Symptoms of obstructive sleep apnea (OSA) typically begin insidiously and are often present for years before the patient seeks medical treatment. Nocturnal symptoms can include loud, habitual snoring that is bothersome to others. People who sleep in proximity with a patient with OSA may witness interrupted breathing during snoring episodes, often ending with a snort or gasp for air. These gasping and choking sensations may arouse the patient from sleep, though the incidence of waking up is generally very low in proportion to the number of apnea events they experience.
Daytime symptoms often present as patients complain of waking up just as tired as when they went to bed, which is known as nonrestorative sleep. Patients may also report symptoms of morning headache, dry/sore throat, gastroesophageal reflux, excessive daytime sleepiness, fatigue/tiredness, impaired memory, hypertension, and morning confusion.
The goal of OSA treatment is to reduce the patient’s apnea-hypopnea index (AHI). AHI is an index used to indicate the severity of sleep apnea and measure the number of apnea or hypopnea events per hour. Other positive outcomes of treatment include increasing the patient’s blood oxygen levels and improving cardiorespiratory indicators.
In July 2019, a 65-year-old man presented to our clinic with a chief complaint of chronic snoring. His body mass index was 32.8 and neck circumference measured 17.8 inches. He takes omeprazole as needed for gastroesophageal reflux disease and was recently diagnosed with type 2 diabetes, for which his primary care physician prescribed metformin. The patient reported that he has snored for as long as he can remember and has felt tired “for decades.” The patient did not wear any oral device or nightguard during sleep.
The patient completed an oximetry study with the primary care physician in October 2018 that showed an oxygen desaturation index of 13.5 and an SpO2 nadir, or lowest oxygen saturation level, of 78%. An in-lab sleep study polysomnography test was completed on November 29, 2018. The sleep study results revealed an AHI of 52 with continuous positive airway pressure (CPAP) titration started after 2 hours of sleep. During CPAP, the patient had onset of central OSA with an AHI of 19.5. With the use of a bilevel positive airway pressure (BiPAP) device, the patient was able to control an AHI of 1.8. However, the patient did not want to be tethered to a BiPAP device all night, stating, “I’d rather just leave the sleep apnea untreated than try to use that.”
A MATRx™ plus theranostic study from Zephyr Sleep Technologies was performed and showed the patient would be a good responder at 5.5 mm of advancement. A Medit i500 intraoral scanner was used to capture scans of the patient’s mouth and upper and lower arches in 2 bite positions: a maximum intercuspation and an open bite position (Figures 1-4). The scans captured by the Medit i500 were used to design and 3D print a custom SomnoDent Avant™ oral appliance specifically designed to treat this degree of obstructive sleep apnea.
The Medit i500 allowed easy and accurate capture of the full arch scans in multiple bite positions. Accuracy of these scans is an absolute must. The Medit i500 is an open-source device, allowing easy export of the scan data into the sleep aligner design platform for custom morning aligners and 3D printing of the oral sleep appliance directly in the office. For offices without a 3D printer, the scan data may be sent to a lab for appliance fabrication via the accompanying case and workflow management platform Medit Link. The accuracy of the Medit i500 scans and detailed digital designs and manufacturing by SomnoMed allows the delivery of the appliance with zero adjustments.
Closed bite scan of upper and lower arches for use in producing the SomnoMed appliance.
Open mouth scan of upper and lower arches.
Closed bite scans of the left, central and right facial profile views, as well as upper and lower arch occlusal surface scans.
Open bite scans of the left, central, and right facial profile views, as well as upper and lower arch occlusal surface scans.
Clinical Outcome and Discussion
The patient experienced excellent results with the use of SomnoMed oral sleep appliance, having completed an at-home sleep apnea test in January 2020 with an overall AHI of 7. The objective of this case was to remove the patient from the severe obstructive sleep apnea category (AHI of above 30), which has an extremely high correlation with heart attack and stroke. A successful case for this severity is considered a 50% reduction in AHI and a final AHI below 20. In this case, the patient started with an AHI of 52, and after treatment with the oral appliance, his final AHI was reduced to 7, which is considered an extremely successful result. The patient reports restful sleep for the first time in decades, is dreaming more than ever, and has lost 10 pounds since beginning therapy