Orofacial myofunctional reeducation assisted by a prefabricated reeducation appliance: a systematic review of the literature / Rééducation myofonctionnelle orofaciale assistée par gouttière de rééducation préfabriquée : une revue systématique de la littérature

Introduction: Several cross-sectional studies have shown the association of a dysfunctional orofacial environment with a greater prevalence of malocclusions. Orofacial myofunctional reeducation (OFMR) is the rehabilitation of the muscles, functions and resting postures of the orofacial complex. It is used in the therapeutic management of orofacial dysfunction in patients of all ages and with a wide range of disorders and comorbidities. RMOF mainly uses isotonic and isometric exercises targeting the oral and oropharyngeal structures, combined with specific exercises for ventilation, swallowing and mastication. It may involve the use of prefabricated reeducation appliances (PRAs), which may also be prescribed to modify the shape and relationship of the dental arches. Objectives: The primary objective of this systematic review of the literature was to describe and evaluate the efficacy of prefabricated reeducation appliance-assisted OFMR in orthodontics, occlusodontics and dental sleep medicine. Its secondary objective was to assess whether the use of currently available PRAs is associated with adverse effects. Materials and Methods: The systematic literature review was undertaken using five electronic databases: Medline (via PubMed), Web of Science, Cochrane Library, Embase, and Google Scholar, to identify studies evaluating the efficacy of PRA-assisted OFMR in the treatment of orofacial dysfunctions and parafunctions, temporo-mandibular dysfunction (TMD) or obstructive sleep apnea (OSA) in children, adolescents and adults, published until 20 March 2023. The primary outcome of interest was the therapeutic efficacy of PRA-assisted OFMR. In patients with obstructive sleep apnoea (OSA), efficacy was assessed primarily by a decrease in the apnoea/hypopnoea index (AHI) of at least five episodes per hour from baseline, improvement in subjective sleep quality, sleep quality measured by nocturnal polysomnography and subjectively measured quality of life. In patients with orofacial dysfunctions, parafunctions or TMD, efficacy was assessed mainly by electromyography (EMG), history and clinical examination. Secondary outcomes were dentoalveolar or skeletal improvements, and possible adverse effects of the PRAs used, including adverse effects on occlusion. Results: Only fourteen studies met all inclusion criteria: two randomised controlled trials, one non-randomised controlled trial, five prospective case-control studies, two retrospective case-control studies, two prospective case series and two retrospective case series. The two randomised controlled trials were assessed as "low risk of bias" according to the Cochrane Back Review Group's 12 risk of bias criteria. The methodological quality of the remaining 12 included studies was assessed using the ROBINS-I tool, according to the recommendations of the Cochrane Handbook. One was judged to have a measured risk of bias, eight a significant risk of bias and three a critical risk of bias. Based on the available evidence, PRA-assisted OFMR results in a statistically significant (p=0.0425) reduction in AHI in children with mild to moderate obstructive sleep apnea. In children with obstructive sleep apnoea undergoing adenoid and/or tonsil surgery, postoperative OFMR combined with a flexible PRA leads to a greater reduction in AHI compared to a control group and an improvement in SaO2 at 6 months and 12 months after surgery (p<0.01). It also contributes to greater improvement in sleep disturbance, physical fitness, daytime lethargy in the treated group than in the control group 6 months and 12 months after surgery (p<0.05). PRA-assisted OFMR provides correction of atypical swallowing and improvement in orofacial muscle balance. GRPs are generally less effective than activators for the treatment of Class II Division 1 malocclusions and appear to cause more adverse effects, mainly vestibuloversion of the mandibular incisors. The use of PRA-assisted OFMR for the management of TMD is not validated by current evidence. Conclusions: Published data, albeit of uneven methodological quality, appear to show the superiority of OFMR combined with the use of a PRA, compared with the implementation of OFMR without PRA. Prospective studies with large sample sizes would be useful to better evaluate the new therapeutic possibilities brought by the combination of OFMR with a PRA. Continued attention should be paid to the monitoring of possible adverse effects of PRA-assisted OFMR on the dental arches, especially the vestibuloversion of the mandibular incisors. It might be useful to reflect on the relevance of the arguments put forward by manufacturers about the particularities of their devices and their supposed effects. PRA-assisted OFMR appears to be a necessary paradigm shift , which it seems useful to bring to our patients. Protocol registration: This protocol was registered on March 02, 2023 in the International Prospective Register of Systematic Review (PROSPERO) and received the CRD number: CRD42023400421.

Introduction: Plusieurs études transversales ont montré l'association d'un environnement orofacial dysfonctionnel avec une plus grande prévalence de malocclusions. La rééducation myofonctionnelle orofaciale (RMOF) est la rééducation des muscles, des fonctions et des postures de repos du complexe orofacial. Elle est utilisée dans la prise en charge thérapeutique des dysfonctionnements orofaciaux chez des patients de tous âges et présentant un large éventail de troubles et de comorbidités. La RMOF met principalement en œuvre des exercices isotoniques et isométriques ciblant les structures buccales et oropharyngées, associés à des exercices spécifiques pour optimiser la ventilation, la déglutition et la mastication. Elle peut faire appel à des gouttières de rééducation préfabriquées (GRP) dont la prescription peut également viser l'objectif d'une modification des formes et des rapports d'arcades dentaires. Objectif: L'objectif principal de cette revue systématique de la littérature était de décrire et d'évaluer l'efficacité de la RMOF assistée par gouttières de rééducation préfabriquées en orthodontie, en occlusodontie et en médecine dentaire du sommeil. Son objectif secondaire était d'évaluer si l'emploi des GRP, actuellement disponibles, s'accompagne d'effets indésirables. Matériels et méthodes: La revue systématique de la littérature fut entreprise à partir de cinq bases de données électroniques : Medline (via PubMed), Web of Science, Cochrane Library, Embase et Google Scholar, afin d'identifier les études évaluant l'efficacité de la RMOF assistée par GRP dans le traitement des dysfonctions orofaciales et des parafonctions, des dysfonctionnements temporaux-mandibulaires (DTM) ou des syndromes d'apnées obstructives du sommeil (SAOS) de l'enfant, de l'adolescent et de l'adulte, publiées jusqu'au 20 mars 2023. Le critère de jugement principal de cette revue systématique était l'efficacité thérapeutique de la RMOF assistée par GRP. Chez les patients souffrant d'apnée obstructive du sommeil (AOS), l'évaluation de l'efficacité s'appuyait principalement sur une diminution statistiquement significative de l'indice d'apnée/hypopnée (IHA) et sur une amélioration de la qualité subjective du sommeil, de la qualité du sommeil mesurée par polysomnographie nocturne et de la qualité de vie mesurée subjectivement. Chez les patients présentant des dysfonctions orofaciales, des parafonctions ou des DTM, l'évaluation de l'efficacité l'était principalement par l'électromyographie (EMG), l'anamnèse et l'examen clinique. Les critères de jugement secondaires étaient les améliorations dentoalvéolaires ou squelettiques, et les éventuels effets indésirables des GRP employées, dont des effets indésirables sur l'occlusion. Résultats: Seulement quatorze études répondaient à tous les critères d'inclusion : deux essais contrôlés randomisés, un essai contrôlé non randomisé, cinq études cas témoins prospectives, deux études cas-témoins rétrospectives, deux séries de cas prospectives et deux séries de cas rétrospectives. Les deux essais cliniques contrôlés randomisés ont été évalués à « faible risque de biais ¼ d'après les douze critères de risque de biais du Cochrane Back Review Group. La qualité méthodologique des 12 autres études incluses a été évaluée à l'aide de l'outil ROBINS-I, conformément aux recommandations du Cochrane Handbook. L'une a été jugée comme présentant un risque de biais mesuré, huit un risque de biais important et trois un risque de biais critique. D'après les données probantes disponibles, la RMOF assistée par GRP permet une réduction statistiquement significative (p = 0,0425) de l'IAH d'enfants souffrant d'apnée obstructive du sommeil légère à modérée. Chez des enfants souffrant d'apnée obstructive du sommeil et opérés des adénoïdes et/ou des amygdales, une RMOF postopératoire associée au port d'une GRP souple conduit à une plus grande réduction de l'IAH, comparativement à un groupe témoin, et une amélioration de la saturation en oxygène (SaO2), 6 mois et 12 mois après l'opération (p < 0,01). Elle contribue également à une amélioration des troubles du sommeil, de la condition physique, de la léthargie diurne plus importante dans le groupe traité que dans le groupe témoin, 6 mois et 12 mois après l'opération (p < 0,05). La RMOF assistée par GRP permet une correction jusqu'à 100 % de la déglutition atypique et une amélioration de l'équilibre musculaire orofacial. Les GRP sont généralement moins efficaces que les activateurs pour le traitement des malocclusions de classe II, division 1 et semblent entraîner davantage d'effets indésirables, principalement une vestibuloversion des incisives mandibulaires. L'utilisation de la RMOF assistée par GRP pour la prise en charge des DTM n'est pas validée par les preuves actuelles. Conclusions: Les données publiées, même de qualité méthodologique inégale, semblent montrer la supériorité d'une RMOF associée au port d'une GRP comparée à la mise en œuvre d'une RMOF sans GRP. La mise en œuvre d'études prospectives avec de grands échantillons serait utile pour mieux évaluer les nouvelles possibilités thérapeutiques apportées par l'association de la RMOF avec une GRP. Une attention constante devra être portée à la surveillance des éventuels effets indésirables sur les arcades dentaires des GRP associées à la RMOF, notamment la vestibuloversion des incisives mandibulaires. Il pourrait être utile de conduire une réflexion quant à la pertinence des arguments avancés par les fabricants sur les particularités de leurs dispositifs et leurs effets supposés. La RMOF assistée par GRP apparaît comme un nécessaire changement de paradigme, dont il semble utile de faire bénéficier nos patients. Enregistrement du protocole: Ce protocole a été enregistré le 2 mars 2023 dans l'International Prospective Register of Systematic Review (PROSPERO) et a reçu le numéro CRD : CRD42023400421.

Documento internacional de consenso sobre apnea obstructiva del sueño / International Consensus Document on Obstructive Sleep Apnea

El objetivo principal de este documento internacional de consenso sobre apnea obstructiva del sueño es proporcionar unas directrices que permitan a los profesionales sanitarios tomar las mejores decisiones en la asistencia de los pacientes adultos con esta enfermedad según un resumen crítico de la literatura más actualizada. El grupo de trabajo de expertos se ha constituido principalmente por 17 sociedades científicas y 56 especialistas con amplia representación geográfica (con la participación de 4 sociedades internacionales), además de un metodólogo experto y un documentalista del Centro Cochrane Iberoamericano. El documento consta de un manuscrito principal, con las novedades más relevantes, y una serie de manuscritos online que recogen las búsquedas bibliográficas sistemáticas de cada uno de los apartados del documento internacional de consenso. Este documento no cubre la edad pediátrica ni el manejo del paciente en ventilación mecánica crónica no invasiva (que se publicarán en sendos documentos de consenso aparte). Palabras clave: Apnea obstructiva del sueño Diagnóstico Tratamiento

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents). Keywords: Obstructive sleep apnea Diagnosis Treatment

Implant-supported Dental Prosthesis and Orthognathic Surgery for Rehabilitation of Patients with Obstructive Sleep Apnea / Prótese Dentária Implanto-suportada e Cirurgia Ortognática para Reabilitação de Pacientes com Apneia Obstrutiva do Sono

ABSTRACT: Among the treatment options for Obstructive Sleep Apnea (OSA) we have surgery to correct dentofacial deformities. OSA patients are routinely and predictably submitted to surgical treatment for dentofacial deformities. Frequently, orthognathic surgery and osseointegrated implants may be necessary to enable fixed rehabilitation. Patients submitted to orthognathic surgery have a transient decrease in blood supply after maxillary and mandibular osteotomy procedures, which can impair the results in these cases. This case report aimed to present and discuss the conflicting situation of an OSA patient in need of orthognathic surgery and dental implants. The treatment consisted of: (1) extraction of all teeth; (2) complete rehabilitation of the upper and lower jaw with dental implants and prosthesis without compensation; (3) bimaxillary orthognathic surgery to re-establish the maxillomandibular relationship and increase the upper airway volume. This rehabilitation sequence was a safe alternative for a case of Class II OSA, and rapidly achieved a final restoration with enhanced esthetics, functionality, biomechanics, maintenance of oral hygiene, and patient satisfaction. (AU)

RESUMO: Entre as opções de tratamento da Apneia Obstrutiva do Sono (AOS) temos a cirurgia para correção das deformidades dentofaciais. Freqüentemente, a combinação de cirurgia ortognática e implantes osseointegráveis pode ser necessária para permitir a reabilitação dental. Pacientes submetidos à cirurgia ortognática apresentam diminuição transitória do suprimento sanguíneo após procedimentos de osteotomia maxilar e mandibular, o que pode prejudicar os resultados nestes casos. Este relato de caso teve como objetivo apresentar e discutir a situação de um paciente com AOS que necessita de cirurgia ortognática e implantes dentários. O tratamento consistiu em: (1) extração de todos os dentes; (2) reabilitação completa da mandíbula superior e inferior com implantes dentários e próteses sem compensação; (3) cirurgia ortognática bimaxilar para restabelecer a relação maxilomandibular e aumentar o volume das vias aéreas superiores. Essa sequência de reabilitação foi uma alternativa segura para um caso de AOS Classe II, e rapidamente alcançou uma reabilitação com estética, funcionalidade, biomecânica aprimorada, manutenção da higiene oral e satisfação do paciente. (AU)

Neuropsychological and executive screening in obstructive sleep apnea: early effect of ventilatory therapy.

BACKGROUND: Obstructive sleep apnea (OSA) is often associated with clinical, psychological and neuropsychological comorbidities such as Mild Cognitive Impairment (MCI). This study evaluated changes in clinical, psychosocial, Health Related Quality of Life (HRQoL) and neuropsychological profile in OSA subjects after ventilatory therapy, making comparison with normative data. The aim of the study was to verify the suitability of the HRQoL and neuropsychological screening tests in detecting variations in OSA subjects. METHODS: At baseline, 32 OSA subjects underwent the following assessment: EuroQol (EQ-5D-3L) and EQ VAS, Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment (MoCA) and Frontal Assessment Battery (FAB). After the ventilatory titration, 31 OSA subjects repeated the EQ VAS, MoCA and FAB assessment. RESULTS: The analyzed subjects (77% male, 58.97±10.06 years old and 47.34±26.67 AHI [ev*hr-1]) showed low emotive distress, a lower perception of HRQoL than normative data and 35.48% of them exhibited executive deficits, too. MCI was detected in 3.2% and 48.4% of subjects after normative Italian and international correction, respectively. Subsequently the ventilatory therapy and the rehabilitative interdisciplinary treatment, subjects improved in EQ VAS (68.23±18.73 vs. 87.13±10.80, P=0.0001), FAB scores (15,30±2.03 vs. 16,65±1,40, P=0.007) and MoCA memory subtest scores (2.16±1.34 vs. 3.06±1.63, P=0.008). CONCLUSIONS: Ventilatory therapy provided during a rehabilitative and interdisciplinary program increased subjects' HRQoL, executive functions and verbal memory.

Longer-term effects of supervised physical activity on obstructive sleep apnea and subsequent health consequences.

Although recent trials have shown promising benefits of exercise on obstructive sleep apnea (OSA) severity, the long-term effect of these interventions remains unknown. The aim of this study was to assess the effect of a 9-month community physical activity program on OSA severity one year later in free-living conditions. OSA patients, previously included in a 9-month randomized controlled trial (EXESAS study) evaluating the effects of supervised community physical activity on OSA severity, were invited to participate in an extra one-year observational study. Twenty-eight patients completed the study. Although OSA severity did not significantly worsen over the real-life period (9 to 21 months of follow-up), reductions in apnea-hypopnea index (AHI) and oxygen desaturation index were no longer significant after 21 months of follow-up compared to baseline (baseline AHI: 22.2 ± 6.3 /h; 9 months: 16.3 ± 6.4 /h; 21 months: 18.7 ± 8.9 /h). Benefits observed at 9 months on daytime sleepiness and mental health were preserved at 21 months, whereas cardiorespiratory fitness slightly decreased. Per-protocol analysis revealed that patients who stopped exercise at 9 months had worsened OSA severity compared to those who continued exercise during the real-life period (AHI: +9.0 ± 8.8 vs. -1.3 ± 5.3 /h; p < .01). In conclusion, our study suggested that improvements in OSA severity remain transient and is dependent on long-term adherence to regular physical activity practice.

Effects of short-term aerobic training versus CPAP therapy on heart rate variability in moderate to severe OSA patients.

We compared the effects of 2-month CPAP or exercise training (ET) therapies on the autonomic balance in moderate to severe obstructive sleep apnea (OSA) through heart rate variability (HRV) analysis. Thirty-nine OSA patients were divided into CPAP (n = 18) and ET (n = 21) groups, being further split into hypertensive and non-hypertensive subgroups. All patients were submitted to continuous ECG recordings for HRV analysis. Hemodynamic parameters were recorded by oscillometry. Excessive daytime sleepiness and sleep quality were assessed through the Epworth Sleepiness Scale and the Pittsburgh questionnaire, respectively. ET decreased systolic arterial pressure in hypertensive and non-hypertensive participants when compared to baseline values, whereas diastolic arterial pressure was decreased only in non-hypertensive ones. CPAP had no effect over hemodynamic parameters in either subgroup. ET significantly increased the HRV parameters SDNN and pNN50 in non-hypertensive participants, while reducing the LF/HF ratio in both subgroups. CPAP significantly decreased SDNN in both subgroups. ET significantly decreased excessive daytime sleepiness in both subgroups, but did not affect sleep quality. CPAP significantly improved sleep quality in both subgroups, although global scores were still those of poor sleepers, while excessive daytime sleepiness was normalized only in hypertensive patients. In conclusion, while short-term ET modulated different HRV parameters, leading to a predominant vagal tone in the cardiac sympathovagal balance and decreasing blood pressure in moderate to severe OSA, short-term CPAP had next to no effect in these parameters. We believe ET should be considered as an adjunct interventional strategy in the conservative management of hypertensive or non-hypertensive OSA patients.

Efectividad de un programa de rehabilitación respiratoria en pacientes con síndrome de apnea obstructiva del sueño: estudio cuasi-experimental / Effectiveness of a respiratory rehabilitation programme in patients with sleep obstructive apnoea syndrome: Quasi experimental study

OBJETIVOS: El objetivo del estudio fue analizar la efectividad de un programa de rehabilitación respiratoria en pacientes obesos sedentarios con síndrome de apnea obstructiva del sueño (SAOS) en el que se incluyó la realización de ejercicio físico terapéutico. Participantes y métodos: Estudio cuasi-experimental de 2 grupos, grupo intervención y grupo control, no aleatorizados con evaluación pre/post. Se seleccionaron 47 pacientes del hospital diagnosticados de SAOS con obesidad y en tratamiento médico, los cuales fueron tratados por el mismo equipo y siguiendo los mismos criterios diagnósticos. Se registraron las siguientes variables: índice de masa corporal, poligrafía respiratoria, capacidad de ejercicio, patrón de comportamiento sedentario y calidad de vida. Se realizó una comparación pre/post a los 3 meses. RESULTADOS: Se analizaron 38 pacientes y los resultados obtenidos al comparar los valores pre/post de todos los individuos muestran diferencias significativas en forma de mejora en todas las variables analizadas a excepción del comportamiento sedentario. En la comparación pre/post entre los grupos se aprecia una diferencia significativa (p = 0,049) en la percepción de la calidad de vida, concretamente, en la dimensión de los síntomas diurnos (0,42; IC 95%: 0,48-1,33), indicando una tendencia a la mejora en el grupo que ha realizado el programa de ejercicio propuesto. CONCLUSIÓN: La combinación del tratamiento médico de los pacientes durante un mínimo de 6 meses junto con la realización del programa de rehabilitación respiratoria en el que se incluye el ejercicio físico terapéutico genera una tendencia a la mejora clínica de estos, aumentando su calidad de vida, pero sin ningún tipo de cambio en su comportamiento sedentario

OBJECTIVES: The objective of the study was to analyse the effectiveness of a respiratory rehabilitation programme in sedentary, obese patients with Obstructive Sleep Apnoea Syndrome (OSAS) which included therapeutic physical exercise. Participants and methods: A quasi-experimental study of two groups, an intervention group and a control group, not randomised and with pre/post evaluation. Forty-seven hospital patients diagnosed with obesity and under medical treatment were selected and treated by the same team, following the same diagnostic criteria. The following variables were recorded: body mass index, respiratory polygraph, exercise capacity, sedentary behaviour pattern and quality of life. A pre/post comparison was made at 3 months. RESULTS: 38 patients were analysed, and the results obtained when comparing the pre/post values of all the individuals show significant differences in the form of improvement in all variables analysed except for sedentary behaviour. In the pre/post comparison between the groups, a significant difference (p=.049) was observed in perception of quality of life, specifically in the daytime symptom dimension (.42; 95% CI: .48-1.33), indicating a trend towards improvement in the group that undertook the proposed exercise programme. CONCLUSION: The combination of the patients' medical treatment over a minimum of 6 months together with completion of the respiratory rehabilitation programme which included therapeutic physical exercise resulted in a tendency to clinical improvement for the patients, increasing their quality of life, but with no change in their sedentary behaviour

The key role of the mandible in modulating airflow amplitude during sleep.

RATIONALE: Mandibular position and motion during sleep rely on the balance between mandibular elevators and depressors. We hypothesized that vertical mandibular position (VMP) modulates airflow amplitude during sleep. METHODS: VMP, tidal nasal flow pressure (NFP) and concurrent surface electromyographic activity of the masseters (sEMG-m) were recorded and processed by a customized algorithm from 100 polysomnographic fragments including a micro-arousal (25 obstructive sleep apnea patients). The relationship between mandibular position and changes in airflow was analysed. RESULT: Concurrent VMP and sEMG-m activity changes routinely occurred before a new steady state of airflow documented by NFP. Vertical mandible depression was associated with a median (95% CI) reduction in NFP of 40.9% (14.6%-71.3%, p = 0.007) while vertical mandible elevation and mouth closure were associated with a median (95% CI) relative increase in NFP after arousal of 52.6% (17.9%-56.2%, p = 0.001). CONCLUSION: Elevation and lowering of the mandible were associated with changes in masseteric EMG activity modulating airflow amplitude during sleep.

Models of anatomically based oropharyngeal rehabilitation with a multilevel approach for patients with obstructive sleep apnea: a meta-synthesis and meta-analysis.

OBJECTIVES: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder associated with dysfunction of oropharyngeal muscles to maintain upper airway patency during sleep. Oropharyngeal rehabilitation (OPR) was developed to restore, reconstruct, and reeducate oropharyngeal muscle function, but current protocols and effectiveness of OPR have been inconsistent. The purpose of this study was to review (1) indications of OPR, (2) protocols of OPR, and (3) effectiveness of OPR. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Library and then conducted both meta-synthesis and meta-analysis according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). RESULTS: A total of eight studies with 203 patients were included. By means of meta-synthesis, the patients with middle age, BMI < 40 kg/m2, mild-to-moderate OSA, and non-severe upper airway anatomical abnormality were found to benefit from OPR. The protocol of OPR was summarized to be an anatomically based, multilevel approach, including the retropalatal, retroglossal, hypopharyngeal, TMJ, and facial levels. By using meta-analysis, overall outcomes were presented as apnea hypopnea index (AHI) with significant improvement from 25.2 ± 7.8/h to 16.1 ± 6.6/h (mean difference [MD] - 9.8 [95% CI - 11.0 to - 8.6], p < 0.0001); the lowest oxygen saturation (LSAT) improved from 80.2 ± 4.7 to 83.8 ± 2.9% (MD 3.0% [95% CI 2.0 to 4.0], p < 0.0001); Epworth sleepiness scale (ESS) improved from 11.8 ± 1.9 to 6.3 ± 1.6 (MD - 5.9 [95% CI - 7.5 to - 4.2], p < 0.001), neck circumference (NC) from 35.2 ± 1.1 to 34.7 ± 0.9 cm (MD - 0.6 [95% CI - 0.9 to - 0.2], p = 0.002), BMI from 24.8 ± 3.7 to 24.8 ± 4.1 kg/m2 (MD - 0.0; 95% CI - 0.5 to 0.5, p = 0.95). All outcomes except BMI demonstrated significant improvement from OPR. CONCLUSIONS: Meta-analysis of previous OPR reports shows an improvement in AHI of 39%, compared with the usual surgical definition of success at 50%. Only mild and moderate cases of OSA were referred for OPR in the prior studies. In order to improve outcomes with OPR, a comprehensive approach to rehabilitation should be emphasized.

Effects of continuous positive airway pressure (CPAP) therapy on neurological and functional rehabilitation in Basal Ganglia Stroke patients with obstructive sleep apnea: A prospective multicenter study.

Obstructive sleep apnea (OSA) adversely affects neurological recovery. This study aimed to determine the impact of continuous positive airway pressure (CPAP) and/or rehabilitation in basal ganglia stroke patients with OSA.A prospective controlled trial was conducted in 2015-2018. The subjects received routine rehabilitation training for up to 2 years and were assigned to the intervention and control groups treated with CPAP or without, respectively. Then, treatment effects on sleep parameters, motor function, stroke severity, daily life activities, cognitive function, and psychological states were assessed at different time points.At 6 months, the CPAP group showed significantly lower mean apnea-hypopnea index (AHI), percentage of time with SpO2 at <90% (TS90%), micro-arousal index, and percentages of time in non-rapid eye movement (non-REM) stages 1-2 and REM stage in total sleeping time compared with the control group, and significantly higher mean minimum of peripheral oxygen saturation (L-SaO2%) and percentage of time in stage 3 (P < .001) sleep. The CPAP group showed significant improvements in average the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer assessment scale (FMA), Barthel index (BI), Minimental state examination (MMSE), Hamilton anxiety scale (HAMA) and Hamilton depression rating scale for depression (HRSD) scores at different times versus the control group, respectively (P < .05). However, no difference in body mass index (BMI) management was observed (P > .05). Repeated-measures ANOVA revealed significant interactions between the two groups for change in FMA, MMSE, BI, HAMA, and HRSD scores from admission to 24 months (P < .001), but no significant was found for BMI (P = .582).Basal ganglia stroke patients with OSA tend to have significantly greater sleeping, neurological and functional recovery after CPAP, and rehabilitation over 2 years.

Puesta al día: síndrome de apnea obstructiva del sueño y abordaje ortopédico en niños / Update: obstructive sleep apnea syndrome and orthopedic approach in children

El síndrome de apnea obstructiva del sueño es un desorden respiratorio que afecta fundamentalmente a la calidad de éste y constituye una patología frecuente en la edad infantil. En la región orofacial existen multitud de factores de riesgo asociados a esta enfermedad, pasando desapercibidos en muchos casos e influyendo negativamente en la resolución de la enfermedad. En esta revisión bibliográfica, abordaremos los principales problemas que presentan estos pacientes y su tratamiento desde un punto de vista ortopédico

Obstructive sleep apnea syndrome is a respiratory disorder that essentially affects the sleep quality and constitutes a frequent pathology in childhood. In the orofacial region exists lots of risk factors associated to this disease, going unnoticed in many cases and negatively influencing in the disease resolution. In this bibliographic review, we present the principal problems that present this patients and its trea

Restoration of sleep using a novel biomimetic protocol for adult OSA: Clinical case report.

BACKGROUND: A sleep study of a 56-year old male with excessive daytime sleepiness demonstrated an AHI of 16.4hr-1 with 13% of total sleep time in REM sleep and a mean oxygen desaturation (SpO2) of 86%. CLINICAL PRESENTATION: On intra-oral examination, it was found that the patient had maxillary hypoplasia and bilateral torus mandibularis. A 3D cone-beam CT (CBCT) scan was taken, and 28 craniofacial parameters were measured. Surgical reduction of the mandibular tori followed by biomimetic oral appliance therapy (BOAT) was initiated. After 14 months, a post-treatment CBCT scan revealed that 70% of parameters measured had improved. Therefore, another sleep study was performed with no device in the mouth. This follow-up home sleep test demonstrated that the AHI fell to 5.3hr-1hr; with 27% REM sleep, and a mean SpO2 of 93% without any device in the mouth. CONCLUSION: These findings suggest that BOAT might be able to restore sleep in certain adult cases.

The effect of physical strain on breeders patients with obstructive sleep apnea syndrome.

AIM: The purpose of this study was to investigate the cardiopulmonary exercise testing (CPET) in breeders patients with obstructive sleep apnea syndrome (OSAS). METHOD: Thirty-two male participants (Age: 42.2 ± 7.3yrs, BMI: 29.5 ± 2.2 kg/m2) underwent full overnight polysomnography (PSG) and were divided into two groups (OSAS group: n = 20 vs. Control group: n = 12). 72-hours after the PSG study, they were subjected to CPET. The Independent t-test was used to measure the differences between the groups. Pearson's correlation coefficient was used among the parameters of CPET and PSG study. RESULTS: The results showed difference between the groups (OSAS vs. Control) during CPET in end-tidal, CO2 pressure in the peak of the exercise (38.7 ± 3.0 vs. 35.4 ± 5.5 mmHg, p = 0.031) and mean arterial pressure (122.7 ± 10.6 vs. 113.7 ± 11.8 mmHg, p = 0.035). Correlation results showed differences between the physical strain and the polysomnography study in physical strain parameters "walking duration per day with the herd" and oxygen desaturation index during sleep (r = 0.370, p = 0.037) and minimum oxygen saturation during sleep (r=-.374, p = 0.035), in the parameter "milking duration" and apnea (r = 0.392, p = 0.048), AHI (r = 0.374, p = 0.035) and oxygen desaturation index during sleep (r = 0.434, p = 0.013). The physical strain parameter "working hours per day" wasn't related to any parameter of the polysomnography study. CONCLUSION: The daily physical activity may have a protective role during the course of the disease in patients with OSAS.

The Effect of Change in Posture on Spirometry in Patients with Obstructive Sleep Apnoea Syndrome.

OBJECTIVES: Obstructive sleep apnoea syndrome (OSAS) is a growing health concern as it is associated with serious comorbidities. OSAS is mainly related to obesity, age, gender and a narrowed upper airway is commonly seen in patients with OSAS. This study aimed to compare spirometry parameters between obese OSAS patients and non-obese OSAS patients when patients moved from sitting to supine. METHODS: This cross-sectional study was conducted at Sultan Qaboos University Hospital, Muscat, Oman, between December 2009 and December 2010. Patients with severe OSAS and who were OSAS treatment naïve were recruited. Spirometry was performed in all patients in sitting and supine positions to assess forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1/FVC, forced expiratory flow (FEF) 50%, FEF 25-75%, maximum forced inspiratory flow and expiratory reserve volume. The mean difference in spirometry parameters between patients in sitting and supine positions was calculated. RESULTS: A total of 27 OSAS patients (19 males and 8 females) were included in this study. There was a significant difference in FEV1/FVC in obese and non-obese patients when changing position (P = 0.03). In addition, there was a significant change between male and female patients' FVC percentages (P <0.05). Male patients with OSAS had reduced FVC compared to females. There was no significant difference in the remaining spirometry parameters with patients' change of position. CONCLUSION: A supine position may cause lower airway obstruction in obese patients with OSAS. The reduced FVC in males possibly contributes to the high prevalence of OSAS in men compared to women.

Efficacy of a mandibular advancement intraoral appliance (MOA) for the treatment of obstructive sleep apnea syndrome (OSAS) in pediatric patients: A pilot-study

BACKGROUND: To evaluate the treatment efficacy of a mandibular advancement intraoral appliance (MOA) for treatment of obstructive sleep apnea syndrome (OSAS) in pediatric patients. MATERIAL AND METHODS: Eighteen patients (mean=8.39 years old, women=44.4%) were selected. Sleep disorders, sleep bruxism, and temporomandibular disorders were assessed by the Sleep Disturbance Scale for Children (SDSC), the BiteStrip (R) (portable SB device), and the Research Diagnostic Criteria for Temporomandibular Disorders, respectively. The clinical diagnosis of OSAS was confirmed with a type 3 portable monitor device (ApNeaLink (TM) Plus). A silicon-based material MOA was used by patients for 60 days, and the results were compared to baseline. RESULTS: The median RDI was significantly reduced from 10 to 4.5 events/hour. Nadir SpO2 significantly increased from 82.6% to 88.9%. Total snoring events/hour have also significantly decreased from 205.5 to 91.5. Signs and symptoms of TMD remained unaltered. There was also a reduction from moderate to absence of SB in 12 patients. Similarly, all variables measured by the SDSC have had very significant reductions: disorders of initiating and maintaining sleep, sleep disordered breathing, disorders of arousal, nightmares, sleep wake transition disorders, disorders of excessive somnolence, and sleep hyperhidrosis. CONCLUSIONS: In selected cases, OA maybe considered as an alternative for the OSAS treatment

Pulmonary rehabilitation and oropharyngeal exercises as an adjunct therapy in obstructive sleep apnea: a randomized controlled trial.

OBJECTIVE: It is well recognized that the most effective treatment for obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP). Different treatment possibilities comprise surgery, mandibular advancement, pulmonary rehabilitation, and oropharyngeal and facial exercises (PR program). However, these treatments showed inconsistent results. The purpose of the study was to compare the short-term effects of CPAP and the combination of PR program with CPAP on OSA severity, ventilatory functions, and changes in body characteristics in a newly diagnosed patient. METHODS: This study was a single-center, two-arm, parallel, randomized, controlled, open-label trial. Forty patients with OSA (20 men, 20 women, aged 54.2 ± 6.8 years) with moderate to severe obstructive sleep apnea were randomized to CPAP and CPAP + PR. The PR group underwent six weeks of 60-min twice-weekly individual PR programs. The primary outcome measure was apnea/hypopnea index, oxygen desaturation index, and Epworth Sleepiness Scale. The secondary outcome measures were a percentage of total sleep time with oxygen saturation below 90%, body mass index (BMI), vital capacity and forced expiratory volume in 1 s (% of predicted), neck, waist, and hip circumferences. RESULTS: Five patients with OSA did not complete the program. The comparison between baseline and final assessment was made in 15 patients in the CPAP + PR group and 20 patients in the control group with CPAP only. Although OSA severity was controlled with CPAP treatment in both groups, a significant reduction of neck, waist, and hip circumferences, BMI, and improvement of pulmonary function were confirmed only in the CPAP + PR group after treatment. CONCLUSION: Treatment with CPAP combined with the PR program improved OSA patients to a greater extent than only CPAP.

Upper Airway Stimulation in Patients Who Have Undergone Unsuccessful Prior Palate Surgery: An Initial Evaluation.

Upper airway stimulation therapy (UAS) is a new option for treatment of obstructive sleep apnea (OSA) in patients unable to tolerate continuous positive airway pressure (CPAP). We set out to evaluate the effectiveness of UAS in patients who have undergone prior palate surgery. We designed a retrospective review and evaluated patients undergoing UAS at 2 academic centers. We recorded demographic and pre- and postoperative polysomnogram (PSG) data. We compared the cohort of patients who had undergone prior palate surgery, "prior surgery," to the cohort who had not, "no prior surgery." A total of 164 patients were included in the study: 23 in the prior surgery and 141 in the no prior surgery groups. The mean age was significantly higher in the no prior surgery group ( P = .020). There were no other significant differences when comparing demographic, quality of life, or PSG variables between cohorts. UAS therapy is an option to treat OSA in patients having undergone unsuccessful prior palate surgery.

Short-term expiratory muscle strength training attenuates sleep apnea and improves sleep quality in patients with obstructive sleep apnea.

This study investigated the effects of 5 weeks of expiratory muscle strength training (EMST) on sleep apnea, sleep quality, and respiratory muscle strength in patients with different levels of obstructive sleep apnea (OSA). Twenty-five outpatients who received a diagnosis of OSA participated in the study and were assigned to either the EMST group (n=13) or control group (CTRL, n=12). The training intensity for the EMST group was 75% of the maximum static expiratory (PEmax) score (5days/week). The PEmax, apnea-hypoapnea index (AHI), Epworth Sleepiness Scale (ESS), and Pittsburgh Sleep Quality Index (PSQI) scores were evaluated before and after the treatment. EMST improved the scores for AHI (-40%), PEmax (+68%), and PSQI (-28%) and reduced the PSQI scores of the moderate OSA subgroup but not the mild OSA subgroup. The percent changes (Δ%) in the AHI and PEmax scores of participants with OSA were negatively correlated. We demonstrated that EMST effectively improved sleep apnea, sleep quality, and expiratory muscle strength in participants with OSA. Participants with moderate OSA exhibited greater improvement than did those with mild OSA, and the improvement in PEmax scores was correlated with a decrease in sleep apnea.

Orofacial motor functions in pediatric obstructive sleep apnea and implications for myofunctional therapy.

OBJECTIVES: The purposes of this study were (1) to identify possible differences in muscular and orofacial functions between children with obstructive sleep apnea (OSA) and with primary snoring (PS); (2) to examine the standardized difference between normal values of myofunctional scores and those of subjects with OSA or PS; and (3) to identify the features associated with OSA. METHODS: Participants were 39 children (mean age 8 ± 1.2 years) of which, 27 had a diagnosis of OSA and 12 had PS. All participants were examined by an otorhinolaryngologist and underwent overnight polysomnography. Orofacial characteristics were determined through a validated protocol of orofacial myofunctional evaluation with scores (OMES), surface electromyography of masticatory muscles, and measurements of maximal lip and tongue strength. Reference values in the OMES were included to quantify the standardized difference (effect size = ES) relative to the groups studied and in the regression analysis. RESULTS: The OSA group had lower scores in breathing and deglutition, more unbalanced masticatory muscle activities than PS group (P < 0.05), but both groups had similar reductions in orofacial strength. OSA had a large ES (Cohen's d > 0.8) in all analysed OMES scores, while PS group showed small and medium differences in breathing and mastication scores, respectively. The mobility of the stomatognathic components score was the most important to contribute for group status (57%, P < 0.0001) in the regression analysis. CONCLUSION: Children with tonsillar hypertrophy and OSA had relevant impairments in orofacial functions and lesser muscular coordination than children with PS.

Oropharyngeal exercises in the treatment of obstructive sleep apnoea: our experience.

INTRODUCTION: Oropharyngeal exercises are new, non-invasive, cost effective treatment modality for the treatment of mild to moderate obstructive sleep apnoea. It acts by increasing the tone of pharyngeal muscles, is more physiological, and effects are long lasting. AIM OF THE STUDY: The aim of our present study was to evaluate the effect of oropharyngeal exercises in the treatment of mild to moderate obstructive sleep apnoea. METHOD: Twenty patients of mild to moderate obstructive sleep apnoea syndrome (OSAS) were given oropharyngeal exercise therapy for 3 months divided into three phases in graded level of difficulty. Each exercise had to be repeated 10 times, 5 sets per day at their home. Oropharyngeal exercises were derived from speech-language pathology and included soft palate, tongue, and facial muscle exercises. Anthropometric measurements, snoring frequency, intensity, Epworth daytime sleepiness and Berlin sleep questionnaire, and full polysomnography were performed at baseline and at study conclusion. RESULTS: Body mass index (25.6 ± 3.1) did not change significantly at the end of the study period. There was significant reduction in the neck circumference (38.4 ± 1.3 to 37.8 ± 1.6) at the end of the study. Significant improvement was seen in symptoms of daytime sleepiness, witnessed apnoea, and snoring intensity. Significant improvement was also seen in sleep indices like minimum oxygen saturation, time duration of Sao2 < 90 %, sleep efficiency, arousal index, and total sleep time N3 stage of sleep at the end of study. CONCLUSION: Graded oropharyngeal exercise therapy increases the compliance and also reduces the severity of mild to moderate OSAS.