Editor's note: This is the second of two articles from Dr. Jeff Rouse's review of the 2019 American Association of Orthodontists (AAO) White Paper – Obstructive Sleep Apnea and Orthodontics. The paper was the culmination of a two-year project by a panel of sleep medicine and dental sleep experts tasked to produce guidelines for the role of orthodontists in the management of obstructive sleep apnea (OSA). In Part 1, Dr. Rouse wrote on the potential impacts of tooth extraction on the airway. Here he examines the paper's guidance for adult and childhood management of obstructive sleep apnea (OSA) by orthodontists.
Author's note: The topic of the impact of tooth extraction on the airway can be very contentious. My hope is these articles serve as a tool to allow collegial discourse between restorative dentists concerned with airway and the orthodontists who they look to for solutions.
In the airway prosthodontic curricula at Spear, the focus is – Just Do Dentistry. The concept builds on the foundation of Facially Generated Treatment Planning (FGTP). In FGTP, complex treatment planning begins by setting the incisal edges of the maxillary central incisors as you would in a denture. The addition of airway reminds us that we never set the teeth in a denture until the anteroposterior (AP) and transverse dimension of the wax rim are ideal. The AP and transverse dimensions have come to represent the airway.
We would never set teeth to a deficient wax rim. Yet, restorative dentists and orthodontists commonly work within and/or camouflage maxillary hypoplasia. This critical difference between treating OSA and “Just Doing Dentistry” can be found in the 2019 AAO White Paper – Obstructive Sleep Apnea and Orthodontics.
In the paper's sixth section, “Orthodontic Management in Adult OSA,” the task force focused extensively on orthodontists fabricating mandibular advancement appliances in concert with sleep physicians. Informed consent, appliance titration, and occlusal alteration were reviewed.
At Spear, we would classify this as sleep dentistry rather than airway focusing on augmenting the oral anatomy with a piece of plastic with the express goal of improving breathing during sleep. If the appliance is not worn or when the appliance is removed, the patient's airway has not been improved. The AAO does conclude with a look at resolving the issue instead it suggests:
“Maxillomandibular advancement (MMA) generally is reserved for patients with severe OSA who are unable to tolerate PAP... and/or oral appliance therapy..., and for those patients who also have an orthodontic indication for the procedure.”
In my opinion, this sentence is backwards. MMA is designed and reserved for patients who have a skeletal requirement for the procedure. FGTP has focused on that for years but, in my office, has failed to deliver on MMA for esthetic and functional reasons.
Severe apnea patients who failed positive airway pressure (PAP) or oral appliance therapy have a greater incentive for care. The idea you should wait until the disease is severe before considering treatment is counterproductive and counterintuitive. Waiting for patients to become extremely ill before you treat their skeletal issues makes surgery less apt to cure or significantly reduce OSA and the healing more problematic, as bone and tissue are negatively affected by long-term OSA.
The vast majority of OSA patients have a skeletal component – retrognathic maxilla, mandible, or both. The “Just Do Dentistry” concept suggests the “orthodontic indication” should be the focus rather than the apnea. In that case, we tell the patient we are going to resolve the skeletal issues impacting their esthetics and function. We then follow the AAO guideline:
“Improvement of the OSA should be highlighted as a 'possible,' or some studies say 'anticipated,' outcome of treatment. But no guarantees of OSA resolution can be implied or stated emphatically by the treating orthodontist.”
The advantage of focusing on the dentistry is that skeletal issues are addressed at an earlier age. Patients do not have to have severe OSA and fail PAP or oral appliance therapy to justify the treatment. Also, the patient doesn't have to go through a litany of “less invasive” options that make MMA results worse. It is my opinion; we should put the skeleton in its optimal position and provide the patient with the best chance to heal as early as possible.
Two additional procedures to alter the maxilla were discussed in the guidelines – surgically assisted rapid maxillary expansion (SARME) and mini‐implant supported rapid maxillary expansion (MARME).
If the maxilla is deficient, there are OSA patient studies that suggest an improvement in sleep parameters are possible with an improvement in nasal volume and flow. These procedures are gaining in popularity and new research published since the AAO review continues to show their positive effects for patients with all levels of apnea and much less invasive surgical techniques.
The pediatric section of the white paper can be summarized in the following statement: The orthodontic treatment plan for patients with OSA should follow the same orthodontic principles for correction of dental and skeletal deformities. In other words, “Just Do Dentistry.”
I have two comments:
- Patients with OSA implies they have had a sleep study. Previous Spear articles have discussed the issues with pediatric sleep studies and the fact that most treatment can be done based on symptoms and not sleep study numbers. Additionally, if you wait for an OSA diagnosis before treating children, you are waiting for disease and will miss most of the patients who could benefit from the intervention.
- The only so-called principle that should change is the timing of therapy. The AAO has recommended the first orthodontic evaluation should be done at seven years old. Historically, the orthopedic expansion would begin after the eruption of the first molars. Today, if skeletal deformities are present, fix them when you find them.
Jeffrey Rouse, D.D.S., is a member of Spear Resident Faculty.