FUNCTIONAL

APPLIANCES/MANDIBULAR

ADVANCEMENT Pamela R. Hanson, DDS, MS

Best Evidence

“All roads lead” to the sleep

medicine physician

• Diagnosis

• Determine:

– Obstruction

• Where?

– Central Nervous System

• Monitor

• Determine “cure”

– Based in science

• Multidisciplinary “team event”

The mandible

• Where does the change need to occur?

• How much change needs to occur?

• Change

– Acute

– Evolves

• Determine modality

• Mandibular advancement appliances vs

mandibular repositioning devices

N. Nazarali, M. Altalibi, S. Nazarali, et al.

Mandibular advancement appliances for the treatment of pediatric

obstructive sleep apnea: a systematic review

Eur J Orthod, 37 (6) (2015), pp. 618-626

I. Ghassan, B. Galland, C. Robertson, et al.

Mandibular advancement appliances efficacy on sleep disordered

breathing in children: a randomized controlled trial

J Sleep Res, 26 (2017), p. 8

G. Idris, B. Galland, C.J. Robertson, et al.

Mandibular advancement appliances for sleep-disordered breathing

in children: a randomized crossover clinical trial

J Dent, 71 (2018), pp. 9-17

W.R. Nunes, R.C.D. Francesco-Mion

Early treatment and preventive strategies for obstructive sleep apnea

and hypopnea with the bioajusta x orthodontic- orthopedic treatment

Sleep Med, 10 (2009), pp. S41-S42

C. Guilleminault, M. Partinen, J.P. Praud, et al.

Morphometric facial changes and obstructive sleep apnea in adolescents

J Pediatr, 114 (6) (1989), pp. 997-999

P. Cozza, R. Gatto, F. Ballanti, et al.

Management of obstructive sleep apnoea in children with modified monobloc

appliances

Eur J Paediatr Dent, 5 (1) (2004), pp. 24-29

A.J. Machado-Júnior, L.G. Signorelli, E. Zancanella, et al.

Randomized controlled study of a mandibular advancement appliance for the

treatment of obstructive sleep apnea in children: a pilot study

Med Oral Patol Oral Cir Bucal, 21 (4) (2016), pp. e403-e407

T.C.B. Schütz, G.C. Dominguez, M.P. Hallinan, et al.

Class II correction improves nocturnal breathing in adolescents

Angle Orthod, 81 (2) (2011), pp. 222-228

C. Zhang, H. He, P. Ngan

Effects of twin block appliance on obstructive sleep apnea in children: a

preliminary study

Sleep Breath, 17 (4) (2013), pp. 1309-1314

A. Stellzig-Eisenhauer, P. Meyer-Marcotty

Interaction between otorhinolaryngology and orthodontics: correlation between

the nasopharyngeal airway and the craniofacial complex

GMS Curr Top Otorhinolaryngol Head Neck Surg, 9 (2010), p. 04

N.T. Huynh, E. Desplats, F.R. Almeida

Orthodontics treatments for managing obstructive sleep apnea syndrome in

children: a systematic review and meta-analysis

Sleep Med Rev, 25 (2016), pp. 84-94

W. Proffit, H. Fields, D. Sarver

(5th ed.), Contemporary orthodontics, Mosby (2012), pp. 242-245

M.P. Villa, E. Bernkopf, J. Pagani, et al.

Randomized controlled study of an oral jaw-positioning appliance for the

treatment of obstructive sleep apnea in children with malocclusion

Am J Respir Crit Care Med, 165 (1) (2002), pp. 123-127

The study was conducted on prepubertal children. The

adenoid tissue is still in the peak of growing at the ages of

the subjects included in this study. However, the

measurements along the nasopharynx increased when

compared with the initial ones. Still, similar retrospective

and prospective studies are needed at older stages.

C. Restrepo, A. Santamaría, S. Peláez, et al.

Oropharyngeal airway dimensions after treatment with

functional appliances in class II retrognathic children

J Oral Rehabil, 38 (8) (2011), pp. 588-594

Conclusions: In the short term, the increase in airway space

improved nocturnal breathing associated with the correction of

mandibular retrognathism.

Objective: To examine modifications in sleep pattern and

in craniofacial morphology of adolescents with mandibular

retrognathism.

T.C.B. Schütz, G.C. Dominguez, M.P. Hallinan, et al.

Class II correction improves nocturnal breathing in

adolescents

Angle Orthod, 81 (2) (2011), pp. 222-228

Materials and Methods: Sixteen subjects at maximum pubertal growth

(12.6 years [±11.5 months]) were selected and treated for 12 months

with maxillary expansion and mandibular advancement with a Herbst

appliance.

Orthopedic management

mandibular advancement

Herbst appliance

Mara

Twin block

Bionator

Jasper Jumper

Forsus

Growth Modification

Mandibular retrognathia

• Encourage

mandibular

growth

• Correct Cl II

malocclusion

• Improve facial

profile

• Most effective

in the growing

child

Orthopedic correction of

Mandibular retrognathia

•

Often in combination with Maxillary expansion

• Surgical options

– Orthognathic surgery

• Mandibular advancement

• Bimaxillary advancement (MMA)

• Very precise

• Usually in the skeletally mature

patient

– Distraction osteogenesis

• Larger magnitude of advancement

can be achieved

• Titrateable

• Less precise

• Skeletally mature or imature patient

When orthopedic management

is not enough

Woodson BT. Hanson PR. Melugin MB. Gama AA. Sequential upper airway

changes during mandibular distraction for obstructive sleep apnea.

Otolaryngology-Head & Neck Surgery. 128(1):142-4, 2003 Jan.

Mandibular Advancement

• 48yr old nonobese male with severe

OSA

• RDI 38 events/hr

• Failed CPAP

• Stoke related to OSA

• DO 37 days, 1mm/day

• Titrated until airway improved

• Patient was monitored and airway

dimension was evaluated, during

distraction, utilizing the following:

– Serial cephalometric radiographs

– Serial polysomnography

– Serial direct nasoendoscopy

• Retropalatal cross-sectional area more than doubled

• Retroepiglotic cross-sectional area almost doubled

• Posterior airway space as measured on lateral ceph increased by 50%

• Lateral cross-sectional area of pharyngeal airway as measured on a lateral ceph increased by over 50%

BT Woodson, PR Hanson, MB Melugin, AA Gama-Sequential upper airway

changes during mandibular distraction for obstructive sleep apnea-OHNS Jan

2003, vol 128: 142-4.

Distraction in the orthognathic patient

Pre-Trx

Melugin MB, Hanson PR. The use of distraction osteogenesis in

the treatment of obstructive sleep apnea. AAOMS 80th Annual Session, 1998

Pre-Trx Post-DO

Sequential upper airway changes during mandibular distraction for obstructive sleep

apnea.

Woodson BT, Hanson PR, Melugin MB, Gama AA.

Otolaryngol Head Neck Surg. 2003 Jan;128(1):142-4.

Mandibular lengthening to improve

airway & mastication

Hanson PR, Melugin

MB: Orthodontic

Management During

Distraction. Sem in

Ortho 1999, 25-34.

Pierre Robin Sequence

• Mandibular hypoplasia

• Mandibular retrognathia

• Associated with

syndromes or may be

isolated

• Glossoptosis

• Associated airway and

masticatory dysfunction

including life-threatening

sleep apnea

• Usually accompanied by

wide cleft of the palate

Distraction proceeds until airway compromise is

corrected as determined by a sleep medicine physician

Pre-distraction Post-distraction

Occlusal “Overcorrection” Normalized by

ongoing Deficient Growth

Patient

decanulated

Post-consolidation

Patient

remains

decanulated

Pre-distraction

During distraction

• \

Pre-distraction

Post-distraction

Preop 6 mos. Post-distraction

Preop 6 mos. Post-distraction

Preop 6 mos. Post-distraction

Note the

vertical device vector

With external multidirectional

Devices you can dial horizontal.

With internal devices you have

to place orthopedic forces to

change the distraction vector

during distraction.

He had a very short rami, so

vertical device placement

lengthens the ramus more

predictably.

Post op posterior openbites are

Dealt with orthopedically.

Preop 6 mos. Post-distraction

Distraction in the Treatment

of Obstructive Sleep Apnea• SR Cohen, C Simms, FD Burstein-Mandibular distraction

osteogenesis in the treatment of upper airway obstruction in

Children with Craniofacial Deformities. PRS: Volume 101(2)

Feb 1998 pp 312-318.

• KK Li, NB Powell, RW Riley, C Guilleminault- Distraction

Osteogenesis in Adult Obstructive Sleep Apnea Surgery : A

preliminary Report. JOMS, Vol 60, Issue 1, Jan 2002 pp 6-

10.

• X Wang, XX Wang, C Liang, B Yi, Y Lin, ZL Li-Distraction

Osteogenesis in correction of micrognathia accompanying

obstructive sleep apnea syndrome. PRS : Vol 112 (6) Nov

2003 pp 1549-1557.

• A Malamud-Machtel-Distraction osteogenesis for Treatment

of obstructive sleep apnea: a Meta-analysis. JOMS 2008 in

press

Distraction in the Treatment

of Obstructive Sleep Apnea• BT Woodson, PR Hanson, MB Melugin, AA Gama-Sequential

upper airway changes during mandibular distraction for

obstructive sleep apnea-OHNS Jan 2003, vol 128: 142-4.

• RM Dasheiff, R Finn -Treatment goals for obstructive sleep

apnea-Distraction Osteogenesis of the Facial Skeleton, WH

Bell, CA Guerrero

• L Shoe, X Wang, C Liang, B Yi, ZL Li-Orthognathic surgery and

distraction osteogenesis for treatment of obstructive sleep

apnea hypopnea syndrome. Pub Med Jun 2005; 27(3): 357-62.

• AD Denny, R Talisman, PR Hanson, RF Recinos-Mandibular

distraction osteogenesis in very young patients to correct airway

obstruction. PRS Aug 2001 Vol 108(2) pp 302-311.

• SR Cohen, C Simms, FD Berstein, J Thomsen-Alternatives to

tracheostomy in infants and children with obstructive sleep

apnea. JPS, 1999

Pre-trx records

-Severe mandibularretrognathia and micrognathia

-Unidentified syndrome

8/05 8/25 10/10 11/17

The red dot is the unerupted Maxillary incisor

The blue dot is the unerupted Mandibular incisor

Pre distraction Post distraction

1) Hanson PR, Melugin MB: Orthodontic Management During Distraction.

Sem in Ortho 1999, 25-34.

2) Volumetric changes of the nose and nasal airway 2 years after tooth-borne

and bone-born surgical assisted rapid maxillary expansion. Nada RM, van

Loon B, Schols JG et al, Eur J oral Sci. 2013 Oct:121(5):450-6.

3) Sequential upper airway changes during mandibular distraction for

obstructive sleep apnea. Woodson BY, Hanson PR, Melugin MB, Gama AA.

Otolaryngol Head Neck surg 2003 Jan:128(1):142-4.

4) Mandibular distraction osteogenesis in very young patients to correct

airway obstruction. Denny AD, Talisman R, Hanson PR, Recinos RF. Plast

Reconstr Surg. 2001 Aug:108(2):302-11.

Distraction & airway

All roads END at the sleep

medicine physician

• Diagnosis

• Treatment decisions based on

science

• Monitoring

• Determine “cure”

• Multidisciplinary “team event”

Protocol

Take home message• Primary or secondary referral

• Sleep Medicine physician

– Assess structural or central

– Where is the obstruction

• Monitor treatment

– Advance structures

– Enlarge structures

• Assess success or not

• Determines course of action