Sleep Apnea: How Orthodontics Can Help — Aug 15, 2016
Obstructive Sleep Apnea (OSA) involves partial or complete blockage of airway followed by a reduction
of blood oxygen level while sleeping, and arousal from sleep. OSA has large negative health, behavioral,
and social implications. Many of health complications of OSA have been recently discovered. Poor
oxygen flow as a result of OSA has been linked to heart disease, stroke, and diabetes. Poor night time
sleep quality affects cognitive function during the day, leading to reduced productivity, and motor
vehicle accidents. As much as 90% of OSA patients in the US remain undiagnosed.
Signs to Watch for
The most easily-recognized sign is snoring while sleeping. The loudness of snoring is particularly
alarming. One of the reasons OSA goes undiagnosed, is that most snorers are unaware of their snoring
unless told by a bed partner. OSA patients also frequently stop breathing while sleeping for a short while
and abruptly wake up and start breathing again. In children, symptoms may show up as poor
performance in school, and hyperactive behavior. Children with OSA could be misdiagnosed as having
The golden standard for diagnosis of OSA is a sleep study, known as polysomnogram. The study can be
done in a sleep lab or at home. The sleep study measures the number of episodes of complete and
partial cessation of airflow (AHI index) as well as blood's oxygen levels. The results of sleep study must
be interpreted by a medical doctor and the diagnosis is arrived at via analysis of the indices.
My practice philosophy is to offer phase I treatment only when I know the child will receive significant
benefits from early treatment. I keep my phase I treatment conservative and short, correcting problems
which studies indicate, if left alone, can become bigger problems by the time the child is a teenager. I
make sure that my patient's parents are fully educated on the objectives of phase I treatment and the
future need for phase II treatment.
The most common cause of a crowded airway is obesity. The increased fatty tissue around the throat
narrows the airway, making it more likely to get blocked in a supine sleeping position. However, many
slender individuals may have OSA. In children, enlarged tonsils can be the cause of airway blockage. The
biggest culprit in crowding the airway, however, is the tongue. When we sleep, the muscles relax, and
the tongue falls back, partially or completely blocking the airway.
The first line of treatment in mild-moderate OSA is lifestyle change such as weight loss, and reduction of
alcohol intake before bedtime. Positional changes such as sleeping elevated with multiple pillows can
help. In cases of diagnosed OSA, a cPAP (continuous Positive Air Pressure) is to be worn at night. The
cPAP is very effective in reducing OSA symptoms, however, can be difficult to tolerate. In children,
removal of enlarged tonsils may be indicated to open the airway. In moderate OSA cases, oral
appliances have been effective as a substitute for cPAP. Oral appliances are worn at night and position
the lower jaw forward which moves the tongue forward out of the airway. In severe adult OSA cases,
surgical treatment may be recommended. Surgical advancement of jaws in a forward direction has been
shown to be the most effective surgical treatment for OSA. Forward repositioning of the lower jaw,
positions the tongue in a more forward position, and clears the airway.
Since the cause of OSA is a blocked oropharyngeal airway, treatment is directed toward increasing the
airway volume. Maxillary expansion has been shown to be effective by widening the floor of the nasal
cavity. Maxillary expansion is particularly effective in children because of the patency of the palatal
sutures. Expansion is done via a custom expander appliance which is typically cemented on two
maxillary molars. The appliance has an expansion screw in the center which is activated by a key. The
orthodontist will give parents instructions on how to activate the expander at home by turning the key.
The expander is designed to be easily tolerated by children with minimal discomfort.
In addition to expansion, bite corrector (functional) appliances can be used in children to not only
correct the bite, but also help with OSA by positioning the lower jaw forward. These custom appliances
can be fixed (cemented), or removable.
In adults with OSA who cannot tolerate the cPAP, oral appliances may be a good option. The
orthodontist can take the steps for appliance fabrication and delivery. Long-term use of oral appliances
can cause changes in the bite. Thus, orthodontic monitoring is an important aspect of oral appliance
In severe adult cases, where orthognathic (jaw corrective) surgery is indicated, the pre-surgical
preparation requires orthodontic treatment. The pre-surgical stage is typically about 1 year of full
orthodontic treatment to align the teeth, and set up the bite for surgery. Post-surgical analyses of the
airway have shown significant increase in airway volume, and reduction of OSA symptoms. Surgical
treatment can bring life-altering changes for certain patients.
In all sleep apnea cases, close monitoring by a sleep specialist medical doctor should accompany