Sleep Apnea

[arbat]

Hi. I am a new member of the forum. I started orthodontic treatment 3 months ago as a precursor for MMA surgery for sleep apnea at the tender age of 63 following a mild heart attack (which my physician thinks was probably caused by severe sleep apnea). I have a small lower jaw which is apparently the structural cause of my narrow airway. For the last 15 years or so I have been using a MAS (mandibular advancement splint) which brings the lower jaw forward when you sleep, opening up the airway. This has definitely improved my sleep quality, however, a recent sleep study showed that I still have severe apnea even when using the splint.
So, here is my question>>> The orthodontic treatment involves moving the teeth in the lower jaw back to maximise the overbite prior to moving the jaw forward for surgery. This potentially will worsen the apnea as the space for the tongue reduces. The tooth movement and braces prevent me from using a MAS or other device to advance the jaw during sleep.... I was wondering whether there were others on this forum undergoing treatment specifically (or principally) for sleep apnea and if so whether any have suggestions as to how sleep apnea is best managed during orthodontic treatment??

Thanks

[snapdresser]

I got the surgery for sleep apnea, but unfortunately I didn't have orthodontic treatment so I can't really comment on that I suppose it's possible to use elastics to keep your lower jaw forward, but this may have negative repercussions on your orthodontic treatment. I'd recommend you ask your orthodontist, but unless they have a lot of experience with sleep apnea patients, I'm not sure they'd know how to deal with it.

[EWUgal15]

I'm not super experienced with sleep apnea, but my boyfriend snores pretty fiercely. He liked the wedge pillow I bought for surgery so much that I had to fight him for it until I actually had surgery. So I bought another for him. He snores less when he sleeps on it...maybe that could help?

[Nozzelnut]

Orthodontic treatment will put the teeth of both jaws in the best place for their post surgery position. Which may or may not be into the "overbite" style.

I have OSA due to smaller lower jaw among other things. I have used my APAP machine the entire time. Using the splint probably won't be an option unless you get one that is moldable every couple days. I think Great Lakes Ortho has a model of that splint on their website.

For the record the surgery helped my sleep apnea but it isn't entirely gone yet.

If you can get the more in depth sleep study to find where the obstructions are, that could greatly improve the treatment you receive, type of surgery/surgeries and movements that are made. ie the base of your tongue is large or your nasal passages are small, or mouth breathing all night dries the mouth and causes tissues to swell....

[jawa]

I am about 70 days from surgery for sleep apnea. I had my lower premolars extracted and my lower incisors pulled back. The spaces just recently closed. I believe it has made my apnea worse, but I can deal with it. Just remember that this is a short-term loss for huge longterm gains. I am definitely more tired and I take more naps but it isn't permanent. Also if your overbite becomes as large as mine you will be able to flop your tongue over your bottom teeth so your tongue rests against your lower lip instead of your lower teeth resting against your lower lip. This is the only reprieve I have thought of to combat the airway stricture.

[arbat]

Many thanks for your responses. It is good to hear from others with similar issues.
For the first three months I was given a twin block appliance by my ortho. This had the twin function of widening the upper arch whilst also holding the jaw forward, however, it no longer fits due to the movement in my teeth and I don't think my ortho (who does not have a lot of experience of patients with sleep apnea) has any other ideas. I think the next stage of my treatment will be extraction of premolars to increase my overbite for surgery, so my concern was exactly as jawa described. I have really struggled with using CPAP but I guess this might be the only solution during the rest of my treatment. At the moment I am not using anything and am struggling with daytime tiredness. I probably have about another 12 to 15 months before surgery.
I have a small lower jaw but I also have obstruction of the upper airway so my surgeon is proposing upper and lower jaw surgery and genioplasty. However, having read a number of threads on this forum about permanent numbness related to this procedure, I am thinking of suggesting that this be done later if needed? Does that seem sensible?

[Nozzelnut]

First you have to decide if you want the surgery. Sooner than later! If you want surgery; your orthodontist will move teeth in a different direction than if you don't want surgery. Are you sure you'd like the extractions? If you're a surgery candidate, you might be able to keep your teeth. Extraction/retraction won't give you an overbite (overjet); they would be used to eliminate it! Unless you're talking about lower premolars.... And that would raise more questions about your treatment.

If you do get your premolars extracted and then some sort of retraction to bring your front upper 6 teeth back; it will limit your tongue space and if that's part of the problem with your OSA it will make it worse.

At this point, I'd start checking with different orthodontists in your area that have more experience with OSA and moving teeth. To make sure you're on the right path with your with your orthodontic treatment. If your current ortho doesn't have other ideas; I'd put your treatment on pause for a little while and find the right person to work with you.

[arbat]

I should explain that after 15 yrs. struggling with OSA (and trying all other options) I was referred to an OMFS for surgery and he is collaborating closely with my ortho (who was his recommendation). They have worked together on MMA surgery cases over many years so I am confident that I am in good hands. When I say my ortho does not have previous experience, I mean specifically experience of interim measures for improving breathing during treatment for OSA. In the UK surgery for OSA is unusual and is seen very much as a treatment of last resort (the NHS will not pay so I am doing this privately) so there are very few ortho's who would have this experience. The orthodontic treatment process for OSA is not significantly different to cosmetic orthodontic treatment for a patient with a large overjet and overbite (due to a small jaw) needing MMA surgery.....it is only the primary goal of the surgery that is different.

I started with an overjet of 8mm but this has reduced as my orthodontic treatment has progressed with the widening of the arches and aligning of the upper and lower teeth. I think the next step will be to procline the upper teeth and retract the lower ones with elastics to maximise overjet for surgery. My ortho told me at the start of treatment that two lower premolars might have to be removed as treatment progressed to make space.

My surgeon has suggested about 4-6mm advancement for the top jaw and about 10-12mm for the mandible. I have very little space for retraction of the lower teeth due to my small lower jaw (I had all my impacted wisdom teeth removed many years ago).

Do you know how much your jaws were moved in surgery? I am concerned to hear that your OSA is not cured....It is a lot to go through if it is not successful!

Thanks

[Nozzelnut]

Ahh. That's sounds better than your Ortho not knowing how to further treat you.

I had 10mm advancement of my upper and lower jaws and a sliding genio which brought my chin forward another 3-4mm. My upper jaw is within 3-4 mm of where it was way back when before the first round of orthodontics.

Growing up I had extraction orthodontics; removing my upper premolars and bringing my upper front 6 teeth back to meet my lowers. Do I think it complicated my current situation? Probably. Decades of mouth breathing changed my upper airway and posture. I also had UPPP last year. The orthognathic surgery recovery was longer but no where near as painful as UPPP and tonsillectomy.

But, yes it's a lot to go through to eliminate OSA. Only those folks with it would understand.

A simple solution would be using elastics to bring the lower jaw forward while you sleep. I did this for a camping trip that I couldn't bring my APAP with me. It wasn't the greatest but it helped.

[bbsadmin]

Dumb question, but why not just use a CPAP or APAP? My husband and I both have sleep apnea (his is severe obstructive; mine is mild to moderate). We just use CPAPs. He would like to get a dental device to help when he's in situations where he can't use a CPAP (e.g., on an airplane, etc).

[arbat]

Fair question. I have tried CPAP over the years, sometimes for a month or two at a time, but I have never been able to tolerate it for more than a couple of hours a night. This is why I have finally settled on surgery as a solution....

[bbsadmin]

Well, it takes time to get used to it. I know that it took me almost 2 months to "not notice it" anymore when I was sleeping. I finally got to the point where I woke up in tbe morning and forgot that it was on! It's not only getting used to needing to wear it, but finding the mask (or nasal pillows) that work well for you. Cpap.com has a really great message board and their retail website is fantastic, as well. You can try out masks and exchange them within 30 days (or something like that). It's where I buy my supplies.

Nobody WANTS to use a CPAP, but I have to tell you, my husband won't be without his, and on the nights when I don't use it (for instance if I'm having sinus trouble, etc), I really feel it the next day. I can't sleep more than a few nights without it, or I just start to feel crappy.

So you may want to give it a try again. I mean, why put yourself through surgery if you don't have to??

[jawa]

I will speak for myself only. The CPAP did not work for me. That is why I am pursuing the surgery. The biometric data sent via Wi-Fi concluded that I keep it on no longer than 3 hours before I rip it off in my sleep. I have attempted to use the CPAP regularly for over 2 years. I have tried many different pressure settings, and many different masks. I don't have a professional opinion to back this up but I believe that when it's structural anatomy causing sleep apnea the CPAP can't really be all that effective. I have pretty bad nasal airway resistance as well which only compounds the problem. If the reason your airway is small is due to the BONE structure of your face, all the pressure in the world isn't going to widen a stricture caused by something as solid as bone. If you are overweight and your fat and soft tissue is choking you at night, then I can see how the CPAP would be effective. Me personally surgery is a desperate attempt and last resort to finally get a good night sleep. It's nice to know that something like 95% of people who undergo the surgery are very happy with the results and would do it again IN SPITE OF any minor complication/permanent numbness.

[Nozzelnut]

Dumb question, but why not just use a CPAP or APAP? My husband and I both have sleep apnea (his is severe obstructive; mine is mild to moderate). We just use CPAPs. He would like to get a dental device to help when he's in situations where he can't use a CPAP (e.g., on an airplane, etc).

Me; I hate using my APAP machine. It does make me feel better than sleeping without it. But if my apnea is due to other issues that are out of my control and I have a chance of living without the night time sleep leash; I'm all for it. Simple things like getting in your bed with freshly washed sheets and pillow cases is awesome and if I put my mask on I can't smell any of it. Small and possibly trivial I know...

I know I have upper airway issues. Some being helped with moving teeth, some being helped with removing infected tonsils, and some with being helped by moving my jaws. My next step is really taking care of my nasal airway; so I can breathe through my nose all night without mouth breathing.

[arbat]

Thanks Lynn, for your sensible advice....from reading extensively on your site it is clear that the impact and possible complications of surgery should not be underestimated.

But, I am with jawa and nozzlenut on this.....I really struggle to come to terms with having to be hooked up to a mask/machine for the rest of my life even if I am able to get it to work for me....

However, I will be trying CPAP (with nasal pillows) again over the next few months (for lack of alternatives). I think I have 2-3 months before my orthodontic treatment changes direction from just improving my occlusion to changes that are more specifically involve repositioning my teeth to increasing my overbite for surgery so I have the opportunity for a final attempt at CPAP before I decide.

I will let you know how this goes....

....and thanks for this great website and forum which is a wonderful resource!