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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4421_Библиотеки_им_академика_М_И_Перельмана.pdf
Clinical, Occlusal, andCephalometric Analyses oftheOSA Patient
. Fig. 23.13 Hyperplastic soft palate and uvula are observed, and
can contribute to oropharyngeal airway obstruction. There can also
be a transverse constricture of the faucial pillars, further contributing to OSA
351
23.2 Radiographic Evaluation
23.2.1 Types ofImaging Techniques
Cone beam technology provides a 1:1 ratio of imaging
with panographic, cephalometric and tomographic
imaging, including 3-D imaging, and is currently the
gold standard for orthognathic surgery imaging. Other
commonly used radiographs for diagnosis of dentofacial deformities are (1) lateral cephalometric radiograph,
(2) panoramic radiograph, and when indicated, (3) periapical radiograph. Panoramic and periapical radiographs can be helpful to determine tooth alignment,
root angulation, and existing pathoses. Other imaging
modalities such as posteroanterior cephalograms, TMJ
tomograms, transcranial radiographs, Water’s view
images, CT scans, and MRI (. Fig. 23.9) may be
required as determined by individualized patient diagnostic needs.
23
cleft palate patients) [22]. Clinical assessment of the
oropharyngeal airway included evaluation of the
Mallampatti score, length of the soft palate and uvula
as well as function, transverse width and function of
the fascial pillars, presence and size of the tonsils, indirect evaluation of the adenoid tissues, etc. A high
Mallampatti score (Class III and IV) can indicate
retrusion of the mandible and a high occlusal plane
facial morphology with associated OSA. When the
oropharyngeal airway is signicantly reduced in the
presence of a hypoplastic mandible and maxilla, this
may indicate the requirement for orthognathic surgery
for maxillomandibular complex advancement with or
without counterclockwise rotation. A hyperplastic soft
palate and uvula (. Fig.23.13) can contribute signicantly to oropharyngeal airway obstruction acting as a
valve blocking the nasal airway. An enlarged uvula can
act as a vibrating structure contributing to snoring, as
can an elongated accid soft palate. Evaluation of the
soft palate/uvula length in conjunction with the lateral
cephalogram and 3-D soft tissue imaging of the oropharyngeal area may indicate the need for an uvulopalatopharyngoplasty (UPPP) procedure if the
structures are hyperplastic.
Hypertrophied tonsils and adenoid tissue
(. Fig.23.12) also can contribute signicantly to oropharyngeal airway obstruction. Particularly those that
suffer from recurrent infections can cause further
enlargement making it difcult to breathe through the
nose or mouth. Hypertrophied tonsils and hypertrophied adenoid tissues often go together, providing a signicant mechanical obstruction. Evaluation of the
tonsils and adenoid tissues as contributory factors to
OSA could indicate the need for a tonsillectomy and
adenoidectomy [22].
23.2.2 Lateral Cephalometric Radiograph
The lateral cephalometric radiograph is one of the most
important tools in the diagnosis of jaw deformities [9].
The lateral cephalometric radiograph is used to analyze
skeletal, dentoalveolar, and soft tissue relationships in
the anteroposterior and vertical dimensions. For proper
head positioning for lateral cephalometric acquisition,
pose the patient’s head so that the jaws are in centric relation with the teeth lightly touching and the lips relaxed.
Position the head so that the clinical Frankfort horizontal plane (line from tragus of the ear through the bony
infraorbital rim) is parallel to the oor. Both hard and
soft tissue structures should be visible on the radiograph.
If the patient’s bite is overclosed (such as in vertical maxillary deciency), then take a second lateral cephalometric radiograph with the condyles still seated in centric
relation but the mouth opened until the lips just begin to
separate. This posture allows assessment of soft tissue
and bony structures without distortion of the lips.
Anteroposterior cephalometric radiographs may be
helpful, particularly in diagnosing and treatment planning for patients with signicant transverse asymmetries.
23.2.3 Cephalometric Analysis Versus
Clinical Diagnosis
Numerous cephalometric analyses are available to evaluate lateral cephalometric radiographs. Regardless of
the specic analysis the clinician uses, it is important to
understand that there may be signicant differences
between the clinical evaluation and the values obtained
from cephalometric analysis. When a signicant differ-
352
L. Wolford
23
ence occurs, the clinical evaluation is far more important for treatment planning [9]. Cephalometric analysis
is only an aid to clinical assessment and should not be
used as the sole diagnostic tool.
23.2.4 Corrected Frankfort Horizontal
Plane
In cases in which the cephalometric values do not correlate with the clinical impression, make adjustments in
the reference cranial base structures (i.e., corrected
Frankfort horizontal line) [9, 24]. Adjust values to correlate with the clinical impression for use in diagnosis
and treatment planning (. Fig. 23.14). The Frankfort
horizontal plane may be positioned aberrantly because
of vertical malposition of porion or orbitale and/or
anteroposterior malposition of nasion. The anatomical
landmarks for Frankfort horizontal plane also may be
. Fig. 23.14 (A) Cephalometric numerical values based on stan-
dard anatomical landmarks may not correlate to the clinical impression or the patient’s deformity. Using the anatomically dened
Frankfort horizontal plane (dotted line A), the cephalometric values
for maxillary depth and mandibular depth (orange rectangle) do not
correlate with the clinical assessment of this patient. In such
instances, a corrected Frankfort horizontal plane (CFH) can be constructed (solid line B) so that the numerical cephalometric values
(red solid rectangle) correlate with the clinical diagnosis of the
patient. Subsequently, normal cephalometric values based on the
CFH can be used in the diagnosis, treatment planning, and development of a surgical prediction tracing
difcult to locate because of difculty in the radiographic identication of porion and orbitale. A corrected Frankfort horizontal plane to correlate the
cephalometric values for maxillary and mandibular AP
positions with the clinical impression provides a cephalometric analysis that assists in diagnosis and treatment
planning (. Fig. 23.14). Cephalometric analysis tempered with good clinical judgment can be a valuable tool
in establishing the most appropriate orthodontic and
surgical treatment plan.
23.2.5 Cephalometric Analysis
Many reasonable cephalometric analyses are available
for clinical decision-making [25]. The author uses an
analysis that evaluates 14 cephalometric relationships.
This analysis permits a rapid diagnostic assessment as
follows:
1. Maxillary depth: The angle formed by the Frankfort
horizontal plane and a line from nasion through
point A (NA line). The normal value is 90 ± 3
degrees (.
Fig.23.15, angle A).
2. Mandibular depth: The angle formed by the
Frankfort horizontal plane and a line from nasion
through point B of the mandible (NB line). The normal value is 88±3 degrees (. Fig.23.15, angle B).
3. Mandibular plane angle: The angle formed by the
Frankfort horizontal plane and a line from the menton through the gonion. The normal value is 25±5
degrees (. Fig.23.15, angle C).
4. Occlusal plane angle: The angle formed by the
Frankfort horizontal plane and a line drawn tangent to the buccal groove of the mandibular second
molars through the cusp tips of the premolars. The
normal value is 8 ± 4 degrees. The occlusal plane
has signicant inuence on function and aesthetics,
particularly when double jaw surgery is performed
(. Fig.23.15 angle D).
5. Aesthetic line (. Fig.23.15, red E and line): A line
tangent to the labial surface of the maxillary central
incisors extended vertically to cross the Frankfort
horizontal plane and should form a 90 degree angle
when ideally aligned. This places the central incisor
crown in the best aesthetic position.
6. Upper incisor angle: The angle formed by the long
axis of the maxillary incisor to the NA line. The
normal value is 22±2 degrees. The labial surface of
the incisor tip should be 4±2mm anterior to the
NA line. Upper incisor angulation is important in
establishing the presurgical orthodontic goals
Fig.23.16, angle A and linear line B).
(.
7. The lower incisor angle: The angle formed by the
long axis of the mandibular incisor to the NB line.
The normal value is 20±2 degrees. The labial sur-
Clinical, Occlusal, andCephalometric Analyses oftheOSA Patient
353
23
. Fig. 23.15 A normal maxillary depth (A) is 90±3 degrees. The
normal mandibular depth (B) is 88±3 degrees. The normal mandibular plane angle to Frankfort horizontal plane (C) is 25 ± 5
degrees. The normal occlusal plane angle (D) is 8±4 degrees. The
normal aesthetic line (red E and line) is constructed tangent to the
labial surface of the maxillary central incisors and should create a
90±2 degrees angle with Frankfort horizontal plane for best aesthetic positioning of the maxillary central incisors
face of the incisor tip should be 4±2mm anterior
to the NB line. Assessment of the lower incisor
angulation is important in determining the presurgical orthodontic goals (. Fig.23.16, angle C and
linear line D).
8. Pogonion projection: The distance from the most
protrusive point of bony pogonion to the NB line.
The normal value is 4±2mm. Optimal mandibular
dentoskeletal balance is achieved when the labial
surface of the lower incisors and pogonion are in a
1:1 ratio anterior to the NB line (. Fig.23.16 linear line E).
9. Upper lip length: The distance from the base of the
nose (subnasale) to the inferior part of the upper lip
(upper lip stomion). The normal length of an adult
male lip is 22±2mm. For a female, it is 20±2mm.
Upper lip length is the basis for establishing vertical
facial dimensions in the lower third of the face
because the upper lip length usually is not altered
easily. This measurement is the basis for establish-
. Fig. 23.16 The long axis from the upper incisor to the NA line
(A) has a normal value of 22±2 degrees. The labial surface of the
upper incisor (B) should be 4± 2mm anterior to the NA line. The
long axis of the lower incisor to the NB line (C) has a normal value
of 20±2 degrees. The labial surface of the mandibular central incisors (D) should be 4±2 mm anterior to the NB line. Hard tissue
pogonion (E) should be 4±2mm anterior to the NB line with a 1:1
ratio, with the position of the labial surface of the mandibular central incisors anterior to the NB line
ing the vertical length of the lower two-thirds of the
lower third of the face (. Fig.23.17, distance A).
10. Upper tooth-to-lip relationship: The distance from
the relaxed upper lip stomion to the incisal edge of
the upper incisor. The normal value is 2.5±1.5mm.
This evaluation is important in establishing the vertical dimensions of the face, particularly when there
are vertical dysplasias present in the maxilla
Fig.23.17, distance B).
(.
11. Lower anterior dental height: The distance from the
lower incisor tip to hard tissue menton. The lower
anterior dental height for a male is 44±2mm, and for
a female is 40 ± 2 mm. For optimal balance in the
lower third of the face, the lower anterior dental
height should be approximately twice the upper lip
length. If the upper lip is longer than normal, then the
lower anterior dental height should be longer than
normal so that the facial dimensions will be balanced
in the lower facial third (. Fig.23.17, distance C).
354
L. Wolford
. Fig. 23.18 The oropharyngeal airway is measured from the pos-
terior pharyngeal wall to the soft palate, and from the posterior pharyngeal wall to the posterior base of the tongue. The normal value
for both areas is 11±2mm
23
. Fig. 23.17 Normal upper lip length (A) for a male is 22±2mm
and for females is 20±2mm. Normal tooth-to-lip relationship (B) is
2.5±1.5mm. The lower anterior dental height (C) is measured from
the mandibular central incisor tips to hard tissue menton. It has a
normal value of 44±2mm in males and 40±2mm in females. An
important interrelationship is two times the upper lip length should
equal the lower anterior dental height. The soft tissue thickness of
the upper lip, lower lip, and chin area (D) usually ranges from 11 to
14mm, but more importantly should be a 1:1:1 ratio. The soft tissue
thickness in the menton area (E) is normally 7±2mm
12. Soft tissue thickness: The thickness of the upper lip,
lower lip, and chin area normally ranges from 11 to
14mm. More importantly, there should be a 1:1:1
ratio. Variations in this ratio may inuence treatment planning decisions regarding the lips and chin
(. Fig.23.17, distance D).
13. Soft tissue thickness of menton: The distance measured perpendicular to Frankfort horizontal plane
from hard tissue menton to soft tissue menton. The
normal dimension is 7±2mm. Excessive thickness
or thinness of this area may inuence alterations in
the height of the anterior mandible (. Fig.23.17,
distance E).
14. Oropharyngeal airway: The oropharyngeal airway
is measured from the posterior pharyngeal wall to
the posterior aspect of the soft palate and from the
posterior pharyngeal wall to the base of the tongue.
The normal dimension for both of these areas is
11±2mm (. Fig.23.18).
23.3 Dental Model Analysis
Dental model analysis is important in establishing
proper diagnoses and treatment goals, particularly in
reference to orthodontics. Proper dental model analysis
improves the understanding and development of the
presurgical orthodontic goals. Nine basic dental model
evaluations to make are as follows:
1. Arch length measurements
2. Tooth size analysis
3. Crowding, spaces
4. Tooth position
5. Arch width analysis
6. Curve of occlusion (curve of Spee)
7. Cuspid-molar position
8. Tooth arch symmetry
9. Buccal tooth tipping (curve of Wilson)
10. Missing, broken down, or crowned teeth
23.3.1 Arch Length Measurements
Arch length measurements should correlate the widths
of the teeth relative to the amount of alveolar bone
available. The evaluation of arch length and cumulative
dental width helps to identify the presence or absence of
crowding or spacing. This evaluation helps to determine
whether teeth need to be extracted, spaces need to be
created, or spaces need to be closed (. Fig.23.19).
Clinical, Occlusal, andCephalometric Analyses oftheOSA Patient
355
23
. Fig. 23.19 The arch length evaluation correlates the widths of
the teeth in relation to the amount of alveolar bone available. It also
helps in determining whether extractions are indicated and what specic orthodontic mechanics may be necessary to align the teeth
properly
Orthodontic treatment can contribute to sleep apnea,
particularly if bicuspid teeth are extracted to facilitate
alignment of the teeth. To this day, some orthodontists
continue to routinely extract bicuspid teeth, use headgear, or other mechanical methods of retraction to
retrude the maxilla and maxillary teeth to t with a
retruded mandible, decreasing the oral cavity volume,
displacing the tongue posteriorly, and contributing to
the development of sleep apnea. Unfortunately, the
sleep apnea symptoms do not surface until many years
later. Sometimes the orthodontics needs to be totally
reversed so that the bicuspid spaces are reopened to
improve the size of the oral cavity to better accommodate the tongue and to provide better functional and
aesthetic alignment of the teeth, with the best results
coupled with orthognathic surgery when indicated.
23.3.2 Tooth Size Analysis
Tooth size analysis relates the relationship of the mesiodistal width of the upper teeth compared with that of the
lower teeth. Although tooth size discrepancies can occur
in the premolar and molar areas, this analysis is used primarily in relation to the anterior six maxillary and mandibular teeth. Many patients with dentofacial deformities
have anterior tooth size discrepancies, often with a
decreased maxillary tooth width (most commonly attributable to small lateral incisors) in relation to the mandibular teeth. In such cases, proper tooth alignment with all
spaces closed often precludes the establishment of a good
Class I cuspid relationship. Instead, an end-on or slight
. Fig. 23.20 A tooth size analysis evaluates the combined widths
of the six mandibular anterior teeth in relation to the widths of the
six maxillary anterior teeth. Measurements are made at the widest
mesial-distal dimension of the crown. Evaluation of the tooth size
compatibility is necessary so that appropriate orthodontic treatment
can be used to correct the problem before surgery. Needlepoint calipers are helpful in this assessment
Class II cuspid-molar occlusal relationship often results.
Bolton’s analysis is a method of correlating the widths of
the upper and lower anterior six teeth. Tooth size discrepancy between the anterior maxillary and mandibular
teeth is determined by direct measurements of the anterior teeth. Needlepoint calipers (.
Fig.23.20) and a tab-
let make for an easy method of calculation. (1) Measure
anterior six teeth in each arch at the widest dimension of
the crowns and punch holes in a tablet for each tooth for
each arch (. Fig.23.21). (2) Measure the length of each
arch to determine the actual arch lengths. (3) Multiply the
lower arch length × 1.3. This provides the calculated
upper arch length, or the length the upper anterior arch
should be to t the lower arch with a normal overbite,
overjet, and a Class I cuspid relationship. (4) Subtract the
actual upper arch length from the calculated arch length
to determine the tooth-size discrepancy. Usually, the
lower teeth are relatively larger than the upper teeth, commonly related to small upper lateral incisors. Tooth size
discrepancies also can occur in the premolar and molar
areas, where the maxillary and mandibular teeth should
be approximately the same mesiodistal width. The management of tooth size discrepancies is important to
achieve the best occlusal relationship. Tooth size discrepancies can be managed by alterations on the lower anterior teeth by changing position or slenderizing the teeth.
Alternatively or in combination, the upper dental arch
can be adjusted, commonly by creating space in the arch
around the lateral incisors, requiring subsequent buildup
of the lateral incisors with bonding, veneers, or crowns.
356
L. Wolford
. Fig. 23.21 Tooth size discrepancy between the anterior maxil-
lary and mandibular teeth is determined by direct measurements of
the anterior teeth. Needle point calipers and a tablet make for an
easy method of calculation. (1) Measure anterior six teeth in each
arch and punch holes in a tablet for each tooth for each arch. (2)
Measure length of each arch to determine the actual arch lengths. (3)
Multiply the lower arch length × 1.3. This provides the calculated
upper arch length, or the length the upper anterior arch should be to
t the lower arch with a normal overbite, overjet, and a Class I cuspid relationship. (4) Subtract the actual upper arch length from the
calculated arch width to determine the tooth-size discrepancy
23.3.3 Tooth Position
Tooth position in the context of orthognathic analysis
refers primarily to the angulation of the maxillary and
mandibular incisors in relation to the basal bone. The dental models are correlated with the cephalometric evaluation (. Fig.23.16), and the ideal axial inclination of the
incisors is determined. The tooth position analysis determines whether extractions are necessary, spaces need to be
created or eliminated, and what mechanics are needed to
align and level the arches or segments of the arches.
23.3.4 Arch Width Analysis
molar relationship, then position the models in a Class I
cuspid-molar relation and evaluate the transverse relationship. Likewise, evaluate a skeletal Class II patient in
a Class II cuspid-molar relationship by positioning the
models into a Class I cuspid-molar relationship.
Consider evaluating the transverse relationship by placing the models into a Class II molar position to determine whether a Class I cuspid and a Class II molar
relationship would be best for that particular patient.
Arch width analysis is helpful in determining presurgical
orthodontic mechanics and contributes to the selection
of the appropriate surgical procedures.
23.3.5 Curve ofOcclusion (Curve ofSpee)
The curve of occlusion has signicant inuence on whether
the curve of occlusion in the arches is corrected orthodontically, whether extractions are necessary, or whether surgical intervention is indicated to level the occlusal plane. If
an accentuated curve of occlusion in the lower arch is leveled orthodontically, the lower incisors will move anteriorly approximately 1mm for every vertical millimeter of
leveling required (.
Fig. 23.22a). After about 2 mm of
leveling the lower arch by intrusion of the lower incisors,
the orthodontics become less stable. Correcting a reverse
curve of occlusion, particularly in the lower arch, by
extruding the incisors may not provide a stable result. To
correct a reverse curve, surgical leveling of the arches may
be preferred. Surgical leveling may be achieved by subapical osteotomies or bilateral body osteotomies in the mandible or a segmental procedure in the maxilla.
In the maxillary arch, an accentuated curve of occlu-
sion (. Fig.23.22b) when relatively minor, can be corrected orthodontically, but with signicant accentuation,
may be best correct surgically. Orthodontic extrusion of
teeth may not be stable with a tendency for postsurgery
orthodontic relapse. Segmental alignment of the maxillary arch with a major curve of Spee and surgical correction will provide a more predictable outcome. Severe
reverse curves of Spee likewise may have limitations as
to orthodontic correction and subsequent stability.
Assessment of the curve of Spee and understanding
limitations orthodontically and surgically, will help formulate a stable treatment plan.
23
Arch width analysis refers to the evaluation of the
intraarch widths between the maxilla and the mandible.
Arch width is best analyzed by holding the dental models in the occlusal position that is to be achieved with the
orthodontic and surgical correction and then assessing
the transverse relationship. For example, if a patient has
a true skeletal Class III occlusion with a Class III cuspid-
23.3.6 Cuspid-Molar Position
The cuspid-molar position dictates the occlusal functions. A Class I cuspid-molar relationship usually is
preferable; however, a Class II molar relationship is
acceptable. A Class III molar relationship is less desirable, but it may be indicated in some cases.
Clinical, Occlusal, andCephalometric Analyses oftheOSA Patient
357
ab
23
. Fig. 23.22 a An accentuated curve of occlusion is seen in the
mandibular arch, with midbuccal teeth being several millimeters
below a line tangent to the incisors and second molars. For every
millimeter of vertical leveling, the lower anterior teeth will come forward approximately 1 mm. b In the maxillary arch, the incisors
23.3.7 Tooth Arch Symmetry
Tooth arch symmetry compares the left to right symmetry within each arch. A signicant asymmetry may be
present within the arch, such as a cuspid on one side
being more anteriorly positioned than the cuspid on the
opposite side. This problem often occurs when one side
of the arch is missing a tooth. Correction may require
special orthodontic mechanics, unilateral extraction, or
additional surgical procedures.
23.3.8 Buccal Tooth Tipping (Curve
ofWilson)
Buccal tooth tipping evaluates the position of the occlusal surfaces of the maxillary posterior teeth in a mediallateral direction (. Fig.23.23). If the occlusal surfaces
of the maxillary posterior teeth are tipped buccally, it
may be difcult to achieve a proper occlusal relationship.
In the presence of a transverse maxillary deciency with
preexisting buccal tipping, such tipping is even more difcult to correct orthodontically, orthopedically, or even
with surgically assisted orthopedic expansion. The buccal tipping usually worsens with these mechanics. Even
with surgically assisted rapid palatal expansion, the palate only expands approximately one-third of the amount
of the expansion that occurs at the occlusal level, thus
increasing the curve of Wilson. Surgical expansion is
usually advantageous because the palate can be expanded
by a greater amount than the occlusal level if indicated,
thus decreasing the curve of Wilson, and segments of the
maxilla can be repositioned in all three planes of space.
should be about 1mm above a at plane with the posterior teeth on
that at plane. The degree of accentuated or reverse curve of occlusion will help dictate the orthodontic and surgical procedures necessary to achieve predictable treatment outcomes
. Fig. 23.23 The maxillary dental model is being evaluated from a
posterior view, showing signicant buccal tipping (increased curve of
Wilson), with the palatal cusp tips being signicantly lower than the
buccal cusps. With an increased curve of Wilson in the presence of a
transverse maxillary hypoplasia, orthodontic, orthopedic, and surgically assisted maxillary expansion will result in further increase of
the curve of Wilson. Surgical expansion may be more predictable, as
the arch can be expanded and curve of Wilson decreased by expanding the palate a greater amount than at the occlusion
23.3.9 Missing, Broken Down, or Crowned
Teeth
Missing, broken down, or crowned teeth may inuence
treatment design. If a tooth is not restorable and requires
extraction in a potential osteotomy location, the extraction space may need to be closed orthodontically or the
space maintained. In some cases, it may be helpful to
maintain the tooth to improve stability during surgical
alignment of the jaws or segments thereof, with removal
after surgery.
358
L. Wolford
23
23.3.10 Ankylosed Teeth
Ankylosis of teeth is the abnormal adherence of alveolar bone to dentin or Cementum. The periodontal ligament and cementum on the root surface are resorbed by
macrophages and osteoclastic cells, and new bone is
produced by osteoblasts on the root surface without formation of a normal periodontal ligament, rendering the
tooth non-movable with orthodontic mechanics. If an
ankylosed tooth does not respond to orthodontic forces,
surgical procedures may be indicated to facilitate movement of the tooth to the correct position. This could
include subluxation of the tooth, segmental osteotomy,
or extraction [26, 27].
23.4 Summary
OSA patients commonly have associated dentofacial
deformities affecting the functional airway. This chapter
was designed to illustrate a systematic method to evaluate dentofacial deformities, develop a comprehensive
diagnosis, and establish an encompassing treatment
plan. Primary factors contributing to sleep apnea are
the following: (1) decreased oropharyngeal airway, (2)
nasal airway obstruction, and (3) mandibular and maxillary hypoplasia. The normal A-P dimension from the
posterior pharyngeal wall to the soft palate and posterior pharyngeal wall to the posterior base of the tongue
is 11±2mm. In patients who have a retruded maxilla
and mandible (very common in OSA patients), this airway may be signicantly decreased. Accompanying
these skeletal deciencies is usually a high occlusal plane
angle facial morphology. A normal occlusal plane to the
Frankfort horizontal plane is 8± 4 degrees, but in the
OSA patient with a retruded maxilla and mandible, the
occlusal plane can be signicantly increased making it
more challenging for many surgeons to correct and open
the oropharyngeal airway. There is a triad of factors
that commonly go together in OSA patients, and they
include the following: (1) a high occlusal plane angle
facial morphology with associated retruded maxilla and
mandible, (2) nasal airway obstruction related to hypertrophied turbinates and/or nasal septal deviation or
spurring, and (3) TMJ pathology. TMJ pathology, particularly involving condylar resorption, is a common
etiology for mandibular and maxillary retrusion, contributing to OSA.When TMJ issues are involved, the
TMJ pathology must be addressed in order to provide
stable treatment outcomes, decrease, or eliminate TMJ
and myofascial pain as well as TMJ-related headaches
and other associated symptoms. Patients with the high
occlusal plane angle facial morphology with a retruded
maxilla and mandible should always be assessed for
nasal airway obstruction, decreased oropharyngeal airway, and TMJ pathology. Proper diagnosis and treatment planning can result in highly predictable and
stable, functional, and aesthetic outcomes. This chapter
reviewed the basic protocols for assessment of the OSA
patient for diagnosis and treatment planning.
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MRI Evaluation forPatients
withTMJ Disorders and
Obstructive Sleep Apnea
LarryWolford
Contents
24.1 TMJ Articular Disc Displacement – 363
24.1.1 Silent TMJ withDisc Displacement – 364
24.1.2 Criteria forArticular Disc Repositioning withtheMitek Anchor
Technique – 368
24.1.3 Implications fortheOSA Patient – 368
361
24
24.2 Adolescent Internal Condylar Resorption (AICR) – 369
24.2.1 Implications fortheOSA Patient – 369
24.3 Reactive Arthritis (ReA) – 370
24.3.1 Implications for the OSA Patient – 370
24.4 Connective Tissue andAutoimmune Diseases (CT/AI) – 371
24.4.1 Implications fortheOSA Patient – 372
24.5 Trauma – 372
24.5.1 Implications fortheOSA Patient – 372
24.6 TMJ Ankylosis – 374
24.6.1 Implications fortheOSA Patient – 374
24.7 Other End-Stage TMJ Conditions – 376
24.8 Summary – 376
References – 376
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_24