Airway centric(™)3

Airway , Breathing and SleepA Collaborative Approach

Airway Centric

Airway , Breathing and SleepA Collaborative Approach

Airway Centric

A New Paradigm

Michael Gelb DDS,MS

Michael L. Gelb DDS,MS

Gel-B™

Gelb 4/7TM

Airway Restorative

H

Airway CentricTM

Airway Centric

Chief complaints: right jaw locking, limited mouth opening, jaw clicking, ear congestion, and nocturnal teeth grinding

BMI = 27.9 Retruded mandible, Deep bite

Revealed enlarged tonsils Forward head posture

Referred to ENT for tonsillar evaluation and referred to physical therapist for postural re-education

Breastfeed for at least 2 months Make sure your child is a nasal breather Avoid thumb sucking and pacifiers Find an orthodontist from AAPMD.org No extraction of permanent teeth except 3rds Avoid retractive headgear Get tonsils and adenoids out early Get your child a sleep study if they have SDB,ADHD, bedwetting, Nightterrors, colic Early intervention ( 0-5) is a team effort Airway Centric

Esthetics Neurobehavioral Neurocognitive Cardiovascular Relationships Performance Chronic Disease Inflammation Fatigue Obesity Aging

Airway Centric

Stuffy Nose

CHIEF COMPLAINTS

• Back pain

• Headaches

• Neck pain

• Sinus Congestion

• Fatigue

DIAGNOSIS

• Anterior disc displacement

• Reduction in Right and Left TMJ

• Capsulitis of Right and Left TMJ

SUBJECT: 74 year old Female

Before Treatment

2/2009

Beginning Treatment

2/2009

Progress3/2011

Progress1/2013

Treatment Plan:

• NYU 6-8 Weeks

• Farrar

• Snap-on-Smile prosthesis

Improvements attributed to:

• Airway Centric™ Mouthwear

• Airway Restorative Dentistry™

• Increased Oxygen Saturation Levels

• Decreased Oxidative Stress

• Increased Stage 3 Deep Sleep

• Corrected Endothelial Dysfunction

Pre-Treatment2-2009

Progress1-2013

LATERAL BEFORE AND AFTER

FRONTALBEFORE AND AFTER

Pre-Treatment2-2009

Progress1-2013

Pre-Treatment: 2-2009Decreased Vertical Dimension of Occlusion, Retruded mandible and nerve compression

Progress with Airway Restorative Dentistry™ : 1-2013

STABILIZED AIRWAY Progress with Appliance

2013

COLLAPSED BASELINE AIRWAY 2009

Airway Assessment20092013

COLLAPSED OPEN AIRWAYAIRWAY

CBCT TMJ Findings

Pre-Treatment2-2009Mild degenerative changes to Right and Left TMJs ossesousstructures.Retruded Right and Left TMJs.

Progress 1-2013Right and Left TMJ noticeably removed from the eminence. Increased joint space.

Right TMJPre-Treatment2009

Right TMJProgress2013

Oral Examination

2-2009.

Retruded Mandible causing compression of

Auriculotemporal Nerve

4-2009.

Daytime Mandibular NYU Orthopedic appliance

prior to prosthetic work.

Vertical dimension reestablished; pain eliminated.

3-2011.

Transitional Snap-on-Smile.

Restoration of vertical dimension of occlusion.

Preliminary Ceph Analysis 2009

Progress Ceph Analysis 2012

SUBJECT: 44 Year Old Male

Epworth sleepiness scale = 7

Baseline PSG

03-18-2008

CPAP Titration

03-18-2008 @8 CM H2Opressure

Follow-up with Oasys03-15-2013* Snoring below

40db

AHI 15.6 0 3.8

Stage N3

4% 4% 18.82%

REM 22.3% 17.34%

Chief Complaints: Frequent heavy snoring Linea Alba Obstructive Sleep Apnea

Clinical Findings:

Narrow Maxilla Vaulted Maxilla Hypertrophic masseters The occlusal plane cants up to the right, the right

ear and right eye are higher than the left Bilateral pain and compression of the

auriculotemporal nerves Previous Laup procedure Previous Septoplasty surgery

Contributing Factors

Enlarged tongue Clenching Narrow Maxilla Severely Constricted Airway

ASSESSMENT

1. Obstructive Sleep Apnea2. Macroglossia3. Anterior Disc Displacement

with Reduction of the Right and Left TMJ

TREATMENT PLAN:

1. Mandibular NYU to decompress the right and left TMJ for 6-8 weeks

2. Oasys Sleep appliance at night3. Patient takes Zyrtec and Flonase

for allergies to decrease congestion

ICAT imaging (07/20/2012) revealed• Hypoplasia of the left condyle• Periodontal recession

throughout posterior bicuspids and molars- all four quadrants

Axiel view Sagittal view

Preliminary scan July 2012 confirms a 1mm anterior-posterior airway when standing

Follow up CBCT with Oasys shows stabilized airway

Min area= 62.1mm2 Open Airway= 178.3mm2

After 6 months of oral appliance therapy with an Oasys repositioning appliance, the airwayAirway increased by 116.2mm2.

Changes to the Patient’s Centric Bite as a result of OA Therapy

Before treatment July 2012 Class II dental relationship Overbite is present

7 months utilizing Oasys at night & NYU during the day February 2013 Protruded mandible Edge to Edge dental relationship No overbite

Oasys 7-2-2012

Oral appliance therapy

Oasys 11-2012

Sleep parameters for success include:

• Airway stabilization to increase oxygen saturation, sleep architecture• Less strain on the vital organs• Decrease endothelial Dysfunction• Improve sleep quality• Increasing energy• Decrease sleep bruxism

6 Months into treatment the patient reports:

1. Spouse’s sleep is no longer disrupted2. Sleeping throughout the night3. Snoring is virtually gone4. No jaw pain5. Temple headaches are now a rare occurrence

Clicking bilateral TMJ Jaw clicking while eating Bilateral jaw pain Migraine HA Bad back for many years

31

Initial CBCT 2009

F-UP CBCT 2010

Airway Centric

Ideal 4/7 condylar position post orthopedic realignment therapy- Mandible is set forward

Airway Centric™ Restored bitePost Veneer and OnlaysRehabilitation 08/05/2013

Completed Centric Bite with Maxillary Farrar appliance 08/19/2013

58-year-old female first presented with

LRQ teeth pain

Numbness in the right mental nerve area

Swollen salivary gland

Clinical examination:

Large tongue, high tongue level, Mallampati Class III airway

Issue a sleep study!

Revealed an AHI = 32.87 and RDI = 33.2

58-year-old female first presented with

LRQ teeth pain

Numbness in the right mental nerve area

Swollen salivary gland

Clinical examination:

Large tongue, high tongue level, Mallampati Class III airway

Issue a sleep study!

Revealed an AHI = 32.87 and RDI = 33.2

Large neck, retrudedmandible

Root Canal Therapy Required, Respire inserted after RCT completed

CHIEF COMPLAINTS• Sensitive teeth: lower right

quadrant• Intermittent jaw pain: Upper right

and lower right quadrants• Numbness in the right mental

nerve region• Swollen gland• Right ear pain

OBJECTIVE FINDINGS

• #30 tested + to percussion with tooth sleuth

• Lingual fracture line observed with periapical tenderness

Myofascial Pain Neuropathic pain OSA

TREATMENT PLAN1. Refer to endodontist for RCT #302. Rx: Klonopin .5mg Dispense 60 tablets , Sig: 1-2 tabs HS3. Farrar appliance4. Respire to treat OSA

Diagnostic sleep report: Severe OSA

Follow –up Sleep Study with Respire- Mild OSA

Benefits of OA therapy: AHI decreased RDI decreased Increased oxygenation-

less desaturation events

Increased REM Sleep

SUBJECT: 56 year old female

CHIEF COMPLAINTS• Left sided jaw locking• Left sided clicking & popping • Left jaw pain radiating into sinus

and ear• Neck pain • Fatigue

DIAGNOSTIC INFORMATION

• Epworth Sleepiness Scale= 8

Medical Hx:

• Asthma• Sinusitis• High Cholesterol• Acid Reflux• Arthritis• Insomnia• Torn rotator cuff

CONTRIBUTING FACTORS

• Decreased vertical dimension of occlusion• Retruded mandible with 10mm overjet• Clenching (#1 indicator for sleep disorder)

Pre-Treatment5-8-2012

Progress1-8-2013

ASSESSMENT

• Pain and compression of the left

auriculo-temporal nerve

• Anterior Disc Displacement with

Reduction of the left TMJ

• Capsulitis of the left TMJ

• Myofascial Pain

• Tension Headaches

Treatment Plan:

• Beginning 5-15-2012

• NYU 6-8 Weeks

• Modified Farrar

Progress9-10-2013

Pre-Treatment5-8-2012

Progress1-8-2013

ASSESSMENT

• Pain and compression of the left

auriculo-temporal nerve

• Anterior Disc Displacement with

Reduction of the left TMJ

• Capsulitis of the left TMJ

• Myofascial Pain

• Tension Headaches

Treatment Plan:

• Beginning 5-15-2012

• NYU 6-8 Weeks

• Modified Farrar

Progress9-10-2013

Pre-Treatment5-8-2012

LATERAL BEFORE AND AFTER

Progress1-8-2013

Pre-Treatment5-8-2012

FRONTALBEFORE AND AFTER

Progress1-8-2013

Airway Centric

Pre-Treatment: 5-8-2012Decreased Vertical Dimension of Occlusion, Retruded mandible and nerve compression

Progress with Farrar Appliance: 2-26-2013

Pre-Treatment: 5-8-2012

Progress with Farrar Appliance: 2-26-2013

Progress with Farrar Appliance: 2-26-2013

Pre-Treatment: 5-8-2012

Pre-Treatment: 5-8-2012

Airway Assessment

CBCT TMJ Findings

Pre-Treatment5-8-2012Mild degenerative changes to Right and Left TMJs ossesousstructures.Retruded Right and Left TMJs.

Progress with Farrar 2-26-13Right and Left TMJ noticeably removed from the eminence. Increased joint space.

RIGHT TMJ

LEFT TMJ

RIGHT TMJ

LEFT TMJ

Pre-Treatment Progress

Beginning Treatment 5/15/2012Modified Farrar

Progress 2/26/2013Modified FarrarRestored Vertical Height

Before Treatment 5/8/2012Without Appliance: Deep overbite

Beginning Treatment 5/15/2012NYU

Close airway Increase systemic inflammation Increase HA Increase jaw clicking and locking Increase daytime fatigue-EDS Decrease HRV

Airway Centric

Airway Centric

Sleep Questionnaire

Airway Centric

Airway Centric

Airway Centric SLEEP, Vol. 30, No. 3, 2007

Airway Centric SLEEP, Vol. 30, No. 3, 2007

Jinkwan Kim, Fahed Hakim, Leila Kheirandish-Gozal, David Gozal, Inflammatory pathways in children with insufficient or disordered sleep, Respiratory Physiology & Neurobiology, Volume 178, Issue 3, 30 September 2011, Pages 465-474, ISSN 1569-9048, 10.1016/j.resp.2011.04.024.(http://www.sciencedirect.com/science/article/pii/S1569904811001625)

Obstructive Sleep Apnoea Syndrome as a Systemic Low-Grade Inflammatory DisorderCarlos Zamarrón1, Emilio Morete1 and Felix del Campo Matias2

Airway Centric

Airway Centric

Airway Centric

Airway Centric

Airway Centric

Airway Centric

Chief complaints:1. Significant daytime somnolence2. Feeling groggy on awakening3. Obstructive sleep apnea4. Frequent heavy snoring5. CPAP intolerance6. Neck stiffness

The patient is CPAP intolerant; due to discomfort from headgear, disturbed or interrupted sleep, CPAP restricted movements during sleep, CPAP does not seem to be effective, claustrophobic associations, does not resolve symptoms, noisy and cumbersome.

Baseline Unattended Sleep Study with the Watchpat 200 Device

Masseters are hypertrophic upon cotton roll clench. lingual orientation of the maxillary dentition teeth as well as a100 degree

nasiolabial angle. Class II (retruded lower jaw) dental relationship. a late opening and a late closing click in the left temporomandibular joint. Mandibular range of motion measurements revealed maximum interincisal

opening of 44 mm and mandible is off to the LEFT by 2 mm. a level III (high) tongue. A Mallampati airway inspection showed a Class IV airway The uvula is small Maxilla is buttressed and retruded by 4mm A small mandibular torus was present

Clinical examination revealed:

Figure: Tongue Level III Figure: MallampatiClassification IV

Imaging Findings:Cone beam CT scan (06/12/2012) revealed1) Osteoarthritic degeneration of the right

condyle- lateral aspect2) Flattening of the superior portion of

both condyles3) Decreased airway space by 1mm4) Right ramus measurement is 69.mm5) Left ramus measurement is 62.99mm6) Decreased joint space on the left

Airway Views

Turbinates' & sinuses are clear Severe airway constriction posterior to soft palate and tongue

Narrowed airwayRetruded mandible and lack of maxillary labial support

Ceph view

Treatment Plan

1. The treatment plan consists of a Telescoping Herbst oral sleep appliance which will be worn every night while sleeping.

2. The treatment plan consists of a mandibular (NYU) orthopedic appliance to realign the mandible. The patient will wear the appliance full time for the first 6-8 weeks. As treatment progresses and the symptoms improve, we will wean the patient off of day wear.

3. The hard/soft mandibular mouth guard will be worn when the patient exercises.4. A follow up sleep study will be performed to monitor OSA

CHIEF COMPLAINTS

Bilateral temple and jaw pain

Headaches Left TMJ clicking Ringing in the ears Excessive daytime

somnolence Teeth don't line up properly Left facial swelling- slight

THE EPWORTH SLEEPINESS SCALE SCORE WAS 12, WHICH MAY INDICATE EXCESSIVE SLEEPINESS DEPENDING ON THE SITUATION. THE PATIENT MAY WANT TO SEEK MEDICAL ATTENTION.

Clinical Findings: Class III (protruded lower

jaw) dental relationship.a level III (high) tongue a Class IV airway "Tonsils Grade 3"

MRI (10/03/2012) revealed:

Anterior Disc Displacement with Reduction (left side)

Osteoarthritis of the left mandibular condyle

Tension Type Headache

Lack of full anterior translation on opening-bilaterally

Flattening of the left condyle- degenerative in nature

Flattening of the articular disc of both condyles-degenerative in nature

Anterior displacement of the articular disc of the left TMJ

Diagnosis:

Prognathic mandibleWith orthopedic NYU in: edge to edge bite by opening vertical dimension and retruding the mandible

Preliminary11-21-2012

Pain & compression of the left auriculotemporalnerveMasseteric Hypertrophy on the LeftMandible is off to the rightPoor posture

4 month Progress without appliances 3-12-2013NO compression on the leftImproved facial symmetryMuscles are more relaxedImproved posture

4 month follow up with NYU 3-12-2013

No pain or compression on the leftSignificantly less headachesLeft masseter still hypertrophic- administered 20 units of Botox

Facial AsymmetrySubject: 22 y/o male

Prognathic mandibleClass III bite

Subject: 63 yr old female

Chief Complaints:

Mandible is shifted to the right

Clinical Findings:

Currently in braces on the

maxillary and mandibular

arches

Anterior Open Bite

C5-C6 rotated to the right

No joint clicking

No pain or compression

Enlarged level III tongue

Mallampati Class II

Diagnosis

Myofascial Pain

Sleep Bruxism

Osteoarthritis of the left TMJ

Treatment Plan & Sequence

Removal of braces

1. Maxillary Farrar with anti retrusion

ramp to use during sleep

2. Lower full coverage appliance to

ideal jaw position- bringing the

mandible to the midline position

3. Once jaw is stabilized, possible

bonding to establish canine

guidance and anterior support (

PRENEW/ PREVIEW)

Jaw is shifted to the right

Preliminary photos April 2010

Without Prenew- Preview January 2013

Orthodontic photos 2009

Initial photos 2004

Post NYU Therapy In January 2013

Prenew- Preview Case In February 2013

• Improved incisal contacts #2-15• Midline is idealized• Mandible is brought to the center to decomress

the right TMJ

Frontal soft tissue model with bone and dentition reveals:• Mandible is off to the right

Preliminary Ceph Analysis

Michael Gelb, DDS,MSmgelb@gelbcenter.com

212.752.1662