1. Awake Airway Dilator Muscles
© W. Keith Thornton DDS
Temporalis
Masseter

2. Digastric-Hyoid Sling
© W. Keith Thornton D.D.S.

3. Medial Pterygoid
© W. Keith Thornton D.D.S.

4. Lateral Pterygoid
© W. Keith Thornton D.D.S.

5. Normal Breathing:
Awake
© W. Keith Thornton DDS
pharynx
P muscle
P muscle

6. Neuromuscular Factors
© W. Keith Thornton DDS
P mus –P lum > atmosphere
Pharynx Open

7. Why is the Passive Pharynx So
Important???
© W. Keith Thornton D.D.S.
• Pharyngeal muscles are hypotonic during
sleep
• REM sleep causes atonia of pharyngeal
muscles.
• Allows the airway to collapse

8. © W. Keith Thornton DDS
Airway Dilator Muscles During Sleep

9. Sleep Eliminates Pharyngeal
Reflexes
© W. Keith Thornton DDS

10. Physics of Airway Collapse
• Poiseuille's Law
– Size of tube and effect on negative pressure to
breath and speed of airflow
• Bernoulli’s law
– Increase in speed of airflow decreases size of
flexible tube
• Pathology
– Large negative Inspiratory pressure
– And/or total collapse
© W. Keith Thornton D.D.S.

11. Poiseuille's Law (Tube Law)
© W. Keith Thornton D.D.S.
The volume (V) of a homogeneous fluid passing per unit time
(T) through a tube (flow) is directly proportional to the
pressure difference between its ends (Δ P) and to the fourth
power of its internal radius (R) , and inversely proportional
to its length (L) and to the viscosity (Vis) of the fluid
V/T (flow) = L x Vis =
R4 ΔP
R4 ΔP

12. Poiseuille's Law (Tube Law) and
Breathing
• Volume per minute is constant (tidal volume) to
maintain proper saturation
• Variable is diameter of pharynx
• Pressure change is to fourth power P4
• Speed increased to second power S2
© W. Keith Thornton D.D.S.
1
1/2
-4 cmw -64 cmw
1 x Speed 4 x Speed

13. Bernoulli's principle
“As the speed of a moving fluid (liquid or
gas) increases, the pressure within the fluid
decreases.”
Examples: shower curtains, sail boats and jet wings
© W. Keith Thornton D.D.S.

14. Bernoulli's principle
© W. Keith Thornton D.D.S.
S 4S
-P

15. Bernoulli's principle
© W. Keith Thornton D.D.S.
S 4S
-P - 4P
- 4P

16. Neuromuscular Factors
© W. Keith Thornton DDS
Pharynx closed
P mus - P lumin < atmospheric

17. Genioglossal EMG in OSA
© W. Keith Thornton DDS

18. No Mandibular Protrusion (Oshima et al.)
© W. Keith Thornton D.D.S.

19. Mandibular Protrusion (Oshima et al.)
© W. Keith Thornton D.D.S.

20. Inspiratory Flow Limitation
© W. Keith Thornton DDS

21. Critical (closing) Pressure is
Elevated in OSA
© W. Keith Thornton DDS

22. Genioglossal EMG is Elevated in
Awake OSA
© W. Keith Thornton DDS

23. Esophageal
pressure
Inspiratory Flow Limitation : IFL
© W. Keith Thornton DDS
Normal
Airflow
Normal
IFL

24. 5 Minutes, RDI 6, T90 = approx. 80%, Severe Hypoventilation
Severe Inspiratory Flow Limitation, No heart rate variability
Mild OSA, 5 min
90%

25. 5 Minutes, RDI 6, T90 = approx. 80%, Severe Hypoventilation
Severe Inspiratory Flow Limitation, No heart rate variability
2 Minutes
90%

26. 10 Minutes, Severe, RDI=96
16 events, RDI = 96
T90 = approx 20%
Little heart rate variability, 50-67

27. 90%
67 bpm
50bpm
2 Minutes, Severe, RDI=96
16 events, RDI = 96
T90 = approx 20%
Little heart rate variablity 50to 67
Lowest desat 83%

28. 90%
67 bpm
50bpm
2 Minutes, Severe, RDI=96
16 events, RDI = 96
T90 = approx 20%
Little heart rate variablity 50to 67
Lowest desat 83%

29. 10 minutes, severe osa, RDI=66
80bpm
40bpm
90%
RDI = 66, T90= 75%, heart rate variability = 40-80
Lowest desat= 63

30. 2 minutes, severe osa, RDI=66
80bpm
40bpm
90%
RDI = 66, T90= 75%, heart rate variability = 40-80
Lowest desat= 63

31. RDI = 66, T90= 70%, heart rate variability = 40-80
Lowest desat= 63
2 minutes, severe osa, RDI=66
80bpm
40bpm
90%

32. ?
• What is your treatment approach on Monday
morning?
• What appliance and why?
• How do you determine endpoints?
• What do you do with oral appliance failures?

33. Definition: Sleep Disordered Breathing
• A disorder of breathing during sleep only, or
significantly affected by sleep. In general, the
patient has little or no problem breathing
while awake.
• Not a true sleep disorder

34. Categories
• Mechanical : The inappropriate collapse of the
pharynx during sleep
– Snoring
– Inspiratory Flow Limitation
– Obstructive sleep apnea
• Chemical : Central Sleep Apnea
• Neuromuscular : paralysis of involuntary
muscle (diaphragm), requiring ventilation at
night

35. Continuum of Sleep Disordered
Breathing
Mechanical
SeverityLeast Most
Chemical Neuromuscular

36. Continuum of Sleep Disordered
Breathing:
Treatment
SeverityLeast Most
Chemical
Cpap
Vpap
Oral Appliances
Combination
Oxygen
Neuromuscular
Ventilator
Tracheotomy
Combination
Mechanical
Oral Appliances
CPAP
Combination
Surgery
Tracheostomy

37. Continuum of Sleep Disordered
Breathing:
Treatment Success
SeverityLeast Most
Chemical
?
Neuromuscular
Ventilator +
Tracheotomy = 100%?
TAP-PAP = 100%?
Mechanical
CPAP <50%
OA’s >50%
TAP-PAP > 95%
Tracheotomy 100% ?

38. Continuum of Mechanical Sleep
Disordered Breathing Treatment
Normal Non-sleepy
snorer
OSA
Uars Mild Moderate Severe
Medical : CPAP
TreatDon’t treat
< 50% success

39. Continuum of Mechanical Sleep
Disordered Breathing Treatment
Normal Non-sleepy
snorer
OSA
Uars Mild Moderate Severe
Dentistry: Home monitor + oral appliance + tap-pap
TreatDon’t treat
> 90% success

40. Patient controlled protrusion

41. Treatment Position
Maximum protrusion: MP
Maximum passive protrusion: MPP

42. Original Maximum protrusion 8mm
Present Maximum portrusion 17mm
170% of original maximum
17 mm

43. 17+3mm 170%

44. 23mm 185%
23mm

45. 25mm 195%

46. Floppy Lid Syndrome

49. Macroglossia, Maxillary
Hypoplasia
Immediate TAP CS
Increase vertical

50. Patient History
• Loud snoring, excessive fatigue, several wrecks
• Uncontrolled hypertension, 5 different
medications per day
• Morning blood pressure on medication 175/120
• Stroke 5 years previous
• Four psg’s, no osa, no diagnosis, tried and failed
cpap
• HST: RDI 3, significant upper airway resistance

51. Macroglossia, Maxillary Hypoplasia
Lateral view,
Patient in occlusion
Centric Occlusion

52. 5. Macroglossia, Maxillary Hypoplasia
Narrow arch,
High palate without
room for tongue
Normal
mandibular arch
size

53. Macroglossia, Maxillary Hypoplasia
Size of tongue
Normal posture of
tongue

54. Macroglossia, Maxillary Hypoplasia
Normal lip posture Freeway space

55. Immediate TAP CS
• Moved screw forward to compensate for
maxillary hypoplasia
• Opened vertical 15 mm to accommodate
tongue
• Patient titrated himself 5mm beyond
maximum protrusion in first week
• Blood pressure on awakening 145/90
• No snoring, head aches, fatigue

56. Immediate TAP CS
15mm
5mm

57. TAP III from lab
Not enough vertical or protrusive
Encroachment on tongue

58. Increase protrusive and vertical
Moved bar back
4mm
Moved bar
up 3mm

59. Final TAP III appliance
Initial vertical 8mm
Added 6mm to plate, 3mm to
bar
Total vertical, 17mm
6mm 17mm

60. Neuromuscular Patients
• Post Polio
• ALS
• Muscular dystrophy
• Brain tumors affecting motor function
• Congenital
• Spinal Cord Injuries

61. Neuromuscular Patients
• Generally need ventilatory assistance during
the day
• Paralysis of diaphragm
• Intercostal muscle deterioration
• Limited function of limbs
• Adequate dentition for retention

62. Neuromuscular Patients:
Treatment
• Tracheotomy (medical)
• Custom mask, oral appliance combination
(dental)
• No other choices except iron lung

63. Neuromuscular Patients:
History
45 yo, post polio
Paralyzed from neck down
Mask developed by DRI using
“bite block”
Pressure: 45 cmw
Volume ventilator
Could use intercostals during
day
Inserted by biting into trays

64. Neuromuscular Patients:
History
Problems:
Fabrication techniques
Retention
Leakage
Reparability
Bulk
Technique sensitivity
Caregiver issues

77. Treatment of the Severe Sleep
Apnic
An eight year history
2002- 2010

78. Patient: Ron Doe

79. Patient: Ron Doe
• History
• Diagnostic Studies
• Xrays
• Therapy
– Models
– Appliances
– Masks

80. HPI
2003
• Hx of loud snoring starting in dental school
• Recent weight gain of 100 lbs (300 lbs)
• Hypersomnolence
• Acid reflux
• Htn

81. HPI
2003
• Fibromyalgia
• Night sweats
• Joint aches
• Numb feet
• Nocturia

82. Family and Social Hx
• Divorced and remarried
• Father died at age 51 of HA
– Professional football player with very large neck
• Son and grandchild have osa by symptoms
• Orthodontist
– Focused on treating non-extraction and
developing airways
– Very knowledgeable in tmd and occlusion

83. Treatment Hx
• No initial sleep study or consultation with
physician
• Numerous oral appliances tried over 1 yr
– Herbst
– Silencer
– Snore guard
– Silent Knight
• Failure of all appliances
• Appliances still fit

84. Results
Before TAP
After TAP
© 2010 Airway Management, Inc.

85. TAP III 2010
Plate anterior to upper incisors

86. PSG
2/2/2009
Diagnostic CPAP alone TAP (4/4/09)
RDI 82.2 23.6 18.2
Minimum O2 Sat 74 77 75
Sleep Efficiency 88.1 65.9 NA
PLM 99 22 NA
Tried Bilevel CPAP at 11/7 cmw
Could not tolerate

87. TAP-PAP 2010
• TAP-PAP custom mask (TPCM)

88. TAP-PAP 2010
• TAP-PAP universal mask(TPUM)

89. TAP-PAP 2010
• TAP-PAP universal mask(TPUM)

90. PSG 12/28/2010
TAP TAP-PAP
Custom
TAP-PAP
Universal
TAP-PAP
Nasal
RDI/ AHI 20.7/18.9 2.5/2.5 0/0 0/0
Mean O2 Sat 92.6 % 94% 93 to 94% 94 to 98%
Lowest O2 Sat 86.0% 94% 90% 94%
Time< 90% 4.8% 0% 0% 0%
CPAP pressure 12-13 cmw 9 to 10 cmw 10 to 11 cmw
Comments Inadequately
treated alone
Mask leak,
Mask was not
attached
correctly
Sealed well,
Preferred by
patient