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A Gephalometric Study of the Maxillofacial Structure In A Gephalometric Study of the Maxillofacial Structure in Obstructive Sleep Apnoea David Sherring B.D.S. (Syd) Oral and Maxillofacial Surgery Faculty of Health Sciences The UnÍversity of Adelaide South Australia 2001 Table of Contents A CEPHALOMETRIC STTJDY OF THE MAXILLOFACIAL STRUCTIJRE IN OBSTRUCTIVE SLEEP APNOEA .....................I SIJMMARY VIII ACKNOIVLEDGEMENTS............... XII xrII CHAPTER 1 I SLEEP I 1.1 INTRODUCTION .2 I.2 NORMAL SLEEP .3 l.3 Clnssl¡lcATIoN oF SleEp Drsonnens .6 1.4 Polvsorr¡NOGRApHy ..... ll 1.5 OBSTRUCITve SLeep ApNos¡. Syr.¡onoue 17 22 COMPLICATIONS OF OBSTRUCTIVE SLEEP APNOEA.... ............22 2.l lNrRooucrron 23 2.2 C,qn¡TovASCULAR CHnNcrs rN OesrnucrrvE Sr-¡¡p ApNoEA 23 2.3 Resprnerony CH¡,NcEs rN OssrnucrrvE SLEEp ApNoee 26 2.4 HYPERSOMNOLENCE., 27 2.5 ENDOCRTNE DISORDERS 30 2.6 Ngunoloclc CovpllcArroNs .. 3l 34 IMAGING OF THE UPPER AIRWAY... 34 3.1 ANnrouY oF THE UppenAlnwey .. 35 3.1 .I Nose.... 35 3. I . 2 Nasopharynx........... 36 3 1.3 Oropharynx ..........., 37 3. I .4 Hypopharynx .......... 38 3.2 Drn-Ecr VrsueLlserloN . 40 3.3 N¡s¡Nooscopy............. 44 3.4 MnNovarRy .............. 45 3.5 SovrNopl-uoRoscopy. 47 3.6 CT ANDMRI 41 3.7 LnrEncL CepHRLorr¿Erny..... 49 57 ERRORS IN LATERAL CEPHALOMETRY.. ...................57 4.1 lNrRonucrloN 58 4.2 Ennons oF PRoJECTroN... 59 4.3 Ennons o¡ L¡.Novnnx loENrrprcRrloN ................ 60 4.4 ERRoRS oF DrcrrrzrNc 62 4.5 ERRORS oF MEASURTMENT 62 4.5.1 The Co-fficient of Reliability 64 4. 5.2 Confidence Limits.... 64 4.6 INrnq-oesERVER AND INTER-oBSERVER VRnrRsrr-lry 65 66 LATERAL CEPHALOMETRIC EXAMINATION OF THE UPPER AIRWAY-HARI) 5.I INTRODUCTION 67 5.2 Cn¡¡¡nrBas¡ 67 5.3 M¡,xu-r-¡. 72 5.4 MANDIBLE 77 5.5 MAXILLÀ RNo MI¡¡o¡gLE INTER-RELATIONSHIP 84 5.6 FACIAL HEIGHT 88 5.9 Cenvrcnl Spru¡ ....... 100 LATERAL CEPHALOMETRIC EXAMINATION OF THE UPPER AIRWAY _ SOFT TISSTJE ........103 6. I lNrnooucrroN ............... 104 6.2 Sopr P¡.r¡.r¡ 106 6.3 Towcll¡ lll 6.4 Hvoln BoN¡ tt7 6.5 NASoPHARYNGEAL ATRwAY t23 6.6 OnopHnnvNc¡¡.1 Arnwev.. t27 6.7 HYPoPHARYNGEAL AlRwRv l3l NON-SURGICAL MANAGEMENT OF OBSTRUCTIVE SLEEP APNOEA... ....I34 7.I INTRODUCTION 135 7,2 V/EIGHT LOSS 136 7.3 PHARMACOLOGY .. 137 7.4 Nnsnl CoNrnquous PosrrrvE ArRwAy PR¡ssuR-e.. 138 7.5 M,qNorsULAR REposrrroNrNG AppLTANCES r4t 7.5.1 Protocolfor Dental Appliance Therapy 146 7.5.2 Comparison of Dental Appliances and nCPAP. 147 7.5.3 Side Effects of Dental Appliances.......... t48 CHAPTER 8 151 SURGICALMANAGEMENTOFOBSTRUCTIVESLEEPAPNOEA... ..............151 8. I I¡lrRooucrroN .......... 152 8.2 Tn¡cseosroMY 153 8.3 Nes,cl Sunce nv......... 153 8.4 Uvulop¡LATopHARyNGopLASTy.... 155 8.5 ToNcue REDUCTToN SURGERY 158 8.6 Hyolo SuspENsloN ..........158 8.7 GENr,cL ADVANCEMENT ............. 159 8.8 M¡.NoteulRR AovRNcEMENT 159 8.9 BtvnxrlrARY ADVANCEMENT 160 168 MATERIALS AND METHODS 168 9.1 SEr-¡crEo PATTENTS 169 9.2 RADrocRApurc TEcsNleuE........... 170 9.3 Tnncnc AND Dtctrrzlruc PnoceouRE................. 170 9.4 R¡r¡n¡NcE Porurs AND LINES... t7t 9.4.1 Hard Tissue Points ldentified on a Lateral Cephalometric Radiograph......... l7t 9.4.2 Soft Tissue Points ldentifed on a Lateral Cephalometric Radiograph........... 174 9.5 CnlcumrroN oF Ln¡E¡.n R¡¡n ANGULAR VARIABLES 177 ll 9. 5. I Constructed Linear Variables 177 9. 5. 2 Constructed Angular Variables ... r80 9.6 Sr¡,nsrrcAt- ANALYSTS 182 CHAPTER 10 r83 ERRORS OF THE METHOD r83 1O.I MATERIALS AND METHODS 184 187 RESUL r87 I 1.1 I¡¡rnooucrlo¡l 188 I1.2 LrruE¡.n VARTABLE Resulrs 190 I l 3 ANcur-eR VRnregle R¡sulrs 191 11.4 SlcNlprc¡Nr CoRn¡r-ATtoNS Wrru RDI 191 11.4.1 Bocly Mass Index (BMI)........ 192 I 1.4.2 Minimum Arterial Oxygen Saturation (SaO) 193 I 1.4.3 Neck Circumference (NC) 194 I 1.4.4 Distancefrom Hyoid to the Fourth Cervical Vertebra (H - C4) 195 I1.4.5 Distancefrom Hyoid to the Third Cervical Vertebra (H - C3).. t96 I 1.4.6 Distancefrom the Mandibular Plane to Hyoíd (MP - H) t97 I L4.7 Pharyngeal Length (PNS - Eb).................... 198 I1.5 Srcr.rmlcANT CoRRELATToNS wrrH BMI.... 199 1 1.5.1 Minimum Arterial Oxygen Saturation (SaO) 200 I1.5.2 Neck Circumference (NC) 201 I I .5.3 Angle Sella - Nasion - Subnasale (SNA) 202 I 1.5.4 Angle Sella - Nasion - Supramentale (SNB)..... 203 1 l .5.5 Upper Incisal Angulation (Ul - SN/. .. 204 I 1.5.6 Distancefrom Hyoid to the Fourth Ceruical Vertebra (H - C4) 205 I I .5 .7 Distance from Hyoid to the Third Cervical Vertebra (H - C3) .. 206 I 1.5.8 Distancefrom Hyoid to Menton (H - Me) 207 I 1.6 GRoup Dr¡n¡nrNc¡s Wrru Cur-oFF RDI l0 208 208 209 1l 6.3 Body Mass Index (BMI). 209 il 6.4 Minimum Arterial Oxygen Saturation (SaO) 209 t1 6.5 N e c k Circnnfer en c e (N C) 209 II 6.6 Distance Hyoid to Fourth Certtical Vertebra (H - C4).. 2t0 H 6.7 Dístance Hyoid to Third Certtical Vertebra (H - C3) .... 2t0 u 6.8 Distance Sella to Hyoid (S- H) ... .. 2t0 I L6.9 Soft Palate Thickness (UI'Yl - UW2) 2t0 t1 6.10 Distance Articulare to Hyoid (Ar - H) 210 tl 6.11 Maxillary Length (MxUL) 211 t1 6.t2 Distance Mandibular Plane to Hyoid (MP - H) . 2tl 11 6.t3 Distance Gonion to H1,oid (Go - H)...... 211 II 6.r4 Hyoid Angle (<H - Hl). 211 I] 6.t 5 Pharyngeal Length (VAL). ........ 211 1 1.7 Gnoup DTFFERENCES wrrH cur-oFF RDI l5 11 7 I Sex............ tl 7 2 Age............. ............... ................................................ I1 7 j Body Mass Index (8M0........-. I1 7 4 Minimum Arterictl Oxygen Saturation (SaO) 11 7 5 Neck Circumference (NC) 1t 7 6 Distance Hyoid to Fourth Cervical Vertebra (H - C4). tl 7 7 Distance Hyoid to Third Certtical Vertebra (H - C3) ... I 1.7.8 Pharyngeal Length (VAL)........... I 1.7.9 Distance Sella to Hyoid (S - H) 1 I .7.10 Tongue Length (TGL) ........... I 1.7.1 1 Soft Palate Thickness (UI'yl - UW2)............... 11r I1.7.12 Hyoid Angle (<H - Hl) 2t5 I 1.7.13 Distance Mandibular Plane to Hyoid (MP - H) 2t6 11.7.14 Angle Between Hyoid and Mandibular Plane (<Go - Gn - H) 2t6 I 1.7. 1 5 Tongue Length (TT - Et) 2t6 1I.8 GRoI-rP DIFFERENCES WITH CI.II-OFFRDI 20...... 217 I1.8.1 Body Mass Index (BMI)........... 2t8 I1.8.2 Minimum Arterial Orygen Saturation (SaO) 2t8 I 1.8.3 Neck Circumference (NC) 2t8 I1.8.4 Soft Palate Thickness (UIYI - UW2)........ 218 I 1.8. 5 Pharyngeal Length (VAL)........... 2t8 ) 1.8.6 Tongue Length gGL)........... 218 I 1.8.7 Tongue Length gf - Et) 2t9 I 1.8.8 Upper Incisal Angle (UI - SN) 2r9 I1.8.9 Distqnce Uvula Tip to Posterior Pharyngeal lltall (UT - PhWl) ... 2t9 1 1.9 M,q.xII-ARY AND MANDIBULAR ANTERO-POSTERIOR POSITION 220 I2.I PnrIeNr SeIgcnOu AND ORGANISATIONAL ISSUES 237 12.2 Mereru¡LS AND METHODS ...................240 12.3 Crurenre FoR DIAGNoSIS oF OBSTRUCTIVE SLEep Aprqoel 242 I2.4 DIFFERENCES IN LATERAL CEpURL0IT,IETRIC RADIOGRAPH MEASURES BFTW¡EN SNOR-ENS NNO OSA Su8JECrs................ ........243 12.4.I Soft Palate ........ ... 244 I 2. 4. 2 Nasopharynx..... 246 I 2.4. 3 Oropharynr ......... 250 I 2.4.4 Tongue............... -. 251 I 2.4. 5 Hyoid Bone.......... 255 12.4.6 Maxilla... 260 I 2.4.7 Mandib\e.................. 263 I 2. 4.8 Mafilla and M andible Inter-Relations hip 268 1 2. 4. 9 Cranial me as uremenls. -. -..................... 273 I 2.4. I 0 Dental Measurements 276 12.4.11 Conclusion... 278 12.5 CEPHALOMETRY AS AN IMAGING MODALITY FOR OSA 280 I 2.6 IMPLICATIONS FoR TREATMENT oF OS4........ 284 I2.7 PUBLIC HEALTH IsSuaS RELATED TO OS4....... 286 288 288 290 APPENDIX 303 BIBLIOGRAPHY 305 List of Figures FIGURE I.4-I PATIENT UNDERGOING POLYSOMNOGR.A,PHY l3 FIcun-a I.4-2 SAMPLE SLEEP STUDY DATA..,......... l5 FTGURE 2.3- I OxvrnEMOGLOBIN DISSOCIATION CURVE ......... 27 FTGURE 2.4-lEpwoRrH SLEEeTNESS QUESIoITNAIRE (ADAITED FRoM JoHNS, l99l) 29 FTGURE 3.2-1 Gnnonc oF rHE oRopHARyNX (nnrenMIIIAMPATI)....... 42 lv FIGURE 3.7- 1 LnrEN¡L CEP}IALOMETRIC RADIOGRAPH......... .50 FIGURE 5.2-I CRANIAL BASE CEPHALOMETRIC MEASURES .71 FIGURE 5.3-I MAXILLARY CEPHALOMETRIC MEASURES... .76 FIGURE 5.4- I MAN DIBULAR CEPHALOMETRIC MEASURES .,................ .83 FIGURE 5.5-I MNXILA AND MANIDIBLE INTER-RELATIONSHIP CEPFIALOMETRIC MEASURES................ .87 FIcunT 5.6-I F¡C¡AI HEIGHT CEPHALOMETRIC MEASURES .92 FIcunT 5.7-I: BONY PHARYNX CEPHALOMETRIC MEASURES .95 FIGURE 5.8-1 DENTIT]ON CEPHALOMETRIC MEASURES .99 FlcuRE 5.9-l CenvrcAI- sPINE cEPHALoMETRIC MEASURES t02 FIGURE 6. 1- 1 SOFT TISSUE CEPUNLOMETRIC MERSUNPUENTS 105 FrcuR¡ 6.2- I Sorr Pelqr¡ cEPHALoMETRIC MEASURES. ................. ll0 FIGTJRE 6.3-I TONGUE CEPHALOMETRIC MEASURES ll6 FrcuRE 6.4-l HyorD BoNe c¡pH¡,LoMETRIc MEASURES 122 Flcun¡ 6.5-l NnSopHARyNGEAL AInwev cEPHALoMETRIc MEASURES. 126 Frcun¡ 6.6-l OnopHARyNcEAL AIRwAY cEPHALoMETRIC MEASURES. 130 FTGURE 6.7-l HvpopHARYNGEAL AIRwAY cEPHALoMETRIc MEASURES. 133 FIcun¡ 7.4-ITITN¡TION OF NCPAP IN THE SLEEP LABORATORY 139 FrCun¡, 7.5-1 NON-IDJUSTABLE MeNonULRR REPOSITIONING APPLIANCE ....................................... 143 Flcun¡, 7.5-2 Ao¡usrABLE MANDTBULAR REPoslrloNING Appln¡qcr.. 144 FIGURE 9.4.I-I HARD TISSUE CEPHALOMETRIC LANDMARKS 173 FTGURT 9.4.2-2 Sont trssuE cEpHALoMETRIC LANDMARKS. 176 F lcun-e 9. 5. I - I LINEA R cEPHALoMETRIc MEASURES 179 Frcum 9.5.2-2 ANGULAR cEPHALoMETRIC MEASURES l8l Frcun¡ I 0.
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