Multidisciplinary Approach in Adult Orthodontic Patient Affected by Severe Obstructive Sleep Apnoea: A Case Report
Dentist, Universitat Jaume I, Castellón de la Plana, Spain Bachelor of Dental Science (University of Queensland), Australia
*Corresponding author: Robert Lin, Dentist, Universitat Jaume I, Castellón de la Plana, Spain Bachelor of Dental Science (University of Queensland), Australia.
Citation: Lin R. (2022) Multidisciplinary Approach in Adult Orthodontic Patient Affected by Severe Obstructive Sleep Apnoea: A Case Report. J Oral Med and Dent Res. 3(1):1-11.
Received: March 09, 2022 | Published: May 10, 2022
Copyright© 2022 by Lin R. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This case report describes the successful multidisciplinary treatment of an adult orthodontic patient with severe obstructive sleep apnoea (OSA). The patient presents with class I dental occlusion and lower anterior crowding. Upon comprehensive orthodontic examination, it was suspected the patient had sleep disordered breathing and was sent for a polysomnography (PSG). The sleep physician diagnosed severe sleep apnoea with an apnoea hypopnoea index (AHI) of 54.1. Cone beam computerized tomography (CBCT) scan, which was taken as part of the orthodontic records, revealed airway issues so the patient was referred to an ear nose throat (ENT) doctor with a sub-specialty in airway and sleep. ENT surgery was performed resulting in the AHI coming down to 20.4. Orthopaedic expansion was done using removable appliances followed by fixed appliances (braces) using the controlled arch technique and protraction mechanics. The post orthodontic treatment AHI was 14.4 and a Farrar splint was made as the retainer which resulted in an AHI of 6.4. This case report demonstrates why a comprehensive orthodontic examination and multidisciplinary approach is essential to the successful treatment of orthodontic patients with obstructive sleep apnoea.
Orthodontics; Expansion; Obstructive sleep apnoea; PSG; AHI; CBCT; ENT
Modern day orthodontics is no longer just about moving the teeth within the jaws to improve aesthetics and function. A good example is the increasing interest in the role orthodontic practitioners can play in the screening for sleep disordered breathing (SDB) and obstructive sleep apnoea. In fact, orthodontic practitioners can play a key role in the multidisciplinary management of OSA in both children and adults . This is a current hot topic because the level of awareness of OSA and its related health issues is rapidly growing within the general population . In addition, the prevalence of OSA is also increasing due to obesity and the ageing population . In fact, it wouldn’t be surprising to see orthodontic patients come in asking about airway and sleep, therefore orthodontic practitioners need to know how to screen for airway and sleep issues and its management . Integrating airway and sleep into orthodontic practice, in addition to working with other health professionals, will achieve the best possible outcome for the patients’ overall health.
OSA is now one of the most common medical disorders in the general population. The prevalence in adults ranges from 9% to 38%, and is typically higher in men and older people . More specifically, the presence of moderate or severe OSA ranges from 6% to 17% .Another study revealed approximately 1 billion adults globally aged 30-69 years have OSA, and of which 425 million have moderate to severe OSA . Unfortunately, OSA prevalence is rising and affects all countries because as the prevalence of the ageing population and obesity increases, the vulnerability towards having OSA increases . The countries most affected by OSA are China, USA, Brazil and India .
Furthermore, there is a higher paediatric sleep disordered breathing prevalence in the orthodontic population (10.8%) than a healthy paediatric population (5%). The prevalence of snoring and sleepiness in the orthodontic population is 13.3% and 17.9%, respectively. Therefore orthodontic practitioners should make airway and sleep screening a routine part of their clinical practice .
This case report describes a unique situation where a young dentist discovers he may have sleep disordered breathing while attending an orthodontics course in Sydney, Australia. The goal is to guide you through the entire treatment process and demonstrate how a multidisciplinary approach can achieve a great outcome not just orthodontically, but also for the patients overall health and wellbeing.
A 26 year old male dentist was evaluated at the International Academy of Advanced Dentistry (IAA Dent) orthodontics residency. He was fit and healthy with a clear medical history and body mass index (BMI) of 23.3. The patient had no orthodontic concerns but thorough examination revealed dental crowding, RHS TMJ clicking, allergies, snoring and daytime sleepiness.
Facial analysis indicated mesofacial, midface deficiency, low tongue posture, lips competent but dry (suspect mouth breathing), flat profile, small nares, lack of cheek bones and forward head posture. Intra oral analysis indicated slightly V-shaped arches, lower posteriors lingually tilted, lower anterior moderate crowding, normal frenal attachments, class I molar relationships, malampatti class 4, tonsils grade 4, transverse and sagittal deficiencies as indicated by Schwarz-Korkhaus analysis and Mews indicator line (Figure 1).
Figure 1: Pre-treatment extra oral and intral oral photographs.
Cone beam computerized tomography (CBCT) scan was analysed and reported on by a dental maxillofacial radiologist. It revealed minor mucosal thickening on the floor of both maxillary sinuses, slight bowing of the nasal septum to the left, right-sided concha bullosa, slight prominence of the adenoidal tissue, prominent palatine tonsils with associated narrowing of the airway, slight prominence of the left anterior joint space and considerable prominence of the right anterior joint space which often correlates with anterior disc displacement. All these radiographic findings plus an Epworth Sleepiness Score (ESS) of 13/24 and STOP BANG score of 5/8 were suggestive of sleep disordered breathing, therefore the patient was referred for a sleep study. Type 2 polysomnography (PSG) diagnosed the patient with severe sleep apnoea with an apnoea hypopnoea index (AHI) score of 54.1, longest apnoea of 46 seconds and oxygen nadir to 83%. Following the alarming sleep study results, referral to an ENT with a sub specialty in airway and sleep was arranged. The ENT used nasal endoscopy for assessment and took images for records purposes and to help explain to the patient. A decision was made to perform ENT surgery to clear the airway passage to improve breathing and sleep. The ENT procedures performed included septoplasty, turbinectomy, adenoidectomy, tonsillectomy, tongue coblation and modified uvulopalatopharyngoplasty (UPPP). Another type 2 PSG was done 5 months after ENT surgery to ensure healing was complete and to determine if surgery was successful in improving breathing and sleep. The AHI score came down to 20.4 (62% reduction), longest apnoea of 24 seconds and oxygen nadir to 90%. The surgery achieved a successful result based on the ENT’s guidelines of success, which includes improvement in quality of life, reduction of OSA symptoms, reducing AHI greater than 50% and improving oxygen nadir to 90% (Figure 2).
Figure 2: Pre ENT surgery vs post ENT surgery photos.
For orthodontic purposes, the CBCT scan was also used to reconstruct alateral cephin order to do a Jefferson ceph analysis to determine the skeletal class of the patient. The Jefferson tracing diagnosis was a slight class IIIA skeletal and short vertical with both jaws just shy of the anterior arc. Airway analysis revealed a narrow oropharyngeal airway with a minimum axial area of 54.9mm2. Occlusal analysis with muscle palpations and Schwarz analysis were also performed. Despite being a slight class IIIA, the patient was 26 years old with no family history of class III, so there was no concerns about the possibility of late mandibular growth (Figure 3).
Figure 3: Pre-treatment radiographic records including Jefferson ceph tracing and 3D airway analysis with minimal axial area measurement of 54.9mm2.
Upon discussion of the various treatment options, including orthognathic surgery and dental extractions, it was decided that maxillary orthopaedic development would be done using removable appliances. The patient chose removable appliances because he wears a mouthguard for sport and is able to remove the appliance for cleaning so his mouth won’t smell bad when talking to patients. The patient started with an anterior push sagittal appliance for 6 months, followed by a 50/50 sagittal for 4 months. Following that, fixed orthodontic appliances (braces) were done using controlled arch technique. Protraction mechanics were performed in the upper arch to move the teeth forward due to class III, improve the profile and nasolabial angle, and to minimize any retraction which may worsen an already compromised airway. In the lower arch, the wire was advanced to upright the posterior segments, which resulted in more tongue space and helped alleviate the anterior crowding. Vertical elastics were used to extrude the lower posteriors, in order to level the curve of Spee and increase the vertical height (Shimbashi) to better support the TMJ. The total fixed appliance process took exactly 3 years to complete. Coincidently, the patient’s RHS TMJ clicking spontaneously disappeared after 2 years into orthodontic treatment. This may have been due to the downward and forward movement of the mandible, resulting in a decompression of the condyle and favourable changes in the disc position and overall TMJ structure (Figure 4).
Figure 4: Upper removable orthopaedic appliances used (anterior push sagittal and 50/50 sagittal); pre vs post expansion study models.
In addition, the patient went to see an immunologist for allergy testing, which revealed a severe allergy to dust mites. Other allergies included grass, mould, cats, dogs and pollen. The patient decided to go through multiple rounds of immunotherapy treatment and also made lifestyle changes such as getting rid of carpet, washing bedsheets weekly and buying an air purifier which significantly helped with the dust mite allergy.
Final orthodontic records were taken including CBCT scan, intra and extra oral photos including profile, occlusal analysis, Schwarz analysis, Jefferson ceph analysis and another sleep study for comparison. The Jefferson tracing showed the patient finished in a class I skeletal with a slightly higher vertical than before and both jaws just in front of the anterior arc. The sleep study showed the AHI score came down further to 14.4 and oxygen nadir to 85%. The patient elected not to have a mandibular advancement splint (MAS) made, due to the risk of long term bite changes resulting in an underbite. Instead, an upper Farrar splint with a lower 3-3 2mm thick Essix retainer was made as a night time appliance. The Farrar splint had a hole in the ramp to attract the tongue forwards and prevent it from blocking the airway. The lower Essix prevents dental pain resulting from the lower anteriors hitting the ramp, and prevents the posteriors from contacting the Farrar splint, which decreases muscle tension by decreasing the masseter activity strength. Another sleep study was done wearing the night time appliance for comparison. The result showed the AHI score came down even further to 6.4 and oxygen nadir improved to 88%. Airway analysis was not done immediately after orthodontic treatment, but a 4 year follow up CBCT revealed a larger oropharyngeal airway with a minimum axial area of 94.9mm2 (Figures 5-7).
Figure 5: Summary table of PSG results with each phase of treatment; Upper Farrar splint with lower 3-3 2mm thick Essix retainer.