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Airway , Breathing and SleepA Collaborative Approach
Airway Centric
Airway , Breathing and SleepA Collaborative Approach
Airway Centric
A New Paradigm
Michael Gelb DDS,MS
Michael L. Gelb DDS,MS
Gel-B™
Gelb 4/7TM
Airway Restorative
H
Airway CentricTM
Airway Centric
Chief complaints: right jaw locking, limited mouth opening, jaw clicking, ear congestion, and nocturnal teeth grinding
BMI = 27.9 Retruded mandible, Deep bite
Revealed enlarged tonsils Forward head posture
Referred to ENT for tonsillar evaluation and referred to physical therapist for postural re-education
Breastfeed for at least 2 months Make sure your child is a nasal breather Avoid thumb sucking and pacifiers Find an orthodontist from AAPMD.org No extraction of permanent teeth except 3rds Avoid retractive headgear Get tonsils and adenoids out early Get your child a sleep study if they have SDB,ADHD, bedwetting, Nightterrors, colic Early intervention ( 0-5) is a team effort Airway Centric
Esthetics Neurobehavioral Neurocognitive Cardiovascular Relationships Performance Chronic Disease Inflammation Fatigue Obesity Aging
Airway Centric
Stuffy Nose
CHIEF COMPLAINTS
• Back pain
• Headaches
• Neck pain
• Sinus Congestion
• Fatigue
DIAGNOSIS
• Anterior disc displacement
• Reduction in Right and Left TMJ
• Capsulitis of Right and Left TMJ
SUBJECT: 74 year old Female
Before Treatment
2/2009
Beginning Treatment
2/2009
Progress3/2011
Progress1/2013
Treatment Plan:
• NYU 6-8 Weeks
• Farrar
• Snap-on-Smile prosthesis
Improvements attributed to:
• Airway Centric™ Mouthwear
• Airway Restorative Dentistry™
• Increased Oxygen Saturation Levels
• Decreased Oxidative Stress
• Increased Stage 3 Deep Sleep
• Corrected Endothelial Dysfunction
Pre-Treatment2-2009
Progress1-2013
LATERAL BEFORE AND AFTER
FRONTALBEFORE AND AFTER
Pre-Treatment2-2009
Progress1-2013
Pre-Treatment: 2-2009Decreased Vertical Dimension of Occlusion, Retruded mandible and nerve compression
Progress with Airway Restorative Dentistry™ : 1-2013
STABILIZED AIRWAY Progress with Appliance
2013
COLLAPSED BASELINE AIRWAY 2009
Airway Assessment20092013
COLLAPSED OPEN AIRWAYAIRWAY
CBCT TMJ Findings
Pre-Treatment2-2009Mild degenerative changes to Right and Left TMJs ossesousstructures.Retruded Right and Left TMJs.
Progress 1-2013Right and Left TMJ noticeably removed from the eminence. Increased joint space.
Right TMJPre-Treatment2009
Right TMJProgress2013
Oral Examination
2-2009.
Retruded Mandible causing compression of
Auriculotemporal Nerve
4-2009.
Daytime Mandibular NYU Orthopedic appliance
prior to prosthetic work.
Vertical dimension reestablished; pain eliminated.
3-2011.
Transitional Snap-on-Smile.
Restoration of vertical dimension of occlusion.
Preliminary Ceph Analysis 2009
Progress Ceph Analysis 2012
SUBJECT: 44 Year Old Male
Epworth sleepiness scale = 7
Baseline PSG
03-18-2008
CPAP Titration
03-18-2008 @8 CM H2Opressure
Follow-up with Oasys03-15-2013* Snoring below
40db
AHI 15.6 0 3.8
Stage N3
4% 4% 18.82%
REM 22.3% 17.34%
Chief Complaints: Frequent heavy snoring Linea Alba Obstructive Sleep Apnea
Clinical Findings:
Narrow Maxilla Vaulted Maxilla Hypertrophic masseters The occlusal plane cants up to the right, the right
ear and right eye are higher than the left Bilateral pain and compression of the
auriculotemporal nerves Previous Laup procedure Previous Septoplasty surgery
Contributing Factors
Enlarged tongue Clenching Narrow Maxilla Severely Constricted Airway
ASSESSMENT
1. Obstructive Sleep Apnea2. Macroglossia3. Anterior Disc Displacement
with Reduction of the Right and Left TMJ
TREATMENT PLAN:
1. Mandibular NYU to decompress the right and left TMJ for 6-8 weeks
2. Oasys Sleep appliance at night3. Patient takes Zyrtec and Flonase
for allergies to decrease congestion
ICAT imaging (07/20/2012) revealed• Hypoplasia of the left condyle• Periodontal recession
throughout posterior bicuspids and molars- all four quadrants
Axiel view Sagittal view
Preliminary scan July 2012 confirms a 1mm anterior-posterior airway when standing
Follow up CBCT with Oasys shows stabilized airway
Min area= 62.1mm2 Open Airway= 178.3mm2
After 6 months of oral appliance therapy with an Oasys repositioning appliance, the airwayAirway increased by 116.2mm2.
Changes to the Patient’s Centric Bite as a result of OA Therapy
Before treatment July 2012 Class II dental relationship Overbite is present
7 months utilizing Oasys at night & NYU during the day February 2013 Protruded mandible Edge to Edge dental relationship No overbite
Oasys 7-2-2012
Oral appliance therapy
Oasys 11-2012
Sleep parameters for success include:
• Airway stabilization to increase oxygen saturation, sleep architecture• Less strain on the vital organs• Decrease endothelial Dysfunction• Improve sleep quality• Increasing energy• Decrease sleep bruxism
6 Months into treatment the patient reports:
1. Spouse’s sleep is no longer disrupted2. Sleeping throughout the night3. Snoring is virtually gone4. No jaw pain5. Temple headaches are now a rare occurrence
Clicking bilateral TMJ Jaw clicking while eating Bilateral jaw pain Migraine HA Bad back for many years
31
Initial CBCT 2009
F-UP CBCT 2010
Airway Centric
Ideal 4/7 condylar position post orthopedic realignment therapy- Mandible is set forward
Airway Centric™ Restored bitePost Veneer and OnlaysRehabilitation 08/05/2013
Completed Centric Bite with Maxillary Farrar appliance 08/19/2013
58-year-old female first presented with
LRQ teeth pain
Numbness in the right mental nerve area
Swollen salivary gland
Clinical examination:
Large tongue, high tongue level, Mallampati Class III airway
Issue a sleep study!
Revealed an AHI = 32.87 and RDI = 33.2
58-year-old female first presented with
LRQ teeth pain
Numbness in the right mental nerve area
Swollen salivary gland
Clinical examination:
Large tongue, high tongue level, Mallampati Class III airway
Issue a sleep study!
Revealed an AHI = 32.87 and RDI = 33.2
Large neck, retrudedmandible
Root Canal Therapy Required, Respire inserted after RCT completed
CHIEF COMPLAINTS• Sensitive teeth: lower right
quadrant• Intermittent jaw pain: Upper right
and lower right quadrants• Numbness in the right mental
nerve region• Swollen gland• Right ear pain
OBJECTIVE FINDINGS
• #30 tested + to percussion with tooth sleuth
• Lingual fracture line observed with periapical tenderness
Myofascial Pain Neuropathic pain OSA
TREATMENT PLAN1. Refer to endodontist for RCT #302. Rx: Klonopin .5mg Dispense 60 tablets , Sig: 1-2 tabs HS3. Farrar appliance4. Respire to treat OSA
Diagnostic sleep report: Severe OSA
Follow –up Sleep Study with Respire- Mild OSA
Benefits of OA therapy: AHI decreased RDI decreased Increased oxygenation-
less desaturation events
Increased REM Sleep
SUBJECT: 56 year old female
CHIEF COMPLAINTS• Left sided jaw locking• Left sided clicking & popping • Left jaw pain radiating into sinus
and ear• Neck pain • Fatigue
DIAGNOSTIC INFORMATION
• Epworth Sleepiness Scale= 8
Medical Hx:
• Asthma• Sinusitis• High Cholesterol• Acid Reflux• Arthritis• Insomnia• Torn rotator cuff
CONTRIBUTING FACTORS
• Decreased vertical dimension of occlusion• Retruded mandible with 10mm overjet• Clenching (#1 indicator for sleep disorder)
Pre-Treatment5-8-2012
Progress1-8-2013
ASSESSMENT
• Pain and compression of the left
auriculo-temporal nerve
• Anterior Disc Displacement with
Reduction of the left TMJ
• Capsulitis of the left TMJ
• Myofascial Pain
• Tension Headaches
Treatment Plan:
• Beginning 5-15-2012
• NYU 6-8 Weeks
• Modified Farrar
Progress9-10-2013
Pre-Treatment5-8-2012
Progress1-8-2013
ASSESSMENT
• Pain and compression of the left
auriculo-temporal nerve
• Anterior Disc Displacement with
Reduction of the left TMJ
• Capsulitis of the left TMJ
• Myofascial Pain
• Tension Headaches
Treatment Plan:
• Beginning 5-15-2012
• NYU 6-8 Weeks
• Modified Farrar
Progress9-10-2013
Pre-Treatment5-8-2012
LATERAL BEFORE AND AFTER
Progress1-8-2013
Pre-Treatment5-8-2012
FRONTALBEFORE AND AFTER
Progress1-8-2013
Airway Centric
Pre-Treatment: 5-8-2012Decreased Vertical Dimension of Occlusion, Retruded mandible and nerve compression
Progress with Farrar Appliance: 2-26-2013
Pre-Treatment: 5-8-2012
Progress with Farrar Appliance: 2-26-2013
Progress with Farrar Appliance: 2-26-2013
Pre-Treatment: 5-8-2012
Pre-Treatment: 5-8-2012
Airway Assessment
CBCT TMJ Findings
Pre-Treatment5-8-2012Mild degenerative changes to Right and Left TMJs ossesousstructures.Retruded Right and Left TMJs.
Progress with Farrar 2-26-13Right and Left TMJ noticeably removed from the eminence. Increased joint space.
RIGHT TMJ
LEFT TMJ
RIGHT TMJ
LEFT TMJ
Pre-Treatment Progress
Beginning Treatment 5/15/2012Modified Farrar
Progress 2/26/2013Modified FarrarRestored Vertical Height
Before Treatment 5/8/2012Without Appliance: Deep overbite
Beginning Treatment 5/15/2012NYU
Close airway Increase systemic inflammation Increase HA Increase jaw clicking and locking Increase daytime fatigue-EDS Decrease HRV
Airway Centric
Airway Centric
Sleep Questionnaire
Airway Centric
Airway Centric
Airway Centric SLEEP, Vol. 30, No. 3, 2007
Airway Centric SLEEP, Vol. 30, No. 3, 2007
Jinkwan Kim, Fahed Hakim, Leila Kheirandish-Gozal, David Gozal, Inflammatory pathways in children with insufficient or disordered sleep, Respiratory Physiology & Neurobiology, Volume 178, Issue 3, 30 September 2011, Pages 465-474, ISSN 1569-9048, 10.1016/j.resp.2011.04.024.(http://www.sciencedirect.com/science/article/pii/S1569904811001625)
Obstructive Sleep Apnoea Syndrome as a Systemic Low-Grade Inflammatory DisorderCarlos Zamarrón1, Emilio Morete1 and Felix del Campo Matias2
Airway Centric
Airway Centric
Airway Centric
Airway Centric
Airway Centric
Airway Centric
Chief complaints:1. Significant daytime somnolence2. Feeling groggy on awakening3. Obstructive sleep apnea4. Frequent heavy snoring5. CPAP intolerance6. Neck stiffness
The patient is CPAP intolerant; due to discomfort from headgear, disturbed or interrupted sleep, CPAP restricted movements during sleep, CPAP does not seem to be effective, claustrophobic associations, does not resolve symptoms, noisy and cumbersome.
Baseline Unattended Sleep Study with the Watchpat 200 Device
Masseters are hypertrophic upon cotton roll clench. lingual orientation of the maxillary dentition teeth as well as a100 degree
nasiolabial angle. Class II (retruded lower jaw) dental relationship. a late opening and a late closing click in the left temporomandibular joint. Mandibular range of motion measurements revealed maximum interincisal
opening of 44 mm and mandible is off to the LEFT by 2 mm. a level III (high) tongue. A Mallampati airway inspection showed a Class IV airway The uvula is small Maxilla is buttressed and retruded by 4mm A small mandibular torus was present
Clinical examination revealed:
Figure: Tongue Level III Figure: MallampatiClassification IV
Imaging Findings:Cone beam CT scan (06/12/2012) revealed1) Osteoarthritic degeneration of the right
condyle- lateral aspect2) Flattening of the superior portion of
both condyles3) Decreased airway space by 1mm4) Right ramus measurement is 69.mm5) Left ramus measurement is 62.99mm6) Decreased joint space on the left
Airway Views
Turbinates' & sinuses are clear Severe airway constriction posterior to soft palate and tongue
Narrowed airwayRetruded mandible and lack of maxillary labial support
Ceph view
Treatment Plan
1. The treatment plan consists of a Telescoping Herbst oral sleep appliance which will be worn every night while sleeping.
2. The treatment plan consists of a mandibular (NYU) orthopedic appliance to realign the mandible. The patient will wear the appliance full time for the first 6-8 weeks. As treatment progresses and the symptoms improve, we will wean the patient off of day wear.
3. The hard/soft mandibular mouth guard will be worn when the patient exercises.4. A follow up sleep study will be performed to monitor OSA
CHIEF COMPLAINTS
Bilateral temple and jaw pain
Headaches Left TMJ clicking Ringing in the ears Excessive daytime
somnolence Teeth don't line up properly Left facial swelling- slight
THE EPWORTH SLEEPINESS SCALE SCORE WAS 12, WHICH MAY INDICATE EXCESSIVE SLEEPINESS DEPENDING ON THE SITUATION. THE PATIENT MAY WANT TO SEEK MEDICAL ATTENTION.
Clinical Findings: Class III (protruded lower
jaw) dental relationship.a level III (high) tongue a Class IV airway "Tonsils Grade 3"
MRI (10/03/2012) revealed:
Anterior Disc Displacement with Reduction (left side)
Osteoarthritis of the left mandibular condyle
Tension Type Headache
Lack of full anterior translation on opening-bilaterally
Flattening of the left condyle- degenerative in nature
Flattening of the articular disc of both condyles-degenerative in nature
Anterior displacement of the articular disc of the left TMJ
Diagnosis:
Prognathic mandibleWith orthopedic NYU in: edge to edge bite by opening vertical dimension and retruding the mandible
Preliminary11-21-2012
Pain & compression of the left auriculotemporalnerveMasseteric Hypertrophy on the LeftMandible is off to the rightPoor posture
4 month Progress without appliances 3-12-2013NO compression on the leftImproved facial symmetryMuscles are more relaxedImproved posture
4 month follow up with NYU 3-12-2013
No pain or compression on the leftSignificantly less headachesLeft masseter still hypertrophic- administered 20 units of Botox
Facial AsymmetrySubject: 22 y/o male
Prognathic mandibleClass III bite
Subject: 63 yr old female
Chief Complaints:
Mandible is shifted to the right
Clinical Findings:
Currently in braces on the
maxillary and mandibular
arches
Anterior Open Bite
C5-C6 rotated to the right
No joint clicking
No pain or compression
Enlarged level III tongue
Mallampati Class II
Diagnosis
Myofascial Pain
Sleep Bruxism
Osteoarthritis of the left TMJ
Treatment Plan & Sequence
Removal of braces
1. Maxillary Farrar with anti retrusion
ramp to use during sleep
2. Lower full coverage appliance to
ideal jaw position- bringing the
mandible to the midline position
3. Once jaw is stabilized, possible
bonding to establish canine
guidance and anterior support (
PRENEW/ PREVIEW)
Jaw is shifted to the right
Preliminary photos April 2010
Without Prenew- Preview January 2013
Orthodontic photos 2009
Initial photos 2004
Post NYU Therapy In January 2013
Prenew- Preview Case In February 2013
• Improved incisal contacts #2-15• Midline is idealized• Mandible is brought to the center to decomress
the right TMJ
Frontal soft tissue model with bone and dentition reveals:• Mandible is off to the right
Preliminary Ceph Analysis
Michael Gelb, DDS,[email protected]
212.752.1662