Upper Airway, Cranial Morphology, and Sleep Apnea.pptx

Upper Airway, Cranial Morphology, and Sleep Apnea.pptx

1. Upper Airway, Cranial Morphology, and Sleep Apnea Graber

2. AIRWAY COMPLICATIONS HAVE FAR-REACHING EFFECTS When nasal obstruction occurs, the body is forced to breathe through the mouth and , the body adapts through extended head posture, anterior tongue position, and low mandibular position, more nasal voice, an open mouth, and pouting lips chronic obstruction in young children, these long-term adaptations can affect craniofacial growth. Angle included airway obstruction as an important etiologic factor in malocclusion, stating that “Of all the various causes of mal-occlusion mouth-breathing is the most potent, constant, and varied in its results.”

3. Moss’ functional matrix theory: nasal breathing allows the proper growth and development of the craniofacial complex. A narrow maxilla, hypotonia, and a small nose are consistent with Moss’ functional matrix theory, in which the lack of function (nasal breathing) creates a lack of area development

4. Adenoid facies ( long face syndrome): facial form can be influenced by enlarged adenoids craniofacial characteristics include: Extraoral: open-mouth posture, hypotonia, narrow base in the area of the ala of the nose, and a vacant facial expression Skeletal: increased lower facial height, high mandibular angle, narrow maxilla, high palate, mandibular retrognathia Dental: proclined maxillary incisors, display of more maxillary anterior teeth when at rest, incidence of caries is increased Soft tissue: upper lip’s muscular tonicity is lost, short and flaccid upper lip, proclined lower lip , gingival display is increased, incomplete keratinization of the gingiva, inflammation, hyperplasia, higher levels of plaque Habits: anterior tongue position, salivary flow to the area is decreased improvements may almost immediately occur after the removal of the obstruction

5. Nasal breathing significance nose is able to filter, warm, moisturize, and dehumidify air Small amounts of nitric oxide are made by the nose and sinus mucous membranes. Nitric oxide is lethal to bacteria and viruses and is also known to increase oxygen absorption in the lungs from 10% to 25%. it increases blood circulation and blood oxygen and carbon dioxide levels, slows the breathing rate, and improves overall lung volumes as a consequence to providing almost double the resistance than when breathing through the mouth. nasal resistance is crucial to maintain adequate elasticity of the lungs reports of hypoxemia (low levels of oxygen in the blood), hypercarbia (high levels of carbon dioxide in the blood), and hypoventilation after only 24 hours of nasal obstruction, forcing the individual to breathe through the mouth Adult mouth breathers: more likely to have sleep disorders and attention-deficit/hyperactivity disorder (ADHD)

6. OSA have high blood pressure as a result of overactivation of the sympathetic nervous system. Exaggerated negative intrathoracic pressure during OSA further increases left ventricular afterload, reduces cardiac output, and may promote the progression of heart failure. Intermittent hypoxia and postapneic reoxygenation cause vascular endothelial damage, which can progress to atherosclerosis and, to coronary artery disease and ischemic cardiomyopathy, Chronic OSA characteristics: apnea, hypoxia, and increased sympathetic nervous system activity and, when present in heart failure, is associated with increased risk of death.

7. ANATOMY AND GROWTH respiratory tract can be divided into: upper respiratory tract or upper airway (UA): nasal cavity, pharynx, and larynx lower respiratory tract or lower airway (LA):trachea, bronchi, and lungs Gray’s Anatomy classification, of pharyngeal airway: Nasopharynx: Located between the nares and hard palate. Oropharynx: Located from the soft palate to the upper border of the epiglottis. Velopharynx or retropalatal oropharynx is located between the soft palate and the posterior pharyngeal wall and is found within the oropharynx. Laryngopharynx or hypopharynx: Located from the base of the tongue to the inferior border of the cricoid cartilage.

8. Muscles surrounding the airway : actively constrict and dilate the UA lumen can be classified into four groups: Muscles regulating the position of the soft palate: ala nasi, tensor palatini, and levator palatine Tongue: genioglossus, geniohyoid, hyoglossus, and styloglossus Hyoid apparatus: hyoglossus, genioglossus, digastric, geniohyoid, and sternohyoid Posterolateral pharyngeal walls: palatoglossus and pharyngeal constrictors Pharyngeal soft tissues exhibited two periods of accelerated change (6–9 years and 12–15 years of age) and two periods of latency (9–12 years and 15–18 years of age) Mechanisms that increase the airway during the 12- to 15-year-old period are: increase in airway size from 6 to 9 years of age because of the continued growth of the pharyngeal region surgical removal of adenoid tissue natural involution of adenoid

9. Mean minimum cross-sectional area across multiple segments of the UA: 320 mm² (acoustic reflection) 59 mm² (fast computed tomography [CT] at functional residual capacity [FRC]) 64 mm² (magnetic resonance imaging [MRI]) 144 mm² , 188 mm² , and 138 mm² (conventional CT) Wide range of sizes reflects: differences attributable to individual variability differing locations of measurement, positional change (sitting or supine), and differences imposed by the choice of imaging modality (e.g., mouth open is required for acoustic reflection) minimum caliber of the UA in the wake state is in the velopharynx, the potential location of collapse during sleep

10. anterior wall of the oropharynx comprises: the soft palate, tongue, and lingual tonsils posterior wall is bounded by a muscular wall made up of the superior, middle, and inferior constrictor muscles that lie in front of the cervical spine. lateral pharyngeal walls are made up of muscles (hyoglossus, styloglossus, stylohyoid, stylopharyngeus, palatoglossus, palatopharyngeus , and pharyngeal constrictors), lymphoid tissue, and pharyngeal mucosa

11. Hyoid Bone Position and Morphologic Features Hyoid bone is the only bone in the head and neck region without a bony articulation suspended by the same muscles related to the pharyngeal region of the airway Arises from the cartilages of the second and third branchial arches consists of a central body that posteriorly projects as a left and right greater horn and on superior surface are the left and right lesser horns It descends and moves slightly anteriorly up to 18 years of age . Anterior movement of the hyoid bone is said to be related to the forward translation of the mandible during cephalocaudal growth. The growth of the cervical vertebra explain to some degree the descent of the hyoid bone However, the position of the hyoid bone is determined by the combined activity of the suprahyoid and infrahyoid muscle groups, with the UA dilator muscles being of great importance. increase in tongue mass relative to the oral cavity may lead to the tongue moving downward, this descent of the tongue may play a role in the inferior and anterior movements of the hyoid bone

12. H(hyoid)-MP distance increased over time snorers displayed a significantly larger H-MP distance excessive submental fat deposition in obese patients could be responsible for inferiorly moving the hyoid bone further. Pharyngeal critical ( Pcrit ) pressure : represents the airway pressure above which airflow can pass through the UA, is a measure of pharyngeal collapsibility. A lower hyoid position was theorized to predispose a subject to pharyngeal collapse by influencing the Pcrit pressure, thus contributing to an anatomic deficit in patients with OSA.

13. Relationship of Different Skeletal Patterns to Airway Morphologic Structure subjects with Class II mandibular retrusion had the lowest airway values Class III mandibular protrusion group, the highest oropharyngeal volume, nasal airway volume, and minimum axial cross-sectional areas were seen. Class III skeletal pattern present a more vertical orientation of the airway in the sagittal plane, whereas a Class II skeletal pattern is associated with a more forward orientation of the airway Area of maximum constriction is most critical. It is responsible for disturbance in breathing periods and is most susceptible to negative pressure

14. “soft tissue stretching hypothesis,” proposed that a change in jaw posture caused by mouth breathing could lead to stretching of the lips, cheeks, and musculature, resulting in upright incisors and narrower dental arches, as observed in patients with a long-face and open-bite growth pattern. Patients with a vertical growth pattern have shown a narrower airway, both anteroposteriorly and coronally, compared with patients showing more horizontal growth

15. AIRWAY MEASUREMENTS AND IMAGING Techniques used to study the airway, include nasal pharyngoscopy , cephalometric radiographs, fluoroscopy, conventional and electron-beam CT, acoustic reflection, and MRI MRI is considered to be very accurate in measuring the soft tissue lining, fat pad, and surrounding structures of the airway in three dimensions, it is not as useful in orthodontics because of the use of metals, which interfere with this imaging modality. the most common imaging modality found in an orthodontic office is the cephalogram, but its use is limited and often may be misleading Cephalograms have been found useful in identifying airway obstruction, adenoid hypertrophy, and very constricted airways

16. Nasoendoscopy presently holds the position of gold standard diagnosis for UA obstruction. but, it has drawbacks as well; as, it allows little opportunity for objective measurement but relies, on professional opinion, often causing low interobserver agreement

17. Cone-Beam Computed Tomography During a CBCT scan, the scanner (x-ray source and a rigidly coupled sensor) rotates, usually 360 degrees, around the head to obtain multiple images (ranging from approximately 150–599 unique radiographic views). In medical imaging, segmentation is defined as the construction of 3D virtual surface models to match the volumetric data. UA segmentation can be performed either manually or semiautomatically. In the manual approach, the user identifies the airway in each slice through the length of the airway. software then combines all slices to form a 3D volume. This method is time-consuming and almost impractical for clinical application

18. semiautomatic approach, the computer automatically differentiates the air and the surrounding soft tissues by using the differences in density values (gray levels) of these structures. In some programs, the semiautomatic segmentation includes two user-guided interactive steps: (1) placement of initial seed regions in the axial, coronal, and sagittal slices, and (2) selection of an initial threshold manual segmentation was more accurate than semiautomatic segmentation using different available software The minimum cross-sectional area (MCA), also known as the area of maximum constriction (mm2 ), is probably more useful than the airway volume.

19. Acoustic Rhinometry Acoustic Reflection (AR) is a method for examining the nasal cavity. It operates by reflecting sound pulses off changes in acoustic impedance. Key advantages include its simplicity, speed (approximately 30 seconds), and noninvasive nature. AR has been widely accepted for its effectiveness in the anterior nasal cavity. However, limitations exist in the posterior nasal cavity and epipharynx , where it overestimates cross-sectional areas compared to MRI and CT  AR significantly overestimates posterior areas. MRI advancements include higher resolution and faster imaging. CT innovations focus on miniaturization for portable scanning. These advancements may influence the comparative effectiveness of AR in the future.

20. Comparing RA to high-resolution CT volumetry, considered one of the best imaging modalities available for evaluating the nasal cavity and paranasal sinus geometry, showing 1% error in segmented volumes compared with actual volumes. AR is clinically useful and shows very good reliability in the anterior and middle parts of the nasal cavities, but decreasing accuracy in the posterior part.

21. Pharyngometry This technique has been previously applied to study the pharynx, glottis, and trachea in humans in vivo. Pharyngometry provides a noninvasive assessment of the dimensions, structure, and physiologic behavior of the UA from the oral cavity to the hypopharnyx while the patient breathes This dynamic test measures the dimensions of the airway through the oral cavity and 25 cm down the pharynx. acoustic pharyngometry was shown to be a useful method to assess OSA and in postoperative monitoring of UA surgery in patients with sleep disorders.

22. Ultrasonography ultrasonography to assess the airway at two different points, first during normal breathing and then while performing the Muller maneuver in which the subject attempts to inhale with the mouth closed and the nostrils plugged, leading to a collapse of the airway The comparison of both images provides an upper airway patency It has the advantages of assessing the upper airway in 3D, while in function, and not using ionizing radiation.

23. INFLUENCE OF ORTHODONTIC TREATMENT ON THE AIRWAY Treatment Including Extractions Rapid Maxillary Expansion Functional Orthopedic Appliances Orthognathic Surgery

24. Treatment Including Extractions Closure of extraction sites with mesial movement carries the molar to a narrower part of the arch, which could potentially have an effect on the tongue position Tongue position is considered to be an important factor for the UA because the root and posterior part of the tongue form the anterior wall of the oropharynx. extraction treatment with maximum anchorage mechanics may cause the tongue’s length and height to decrease slightly and move to a more retracted position against the soft palate-----lead to the narrowing of the UA UA reduction after incisor retraction is the movement of the hyoid bone in a posterior and inferior direction. mesial movement of the molars to extraction spaces enlarge the space behind the tongue, which is considered to play a role in improving UA dimensions

25. hyperdivergent patients with an obtuse mandibular plane angle have a narrower AP pharyngeal dimension Summary: Extraction treatment does not seem to affect the airway’s size, but caution may be taken in patients who have respiratory problems, possibly avoiding maximum anchorage approaches, if appropriate. The function and collapsibility of the airway is the important factor, not the size or how narrow it is.

26. Rapid Maxillary Expansion Rapid maxillary expansion (RME) is commonly used to correct maxillary constriction It not only attributable to the opening of the median palatal suture but also to an increase in the sagittal and vertical dimensions (MARPE) and (SARPE) are frequently used modalities of RME preferred in skeletally mature individuals to overcome potential suture resistance RME may help solve the nasal resistance to airflow if the problem originates from the anterior nasal cavity.

27. Functional Orthopedic Appliances The position of the mandible, relative to the anterior cranial base and mandibular length, seems to have an impact over the oropharyngeal airway When the mandible is protruded, a different posture of the tongue caused by increased genioglossus muscle activity and/ or other soft tissue activity may play an important role over airway dimension With functional appliance at the prepubertal growth spurt, majority of the airway enlargement occurs in the mediolateral dimension—in other words, in the width of the airway. fixed functional appliances are used in the later stages of growth, when most dental changes take place, no significant posterior airway changes are usually seen after treatment is completed Functional appliances are most useful in patients with a horizontal growth pattern of the mandible. If so, using fixed or removable appliances in a timely fashion may increase the dimensions of the airway. On the contrary, vertical-growing patients may not benefit from such a treatment because it is not the sagittal correction but rather a counterclockwise rotation that may increase the airway space.

28. Orthognathic Surgery When planning surgical treatments, consideration should be given to avoiding large amounts of mandibular setback, even if the patient’s diagnostic records indicate mandibular prognathia as it leads to narrowing in the width and depth of the hypopharyngeal and oropharyngeal areas mandibular advancement surgery results in an increase in the dimensions of the oropharyngeal airway Maxillary advancement, on the other hand, creates a significant increase in nasopharyngeal, hypopharyngeal airway and oropharyngeal airway dimensions

29. highest gain in the UA is obtained with maxillomandibular advancement surgery, maxillomandibular advancement surgery is performed in conjunction with genial tubercle advancement, which pulls the geniohyoid and genioglossus muscles forward, the gain in the UA is even better. Distraction osteogenesis (DO) has become an accepted method of treatment for patients requiring reconstruction of a hypoplastic mandible and a severely retruded maxilla to increase airway dimensions There are external and internal distraction devices, External distractors, although they are bulky and have a negative impact on a patient’s psychosocial life, appear to provide more extended bone osteogenesis advancement compared with internal devices

30. SLEEP-DISORDERED BREATHING: AIRWAY DISORDERS AND MANAGEMENT OSA, is part of a group of disorders called sleep-disordered breathing (SDB) or sleep-related breathing disorders (SRBDs). This class of disorders refers to abnormal respiratory patterning during sleep; but, its presence or a suspicion of disease is made when the patient is awake Proper documentation of types and severity of SDB is done through polysomnography (PSG, gold standard)or home testing with portable monitors;

31. Definitions and Testing Reports Breathing abnormalities detected during sleep are classified as apnea, hypopnea, respiratory effort–related arousals, and hypoventilation. Anea is the cessation, or near cessation, of airflow. It exists when airflow is less than 20% of baseline for at least 10 seconds in adults. In children, the duration criteria are shorter Inspiratory airflow is typically used to identify apnea, Types OSA occurs when airflow is absent or nearly absent but ventilatory effort persists. Caused by complete or nearly complete UA obstruction. Central apnea occurs when both airflow and ventilatory effort are absent. Mixed apnea is a mix of intervals during which no respiratory effort occurs (i.e., central apnea pattern) and intervals during which obstructed respiratory effort occurs.

32. Hypopnea is an abnormal reduction of airflow to a degree that is insufficient to meet the criteria for apnea. Obstructive hypopneas are caused partial UA obstruction, which can be heard as snoring Central hypopneas are caused by reduced inspiratory effort.

33. Apnea-Hypopnea Index (AHI) AHI is the total number of apneas and hypopneas per hour of sleep. AHI is occasionally calculated per hour of non-REM sleep, per hour of REM sleep, or per hour of sleep in a certain position to provide insight into the sleep-stage dependency or sleep-position dependency. If AHI values are 4 or less, then the patient is within normal limits. OSA is mild when the AHI reflects 5 to 15 episodes per hour of sleep, moderate when the AHI reflects 15 to 29 episodes per hour of sleep, and severe when the AHI reflects 30 and higher episodes per hour of sleep

34. Respiratory Disturbance Index (RDI) total number of events (apneas, hypopneas, and respiratory effort related arousals RERAs) per hour of sleep OSA severity mild when the RDI reflects 5 to 15 episodes per hour of sleep moderate when the RDI reflects 15 to 30 episodes per hour of sleep severe when the RDI reflects 30 or more episodes per hour of sleep.

35. Classification OSA is defined as either More than 15 apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI >15 events per hour) in an asymptomatic patient More than 5 apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI >5 events per hour) in a patient with symptoms (e.g., sleepiness, fatigue, inattention) or signs of disturbed sleep (e.g., snoring, restless sleep, respiratory pauses). OSA syndrome applies only to the latter definition. In both situations, more than 75% of the apneas or hypopneas must have an obstructive pattern

36. Epidemiologic Factors In OSA, the most common form of sleep apnea, episodes of apnea occur during sleep as a result of airway obstruction at the level of the oropharynx and velopharynx. Several studies have shown that OSA is a common disorder that represents a significant public health problem. OSA in children presenting symptoms are behavioral problems during the day and below-expected performance in school. Sleepiness during the day is less common than adults, hyperactivity from sleep fragmentation and chronic sleepiness is more common, Adenotonsillar hypertrophy by itself or in the presence of obesity scoring rules for diagnosis are different in children, with more emphasis on the number of hypopneas, RERAs, and arousals from sleep. Young women/ before menupause : more complaints of fatigue and depression than with snoring or sleepiness, and hypothyroidism is more often negative Pregnant woman is more vulnerable to OSA because of edema, nasal congestion, progesterone, and small lung volumes, resulting in increased oscillation from hyperventilation to apnea

37. Pathophysiology pharynx is abnormal in size and/or is capable of collapsing or being collapsed in patients with OSA An abnormal pharynx can be kept open in wakefulness by an appropriate compensatory increase in dilator muscle activity, but this compensation fails during sleep and the airway collapses. Partial collapse results in snoring, hypopneas, and, in some cases, prolonged obstructive hypoventilation. Complete closure results in an apnea. most frequent site of primary obstruction being the velopharynx at the level of the soft palate and the oropharynx. physiologic causes for recurrent apneas during sleep are threefold: ventilation transitions from waking to sleeping and back (for it is sleep apnea rather than wake apnea) a reduced UA activation in response to an apnea or hypopneas a high arousal threshold that awakens the patient with a ventilatory overshoot before a compensatory response occurs during sleep

38. Clinical Presentations OSA increases with age and is twofold higher in men than in women until the age of approximately 60 years, after which the opportunity for finding snoring, increased AHI, and OSA is equal Physically restless sleep and reports of insomnia Morning dry mouth or sore throat from mouth breathing upon recovery from apnea and/or hypopnea Morning confusion and headache from increases in carbon dioxide levels Personality changes (irritability and distracted demeanor) and judgment changes resulting from sleepiness Night sweats, secondary to increased work of breathing Erectile dysfunction, especially in the setting of hyperlipidemia stentorian snoring and severe sleepiness, fatigue, or inattention

39. Physical Risks in Wakefulness prevalence of hypertension, obesity, a large neck, and a structurally abnormal or crowded UA orthodontist can detect nasal obstruction, a low hanging soft palate and large uvula, enlarged tonsils and adenoids, and retrognathia or micrognathia Neck size is an important predictor of sleep apnea

40. Clinical Prediction of Significant Sleep-Disordered Breathing range of severity is from 5 events (1 event every 12 minutes) to 60 events or more Presence of hypertension (or hypertension treatment) BMI 30 or higher Neck circumference (or collar size) of >17 inches for men and >16 inches for women History of habitual snoring, snorts, observed apneas, and restless sleep Observed reports of nocturnal choking or gasping Reported or observed sleepiness, inattention, and nocturnal changes in energy A patient with a low clinical score will have a low or very low posttest probability of having clinically important sleep apnea and does not need further evaluation. Moderate severity may be initially managed by weight loss or the treatment of an anatomic problem, such as a nasal polyp or rhinitis, leaving the use of a CPAP device or an OA and surgery for consideration after appropriate diagnostic testing

41. Patient-Based Tests and Questionnaires Friedman Classification Tonsil size can be graded from 0 to 4 e Mallampati classification clinically predict the ease versus difficulty of laryngeal intubation This scoring system is based on direct visualization of the soft palate, uvula, faucial pillar, and hard palate and on the concept of examining the tongue size relative to the oral cavity. the Mallampati classification is considered an indirect way of assessing the size of the base of the tongue.

42. Modified Mallampati Classification Patients are asked to take a seated or supine position.. If seated in an upright position, the head is in neutral position. Patients are asked to protrude their tongue as far forward as they can without emitting a sound. In the Friedman classification, the patient opens his or her mouth wide without protruding the tongue. Through visual observation, a Class I to Class IV MM classification is determined.

43. Pediatric Sleep Questionnaire

44. STOP-Bang Questionnaire stands for yes or no questions on snoring (S), tiredness (T), observed events (O), and blood pressure (P). It was later modified to STOP Bang, adding BMI (B), age (A), neck circumference (N), and gender (G)

45. Epworth Sleepiness Scale it assesses eight situations with a likelihood of falling asleep and assigns scores from 0 to 3, giving a total scale of 0 to 24. relatively small role in screening patients at high risk of OSA and cannot be used to predict or screen patients

46. Nasal Obstruction Symptom Evaluation Scale NOSE scale showed excellent sensitivity, consists of five questions that can be answered in less than 1 minute

47. Diagnostic Testing of Obstructive Sleep Apnea Diagnosis of OSA requires that the patient be examined during sleep, and the gold standard is to diagnose through PSG PSG includes analysis of the following tests: electroencephalogram, electrooculogram, chin electromyogram, airflow analysis, oxygen saturation, respiratory effort, and electrocardiogram, sometimes replaced by heart rate. Body position and excessive movements are also observed during this test

48. Treatment Options Lifestyle and Behavior Modification loss of weight to a BMI of 25 kg/m2 or less Exercise positional therapy during sleep avoidance of alcohol or sedatives before going to sleep Positional therapy consists of a method that keeps the patient sleeping in a non-supine position. To prevent the patient from sleeping in a supine position, using objects such as tennis balls, pillows, or a backpack is recommended

49. Positive Airway Pressure treatment of choice for all levels of OSA; it provides pneumatic splinting of the UA PAP may be delivered as continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP), or autotitrating positive airway pressure (APAP) modes CPAP therapy is highly efficacious and currently the reference standard of treatment in preventing airway collapse

50. Oral Appliances Patients often prefer OAs instead of a CPAP device because of their portability, ease of use, and comfort used in mild and moderate OSA cases, increasing evidence of the potential role of in patients with severe OSA who are intolerant or fail a trial of CPAP therapy CPAP therapy has shown better results than OA therapy in bringing the AHI to <10 events per hour, but when substituted an OA for a CPAP device for 1 month, OA therapy produced a similar reduction in hypopneas from 29 to 4 events per hour Better treatment responses have been found in younger patients, patients with smaller neck circumferences, women, and supine-dependent patients with OSA

51. The three general groups of OAs include soft palate lift devices, tongue retention devices, and mandibular advancement splints (MASs) The MAS is the predominant type of OA used in clinical practice withbest results. MAS effects include the following: Enlargement of velopharyngeal airway caliber in the lateral dimension Increased UA neuromuscular tone Stimulation of UA dilator muscles Contraindications Multiple conditions such as heart failure and respiratory failure central apnea and/or central hypoventilation Severe periodontal disease, teeth mobility Severe TMD in which the pain and dysfunction aggravated with mandibular protrusion Severe gag reflex Side effects excessive salivation, dry mouth, tooth discomfort, gingival irritation, masticatory muscle tenderness, and temporomandibular joint (TMJ) discomfort. With as few as 6 months of OA use, changes in facial height and in tooth and jaw positions have been noted

52. Surgical Treatment tonsillectomy and adenoidectomy is the recommended first-line treatment UA bypass procedure or tracheostom y Nasal procedures Uvulopalatopharyngoplasty Radiofrequency ablation Orthognathic surgery

53. Oropharyngeal Exercises 1.Soft palate: An oral vowel is intermittently and continuously pronounced. A blowing exercise is also performed, whether blowing a balloon or inhaling through the nose and exhaling through the mouth while keeping the lips together. 2. Tongue: brushing the superior and lateral surfaces of the tongue while the tongue is positioned in the floor of the mouth; placing the tip of the tongue against the front of the palate and sliding the tongue backward, which forces tongue sucking upward against the palate; pressing the entire tongue against the palate; and forcing the back of the tongue against the floor of the mouth while keeping the tip of the tongue in contact with the inferior incisive teeth. 3. Facial: a. Muscle pressure of the orbicularis oris with the mouth closed b. Suction movements contracting only the buccinators c. Recruitment of the buccinator muscle against the finger that is introduced in the oral cavity, pressing the buccinator muscle outward d. Alternating elevation of the mouth angle muscle e. Lateral jaw movements with alternating elevation of the mouth angle muscle 4. Stomatognathic functions: Breathing and speech : Forced nasal inspiration and oral expiration in conjunction with phonation of open vowels, while sitting; balloon inflation with prolonged nasal inspiration and then forced blowing Swallowing and chewing: Alternate bilateral chewing and deglutition, using the tongue in the palate, closed teeth, without perioral contraction, whenever feeding

54. Upper Airway Electrical Neurostimulation UA stimulation using a unilateral implantable neurostimulator for the hypoglossal nerve treatment of patients with moderate to severe OSA who are intolerant to CPAP therapy Patients with AHI > 65 and/ or BMI > 32 are not good candidates for this therapy contraindicated when central and mixed apneas The device is implanted in the chest and has a small generator, a breathing sensor lead, and a stimulation lead. The patient can turn on the therapy before bedtime and turn it off in the morning through a remote control When the device is activated, it senses the person’s breathing patterns and delivers a mild stimulation to keep the airway open, acting in a similar fashion as a pacemaker