Dave Singh DDSc Adult model

Dental Sleep Medicine in the 21st century

Recent advances in sleep technology, 3D digital imaging and molecular genetics have given new insights into the role that dentists play in dental sleep medicine.  It is important to appreciate that dental sleep medicine is a multi-disciplinary endeavor with a team of professionals that aim to achieve maximum medical benefit for their patients.  Another important concept is to understand that obstructive sleep apnea is one slice in the broad spectrum of sleep medicine, so professional collaboration and cooperation with sleep specialists is the key to successful patient outcomes.  There are other historic examples of professional multi-disciplinary teams.  For example, patients with craniofacial pain, and children born with cleft lip and/or palate, are best managed by a team that includes both medical and dental personnel.  Therefore, this article provides a brief overview of some new concepts that lie in the hands of dentists working towards improved systemic health of their patients by addressing the putative root causes of OSA.

It is now firmly established that OSA is a relatively common, serious, medical condition that can affect both the quality and quantity of life of patients.  But many patients are unaware of this life-threatening condition until a serious medical complication, such as a stroke or heart attack, suddenly occurs; while others believe that CPAP is the only solution.  However, research is showing that oral appliances can play a significant role in treating this condition in both adults and children. On the other hand, apart from the unwanted side effects of mandibular advancement devices (MADs), such as occlusal changes and TMJ issues, life-time wear of MADs during sleep is mandatory, similar to CPAP, if the condition is to be managed.  Alternatively, a biomimetic approach might be adopted.

Biomimetics (biomimicry) is a science that studies natural models and uses these designs and processes to solve human health issues.  For example, in modern humans (homo sapiens sapiens), the natural design includes 32 teeth symmetrically-arranged within the craniofacial architecture.  This pattern is achieved through developmental processes (e.g. temporo-spatial patterning) that are encoded within the human genome, including growth and development of the jaws and eruption of the teeth.  Figure 1 shows an adult patient who underwent biomimetic appliance therapy using an FDA-cleared device (mRNA appliance®). This biomimetic approach remodels the upper airway [1] and provides combined maxillo-mandibular correction [2]. The appliance is worn in both the evening and at night, and this protocol allows the body to redevelop the midface [3], as well as remodeling the upper airway in adults [4], while gently correcting the positions of the teeth and mandible into a more natural position [5].  Note that in Figure 1 the upper airway volume is significantly increased, from 2.2cm3 pre-treatment to 12.6cm3 with no appliance in the mouth when the post-treatment CBCT CT scan was taken.  In addition, the minimum retroglossal surface area increased from 41mm2 to 306mm2 after treatment.  Therefore, these innovative solutions might provide a more natural way to improve snoring, the upper airway and OSA in various patients.

Upper AIrway Changes
Figure 1: Upper airway changes in an adult patient who underwent mRNA appliance® therapy. Note that no appliance is in mouth when the pre- and post-treatment CBCT scans are taken. Courtesy: Dr Felix Liao DDS

It is known that other oral appliances can also be used to manage snoring and OSA but these are predominantly MADs that are typically titrated to protrude the lower jaw.  However, mandibular advancement might not always be appropriate for African-American and Asian patients [6] and other patients with Class III malocclusions that have been diagnosed with OSA.  In addition, MADs are worn over a lifetime, but do not address the underlying etiology of the condition, similar to CPAP.  The biomimetic technique is different from other appliance protocols because instead of simply repositioning the mandible, the devices are worn during the evening and at nighttime while asleep, to allow the body to gently increase midfacial bone volume [3], increase the volume of the upper airway [1], including the nasal airway [7], and re-coordinate the lower jaw, sometimes to the extent that the underlying issues appear to be eliminated in some cases [8] by the end of active treatment with no device in the mouth when the post-treatment sleep studies are performed [1, 9].  The biomimetic protocol is painless and does not involve surgery, drugs or injections.  Somewhat similar to the way that orthodontics moves teeth and orthopedics reshapes bone, a biomimetic technique for upper airway remodeling (Pneumopedics®) is used to re-develop the upper airway (Figure 3) so that the underlying OSA can be resolved.  This pneumopedic procedure typically lasts about 18-24 months, although some cases can take longer and some cases respond faster, but the initial effects can be felt in the first few nights.

Dave Singh DDSc 3D airway model
Figure 2: Left: 3D models of upper airway of an adult patient prior to treatment. Right: 3D models of same patient after mRNA appliance® therapy with no appliance in the mouth during CBCT scanning.

Pneumopedics® and Craniofacial Epigenetics, includes epigenetic orthodontics.  In adults and children, both tooth alignment and facial appearance can be improved [2], using the concepts noted above.  The craniofacial region includes the face, the teeth, the jaws and the upper airway.  Craniofacial epigenetics is used to improve these structures, by using biomimetic appliances that utilize a patient’s natural genes; their genetic potential.  Here, I define genetic potential as “achieving an optimized outcome in the prevailing conditions, subject to a viable population of stem cells”.  In other words, as long as undifferentiated (adult, mesenchymal) stem cells are available, a biomimetic protocol might be able to address human craniofacial health issues.  Figure 2 shows an adult patient who underwent biomimetic appliance therapy using an FDA-registered Daytime-Nighttime Appliance® (DNA appliance®).  This device is worn during the late afternoon, early evening and all night during sleep. It is not worn during the day and not while eating.  This biomimetic device allows the body to gently realign the teeth [4, 5], increase the size of the jaws [3], improve facial symmetry [4, 5] and increase the volume of the airway [1] even it adult patients.

Dave Singh DDSc Adult model
Figure 3: Facial and dental changes in adult patient who underwent DNA appliance® therapy
Courtesy: Dr Tara Griffin DMD

In addition, the DNA appliance® protocols are effective in addressing issues such as TMD/TMJ and headaches [10] in adults through natural, craniofacial enhancement, utilizing these new protocols that harness a patient’s genetic potential to improve their craniofacial and system health.  Guilleminault and Stoohs [11] regard OSA as a craniofacial issue.  Therefore, Pneumopedics® and Craniofacial Epigenetics might represent a craniofacial solution for dental sleep medicine in the 21st century.

References

  1. Singh GD, Wendling S, Chandrashekhar R. Midfacial development in adult obstructive sleep apnea. Dent. Today, 30(7), 124-127, 2011.
  2. Singh GD, Lipka G. Case Report: Introducing the Wireframe DNA applianceTM. J Am Acad Gnathol Orthop. 26(4); 8-11, 2009.
  3. Singh GD, Heit T, Preble D. Changes in 3D midfacial parameters after biomimetic oral appliance therapy in adults. J Ind Orthod Soc. 48(2), 2014.
  4. Singh GD, Cress SE. Craniofacial Enhancement using a Biomimetic Oral Appliance: Case Report. Dent Today, 329(12):92-92, 2013.
  5. Harris WG, Singh GD. Resolution of ‘gummy smile’ and anterior open bite using the DNA applianceTM: Case Report. J Amer Orthod. Soc. 30-34, 2013.
  6. Banabilh SM Suzina AH, Dinsuhaimi S, Samsudin AR, Singh GD. Dental arch morphology in South East Asian adults with obstructive sleep apnoea: Geometric morphometrics. J Oral Rehab. 36: 184–192, 2009.
  7. Singh GD, Heit T, Preble D, Chandrashekhar R. Changes in 3D nasal cavity volume after biomimetic oral appliance therapy in adults. Cranio 2015 doi/abs/10.1179/2151090315Y.0000000001?journalCode=crn (ePub ahead of print).
  8. Singh GD and Callister JD. Use of a maxillary oral appliance for the resolution of obstructive sleep apnea. J Cranio Sleep Prac. 31(3):171-179, 2013.
  9. Singh GD, Griffin TM, Chandrashekhar R. Biomimetic oral appliance therapy in adults with mild to moderate obstructive sleep apnea. Aust J Sleep Dis, 1(1);5, 2014.
  10. Utama J, Singh GD. Effect of the DNA applianceTM on migraine headache: Case report. Int J. Orthod. 24(1); 45-49, 2013.

11. Guilleminault C, Stoohs R. Obstructive sleep apnea syndrome in children.  Pediatrician 17(1):46-51, 1990

Dave Singh DDSc, PhD, DMD

Dave Singh DDSc, PhD, DMD

Dr. Dave Singh was born, educated and trained in England, UK. He holds three doctorates, including a Degree in Dental Surgery; a Ph.D. in Craniofacial Development, and a D.D.Sc. in Orthodontics. He was invited to relocate to the Center for Craniofacial Disorders, USA on the basis of being an “outstanding professor”, where he led a NIH-funded program of craniofacial research. Currently, he is a Member of the World Association of Sleep Medicine, American Academy of Dental Sleep Medicine, an Academic Fellow of the World Federation of Orthodontists, and Fellow of the International Association for Orthodontics, where he was awarded prizes in 2005, 2013 and 2014. Dr Singh holds several patents in the USA, Canada and Europe as well as international patents. He has published numerous articles and books in the peer-reviewed medical, dental and orthodontic literature, and has lectured in Australia, Asia, Europe and North America.

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2 comments

  1. David, I do see similar changes after maxillary expansion sometimes with orthopaedic maxillary appliances and sometimes with dentoalveolar expansion. I am cautious though about making claims of “widening” the airway especially when I see the differences in the position of the cervical column due to head positioning in the CBCT units. It is variable so the question also should be verified by head posture photos before and after treatment.
    Keep up the investigations, we see similar things and it is hard to “convince” mainstream orthodontics still about the necessity of airway evaluation.
    Terry Carlyle
    Edmonton, Alberta

  2. Terry:

    Thanks for your comment. Note that we do not “widen” the upper airway; we increase it volumetrically. These studies were presented at the World Association of Sleep Medicine. The medical specialists are very interested in my findings of a potential cure for sleep apnea – and have begun collaboration with us. Also, this is new concept of Pneumopedics is above and beyond traditional orthodontics that focuses on dentoalveolar tooth movement but I have been invited to speak at international orthodontic conferences next year.

    I look forward to meeting you at Tammarie’s seminar in November.

    Best wishes –

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