion
Several screening, diagnostic, and treatment
advancements for patients with sleep-disor-
dered breathing—and published literature
regarding their efficacy and appropriateness
for identifying and resolving different types
of obstructions—have become available in re-
cent years. Combined, they provide dentists
and their sleep physician colleagues with re-
sources on which to base their decisions re-
garding how best to treat patients with sleep-
disordered breathing.
Paramount to the success of any treatment
that is undertaken is knowledge of the cause
of the problem (ie, type, extent, and location
of the obstruction). Although some of these
causes can be determined through a visual
oral examination, others must be more thor-
oughly identified through precise diagnostic
imaging. Additionally, given the growing body
of evidence that supports and/or cautions
against the application of different diagnostic
CLINICAL REVIEW
techniques and treatment approaches, it is in-
cumbent upon dentists working with patients
with sleep-disordered breathing conditions to
pursue quality and reputable ongoing continu-
ing education and training, as well as develop
strong and mutually respectful collaborative
relationships with sleep physician colleagues.
ABOUT THE AUTHOR
Stephen Poss, DDS
Private Practice
Poss Dental Designs
Brentwood, Tennessee
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December 2018 COMPENDIUM EBOOK SERIES 15
You didn’t fill a cavity
before dental school.
Don’t treat patients with OSA until you receive the proper
education and training to safely provide oral appliance therapy.

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