|Sleep Apnea from an Anatomical and Developmental Perspective|
on Sleep Apnea
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Section A - Basics of sleep and sleep apnea (64 slides) File size: 2.3 mg
Section B - Non-surgical treatments for OSA (53 slides) File size: 2.2 mg
Section C - Surgical options for OSA (44 slides) File size: 2.1 mg
Section D - Cause and prevention of OSA (68 slides) File size: 2.9 mg
Section A – Basics of sleep and sleep apnea
- Basics of sleep
- Basics of sleep apnea
- Physical characteristics associated with OSA
A9 – Deep
sleep is very important for a child’s growth and development. Growth hormone reaches its peak levels during Stage 4 of deep
A 10 –
Research by Dr. Soichiro Miyazaki demonstrates more deep sleep improved
production of growth hormone (GH) in deep sleep when airway obstruction
(tonsils) was removed.
Physical characteristics of OSA: A
large body mass, large neck size and age are common and fairly well know risk
factors for OSA. There are however,
other risk factors that are not as well known.
These factors include, but are not limited to: the shape of the oral
cavity, facial form, tongue size, tongue activity and anything that might
infringe on the airway space including, including tonsils, adenoids, tori,
polyps, deviated septum and elongated soft palates, etc.
A29 to 31
– It is very important for all health care providers to understand this
formula that was developed at Stanford. You
can link to this article through this website.
A32 – Read
my article “The Significance of the Delivery System During Infant Feeding and
Nurturing” found under “articles” on this website to better understand
– Models demonstrate illustration of A32.
A34 shows close up of resultant crossbite.
A36 to 41
– This gentleman is a classic example of Stanford’s morphometric formula.
Obesity is a major contributing factor to the health care crisis we are now in.
A BMI over 25 puts an individual at risk for OSA.
A45 to 50
– Some researchers are looking for genetic markers for abnormal tongue
activity. Only genetic markers that
will be found are for ankyloglossia (tongue tie) and large tongues (macroglossia).
Nearly all other abnormal tongue activity is a “learned” behavior.
This will be covered more fully in another presentation that will be on
this website. Ankyloglossia and
tongue thrusting will also be covered eventually in a separate presentations on
A47 to 50
– This patient was bottle-fed and was also a thumb sucker – both caused
severe malocclusion, overjet and tongue thrust. Tongue thrusting is fairly
common in individuals with OSA. Read
article on this website: “The Influence of Breastfeeding on the Development of
the Oral Cavity” to better understand this point.
A51 to 62
– Anything that reduces airway
space can contribute to OSA.
A62 - The
common orthodontic practice of removing bicuspids and retruding the anterior
teeth can be potentially deadly - because it reduces oral cavity space.
Back to Top
Section B – Non-surgical treatment options for OSA
- Oral Appliances
There are no
guarantees that any one treatment or appliance will resolve OSA.
B7 to 9 –
CPAP is currently the “Gold standard” for the treatment of OSA.
Challenges with using it include claustrophobia, leakage around the mask,
ill-fitting masks, dying of mucous membranes, etc.
C – Surgical treatment
options for OSA
- Hyoid suspension / advancement
- Genioglossal advancement
- Maxillary and Mandibular Osteotomy
There are no
guarantees that any one surgery will resolve OSA except a tracheotomy.
C2 – Tracheotomy. My brother had a massive stroke on Easter Sunday, 1995.
OSA was a contributing factor in his stroke.
His story and basic information on OSA is the topic of my article on this
website – “Are you sleeping with a killer” found under “articles”.
In 2001 he is still in a long-term care facility.
The financial burden to the health care system has been tremendous for
this one case alone.
C3 to 7 –
Various surgeries designed to reduce tissue bulk.
C8 & 9
– Hyoid suspension.
Hyoid bone is sutured to chin or thyroid cartilage.
A hyoid bone lower than 20mm below the lower border of the mandible is
considered a risk factor for OSA.
C10 to 17
– Genioglossal advancement.
The tongue is attached to the inside of the lower jaw (mandible).
This attachment is moved forward and advances the tongue the thickness of
C18 to 23
The uvula and portion of the soft palate are removed.
This surgery can be quite painful.
C24 to 27.
Too much tissue was removed during this UPPP.
This created a velo-pharyngeal insufficiency (poor seal between throat
and nasal cavity) which allowing food and water to regurgitate through the nose
while eating or drinking. An
obturator had to be placed on the denture and placed behind the soft palate to
stop this regurgitation. The
patient’s large tongue was a contributing factor to her OSA.
A tongue-retaining appliance helped resolve her problem.
C28-35 – Glossectomy. Various tongue surgery techniques are used to reduce
C36 to 43 - Osteotomy. Maxilla and mandible are sectioned and moved forward.
If patient’s malocclusion had been addressed as a youngster, he would
not have needed this surgery as an adult. Prevention
in this case would have saved this patient and the health care system a lot of
Back to Top
D – Cause and Prevention
principles involved in airway collapse
D3 – Vacuum.
Any type of EXCESSIVE
sucking on a bottle, pacifier, digits, etc., can cause an implosion or inward
collapse of the oral cavity, throat and airway. Permanent deformation of these structures can occur over
D4 – Gravity. As muscles relax and lose tone, gravity can pull the tongue
and other surrounding tissues back into the airway space.
D5 & 6
– Venturi. When the airway gets reduced in size by any manner, air must
move faster to move the same volume of air.
D7 to 10 –
Bernoulli. The faster the air moves through a tube (airway), the greater
the risk the walls of the tube will collapse – which in turn worsens the
D10 & 11
– Possible cause of elongation of soft palate and uvula.
If the nasal passage or the mouth (or both) is reduced in size for any
reason, the Venturi principle comes into play.
The increase in speed of air movement creates a wind tunnel effect.
Place pliable, soft, stretchable tissue like the soft palate and / or
uvula – and it is scientifically logical that you could get a permanent
stretching of this tissue – as seen in the throat of the 14 year old in D11.
D12 & 13
– This is a skull from a prehistoric breastfed culture (bottles and pacifiers
were not available in those times). A
wide palate creates a large posterior nasal aperture. Note width of pterygoid plates that are the lateral
“pillars” for this aperture. The
larger this aperture the less risk the airway will collapse.
D14 to 16
– This relatively modern skull (1940s) has a high palate and small posterior
nasal aperture. Note the narrowness
of the pterygoid plates – the bony columnar supports on both sides of the
aperture. The smaller aperture puts
this individual at a greater risk for airway collapse.
D17 – This
is a very key point. Rapid palatal
expansion BEFORE the mid-line palatal
suture fuses – will create a widening of the dental arch, a flattening of the
palate and the widening of the pterygoid plates.
This results in a larger posterior nasal aperture as well as larger nasal
volume. Sectioning the maxilla
after the mid-palatal suture fuses will not give the benefit of creating a
larger posterior nasal aperture. The
only benefit is widening of the dental arch.
D18 to 22
– I hypothesize that prehistoric man did not have OSA because they did not
have the morphometric features as described in Stanford’s morphometric formula
(I am assuming they were not as obese as our modern culture).
D23 & 24
– Many “modern” people have high palates and narrow arches. Because of this they have smaller posterior nasal apertures
as seen in D24.
D25 – It
is critical to prevent OSA by early treatment.
Rapid palatal expansion is one such treatment.
The option of removing bicuspids for orthodontic reasons instead of
expanding the arch can have serious consequences by contributing to the
development of OSA.
D26 – To
reduce the high cost of treating OSA, our society has to encourage prevention.
Breastfeeding is the best and cheapest way to prevent OSA.
We MUST educate everyone on the many benefits of breastfeeding and
encourage mothers to do so. Reading
articles already on this website will help you better understand this position.
D26 to 28
– Malocclusions are common today. Most
prehistoric cultures did not have malocclusions – mainly because they were
breastfed. There is a direct link
between malocclusion and OSA. If a
newborn could not breastfeed during prehistoric times it probably died – only
the fittest survived!
D29 to 31
– Breastfeeding develops the proper infant and adult swallowing pattern –
which helps mold and shape the oral cavity. There are several reasons for
malocclusions (slide D40) but the major contributing factors today include
bottle-feeding, pacifiers and “excessive”
infant habits (see articles on this website plus future presentation on oral
cavity development). The ACTION OF
THE TONGUE during breastfeeding IS THE KEY to proper oral cavity development.
During breastfeeding there is a forward to backward peristaltic type
motion of the tongue. This is critical for the development of a proper adult
swallow and shaping of the oral cavity (read articles on website on this topic).
D32 – This
picture demonstrates the normal position of the tongue in the mouth while at
rest. There are no abnormal muscles
forces exerted on any bony structure.
Picture showing oral structures in a “neutral state”.
During breastfeeding, the breast adapts to the shape of the oral cavity.
During bottle-feeding, pacifier use, digit sucking, etc. the oral cavity must
adapt to the foreign object. Read
articles on website for more insight.
D35 to 37–
Objects firmer than the breast during infant swallowing – like bottle nipples,
digits and pacifiers can interfere with a proper swallow by not allowing the
tongue to come in contact with the hard palate.
This can lead to an abnormal tongue activity, which I will generically
call a “tongue thrust”.
Slide demonstrates how the tongue and soft palate can block off the airway.
Cadaver slide demonstrates insertion of tongue on mandible, thick soft palate, Eustachian
tube and turbinates in nasal chamber.
D40 – Main
reasons for the collapse of the oral cavity and airway space. Any collapse becomes a direct risk factor for OSA.
There is no one ideal treatment for OSA. All
treatments can have unwanted side effects.
OSA is grossly under diagnosed and under treated.
OSA and its many side effects can potentially bankrupt our health care
system in the future.
D42 – Key
principle: The easier it is for an
individual to breathe – the healthier that individual will be – or in
reverse – the harder it is for an individual to breathe, the more unhealthy
he/she is likely to be.
There are many health and mental issues related to breathing problems.
These issues will eventually bankrupt health care and the insurance
Craniofacial development is 90% complete by the age of 12.
Since there is a direct link between craniofacial development and OSA,
treatment / prevention of OSA must be initiated in early childhood days.
D46 – Key
slide – it is rare to find occlusal disharmony in prehistoric skulls – that
society had no option except to breastfeed their young.
D49 – One
of the most important formulas in the medical field.
It is a formula all health care providers need to understand and
Models of individual demonstrating a high palate and narrow maxillary dental
Skull demonstrates how a high palate and narrow arch results in a small
posterior nasal aperture.
Drawing demonstrates how a high palate decreases nasal chamber volume and a
Potentially deadly orthodontic treatment in which removing bicuspids can
decrease oral cavity volume. This
can become a contributing factor to OSA.
treatment for crowded dentition – expansion of the palate and dental arch – BEFORE
the mid palatal suture fuses.
Models placed in patient’s normal bite. Models
demonstrate a Class II retruded (pushed back mandible) relationship and overjet
(upper teeth way out in front of lower teeth).
Lower model advanced to a Class I occlusion.
Flaring of upper front teeth would allow teeth to settle into a more
ideal relationship. This is the
position an oral appliance places the jaw when treating for OSA.
D58 – A
Herbst appliance advances the mandible. It
is worn nightly by this adult to treat his OSA.
Eleven year old wearing cemented Herbst during growth spurt period to correct
Class II malocclusion – reducing the risk for having OSA as an adult.
This can significantly reduce future medical costs.
D60 – Macroglossia
– a genetic trait – increases the risk of OSA.
Need to be aware of this potentially deadly trait.
D61 to 63
– Abnormal tongue activity is a
risk factor for OSA for 2 reasons: 1) It contributes to malocclusions and 2) It
fatigues the tongue (will be covered in another presentation on this website).
D63 & 64
– Ankyloglossia (tongue tie) is
also a contributing factor to OSA (covered in separate presentation on tongue
D65 & 66
– Enlarged tonsils can obstruct
airway and impact health and development of individual. Removal of these tonsils had a significant improvement in
attitude and grades for this youngster.
Conclusion: I hope this presentation has helped you better understand the complexity of health problems, especially those problems related to snoring and sleep apnea. One’s ability to breathe well directly determines how one feels. At this point, please review the “Summary of Points” on this website. You can access this from a tab on the home page.
Brian Palmer, DDS,
Kansas City, Missouri, USA.