Objectively measured adherence may affect side effects of mandibular advancement therapy in subjects with obstructive sleep apnea.

PURPOSE: The purpose of this study was to determine if objectively measured adherence to oral appliance (OA) treatment may affect dental changes and temporomandibular disorders (TMD) in patients with obstructive sleep apnea (OSA). METHODS: The original study group consisted of adults with OSA who were referred for OA therapy. Eight indicators of subjective side effects of using OA (temporomandibular joint (TMJ) and muscle pain, pain in teeth, jaw stiffness in the morning, clicking, dry mouth, hypersalivation, gingival irritation) were evaluated by a questionnaire. Three occlusal indicators (overjet, overbite, molar occlusion) and clinical TMD signs (TMJ pain, muscle pain, clicking, jaw deviation on opening) were evaluated at baseline and at the 3-, 6-, and 12-month follow-up. In addition, objective adherence monitoring for OA was registered. Statistical analyses included the chi-square test, Fisher's exact test, paired sample t-test, and linear regression analyses. RESULTS: A total of 58 adults with OSA were referred for OA therapy. Mean (SD) age was 50.7 (11.7) and mean apnea-hypopnea index (AHI) was 19.5 (10.0). At 1-year follow-up, the study group consisted of 28 men and 12 women. Overjet but not overbite reduced significantly after 1-year OA therapy. The average nightly wear of OA was related to overjet and overbite reduction, and to TMD signs. Hypersalivation, dry mouth, and tooth discomfort were the most common subjective side effects of OA therapy. CONCLUSION: There was a time-dependent relationship with the nightly wear of OA and reduction in overjet and overbite, and clinical TMD signs. With 60% of mandibular advancement, dental changes and TM-disorders were considered mild/minor in the 1-year study period.

Adherence to oral appliance treatment and its determinants in obstructive sleep apnoea patients.

BACKGROUND AND OBJECTIVES: Treatment effectiveness, in terms of health benefits, is a composite of efficacy and adherence. Oral appliance (OA) usage is mainly based on self-reports, but nowadays, objective adherence monitoring for OAs is available. This study investigated the objective OA adherence and its determinants in obstructive sleep apnoea (OSA) patients. MATERIALS AND METHODS: There were 29 subjects who were treated with OA; mean [SD] age 51.4 [11.1]; mean apnoea-hypopnoea index (AHI) [SD] 19.5 [10.0]. Anthropometric and sociodemographic parameters, AHI, daytime sleepiness, snoring, and adverse effects of OA as potential determinants were evaluated. Patients were classified as regular users if they wore OA at least 4 hours nightly 5-7 nights a week. Statistical analyses included the chi-square test, t-test, Mann-Whitney U-test, and linear regression analyses. RESULTS: At the 3-month follow-up, 68% of subjects were regular users and at 12-month follow-up, 64%. AHI, sociodemographic parameters, or adverse effects were not associated with OA adherence. Snoring seemed to improve weakly adherence, whereas mandibular retrusion reduced the weekly use, and smoking the nightly use of OAs. LIMITATIONS: The follow-up time was short, and there were a relatively small number of patients with obtainable adherence data, therefore it is difficult to establish if OA therapy alone is a successful long-term treatment option for OSA patients. CONCLUSIONS/IMPLICATIONS: Adherence to OA therapy is mainly the outcome of patients' subjective comfort in everyday life through eliminating social disturbance of snoring. To best meet a subject's individual treatment need and to prevent suboptimal use of OA, a patient-tailored therapy including digital wear-time documentation is recommended.

Long-term patient satisfaction and the sense of coherence - a longitudinal study 10-15 years after orthognathic surgery.

OBJECTIVE: This study focuses on evaluating the long-term treatment outcome (10-15 years) and patient satisfaction after orthognathic treatment with bisagittal split osteotomy (BSSO). Furthermore, the aim was to evaluate whether the psychosocial factor, sense of coherence (SOC) associates with long-term patient satisfaction. MATERIALS AND METHODS: Study sample consisted of 57 patients who had orthognathic treatment with BSSO. Self-completion questionnaires were distributed approximately 1.8 years and 10-15 years after surgery to evaluate treatment outcome. SOC was evaluated with a 12-scale questionnaire 10-15 years after the surgery. RESULTS: After 10-15 years following BSSO, 96% of patients were highly or moderately satisfied with the treatment outcome and none expressed dissatisfaction. Less educated patients were more satisfied with the treatment outcome than those with a higher educational level. Patients who felt clear improvement in their facial appearance expressed higher satisfaction than those experiencing only minor facial improvement. Furthermore, patients with improvement in orofacial pains and headaches more often expressed high satisfaction than those without improvement of these symptoms. Patients with strong SOC seemed to have somewhat higher scores for functional aspects of long-term treatment outcome. CONCLUSIONS: Post-treatment satisfaction with orthognathic treatment appears to be long-lasting. Psychosocial factors may play a role in long-term post-treatment satisfaction. Our study strongly suggests that psychosocial factors should be taken into account in the treatment planning of orthognathic patients.

The impact of oral appliance therapy with moderate mandibular advancement on obstructive sleep apnea and upper airway volume.

PURPOSE: To find out if a moderate protrusion with a mandibular advancement device (MAD) can significantly increase the upper airway volume and, further, what signs and symptoms of obstructive sleep apnea (OSA) can be improved by this maneuver. METHODS: There were 58 adults diagnosed with OSA who were referred for MAD therapy. The mean apnea-hypopnea index (AHI) was 19.2 (SD 8.6). Five indicators of signs and symptoms of OSA (AHI, oxygen saturation, snoring, daytime sleepiness, and health-related quality of life) were evaluated at the baseline and after 6 months of MAD therapy. Nasal resistance and airway volume and cross-sectional areas with and without the MAD in situ were recorded. Based on AHI reduction, the treatment response was classified as complete, partial, or non-complete. Statistical analyses included the chi-square, t tests, Mann-Whitney U tests, and regression analyses (linear and logistic). RESULTS: Twenty-three patients attained a complete response (residual AHI < 5 events/h) to MAD therapy. In 13 subjects, the response was partial, and in 9 patients, it was non-complete. The complete responders were significantly younger, and they had a deeper overbite than partial/non-complete responders. A convex profile associated positively, but a vertically restricted throat and increased lower facial height associated negatively with the increase in airway volume. CONCLUSIONS: Excellent MAD therapy outcomes were achieved in most patients. Only age and deep bite had some influence on AHI reduction, indicating multifactorial nature in the response to MAD therapy.

Health-related correlates of psychological well-being among girls and boys 6-8 years of age: The Physical Activity and Nutrition in Children study.

AIM: Due to limited knowledge on the differences in the correlates of psychological well-being (PSWB) between girls and boys, we compared the correlates of PSWB between primary school girls and boys. METHODS: A population sample of 412 children participated in the Physical Activity and Nutrition in Children study. Parents completed a questionnaire that included 19 questions on the components of PSWB, and a PSWB score was computed. We assessed correlates of PSWB, including physical activity, sedentary behaviour, cardiorespiratory fitness, diet quality, body fat content, sleep duration, sleep disordered breathing, prevalent diseases and parental characteristics. We used logistic regression to analyse the risk of being in the lowest third of the PSWB scores. RESULTS: Low parental education was associated with increased risk (odds ratio (OR) 2.34, P = 0.039) and high cardiorespiratory fitness with decreased risk (OR 0.26, P = 0.006) of poor PSWB in girls. At least 2 h of screen-based sedentary behaviour per day (OR 1.93, P = 0.037), daily parental smoking (OR 2.10, P = 0.034) and sleep disordered breathing (OR 4.24, P = 0.003) were related to increased risk of poor PSWB in boys. CONCLUSIONS: There are large differences in the correlates of PSWB between girls and boys. Most of these correlates are modifiable and related to the health behaviour of children and their parents.

Predictors of sleep disordered breathing in children: the PANIC study.

Objective: We studied longitudinally the associations of craniofacial morphology, mouth breathing, orthodontic treatment, and body fat content with the risk of having and developing sleep disordered breathing (SDB) in childhood. We hypothesized that deviant craniofacial morphology, mouth breathing, and adiposity predict SDB among children. Materials and methods: The participants were 412 children 6-8 years of age examined at baseline and 329 children aged 9-11 years re-examined at an average 2.2-year follow-up. An experienced orthodontist evaluated facial proportions, dental occlusion, soft tissue structures, and mode of breathing and registered malocclusions in orthodontic treatment. Body fat percentage was assessed by dual-energy X-ray absorptiometry and SDB symptoms by a questionnaire. Results: Children with SDB more likely had convex facial profile, increased lower facial height, mandibular retrusion, tonsillar hypertrophy, and mouth breathing at baseline and convex facial profile, mandibular retrusion, and mouth breathing at follow-up than children without SDB at these examinations. Male gender and body adiposity, mouth breathing, and distal molar occlusion at baseline were associated with SDB later in childhood. Adipose tissue under the chin, mandibular retrusion, vertically large or normal throat and malocclusion in orthodontic treatment at baseline predicted developing SDB during follow-up of among children without SDB at baseline. Limitations: We could not conduct polysomnographic examinations to define sleep disturbances. Instead, we used a questionnaire filled out by the parents to assess symptoms of SDB. Conclusions: The results indicate that among children, deviant craniofacial morphology, mouth breathing, body adiposity, and male gender seem to have implications in the pathophysiology of SDB.

Perception and Respiratory Responses of the Upper Airway Mechanism to Added Resistance With Aging.

Objectives: To assess breathing behaviors and perception of added respiratory loads in young compared to old individuals, and to determine whether aging affects the perception and response to changes in nasal airway resistance. Study design: In a clinical study, 40 young (11-20 years) and 40 older (59-82 years) subjects were evaluated during rest breathing and during the application of added airway resistance loads. Methods: The pressure-flow technique was used to measure airflow rate (mL/s) and oral-nasal pressures (cmH2O) to calculate nasal resistance (cmH2O/L/s). To create calibrated resistance loads for the test conditions, we used a device modified from a precision iris diaphragm. Results: During rest breathing airflow rate was significantly lower for the younger group compared to older group. Using the loading device, 11-20-year-olds detected increased resistance at the level of 2.26 cmH2O/L/s compared to 4.55 cmH2O/L/s in 59-82-year-olds. In contrast to the younger group, mean airflow rate was higher during expiration than during inspiration among 59-82-year-olds except at rest breathing. Conclusions: The data revealed that the perception and respiratory response to increased airway resistance changed with aging. Younger subjects were more sensitive to changes within the airway. In both groups, subjects responded to increased airway resistance by decreasing airflow rate. However, expiratory phase became more active than inspiratory phase only in the older group. Level of Evidence: N/A.

Changes in posterior airway space and hyoid bone position after surgical mandibular advancement.

OBJECTIVE: To evaluate cephalometric changes in posterior airway space (PAS) and in hyoid bone distance to mandibular plane (MP) 1-3 years after bilateral sagittal split osteotomy (BSSO). MATERIAL AND METHODS: The sample consisted of 36 females and 16 males who underwent mandibular advancement by BSSO. To observe sagittal changes in PAS and in hyoid bone distance to MP both pre- and postoperative cephalograms were analyzed using WinCeph® 8.0 software. For the statistical analyses paired T-test and multivariate logistic regression models were used. RESULTS: By the surgical-orthognathic treatment the sagittal dimension of PAS showed variable changes but it mainly diminished when the mandibular advancement exceeded 6 mm. In most cases the hyoid bone moved superiorly by BSSO. Logistic regression models showed that males, patients with narrow PAS at the baseline, and those with counterclockwise rotation of the mandible by the treatment gained more increase in PAS. However, an increase in sagittal PAS dimension tended to relapse over time. Concerning the movement of the hyoid it was found that the more PAS increased the less hyoid moved superiorly. In males the change in hyoid position was more obvious than in females. CONCLUSION: Males, patients with narrow PAS at the baseline, and those whose mandible moved in the counterclockwise direction with moderate advancement gained more retrolingual airway patency by BSSO.

Lateral facial profile may reveal the risk for sleep disordered breathing in children--the PANIC-study.

OBJECTIVE: To evaluate the lateral view photography of the face as a tool for assessing morphological properties (i.e. facial convexity) as a risk factor for sleep disordered breathing (SDB) in children and to test how reliably oral health and non-oral healthcare professionals can visually discern the lateral profile of the face from the photographs. MATERIALS AND METHODS: The present study sample consisted of 382 children 6-8 years of age who were participants in the Physical Activity and Nutrition in Children (PANIC) Study. Sleep was assessed by a sleep questionnaire administered by the parents. SDB was defined as apnoeas, frequent or loud snoring or nocturnal mouth breathing observed by the parents. The facial convexity was assessed with three different methods. First, it was clinically evaluated by the reference orthodontist (T.I.). Second, lateral view photographs were taken to visually sub-divide the facial profile into convex, normal or concave. The photos were examined by a reference orthodontist and seven different healthcare professionals who work with children and also by a dental student. The inter- and intra-examiner consistencies were calculated by Kappa statistics. Three soft tissue landmarks of the facial profile, soft tissue Glabella (G`), Subnasale (Sn) and soft tissue Pogonion (Pg`) were digitally identified to analyze convexity of the face and the intra-examiner reproducibility of the reference orthodontist was determined by calculating intra-class correlation coefficients (ICCs). The third way to express the convexity of the face was to calculate the angle of facial convexity (G`-Sn-Pg`) and to group it into quintiles. For analysis the lowest quintile (≤164.2°) was set to represent the most convex facial profile. RESULTS: The prevalence of the SDB in children with the most convex profiles expressed with the lowest quintile of the angle G`-Sn-Pg` (≤164.2°) was almost 2-fold (14.5%) compared to those with normal profile (8.1%) (p = 0.084). The inter-examiner Kappa values between the reference orthodontist and the other examiners for visually assessing the facial profile with the photographs ranged from poor-to-moderate (0.000-0.579). The best Kappa values were achieved between the two orthodontists (0.579). The intra-examiner Kappa value of the reference orthodontist for assessing the profiles was 0.920, with the agreement of 93.3%. In the ICC and its 95% CI between the two digital measurements, the angles of convexity of the facial profile (G`-Sn-Pg`) of the reference orthodontist were 0.980 and 0.951-0.992. CONCLUSION: In addition to orthodontists, it would be advantageous if also other healthcare professionals could play a key role in identifying certain risk features for SDB. However, the present results indicate that, in order to recognize the morphological risk for SDB, one would need to be trained for the purpose and, as well, needs sufficient knowledge of the growth and development of the face.

Craniofacial morphology but not excess body fat is associated with risk of having sleep-disordered breathing--the PANIC Study (a questionnaire-based inquiry in 6-8-year-olds).

UNLABELLED: We investigated the associations of dental occlusion, other craniofacial features and body fat with paediatric sleep-disordered breathing (SDB) in a representative population sample of 491 Finnish children 6-8 years of age. Overweight and obesity were defined using age- and sex-specific body mass index cutoffs by International Obesity Task Force (IOTF) criteria. Body fat percentage was assessed by dual-energy X-ray absorptiometry. Facial proportions, dental occlusion and soft tissue structures were evaluated by an orthodontist. Sleep was assessed by a sleep questionnaire administered by the parents. SDB was defined as apnoeas, frequent or loud snoring or nocturnal mouth breathing observed by the parents. The prevalence of SDB was 9.9 % with no difference between boys and girls. The median (interquartile range) of body fat percentage was 20.6 (17.4-27.1) in girls and 15.0 (11.4-21.6) in boys. Altogether 11.4 % of boys and 15.6 % of girls were classified as having overweight or obesity according to the IOTF criteria. There was no difference in the prevalence of overweight, obesity or body fat percentage between children with SDB and those without it. Children with tonsillar hypertrophy had a 3.7 times higher risk of suffering SDB than those with normal size tonsils after adjustment for age, sex and body fat percentage. Furthermore, children with cross bite had a 3.3 times higher risk of having SDB than those without cross bite, and children with a convex facial profile had a 2.6 times higher risk of having SDB than those with a normal facial profile. CONCLUSION: Abnormal craniofacial morphology, but not excess body fat, is associated with an increased risk of having SDB in 6-8-year-old children. A simple model of necessary clinical examinations (i.e. facial profile, dental occlusion and tonsils) is recommended to recognize children with an increased risk of SDB.

Risk factors for sleep-disordered breathing: the role of craniofacial structure.

OBJECTIVE: To evaluate possible differences in craniofacial structure between overweight patients and normal-weight patients with mild sleep-disordered breathing (SDB). MATERIAL AND METHODS: Subjects were recruited from patients referred to Kuopio University Hospital due to suspicion of SDB. They were divided into two groups based on their body mass index (BMI). The overweight group (BMI > 27 kg/m(2)) consisted of 58 males and 19 females and the normal weight group (BMI ≤ 27 kg/m(2)) of 33 males and 15 females. The mean age of the subjects was 51.4 years. All subjects underwent an overnight cardiorespiratory recording. The mean apnea-hypopnea index (AHI) was 9.3 events/h for the entire study population. Occlusion and craniofacial morphology were examined by an experienced orthodontist. RESULTS: Significant differences in craniofacial morphology and occlusion were found between the groups: the craniofacial profile in normal-weight patients was more convex (P < 0.000) and the mandible more retrusive (P = 0.004) than in overweight subjects. In addition, distal molar occlusion (P = 0.005) was more prevalent in normal-weight subjects, and their overjet and overbite were increased as compared to overweight patients (P = 0.009 and 0.006, respectively). Similarly, cross bite was detected significantly more often in normal-weight subjects (P = 0.052). CONCLUSIONS: These results reveal that deviations in craniofacial morphology and occlusion are more frequent in normal subjects than in overweight subjects with mild SDB; this may well have implications in the pathophysiology of SDB.

Surgical-orthodontic treatment and patients' functional and psychosocial well-being.

INTRODUCTION: Surgical-orthodontic treatment is a common treatment approach for adult patients with skeletal maxillomandibular discrepancy. Some patients report improvement in signs and symptoms of temporomandibular disorder (TMD) after surgery. Whether the correction of malocclusion is responsible for the improvement of TMD symptoms after orthognathic surgery is still controversial. The objectives of this prospective study were to evaluate subjective treatment outcomes in patients with bilateral sagittal split osteotomy (BSSO) and to find out whether signs and symptoms of TMD and changes in occlusion are related to patient satisfaction. METHODS: Eighty-two patients (53 female, 29 male) with a mean age of 32 years (range, 16-53 years) treated with BSSO in the Oral and Maxillofacial Department at Kuopio University Hospital in Finland were examined; 64 had mandibular advancement, and 18 had mandibular setback. Occlusion and signs and symptoms of TMD were registered pre- and postoperatively. At the postoperative examination (mean, 1.8 years after BSSO), the patients were asked to fill out a questionnaire about the influence of treatment on their masticatory function and symptoms of TMD, as well as their satisfaction with the treatment outcome. RESULTS: TMD symptoms were significantly reduced after treatment. Improvements were also reported in facial appearance (82%) and chewing ability (61%); also, facial (56%) and temporomandibular joint (40%) pain disappeared. However, in 12% of the patients, temporomandibular joint problems were worse after treatment. Most patients (73%) were very satisfied with the outcomes; no one expressed dissatisfaction. Multiple logistic regression analysis showed that subjects with improved mastication and self-confidence, and those without long-term neurosensory deficits, expressed high satisfaction with the treatment outcome. Patients with mandibular setback were more pleased with the outcome than those with mandibular advancement. CONCLUSIONS: Orthognathic patients generally experience functional and psychosocial benefits after surgical-orthodontic treatment. In addition to functional and morphological reasons, the psychosocial factors should be more emphasized when making the treatment decision and comparing the alternative treatment approaches.

Effects of sagittal split ramus osteotomy on temporomandibular disorders in seventy-two patients.

Preoperative and postoperative temporomandibular disorders (TMDs) were observed in 72 patients before surgical-orthodontic treatment and about 2 years after bilateral sagittal split osteotomy. Prevalence and degree of TMD were assessed using the modified clinical dysfunction index of Helkimo. A total of 49 women and 23 men (mean age 32 years) were included in the study. To find out which patients benefit most from the treatment, the sample was classified into subgroups--myogenous, arthrogenous, or both components of TMD. The prevalence of clicking and headache decreased significantly with the treatment, while the incidence of crepitation increased. In general, severity of the dysfunction was greatly reduced. Furthermore, multiple regression analysis showed that patients with excessive overjet and previous occlusal splint therapy benefit most from orthognathic treatment. In addition, patients with signs of mainly myogenous origin got more relief from their dysfunction than patients with mainly arthrogenous components of TMD. The results suggest that in patients with severe maxillomandibular discrepancy surgical-orthodontic therapy is a good choice of treatment for reducing myogenous TMD pain and discomfort.

Can temporomandibular dysfunction signs be predicted by early morphological or functional variables?

The aim of the present study was to establish whether the early signs of various orofacial dysfunctions, malocclusions, or occlusal interferences can predict the development of temporomandibular dysfunction (TMD) in young adults. Forty-eight subjects referred for speech therapy and 49 controls participated in all four stages of this longitudinal study. The subjects were examined at the ages of 7, 10, 15, and 19 years. The phoniatrician diagnosed errors in place of articulation and problems in the movement and co-ordination of the speech articulators. Occlusion, TMD signs (palpatory tenderness of the masticatory muscles, and of temporomandibular joints (TMJ), jaw deviation on opening, and clicking), mandibular movement capacity and occlusal interferences were registered by the orthodontist. Multiple logistic regression models were applied in order to evaluate whether single signs of TMD at the age of 19 years were related to previous/present malocclusions or interferences, to misarticulations of speech, problems in oral motor skills, or other signs of TMD. The effect of gender was also considered. The results showed that excessive overjet was the only variable which seemed to consistently increase the risk of TMD. In addition, girls seemed to be more prone to the development of TMD than boys. Although, during growth, there were both local and central factors associated occasionally with TMD development, the predictive value of those variables in the estimation of the individual risk of TMD was rather small.

Mandibular movement capacity in 19-year-olds with and without articulatory speech disorders.

Associations between articulatory speech disorders and mandibular movement capacity, as well as between malocclusions and jaw movements, were examined in two groups of adolescents, i.e. 52 individuals with and 45 without misarticulations of speech. The mean age of the whole sample was 19.2 years. Articulatory speech disorders and functioning of the speech articulators were diagnosed by a phoniatrician. Mandibular movement capacity, malocclusions, occlusal interferences, and signs of temporomandibular dysfunction were recorded by an orthodontist. Multiple regression analyses showed that subjects with articulatory speech disorders were likely to have smaller opening capacity than subjects with a correct speech articulation. Excessive overjet, lateral cross bite, and a tendency to anterior open bite were associated with large movements of the jaw. These results suggest that in young adulthood mandibular movement capacity seems to vary depending on occlusion and is related to misarticulations of speech.