Obstructive Sleep Apnea Syndrome and the Role of Orthodontics: Diagnosis, Treatment and Multidisciplinary Approach

Abstract

Obstructive sleep apnea syndrome is a common sleep disorder characterized by symptoms such as sleep disruption, decreased blood oxygen levels, and excessive daytime sleepiness due to obstruction in the upper airways during sleep. Obstructions in areas such as the soft palate, tonsils, and base of the tongue play a significant role in its pathophysiology. Its etiology is based on various factors. If left untreated, it can lead to serious health problems such as cardiovascular disease, cerebrovascular disease, and metabolic disorders. The diagnosis and treatment process requires a multidisciplinary approach. Changes in the upper respiratory tract, which are of interest to orthodontists, play an important role in the diagnosis and treatment of this syndrome. The treatment of this syndrome includes psychological treatment, devices that provide continuous positive airway pressure, surgical interventions, and orthodontic treatment options. Orthodontic approaches correct anatomical problems such as maxillary and mandibular insufficiency, providing expansion of the upper airway and reducing the apnea-hypopnea index. Favorable results have been obtained with treatment modalities such as face mask use, orthognathic surgery, and maxillary expansion appliances in young patients. Additionally, treatments with mandibular advancement appliances provide temporary improvements in adults. However, orthodontic treatment may not always be the solution, and surgical interventions may be required. In conclusion, the treatment of obstructive sleep apnea syndrome should be tailored to the individual. Orthodontic approaches can also be an important part of the treatment process.

Keywords

• Apnea
• Obstructive
• Sleep Apnea

Obstrüktif Uyku Apne Sendromu ve Ortodontinin Rolü: Tanı, Tedavi ve Multidisipliner Yaklaşım

Öz

Obstrüktif uyku apne sendromu, uyku esnasında üst solunum yollarında oluşan tıkanıklık nedeniyle uyku bölünmesi, kan oksijen seviyelerinin düşmesi ve gündüz aşırı uyku hali gibi semptomlarla kendini gösteren yaygın bir uyku bozukluğu hastalığıdır. Patofizyolojisinde yumuşak damak, bademcikler ve dil tabanı gibi bölgelerdeki tıkanmalar önemli bir rol oynamaktadır. Etiyolojisi, çeşitli faktörlere dayanmaktadır. Tedavi edilmezse kardiyovasküler hastalık, serebrovasküler hastalık ve metabolik bozukluklar gibi ciddi sağlık sorunlarına yol açabilir. Tanı ve tedavi süreci multidisipliner bir yaklaşım gerektirir. Ortodontistlerin ilgi alanına giren üst solunum yollarındaki değişiklikler bu sendromun tanı ve tedavisinde önemli bir rol oynamaktadır. Bu sendromun tedavisinde psikolojik tedavi, sürekli pozitif hava yolu basıncı sağlayan cihazlar, cerrahi müdahaleler ve ortodontik tedavi seçenekleri yer almaktadır. Ortodontik yaklaşımlar, maksiller ve mandibular yetersizlik gibi anatomik sorunları düzelterek üst hava yolunda genişleme sağlamakta ve apne hipopne indeksini düşürmektedir. Genç hastalarda yüz maskesi kullanımı, ortognatik cerrahi ve maksiller genişletme apareyleri gibi tedavi yöntemleri ile olumlu sonuçlar elde edilmiştir. Ayrıca, mandibular ilerletme apareyleri ile yapılan tedaviler de yetişkinlerde geçici iyileşmeler sağlamaktadır. Bununla birlikte, ortodontik tedavi her zaman çözüm olmayabilir ve cerrahi müdahaleler gerekebilir. Sonuç olarak, obstrüktif uyku apnesi sendromunun tedavisi kişiye özel olarak belirlenmelidir. Ortodontik yaklaşımlar da tedavi sürecinin önemli bir parçası olabilmektedir.

Anahtar Kelimeler

• Apne
• Tıkayıcı
• Uyku Apnesi

References

1. 1. Balk EM, Moorthy D, Obadan NO, Patel K, Ip S, Chung M, et al. Diagnosis and treatment of obstructive sleep apnea in adults. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011.
2. 2. Jonas DE, Amick HR, Feltner C, Weber RP, Arvanitis M, Stine A, et al. Screening for obstructive sleep apnea in adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA. January 24, 2017;317(4):415-33.
3. 3. Fouke JM, Strohl KP. Effect of position and lung volume on upper airway geometry. J Appl Physiol. July 1987;63(1):375-80.
4. 4. Hohenhorst W, Ravesloot MJL, Kezirian EJ, de Vries N. Drug-induced sleep endoscopy in adults with sleep-disordered breathing: technique and the VOTE classification system. Operative Techniques in Otolaryngology-Head and Neck Surgery. March 1, 2012;23(1):11-8.
5. 5. Tan SN, Yang HC, Lim SC. Anatomy and pathophysiology of upper airway obstructive sleep apnoea: review of the current literature. Sleep Med Res. 2021;12(1):1-8.
6. 6. Bosschieter PFN, Liu SYC, Chao PY, Chen A, Kushida CA. Using standardized ultrasound imaging to correlate OSA severity with tongue morphology. Sleep Med. 2024;120:15-21.
7. 7. Dobrowolska-Zarzycka M, Dunin-Wilczyńska I, Szymańska J. Craniofacial structure in patients with obstructive sleep apnoea. Folia Morphol. January 25, 2016;75(3):311-5.
8. 8. Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. February 15, 2008;5(2):242-52.

9. 9. Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. Kaohsiung J Med Sci. January 2020;36(1):7-12.
10. 10. Park JG, Ramar K, Olson EJ. Updates on definition, consequences, and management of obstructive sleep apnea. Mayo Clin Proc. June 2011;86(6):549-54; quiz 554-5.
11. 11. Knauert M, Naik S, Gillespie MB, Kryger M. Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome. World J Otorhinolaryngol Head Neck Surg. September 2015;1(1):17-27.
12. 12. Koretsi V, Eliades T, Papageorgiou SN. Oral interventions for obstructive sleep apnea. Dtsch Arztebl Int. March 23, 2018;115(12):200-7.
13. 13. Abtahi S, Phuong A, Major PW, Flores-Mir C. Cranial base length in pediatric populations with sleep disordered breathing: a systematic review. Sleep Med Rev. June 2018;39:164-73.
14. 14. Tanayapong P, Kuna ST. Sleep disordered breathing as a cause and consequence of stroke: a review of pathophysiological and clinical relationships. Sleep Med Rev. October 2021;59:101499.
15. 15. Perez CV. Sleep disordered breathing in children. In: Soxman DDS, JA, editor. Handbook of Clinical Techniques in Pediatric Dentistry. p. 301-12.
16. 16. Gottlieb DJ, Punjabi NM. Diagnosis and management of obstructive sleep apnea: a review. JAMA. April 14, 2020;323(14):1389-400.
17. 17. Marin JM, Carrizo SJ, Vicente E, Agusti AGN. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046-53.
18. 18. Azagra-Calero E, Espinar-Escalona E, Barrera-Mora JM, Llamas-Carreras JM, Solano-Reina E. Obstructive sleep apnea syndrome (OSAS). Review of the literature. Med Oral Patol Oral Cir Bucal. November 1, 2012;17(6):e925-9.
19. 19. Arnardottir ES, Bjornsdottir E, Olafsdottir KA, Benediktsdottir B, Gislason T. Obstructive sleep apnoea in the general population: highly prevalent but minimal symptoms. Eur Respir J. January 2016;47(1):194-202.
20. 20. Lal C, Weaver TE, Bae CJ, Strohl KP. Excessive daytime sleepiness in obstructive sleep apnea: mechanisms and clinical management. Ann Am Thorac Soc. May 2021;18(5):757-68.
21. 21. Russell MB, Kristiansen HA, Kværner KJ. Headache in sleep apnea syndrome: epidemiology and pathophysiology. Cephalalgia. September 2014;34(10):752-5.
22. 22. Chervin RD. Sleepiness, fatigue, tiredness, and lack of energy in obstructive sleep apnea. Chest. August 2000;118(2):372-9.
23. 23. Vanek J, Prasko J, Genzor S, Ociskova M, Kantor K, Holubova M, et al. Obstructive sleep apnea, depression and cognitive impairment. Sleep Med. August 2020;72:50-8.
24. 24. American Academy of Sleep Medicine. International Classification of Sleep Disorders Third Edition: Text Revision. 2023.
25. 25. American Academy of Sleep Medicine. International Classification of Sleep Disorders. 2014. 383 p.
26. 26. Palomo JM, Piccoli VD, Menezes LM. Obstructive sleep apnea: a review for the orthodontist. Dental Press J Orthod. 2023;28(1):e23spe1. Published 2023 Apr 14.
27. 27. Hudgel DW, Patel SR, Ahasic AM, Bartlett SJ, Bessesen DH, Coaker MA, et al. The role of weight management in the treatment of adult obstructive sleep apnea. An official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. September 15, 2018;198(6):e70-87.
28. 28. Ashrafian H, Toma T, Rowland SP, Harling L, Tan A, Efthimiou E, et al. Bariatric surgery or non-surgical weight loss for obstructive sleep apnoea? A systematic review and comparison of meta-analyses. Obes Surg. December 25, 2014;25(7):1239-50.
29. 29. Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. February 15, 2019;15(2):301-34.
30. 30. Qaseem A, Holty JEC, Owens DK, Dallas P, Starkey M, Shekelle P, et al. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. October 1, 2013;159(7):471-83.
31. 31. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. September 2012;130(3):e714-55.
32. 32. Socarras MA, Landau BP, Durr ML. Diagnostic techniques and surgical outcomes for persistent pediatric obstructive sleep apnea after adenotonsillectomy: a systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. June 2019;121:179-87.
33. 33. Wray CM, Thaler ER. Hypoglossal nerve stimulation for obstructive sleep apnea: a review of the literature. World J Otorhinolaryngol Head Neck Surg. December 2016;2(4):230-3.
34. 34. de Felício CM, da Silva Dias FV, Trawitzki LVV. Obstructive sleep apnea: focus on myofunctional therapy. Nat Sci Sleep. September 6, 2018;10:271-86.
35. 35. Bucci R, Rongo R, Zunino B, Michelotti A, Bucci P, Alessandri-Bonetti G, et al. Effect of orthopedic and functional orthodontic treatment in children with obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. February 2023;67:101730.
36. 36. Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, et al. Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep. May 1, 2015;38(5):669-75.
37. 37. Pirklbauer K, Russmueller G, Stiebellehner L, Nell C, Sinko K, Millesi G, et al. Maxillomandibular advancement for treatment of obstructive sleep apnea syndrome: a systematic review. J Oral Maxillofac Surg. June 2011;69(6):e165-76.
38. 38. Huang CS, Hsu SSP, Chen YR. Systematic review of the surgery-first approach in orthognathic surgery. Biomed J. Jul-Aug 2014;37(4):184-90.
39. 39. Boyd SB, Walters AS, Song Y, Wang L. Comparative effectiveness of maxillomandibular advancement and uvulopalatopharyngoplasty for the treatment of moderate to severe obstructive sleep apnea. J Oral Maxillofac Surg. April 2013;71(4):743-51.
40. 40. Shilo D, Emodi O, Aizenbud D, Rachmiel A. Controlling the vector of distraction osteogenesis in the management of obstructive sleep apnea. Ann Maxillofac Surg. Jul-Dec 2016;6(2):214-8.
41. 41. Ming Y, Hu Y, Li Y, Yu J, He H, Zheng L. Effects of maxillary protraction appliances on airway dimensions in growing class III maxillary retrognathic patients: a systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. February 2018;105:138-45.
42. 42. Wells AP, Sarver DM, Proffit WR. Long-term efficacy of reverse pull headgear therapy. Angle Orthod. November 2006;76(6):915-22.
43. 43. Camacho M, Chang ET, Song SA, Abdullatif J, Zaghi S, Pirelli P, et al. Rapid maxillary expansion for pediatric obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope. July 2017;127(7):1712-9.
44. 44. Kim KA, Oh SH, Kim BH, Kim SJ. Asymmetric nasomaxillary expansion induced by tooth-bone-borne expander producing differential craniofacial changes. Orthod Craniofac Res. November 2019;22(4):296-303.
45. 45. Bucci R, Montanaro D, Rongo R, Valletta R, Michelotti A, D’Antò V. Effects of maxillary expansion on the upper airways: evidence from systematic reviews and meta-analyses. J Oral Rehabil. April 2019;46(4):377-87.
46. 46. Vale F, Albergaria M, Carrilho E, Francisco I, Guimarães A, Caramelo F, et al. Efficacy of rapid maxillary expansion in the treatment of obstructive sleep apnea syndrome: a systematic review with meta-analysis. J Evid Based Dent Pract. September 2017;17(3):159-68.
47. 47. Machado-Júnior AJ, Zancanella E, Crespo AN. Rapid maxillary expansion and obstructive sleep apnea: a review and meta-analysis. Med Oral Patol Oral Cir Bucal. July 1, 2016;21(4):e465-9.
48. 48. Storto CJ, Garcez AS, Suzuki H, Cusmanich KG, Elkenawy I, Moon W, et al. Assessment of respiratory muscle strength and airflow before and after microimplant-assisted rapid palatal expansion. Angle Orthod. September 2019;89(5):713-20.
49. 49. de Britto Teixeira AO, Abi-Ramia LBP, de Oliveira Almeida MA. Treatment of obstructive sleep apnea with oral appliances. Prog Orthod. May 23, 2013;14:10.
50. 50. Li L, Liu H, Cheng H, Han Y, Wang C, Chen Y, et al. CBCT evaluation of the upper airway morphological changes in growing patients of class II division 1 malocclusion with mandibular retrusion using twin block appliance: a comparative research. PLoS One. April 4, 2014;9(4):e94378.
51. 51. Mandibular advancement device design: A systematic review on outcomes in obstructive sleep apnea treatment. Sleep Medicine Reviews. December 1, 2021;60:101557.
52. 52. Faber J, Faber C, Faber AP. Obstructive sleep apnea in adults. Dental Press J Orthod. August 1, 2019;24(3):99-109.
53. 53. Sheats RD, Schell TG, Blanton AO, Braga PM, Demko BG, Dort LC, et al. Management of side effects of oral appliance therapy for sleep-disordered breathing. J Dent Sleep Med. 2017;4(4):111-125.
54. 54. Knappe SW, Bakke M, Svanholt P, Petersson A, Sonnesen L. Long-term side effects on the temporomandibular joints and oro-facial function in patients with obstructive sleep apnoea treated with a mandibular advancement device. J Oral Rehabil. May 2017;44(5):354-62.
55. 55. Martins O de FM, Chaves Junior CM, Rossi RRP, Cunali PA, Dal-Fabbro C, Bittencourt L. Side effects of mandibular advancement splints for the treatment of snoring and obstructive sleep apnea: a systematic review. Dental Press J Orthod. August 1, 2018;23(4):45-54.
56. 56. Xiang M, Hu B, Liu Y, Sun J, Song J. Changes in airway dimensions following functional appliances in growing patients with skeletal class II malocclusion: a systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. June 2017;97:170-80.
57. 57. Kannan A, Sathyanarayana HP, Padmanabhan S. Effect of functional appliances on the airway dimensions in patients with skeletal class II malocclusion: a systematic review. J Orthod Sci. Apr-Jun 2017;6(2):54-64.