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Dental appliances in the treatment of obstructive sleep apnea syndrome
American Journal of Orthodontics and Dentofacial Orthopedics Volume 104, No. 2
again, "We assume that any clinician implementing one or more of the treatment protocols outlined herein has a thorough understanding of fixed appliance therapy as well as the underlying principles of growth and development that are related to the mixed dentition patient. It is assumed that anyone implementing these protocols already will have received appropriate education in orthodontics." An important point is made that "much o f routine orthodontic treatment is a series of midcourse corrections with progress of the patient monitored at each treatment visit." These caveats should be considered seriously. Even a superb clinician like James McNamara points to the ever changing nature of orthodontic treatment and diagnosis and the need for substantiation from both experimental and clinical studies conducted within a university setting. Chapters 1, 4, 5, and 6 Provide a general background concerning early orthodontic and orthopedic treatment. The profusion of excellent drawings and cephalome!ric tracings make comprehension easier. Of vital importance are Chapters 2 and 3 on diagnosis and treatment planning with a detailed description of the cephalometric analysis used in decision making. As a very complete bibliography indicates, this chapter melds the concepts of internationally renowned orthodontists. Credit is given throughout, wherever credit is due. Chapters 7 to 20 are directed toward the orthodontic clinician. Here again, an exhaustive overview of much of the current literature dealing with specific techniques and protocols serves as the basis. Detailed descriptions of clinical management for various techniques are presented. After discussions of treatment of tooth size/arch size discrepancy problems, treatment of Class II and Class III malocclusions, and the strategies employed, (Chapters 4 to 6), various chapters discuss the banded and bonded rapid maxillary expansion appliances, the lower Schwarz plate; transpalatal, and utility arches. There is nobody in America who has had more experience in functional appliances than Dr. McNamara. His Chapter 12 on the function regulator (FR 2) is a superb treatment of this growth guidance appliance. Photographs and drawing~ allow the text to be kept to a minimum. Subsequent chapters on the bionator, Herbst appliance, orthopedic facial mask and the FR-3 of Frankel provide significant "how-to-do" guidance. Chapter 9 17 on the comprehensive fixed appliance phase, again, highlights the artistic expertise of William Brudon with many detailed drawings that simply do not show in photographs. Chapter 18 on finishing and retention protocol expresses the philosophy that finishing and retentionare two continuous phases of orthodontic treatment, With some retention procedures being initiated before
Reviews and abstracts
207
the completion of active orthodontic treatment through fixed appliances. Although relatively short, this chapter presents dynamic approaches to optimal posttreatment stability that incorporate a great deal more than the traditional Hawley retainer and fixed lower lingual arch used so commonly for every patient who must fit the Procrustean Bed of mechanotherapy. These practiceproven techniques are, again, substantiated by a comprehensive bibliography. Discussion of retention is continued again with a chapter on "invisible retainers," which were actually developed by Robert Ponitz of Ann Arbor, Mich., in 1971. The ability to use this simple, acrylic appliance, making minor tooth repositioning changes, provides a valuable adjunct for clinicians. The last chapter is on study models. Because this is one of the most important sources of information, the authors believe that standardization of this diagnostic criteria, with the ABO recommendations, is essential. It is a reviewer's job to try to be as objective and critical as possible. This reviewer has written enough books to know that nothing is perfect, try as we might. The only criticism I could make is I believe that Chapter 20, which is very well done, probably should have gone under orthodontic diagnosis and treatment planning, together with Chapter 2 on cephalometric evaluation of the orthodontic patient. This is of minuscule importance, and the authors obviously had some reason for the placement of the chapter. Beautiful production, the very readable type font, the easy flow of the text, the attractive cover provide this reviewer the best discussion of the topic of "orthodontic and orthopedic in the mixed dentition" that has been done to date. This ~,olume is not only a "must" for every graduate orthodontic student, but for every clinician. T. M. Graber, DMD, MSD, PhD, Odont. Dr. h.c., DSc
Dental Appliances in the Treatment of Obstructive Sleep Apnea Syndrome MasafumiTsuchiya, Alan A. Lowe, and John A. Fleetham J Jpt~ O~:thod Soc 1992,51(3):244-55
Obstructive sleep apnea (OSA) is defined as a cessatio n of breathing during sleep and is characterized by an occlusion of the upper airway9 in the presence of continued diaphragmatic movement. The upper ainvay collapse is believed to be a result of interrelated anatomic abnormalities and functional disorders. The purpose of this report was to evaluate the effectiveness of
American Journal of Orthodontics and Dentofacial Orthopedics August 1993
208 Reviews and abstracts several dental appliances for patients with OSA and to discuss the role of an orthodontist in the treatment of this syndrome. Thirteen adult OSA patients with apnea indices (AI) greater than 5 (15.28 _ 14.01 apneas per hour of total sleep time) were evaluated after treatment with one of three dental appliances: a tongue retaining device, a tlerbst appliance, or a mandibular repositioning appliance. Patients underwent overnight polysomnograms before dental treatment and 2 to 6 months after appliance insertion. The AI decreased significantly from 15.28 to 3.53 apneas per hour (P < 0.05). A significant decrease in the respiratory disturbance index and total apnea time was determined (P < 0.01). Apnea severity was significantly improved after insertion of a dental appliance. A significant weight change was not found. Eight patients (62%) had a good response as defined by a posttreatment AI of --<4 and a reduction in the AI of ---60%. Two cases were reported in detail on the basis of overnight polysomnographs, in addition one was evaluated by cephalometric and CT analysis, and the other was evaluated by supin'e cephalometric radiographs. The analyses revealed mandibular forward postures and increased upper airway volumes. Improvement of sleep apnea may be attributed to the effect of the appliance on the oropharyngeal structures. Dental appliances may be a successful treatment alternative to relieve symptoms in patients with OSA. These results suggest that orthodontists may play a significant role in the diagnosis and treatment of OSA patients. Alex Jacobson
Cephalometric Analysis of Class III Patients After Surgery Ingrid Grunert and Christian Krenkel
of mandibular incisors and protrusion of maxillary incisor teeth. Surgical results remained stable in 14 cases, three patients incurred a slight partial relapse, whereas six patients had a significant relapse, though the original extent of the malocclusion with anterior crossbite reoccurred in only two cases. It was possible to prove the relationship between relapse and the existence of myofunctional disturbances. Consequently, safe long-term results may only be obtained by means of interdisciplinary planning and treatment. Alex Jacobson
Optimization of Arch Guided Tooth Movement by the Use of Powerhooks Dieter Drescher, Chrlstoph Bourauel, and Hans-Albert Schumacher Praki Kieferorthop 1991:5(3):201-8
Arch guided tooth movement is the most often used technique to move teeth bodily in mesiodistal direction. One of the most important disadvantages of this method, however, is friction between bracket and arch wire, which impairs tooth movement and may result in dangerous overload of the anchorage units. Powerhooks are used to accomplish a more effective orthodontic tooth movement by reduction of the tipping and rotating movements. This investigation answers the question regarding mechanical dimensions of powerhooks to minimize friction. If the point of force application lies coronally to the center of resistance (CR) and rotatory moments are eliminated, friction can be reduced by as much as 90%. If the length of the powerhooks extends apically beyond the CR, friction is dramatically increased. In the horizontal direction, a unilateral powerhook should not be extended.to more than the half of its length. Alex Jacobson
Prakt Kieferorthop 1991.5(3):215-28
The University of Innsbruck, Department of Dentistry, analyzed the cephalograms of 23 prognathic patients whose dysgnathia was corrected by an osteotomy of the mandible only. The obtained results were compared with an analysis of the respective models. Documentation was obtained before surgery, after surgery, and during followup examinations over a period of at least 6 years. Evaluation of the results focused on occlusion and the WITS appraisal. Before surgery, 21 patients presented with prognathic mandibles, 50% of which had either micropositioned or retropositioned maxillae. As a rule, there were also dentoalveolar compensations with retrusion
The Effects of Orthodontic Treatment on Periodontal Tissues in Patients with Advanced Periodontal Disease Yuuko Shinbo, Hitoshi Sasakura, Shuichi Morita and Kooji Hanada J Jpn Orthod Soc 1992,51(4):318-27
The changes of periodontal tissue condition through orthodontic treatment in patients with advanced periodontal disease were examined and evaluated. Subjects consisted of three males and five females who had advanced periodontal disease with severe al: veolar bone loss and were treated orthodontically after periodontal therapy. Periodontal tissue condition (peri-
again, "We assume that any clinician implementing one or more of the treatment protocols outlined herein has a thorough understanding of fixed appliance therapy as well as the underlying principles of growth and development that are related to the mixed dentition patient. It is assumed that anyone implementing these protocols already will have received appropriate education in orthodontics." An important point is made that "much o f routine orthodontic treatment is a series of midcourse corrections with progress of the patient monitored at each treatment visit." These caveats should be considered seriously. Even a superb clinician like James McNamara points to the ever changing nature of orthodontic treatment and diagnosis and the need for substantiation from both experimental and clinical studies conducted within a university setting. Chapters 1, 4, 5, and 6 Provide a general background concerning early orthodontic and orthopedic treatment. The profusion of excellent drawings and cephalome!ric tracings make comprehension easier. Of vital importance are Chapters 2 and 3 on diagnosis and treatment planning with a detailed description of the cephalometric analysis used in decision making. As a very complete bibliography indicates, this chapter melds the concepts of internationally renowned orthodontists. Credit is given throughout, wherever credit is due. Chapters 7 to 20 are directed toward the orthodontic clinician. Here again, an exhaustive overview of much of the current literature dealing with specific techniques and protocols serves as the basis. Detailed descriptions of clinical management for various techniques are presented. After discussions of treatment of tooth size/arch size discrepancy problems, treatment of Class II and Class III malocclusions, and the strategies employed, (Chapters 4 to 6), various chapters discuss the banded and bonded rapid maxillary expansion appliances, the lower Schwarz plate; transpalatal, and utility arches. There is nobody in America who has had more experience in functional appliances than Dr. McNamara. His Chapter 12 on the function regulator (FR 2) is a superb treatment of this growth guidance appliance. Photographs and drawing~ allow the text to be kept to a minimum. Subsequent chapters on the bionator, Herbst appliance, orthopedic facial mask and the FR-3 of Frankel provide significant "how-to-do" guidance. Chapter 9 17 on the comprehensive fixed appliance phase, again, highlights the artistic expertise of William Brudon with many detailed drawings that simply do not show in photographs. Chapter 18 on finishing and retention protocol expresses the philosophy that finishing and retentionare two continuous phases of orthodontic treatment, With some retention procedures being initiated before
Reviews and abstracts
207
the completion of active orthodontic treatment through fixed appliances. Although relatively short, this chapter presents dynamic approaches to optimal posttreatment stability that incorporate a great deal more than the traditional Hawley retainer and fixed lower lingual arch used so commonly for every patient who must fit the Procrustean Bed of mechanotherapy. These practiceproven techniques are, again, substantiated by a comprehensive bibliography. Discussion of retention is continued again with a chapter on "invisible retainers," which were actually developed by Robert Ponitz of Ann Arbor, Mich., in 1971. The ability to use this simple, acrylic appliance, making minor tooth repositioning changes, provides a valuable adjunct for clinicians. The last chapter is on study models. Because this is one of the most important sources of information, the authors believe that standardization of this diagnostic criteria, with the ABO recommendations, is essential. It is a reviewer's job to try to be as objective and critical as possible. This reviewer has written enough books to know that nothing is perfect, try as we might. The only criticism I could make is I believe that Chapter 20, which is very well done, probably should have gone under orthodontic diagnosis and treatment planning, together with Chapter 2 on cephalometric evaluation of the orthodontic patient. This is of minuscule importance, and the authors obviously had some reason for the placement of the chapter. Beautiful production, the very readable type font, the easy flow of the text, the attractive cover provide this reviewer the best discussion of the topic of "orthodontic and orthopedic in the mixed dentition" that has been done to date. This ~,olume is not only a "must" for every graduate orthodontic student, but for every clinician. T. M. Graber, DMD, MSD, PhD, Odont. Dr. h.c., DSc
Dental Appliances in the Treatment of Obstructive Sleep Apnea Syndrome MasafumiTsuchiya, Alan A. Lowe, and John A. Fleetham J Jpt~ O~:thod Soc 1992,51(3):244-55
Obstructive sleep apnea (OSA) is defined as a cessatio n of breathing during sleep and is characterized by an occlusion of the upper airway9 in the presence of continued diaphragmatic movement. The upper ainvay collapse is believed to be a result of interrelated anatomic abnormalities and functional disorders. The purpose of this report was to evaluate the effectiveness of
American Journal of Orthodontics and Dentofacial Orthopedics August 1993
208 Reviews and abstracts several dental appliances for patients with OSA and to discuss the role of an orthodontist in the treatment of this syndrome. Thirteen adult OSA patients with apnea indices (AI) greater than 5 (15.28 _ 14.01 apneas per hour of total sleep time) were evaluated after treatment with one of three dental appliances: a tongue retaining device, a tlerbst appliance, or a mandibular repositioning appliance. Patients underwent overnight polysomnograms before dental treatment and 2 to 6 months after appliance insertion. The AI decreased significantly from 15.28 to 3.53 apneas per hour (P < 0.05). A significant decrease in the respiratory disturbance index and total apnea time was determined (P < 0.01). Apnea severity was significantly improved after insertion of a dental appliance. A significant weight change was not found. Eight patients (62%) had a good response as defined by a posttreatment AI of --<4 and a reduction in the AI of ---60%. Two cases were reported in detail on the basis of overnight polysomnographs, in addition one was evaluated by cephalometric and CT analysis, and the other was evaluated by supin'e cephalometric radiographs. The analyses revealed mandibular forward postures and increased upper airway volumes. Improvement of sleep apnea may be attributed to the effect of the appliance on the oropharyngeal structures. Dental appliances may be a successful treatment alternative to relieve symptoms in patients with OSA. These results suggest that orthodontists may play a significant role in the diagnosis and treatment of OSA patients. Alex Jacobson
Cephalometric Analysis of Class III Patients After Surgery Ingrid Grunert and Christian Krenkel
of mandibular incisors and protrusion of maxillary incisor teeth. Surgical results remained stable in 14 cases, three patients incurred a slight partial relapse, whereas six patients had a significant relapse, though the original extent of the malocclusion with anterior crossbite reoccurred in only two cases. It was possible to prove the relationship between relapse and the existence of myofunctional disturbances. Consequently, safe long-term results may only be obtained by means of interdisciplinary planning and treatment. Alex Jacobson
Optimization of Arch Guided Tooth Movement by the Use of Powerhooks Dieter Drescher, Chrlstoph Bourauel, and Hans-Albert Schumacher Praki Kieferorthop 1991:5(3):201-8
Arch guided tooth movement is the most often used technique to move teeth bodily in mesiodistal direction. One of the most important disadvantages of this method, however, is friction between bracket and arch wire, which impairs tooth movement and may result in dangerous overload of the anchorage units. Powerhooks are used to accomplish a more effective orthodontic tooth movement by reduction of the tipping and rotating movements. This investigation answers the question regarding mechanical dimensions of powerhooks to minimize friction. If the point of force application lies coronally to the center of resistance (CR) and rotatory moments are eliminated, friction can be reduced by as much as 90%. If the length of the powerhooks extends apically beyond the CR, friction is dramatically increased. In the horizontal direction, a unilateral powerhook should not be extended.to more than the half of its length. Alex Jacobson
Prakt Kieferorthop 1991.5(3):215-28
The University of Innsbruck, Department of Dentistry, analyzed the cephalograms of 23 prognathic patients whose dysgnathia was corrected by an osteotomy of the mandible only. The obtained results were compared with an analysis of the respective models. Documentation was obtained before surgery, after surgery, and during followup examinations over a period of at least 6 years. Evaluation of the results focused on occlusion and the WITS appraisal. Before surgery, 21 patients presented with prognathic mandibles, 50% of which had either micropositioned or retropositioned maxillae. As a rule, there were also dentoalveolar compensations with retrusion
The Effects of Orthodontic Treatment on Periodontal Tissues in Patients with Advanced Periodontal Disease Yuuko Shinbo, Hitoshi Sasakura, Shuichi Morita and Kooji Hanada J Jpn Orthod Soc 1992,51(4):318-27
The changes of periodontal tissue condition through orthodontic treatment in patients with advanced periodontal disease were examined and evaluated. Subjects consisted of three males and five females who had advanced periodontal disease with severe al: veolar bone loss and were treated orthodontically after periodontal therapy. Periodontal tissue condition (peri-