Posted on 10/09/2017
Following is the case report of a patient suffering from pediatric OSA who was treated by teledontic treatment protocol and GAC in-Ovation R self-ligating brackets. The patient’s treatment results were presented at the Pacific Northwest Dental Conference one of the most prestigious dental meetings in the United States and Canada:
Hygienist of the referring dentist referred her 10 years old son for evaluation and treatment of possible OSA. Family’s chief complaint was excessive day time sleepiness, fatigue, snoring, non-restful sleep and nocturnal clenching.
Patient had class two facial skeletal relationship, class I malocclusion, constricted jaws, large tonsils and adenoids. Considering his other symptoms and familial history including his father having OSA, he was referred for in lab sleep study. He was diagnosed with mild obstructive sleep apnea, AHI of 3.7, nadir 94%. He snored with restless sleep and his school performance had significantly declined in the last few years. 1,2
He was referred to an ENT specialist to get tonsillectomy and adenoidectomy. The post-surgical polysomnogram surprisingly showed deterioration of OSA with moderate severity, AHI of 8.9 which was very severe in REM sleep, (REM AHI of 21.9, nadir 85%).
The treatment proceeded with phase one teledontic therapy including expansion of pharyngorofacial system followed by restoration of malocclusion by use of GAC In-Ovation R brackets with total time of 13 months. Teledontic protocol was followed by bed time use of pharyngorofacial stabilizing orthotic (PSO) and periodic evaluation every four to six months.
Although it was recommended that patient wears the CPAP in combination with PSO, family reported unsuccessful progress with wearing CPAP. It was determined that patient was wearing the PSO four to five nights a week.
The second stage of treatment started at age 15 including six months of pharyngorofacial expansion followed by full braces for proper correction of occlusion. This stage of treatment was completed in 16 months.
The third sleep test after completion of his treatment showed complete relief of the OSA with an AHI of 1.5 and nadir of 93% which was mild in REM sleep, (REM AHI of 2.1).
He stopped snoring and started sleeping well. His excessive daytime sleepiness and fatigue was completely resolved. He has been doing very well academically and just got accepted in the UW engineering program which is one of the toughest schools in the northwest to get in. The cephalometric evaluation demonstrated normalized growth of pharyngorofacial (POF) system to ideal Class I facial skeletal relation and class I occlusion.
It’s a lot easier to “see” the problem in a child who has snoring, loud mouth breathing and what seems to be obvious signs of airway dysfunction. But indeed, often children only exhibit one or two symptoms, and they may be symptoms like behavioral problems, bedwetting, and/or bruxism.3
“Obstructive sleep apnea is a preventable and curable disease”, children with airway pathology require a treatment protocol significantly different than traditional orthodontic treatment that may involve use of headgear, functional appliances like Herpes appliance, distalizing treatment protocols or extraction of teeth to create straight teeth. Improvement of the whole POF complex, not just correction of crossbite or a narrow palate, is required to have an impact on the upper airway for treatment of OSA.3
While oral surgeons are rethinking their approach from ‘orthognathic’ to ‘telegnathic’ to reflect the forward positioning of the maxilla and mandible for treatment of OSA, orthodontists and dentists with a medical focus can provide ‘teledontic therapy’ – a medically necessary dental treatment for OSA. 3-6
Teledontic therapy not only can be utilized as preventive measures of OSA by avoiding extractions, use of headgear and functional appliances but also is cable of curing the most severe forms of pediatric or adult OSA. 3,7