ResearchPDF Available

Changes in 3D nasal cavity volume after biomimetic oral appliance therapy in adults

Authors:
Full Terms & Conditions of access and use can be found at
http://www.tandfonline.com/action/journalInformation?journalCode=ycra20
Download by: [Professor G. Dave Singh DDSc PhD DMD] Date: 06 March 2016, At: 10:27
CRANIO®
The Journal of Craniomandibular & Sleep Practice
ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20
Changes in 3D nasal cavity volume after
biomimetic oral appliance therapy in adults
G. Dave Singh DDS, PhD, BDS, Tammarie Heit DDS, Derek Preble BFA &
Ravindra Chandrashekhar MD,MS
To cite this article: G. Dave Singh DDS, PhD, BDS, Tammarie Heit DDS, Derek Preble BFA &
Ravindra Chandrashekhar MD,MS (2016) Changes in 3D nasal cavity volume after biomimetic
oral appliance therapy in adults, CRANIO®, 34:1, 6-12
To link to this article: http://dx.doi.org/10.1179/2151090315Y.0000000001
Published online: 01 Mar 2016.
Submit your article to this journal
Article views: 45
View related articles
View Crossmark data
Sleep
Changes in 3D nasal cavity volume after
biomimetic oral appliance therapy in adults
1
BioModeling Solutions, Inc., Beaverton, OR, USA,
2
Scotia Square Dentistry, Edmonton, AB, Canada,
3
C Inside,
LLC, Salt Lake City, UT, USA,
4
Private Practice, Victorville, CA, USA
Objective: In this study, the authors investigated 3D changes in nasal volume, to test the hypothesis that
nasal cavity volume can be changed in adults.
Methods: After obtaining informed consent, the authors undertook 3D cone-beam computerized axial
tomographic (CBCT) scans of 11 consecutive adults (mean age: 37.9 years), before and after biomimetic
oral appliance therapy (BOAT). The mean treatment time was 18.462.5 months. Volumetric reconstruction
of the nasal cavity was undertaken, and the nasal volume was calculated in all cases. The findings were
subjected to statistical analysis, using paired t-tests.
Results: The mean nasal cavity volume was 41.9612.0 cm
3
before treatment. After BOAT, the mean
volume increased to 44.0612.7 cm
3
(P50.022).
Conclusions: These data support the notion that nasal cavity volume can be changed in adults. Use of
BOAT might improve continuous positive airway pressure (CPAP) compliance in adults diagnosed with
obstructive sleep apnea (OSA), by increasing the nasal cavity volume and decreasing nasal airflow
resistance.
Keywords: Nasal airway, Palatal expansion, Obstructive sleep apnea, Biomimetic oral appliance
Introduction
Obstructive sleep apnea (OSA) is a sleep-related
breathing disorder characterized by disruptive snor-
ing, daytime somnolence, and abnormal sleep archi-
tecture. Contributory conditions to upper airway
obstruction, such as jaw deformities, central nervous
system disorders, and obesity, may lead to life-
threatening systemic complications. Additional con-
tributory factors for OSA include nasal airway
obstruction (particularly hypertrophied inferior tur-
binates), and decreased oropharyngeal airway dimen-
sion (particularly adeno-tonsillar hypertrophy). In
children, rapid maxillary expansion (RME) may
provide a treatment option for OSA. For example,
in preschool children with OSA, Marino et al.
1
reported that those with retrognathic jaws might find
RME beneficial, while Villa et al.
2
noted the effects of
RME can persist for some 2 years after treatment.
Another treatment option for patients with OSA
involves continuous positive airway pressure (CPAP),
which acts as an upper airway stent to prevent
pharyngeal collapse and consequent obstruction.
However, many patients do not tolerate CPAP well.
For example, using 4 h/day as effective CPAP usage,
Boyaci et al.
3
report that less than half of adults were
able to comply with CPAP therapy sufficiently. Other
commonly used treatments for OSA include: oral
appliances to reposition the mandible anteriorly, and
orthognathic surgery to advance both the maxilla
and mandible. For any of these treatments to be
maximally effective, however, a patent nasal airway is
required. Thus, nasal airway obstruction or occult
nasal obstruction may hinder CPAP compliance, as
well as the effectiveness of other treatment options
for OSA.
There are several factors that can contribute to
nasal airway obstruction and increased nasal airway
resistance, including: narrow nostrils; nasal valve
collapse; turbinate hypertrophy; nasal septal devia-
tion; nasal congestion secondary to allergies; polyps;
hyperplastic adenoidal tissues; parasympathetic ner-
vous system activation, and choanal atresia. In
addition, the transverse dimension of the nasal cavity
may be excessively narrow, further diminishing the
tolerance of CPAP. Singh et al.
4
reported variations
Correspondence to: G. D. Singh, BioModeling Solutions, Inc.,15455 NW
Greenbrier Pkwy, Ste. 250, Beaverton, OR 97006, USA. Email:
ß
DOI 10.1179/2151090315Y.0000000001 CRANIOH: The Journal of Craniomandibular & Sleep Practice 2016 VOL. 34 NO. 1 1
Prof.
drsingh@drdavesingh.com
6
G. Dave Singh DDS, PhD, BDS1, Tammarie Heit DDS2, Derek Preble BFA3,
Ravindra Chandrashekhar MD, MS4
Taylor & Francis
2016
Downloaded by [Professor G. Dave Singh DDSc PhD DMD] at 10:27 06 March 2016
in nasal cavity width, which may be secondary to a
high-arch palate. Indeed, Banabilh et al.
5
confirmed
that the upper dental arch is narrower in adults
diagnosed with OSA when compared with controls.
Similarly, comparing nasal airways using finite-
element morphometry, Banabilh et al.
6
reported that
the mean, 3D nasal airway was significantly narrower
in Asian subjects with OSA compared to matched
controls. Mehra and Wolford,
7
Morales-Ryan and
Wolford,
8
and Wolford et al.
9
have identified specific,
morphological characteristics that predispose to
nasal airway obstruction and hypertrophied turbi-
nates, including a retruded maxilla and mandible.
Thus, craniofacial architecture may contribute sig-
nificantly to CPAP impedance reaching the critical
pressures required to overcome resistance from nasal
and oropharyngeal airway obstructions. Therefore,
the aim of this study is to determine 3D changes in
nasal volume, to test the hypothesis that nasal cavity
volume can be changed in non-growing adults.
Sample and Methods
After obtaining informed consent, 13 consecutive
patients were recruited for this study. The rights
of the subjects were protected by following the
Declaration of Helsinki. Inclusion criteria were:
adults over age 21 years diagnosed with clinical,
midfacial underdevelopment (such as a narrow palate
or posterior crossbite); good oral appliance compli-
ance; no history of hospitalization for craniofacial
trauma or surgery; no congenital craniofacial anoma-
lies, and a fully-dentate upper arch. The exclusion
criteria included: age ,21 years; lack of oral appli-
ance compliance; active periodontal disease; tooth
loss during treatment; poor oral hygiene, and
systemic bisphosphonate therapy. The study protocol
(#1022013) was reviewed and approved by the
institution’s review board. After careful history
taking and craniofacial examination, the authors
undertook 3D cone-beam computerized axial tomo-
graphic (3D CBCT) scans using an iCAT 3D CBCT
machine (Imaging Sciences International, Hatfield,
PA, USA). Strict positioning protocols were used,
and a 20-second scan was performed using a wide
(13 cm) field of view.
A neuromuscular bite registration was obtained in
the upright-sitting position with corrected jaw posture
in the vertical axis specific for each subject. The
protocol for capturing the physiological rest position
of the jaw
10
starts with baseline data collection of the
initial bite, jaw position, and posture, using photo-
graphy and K-7 data (Myotronics, Kent, WA, USA).
The muscles of mastication are relaxed using ultra-low
frequency, transcutaneous electrical neural stimula-
tion (ULF-TENs) for a minimum of 45 minutes of
cranial nerves V, VII, and XI that are accessed through
the coronoid notch and the upper portion of the
middle one-third of the posterior cervical triangle, just
posterior to the sternocleidomastoid muscle (SCM).
Cranial nerve XI innervates SCM and trapezius, and
if stimulated with ULF-TENS, these muscles and
associated muscles can be relaxed simultaneously
without risk of direct stimulation of the carotid sinus
nerve.
11
Following relaxation of the jaw and neck
muscles, K-7 data are used to find the most relaxed
position of the jaw where the muscles coordinate
together, documented in a single point in space. The
physiological rest position is captured using a poly-
vinylsiloxane bite registration material when the
EMGs are the lowest. The bite position is then verified
using K-7 data. The physiological rest position is thus
determined by measurable and repeatable data.
12
Upper and lower polyvinylsiloxane impressions were
also obtained. The upper model was then mounted
using the hammular notch-incisive papilla plane
method on a Stratos articulator (Ivoclar-Vivadent,
Amherst, NY, USA), and the lower model was
mounted relative to the upper model, using the bite
registration captured in the physiological rest position.
Following diagnostics, a biomimetic, upper Daytime-
Nighttime Appliance (DNA appliance
H
)(Fig.1)was
prescribed for each subject. Biomimetic oral appliance
therapy (BOAT) is designed to correct maxillo-man-
dibular underdevelopment in both children and
adults.
13–19
The BOAT used in this study had: six
(patented) anterior 3D axial springs
TM
, midline anterior
and posterior omega loops, posterior occlusal rests,
Figure 1 The wireframe Daytime-Nighttime Appliance (DNA
appliance) that was used for each subject in this study. The
wireframe DNA appliance shown in situ consists of: 6
(patented) anterior 3D axial springs; midline anterior and
posterior omega loops; bilateral posterior occlusal rests;
bilateral retentive clasps, and a wrap-around labial bow with
U loops.
Singh et al. 3D nasal cavity volume
27
CRANIOH: The Journal of Craniomandibular & Sleep Practice 2016 VOL. 34 NO. 1
Downloaded by [Professor G. Dave Singh DDSc PhD DMD] at 10:27 06 March 2016
retentive clasps, and a labial bow (Fig. 1). All subjects
were instructed to wear the appliance during the
evening and at night-time (for approx. 12–16 hours in
total), but not during the day time and not while eating,
partly in line with the circadian rhythm of tooth
eruption,
20
although this only occurs in children. Note
that, according to Proffit and Fields,
21
an appliance
needs to be worn for at least 8 hours to have a clinical
effect. The appliance was adjusted every 4 weeks,
approximately. The subjects were also instructed on
how to perform an orofacial/myofunctional exercise
(the ‘‘zygoma lift’’),
22
and had to demonstrate success-
ful implementation of the exercise routine prior
to discharge. Written and verbal instructions were
given to all subjects.
All subjects reported for review each month. At
each monthly follow-up, examination for the progress
of midfacial development was recorded. Adjustments to
Figure 2 (A) From the 3D CBCT scan data, gray-scale images were used to identify bony landmarks. To acquire the nasal
cavity volume, the CBCT scan was trimmed anteriorly from nasion to the anterior nasal spine. (B) The superior aspect of the 3D
CBCT image was trimmed from nasion to the most superior part of sella turcica. (C) From the previous 3D CBCT image, the
posterior aspect was trimmed from the most superior point of the sella turcica to basion. (D) The inferior aspect of the 3D CBCT
image was trimmed following the hard palate. This procedure was followed systematically for each pre-treatment and post-
treatment volume, leaving only the nasal cavity for volumetric analysis.
Singh et al. 3D nasal cavity volume
3
8CRANIOH: The Journal of Craniomandibular & Sleep Practice 2016 VOL. 34 NO. 1
Downloaded by [Professor G. Dave Singh DDSc PhD DMD] at 10:27 06 March 2016
the devices were performed to optimize their efficacy.
Only gentle pressures were transmitted to the teeth, and
the functionality of the device was checked with the
subject activating a mild force on biting. The subjects
were encouraged to maintain their treatment regimen as
outlined at the outset. Development of the lower arch
was implemented using a lower appliance to permit
arch re-coordination. A lower appliance was imple-
mented between 6 and 12 months, depending on the
subject’s progress.
For the 3D CBCT scan data, gray-scale images
were used to identify bony landmarks to enable
digital trimming of the majority of the CBCT data set
(Fig. 2). To acquire the nasal cavity volume, the
CBCT scan was trimmed anteriorly from nasion to
the anterior nasal spine. The superior aspect was
trimmed from nasion to the most superior part of
sella turcica. The posterior aspect was trimmed from
the most superior point of the sella turcica to basion.
The inferior aspect was trimmed following the hard
Figure 3 (A) For 3D reconstruction of the nasal cavity, appropriate software was implemented (Anatomage; inVivo Dental, San
Jose, CA, USA). Pseudo-color objects were used to work on inverse volume reconstructions, which allowed visualization of
spaces and trimming away the maxillary sinuses. (B) Object visualization was undertaken at each step when trimming away
data from the CBCT data so that, eventually, the only information left was for volumetric reconstruction of the nasal cavity. (C)
Volumetric reconstruction of the nasal cavity was undertaken between the anterior and posterior nasal spines, extending
superiorly from the palatine process of the maxilla and the palatine bone to the cribriform plate of the ethmoid bone.
Singh et al. 3D nasal cavity volume
49
CRANIOH: The Journal of Craniomandibular & Sleep Practice 2016 VOL. 34 NO. 1
Downloaded by [Professor G. Dave Singh DDSc PhD DMD] at 10:27 06 March 2016
palate. Next, the nasopharynx was trimmed out of
the remaining volume, and laterally, the maxillary
sinuses were trimmed out at their junction to the
nasal cavity. This procedure was followed system-
atically for each pre-treatment and post-treatment
volume, leaving only the nasal cavity for volumetric
analysis. Next, pseudo-color objects were used
to work on inverse volume reconstructions, which
allowed visualization of spaces and trimming away
the maxillary sinuses. Object visualization was under-
taken at each step when trimming away data from the
CBCT data, so that, eventually, the only information
left was for volumetric reconstruction of the nasal
cavity. For 3D reconstruction of the nasal cavity
(Fig. 3), appropriate software was implemented
(Anatomage; inVivo Dental, San Jose, CA, USA).
Volumetric reconstruction of the nasal cavity was
undertaken between the anterior and posterior nasal
spines, extending superiorly from the palatine process
of the maxilla and the palatine bone to the cribriform
plate of the ethmoid bone. Finally, the nasal cavity
volume was calculated in all cases (Fig. 4). The 3D
measurement protocol was repeated three times to
determine the percentage measurement error. At
18 months, these volume measurements were repeated,
and the findings were subjected to statistical analysis,
using paired t-tests.
Results
Two subjects were excluded from the study; one
subject did not meet the age criteria for inclusion, and
one subject had maxillary third molars removed
during the active phase of BOAT. The mean treatment
time was 18.462.5 months. The 3D measurement
error was found to be 0.92%, so statistical analysis was
warranted. The mean nasal cavity volume for the
sample of 11 adults was 41.9612.0 cm
3
before
treatment. After BOAT, the mean nasal cavity volume
increased to 44.0612.7 cm
3
(P50.022). The mean
percentage increase in nasal cavity volume was found
to be 5.668.7%. These results are summarized in
Table 1. Figure 5 shows the external appearance of the
nose pre- and post-treatment.
Discussion
The first line of treatment for OSA is typically CPAP,
but poor compliance due to nasal obstruction/nasal
resistance often hinders effective CPAP use. But, if the
nasal airway volume could be increased, patient
compliance with CPAP might be improved. Patients
diagnosed with OSA require higher CPAP pressures,
23
because in cases of nasal obstruction, the cross-
sectional area in the nasal cavity may be decreased.
Using Ohm’s law for electrical circuits (which corre-
sponds to Poiseuille’s law for fluid flow), where the
pressure drop is analogous to the voltage and
volumetric flow rate is analogous to the current, the
resistance (R) is given by:
R~
8gDx
pr4
where gis the flow rate and Dxis the pressure
gradient.
This concept is useful because it illustrates that the
effective resistance to flow in a tube (R) is inversely
proportional to the fourth power of its radius (r).
Therefore, a small decrease in the radius of the aperture
will increase resistance to (nasal) airflow significantly.
In addition, Fajdiga
24
discussed Bernoulli forces that
can cause a vacuum effect that may disturb laminar
fluid flow, which could be associated with snoring, and
possibly sinusitis. Thus, patients with OSA who require
higher CPAP pressures experience a change in the
physics of nasal breathing, and the basis of this study is
to address that issue.
Kim and Guilleminault
25
noted that craniofacial
structures limiting nasal breathing can be considered
to be risk factors for sleep disordered breathing, and
Figure 4 The final nasal cavity model that was recon-
structed. The nasal cavity volume of the model was
calculated in all cases.
Table 1 Nasal cavity volume (mm
3
)
Subject Pre-treatment Post-treatment
ASE 33 247 33 596
FEA 55 344 56 001
HFT 49 453 50 067
CHD 55 240 55 534
KHN 40 802 43 614
NNR 27 505 30 981
KRI 35 183 35 785
JDH 66 291 68 923
EAN 31 439 33 515
TRR 30 217 29 460
ATE 36 604 47 114
Mean 41 938 44 053
Pvalue 0.022789
Singh et al. 3D nasal cavity volume
5
of
10 CRANIOH: The Journal of Craniomandibular & Sleep Practice 2016 VOL. 34 NO. 1
Downloaded by [Professor G. Dave Singh DDSc PhD DMD] at 10:27 06 March 2016
are identifiable during clinical assessment of craniofa-
cial features in patients being screened for OSA. For
example, hypertrophied nasal turbinates commonly
contribute to nasal airway obstruction. Typically, the
enlargement extends along the entire length of the
inferior turbinate, so in order to provide structural
patency, the anterior, middle, and posterior aspects of
the hypertrophied turbinates need to be addressed. In
general, otolaryngologists focus on the anterior one-
third of the turbinate due to the highest level of nasal
airway resistance occurring in the nasal valve region.
Therefore, turbinate surgery is focused on this region.
Alternatively, increasing nasal cavity volume could
more easily accommodate the hypertrophied inferior
turbinates.
A deviated nasal septum and/or septal spurring can
also play a significant role in nasal airway obstruc-
tion, and these features may require a septoplasty to
eliminate their contributions to airflow resistance in
patients with OSA.
26
Indeed, if other functional nasal
airway obstructions are present, such as narrow
nostrils (Fig. 5A), collapsed nasal valves, presence
of nasal polyps, etc., they must also be identified and
addressed to provide a patent nasal airway. In
addition, Wang et al.
27
report adverse changes in
pharyngeal airway size and hyoid bone position,
following conventional orthodontic treatment, which
may also lead to occult upper airway obstruction
(presumably by retracting the anterior teeth, decreas-
ing the oral cavity volume and displacing the tongue
posteriorly). Alternatively, BOAT may be proposed
to reduce nasal airway resistance. In this particular
study, the authors were able to demonstrate increased
nasal cavity volumes post-treatment (Table 1), so it is
possible that decreased nasal airway resistance may
be a clinical consequence, but further studies are
required to determine this, as within-sample hetero-
geneity could possibly confound the results.
Skeletal and dental changes after RME have been
reported in the orthodontic literature, and RME has
long been used to correct transverse discrepancies of
the maxillary arch. For example, in children, the
Haas expansion appliance produces increased nasal,
as well as maxillary width.
28
Similarly, when the
Haas, Minne, Hyrax, and Quad-Helix appliances
were compared,
29
RME resulted in increased nasal
width, with significant effects on the palatine,
lacrimal, and zygomatic bones in children. While
most of the widening is usually observed in the dento-
alveolar areas, the width of the floor of the nasal
cavity can also be increased. Despite these reports,
nasal improvements that might occur using similar
techniques in adults have not been fully investigated.
But, in recent studies, increased maxillary bone width
and bone volume has been reported in adults
following BOAT
30
as an alternative to increasing
maxillary bone width using surgery
31
. As the roof of
the mouth is the floor of the nose, it appears that the
target of nasal obstruction might be addressed by
increasing nasal volume in adults using a palatal
approach. Indeed, in a recent study, Nada et al.
32
reported that after 22 months of combined treatment,
nasal airway volume increased by 9.5% in the surgical
group treated in combination with the Hyrax appli-
ance, and by 13% in the surgical group treated in
combination with RME, although statistically no
Figure 5 (A) The external appearance of the nose before biomimetic oral appliance therapy. Note the width and asymmetry of
the nares with some evidence of alar cartilage collapse. (B) The external appearance of the nose of the same subject as A after
biomimetic oral appliance therapy. Note the improved width and symmetry of the nares.
Singh et al. 3D nasal cavity volume
611
CRANIOH: The Journal of Craniomandibular & Sleep Practice 2016 VOL. 34 NO. 1
Downloaded by [Professor G. Dave Singh DDSc PhD DMD] at 10:27 06 March 2016
difference between the two groups was found. Their
results are similar to the 5.6% volume increase
reported in this present study after 18 months, which
were achieved without any surgical interventions.
Therefore, use of BOAT before, or in conjunction
with, CPAP therapy might potentially improve CPAP
compliance in adults diagnosed with OSA, by increas-
ing the nasal cavity volume and decreasing nasal
airflow resistance. But, the findings of this preliminary
study need to be viewed with some caution, as many
dental professionals are not familiar with the techni-
que-sensitive protocol employed in this particular
investigation. Nevertheless, future studies will use
sleep indices to correlate functional airway changes
in clinical trials on subjects with OSA, using BOAT
with those on CPAP therapy.
Disclaimer Statements
Contributors
Funding
Conflicts of interest
Ethics approval
References
1 Marino A, Ranieri R, Chiarotti F, Villa MP, Malagola C.
Rapid maxillary expansion in children with Obstructive Sleep
Apnoea Syndrome (OSAS). Eur J Paediatr Dent. 2012;13:57–
63.
2 Villa MP, Rizzoli A, Miano S, Malagola C. Efficacy of rapid
maxillary expansion in children with obstructive sleep apnea
syndrome: 36 months of follow-up. Sleep Breath. 2011;15:179–
84.
3 Boyaci H, Gacar K, Baris¸ SA, Bas¸yig˘it I, Yildiz F. Positive
airway pressure device compliance of the patients with
obstructive sleep apnea syndrome. Adv Clin Exp Med.
2013;22:809–15.
4 Singh GD, Rozihan MH, Nidzam MTM, Shamim AK, Samsudin
AR, Suhaimi D. 3-D reconstruction of nasopharyngeal airways in
Malaysian subjects. IFMBE Proc. 2007;15: 8–11.
5 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
Rehabil. 2009;36:184–92.
6 Banabilh SM, Suzina AH, Mohamad H, Dinsuhaimi S,
Samsudin AR, Singh GD. Assessment of 3-D nasal airway
morphology in Southeast Asian adults with obstructive sleep
apnea using acoustic rhinometry. Clin Oral Investig.
2010;14:491–8.
7 Mehra P, Wolford LM. Surgical management of obstructive
sleep apnea. Bayl Univ Med Cent Proc. 2000;13:338–42.
8 Morales-Ryan CA, Wolford LM. Hypertrophic turbinates:
prevalence, surgical indications and outcomes in the orthog-
nathic surgery patient. J Oral Maxillofac Surg. 2001;59:35–6.
9 Wolford LM. Surgical planning in orthognathic surgery
(Chapter 60). In: Booth PW, Schendel SA, Hausamen JE,
editors. Maxillofacial surgery. Vol. 2. St Louis, MO: Churchill
Livingstone; 2007. p. 1155–210.
10 Jankelson R. Neuromuscular dental diagnosis and treatment.
Vol. 1. St Louis, MO: Ishiyaku EuroAmerica; 2005. p. 87–96.
11 Raman P. Neurally mediated ULF-TENs to relax upper
cervical and upper thoracic musculature as an aid to obtaining
improved cervical posture and mandibular posture. In: The
application of the principles of neuromuscular dentistry to
clinical practice (Anthology Vol. IX). Seattle, WA: The
International College of Cranio-Mandibular Orthopedics;
2010. p. 77–85.
12 Heit T, Derkson C, Bierkos J, Saqqur M. The effect of the
physiological rest position of the mandible on cerebral blood
flow and physical balance: an observational study. Cranio
2014; Jul 18:886963414Z00000000063.
13 Singh GD, Lipka G. Case report: introducing the wireframe
DNA appliance
TM
. J Am Acad Gnathol Orthop. 2009;26:8–11.
14 Singh GD, Wendling S, Chandrashekhar R. Midfacial devel-
opment in adult obstructive sleep apnea. Dent Today.
2011;30:124–7.
15 Singh GD, Utama J. Effect of the DNA appliance
TM
on
migraine headache: case report. Int J Orthod. 2013;24:45–9.
16 Singh GD, Cress SE. Craniofacial enhancement using a
biomimetic oral appliance: case report. Dent Today.
2013;329:92–4.
17 Singh GD, Callister JD. Use of a maxillary oral appliance
for the resolution of obstructive sleep apnea. Cranio.
2013;31:171–9.
18 Singh GD, Ataii P. Combined DNA appliance
TM
and
Invisalign
TM
therapy without interproximal reduction: a pre-
liminary case series. J Clin Case Rep. 2013;3:1–3.
19 Harris WG, Singh GD. Resolution of ‘gummy smile’ and
anterior open bite using the DNA appliance
TM
: case report. J
Am Orthod Soc. 2013; :30–4.
20 Proffit WR, Frazier-Bowers SA. Mechanism and control of
tooth eruption: overview and clinical implications. Orthod
Craniofac Res. 2009;12:59–66.
21 Proffit WR, Fields HW. Contemporary orthodontics. New
York: Mosby Inc.; 2005.
22 Singh GD, Krumholtz JA. Epigenetic orthodontics in adults.
Chatsworth: Appliance Therapy Group; 2009. p. 155–6.
23 Patra AL, Gooya A, Me´nache MG. A morphometric compar-
ison of the nasopharyngeal airway of laboratory animals and
humans. Anat Rec. 1986;215:42–50.
24 Fajdiga I. Snoring imaging: could Bernoulli explain it all?
Chest. 2005;128:896–901.
25 Kim JH, Guilleminault C. The nasomaxillary complex, the
mandible, and sleep-disordered breathing. Sleep Breath.
2011;15:185–93.
26 Takahashi R, Ohbuchi T, Hohchi N, Takeuchi S, Ohkubo J,
Ikezaki S, et al. [Effect of septoplasty and turbinectomy on
obstructive sleep apnea syndrome]. Nihon Jibiinkoka Gakkai
Kaiho. 2013;116:789–92. Japanese.
27 Wang Q, Jia P, Anderson NK, Wang L, Lin J. Changes of
pharyngeal airway size and hyoid bone position following
orthodontic treatment of Class I bimaxillary protrusion. Angle
Orthod. 2011;82:115–21.
28 Haas AJ. Rapid expansion of the maxillary dental arch and
nasal cavity by opening the midpalatal suture. Angle Orthod.
1961;73–90.
29 Cross DL, McDonald JP. Effect of rapid maxillary expansion
on skeletal, dental and nasal structures: a posteroanterior
cephalometric study. Eur J Orthod. 2000;22:519–28.
30 Singh GD, Heit T, Preble D. Changes in 3D midfacial
parameters after biomimetic oral appliance therapy in adults.
J Ind Orthod Soc. 2014;48:104–8.
31 Nada RM, Fudalej PS, Maal TJ, Berge´ SJ, Mostafa YA,
Kuijpers-Jagtman AM. Three-dimensional prospective evalua-
tion of tooth-borne and bone-borne surgically assisted rapid
maxillary expansion. J Craniomaxillofac Surg. 2012;40:757–62.
32 Nada RM, van Loon B, Schols JG, Maal TJ, de Koning MJ,
Mostafa YA, et al. Volumetric changes of the nose and nasal
airway 2 years after tooth-borne and bone-borne surgically
assisted rapid maxillary expansion. Eur J Oral Sci.
2013;121:450–6.
Singh et al. 3D nasal cavity volume
7
[Epub ahead of print]
13 13
None.
None.
Prof . S i ng h is CE O o f Bio M o d e li n g
Solu tions, Inc.
#1022013
12 CRANIOH: The Journal of Craniomandibular & Sleep Practice 2016 VOL. 34 NO. 1
Downloaded by [Professor G. Dave Singh DDSc PhD DMD] at 10:27 06 March 2016
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Background/objectives/aims: Controversy exists regarding maxillary bone changes in nongrowing adults. However, previous studies have relied on two-dimensional (2D) cephalometric analyses, which may be unable to capture three-dimensional (3D) phenomena. In this study, we investigated 2D and 3D parameters to test the null hypothesis that maxillary bone volume cannot be changed in nongrowing adults that had been diagnosed with midfacial underdevelopment. Methods: After obtaining informed consent, we undertook 3D cone beam computed tomography scans of 11 consecutive, adult patients prior to and after biomimetic, oral appliance therapy. The mean treatment time was 18.4 months ± 2.5 using the DNA appliance® system. The intramolar width and 3D volume of the midface was calculated prior to and after the midfacial redevelopment protocol. The findings were subjected to statistical analysis. Results: The mean intramolar increased from 33.5 mm ± 3.4 prior to treatment to 35.8 mm ± 2.9 after appliance therapy (p = 0.0003). Similarly, the mean midfacial bone volume was 17.4 cm3 ± 3.9 prior to treatment and increased to 19.1 cm3 ± 2.6 after appliance therapy (p = 0.0091). Conclusion: These data support the notion that maxillary bone width and volume can be changed in nongrowing adults. Furthermore, midfacial redevelopment may provide a potentially-useful method of managing adults diagnosed with obstructive sleep apnea, using biomimetic, oral appliances.
Article
Full-text available
This case report demonstrated the use of a novel, biomimetic, oral appliance (DNA appliance) that produced cosmetic facial enhancement, improved dental alignment, increased bone volume, and achieved upper aiway development without using any invasive procedures. Furthermore, this particular case demonstrated widening of the arch form and smile without reducing tooth structure. Indeed, 3D analysis was undertaken, which localized the regions in which the changes were produced by the oral appliance to confirm the clinical findings. It is concluded that this innovative protocol may be used in cosmetic dental practice as an alternative technique to surgery or other invasive procedures to enhance facial aesthetics and gain other beneficial functional changes.
Article
Full-text available
The aim of this study was to evaluate factors affecting the usage of continuous positive airway pressure (CPAP) device in patients with obstructive sleep apnea syndrome (OSAS). This study included 47 patients with OSAS who were suggested to use CPAP device at home and expected to use the device for at least 6 months. The compliance of CPAP device was determined by 2 different methods. In subjective evaluation, total time for usage of the device was recorded according to patients' declaration. In objective evaluation, total time of usage was recorded from the counter on device and it was divided into the number of days passed from the beginning of the treatment and at least 4 h of usage in a day was accepted as an effective usage. Data of compliant and non-compliant patients were compared in order to determine the factors affecting CPAP treatment. Ten patients were female, 37 of them were male and mean age was 52.98 ± 20.4 years. Mean Apnea Hypopnea Index (AHI) was 54.4 ± 20, mean oxygen saturation (SO2) was 87.3 ± 4.6 and mean CPAP pressure was 7.4 ± 1.9 in the whole study population. The compliance of CPAP treatment was found to be 48.9% according to objective evaluation whereas it was 80.9% according to subjective evaluation. Five of 8 patients (62.5%) who did not use the device stated the problems about the device mentioning the mask as a reason for their non-compliance. Treatment compliance was better in the patients with high Epworth sleepiness scale (16.5 ± 5.5 vs. 11.8 ± 4.1, p < 0.05). Epworth sleepiness scale of the patients who were compliant to the treatment was significantly decreased after the treatment both in subjective and objective evaluation. Treatment compliance wasn't different between male and female patients, however it was significantly lower in active smokers compared to non-smokers and ex-smokers. It was concluded that the most important factor associated with compliance to CPAP treatment in the patients with OSAS was Epworth sleepiness scale while mask related side effects might be a reason of treatment withdrawal and all these issues should be addressed carefully in order to increase compliance.
Article
Aims: There has been much published evidence that balance can improve by changing the mandible's position relative to the maxilla as it comes together with the teeth (or oral device) as the endpoint. To help with the complexity of this topic, a definitions table* (in Appendix) has been included at the end of the manuscript for reference as needed. The aim of the current study is to evaluate whether the physiologic rest position of the jaw* (oral device overtop of the teeth as endpoint where the muscles of mastication are optimized) can have an effect on cerebral blood flow and physical balance using measurable data relative to the person's natural, or habitual bite (teeth as endpoint) in both healthy and diseased volunteers. Methodology: Seven healthy male professional football athletes and two females with multiple sclerosis were included in this observational study, which tested the subjects in both jaw positions. Cerebral blood flow was measured non-invasively by ultrasound over the temporal region of the skull using mean flow velocity (MFV)* and pulsatility index (PI)* of the right and left middle cerebral arteries while the subject clenched the teeth together in both jaw positions. The MFV is the average speed of the blood flow in a given region of a blood vessel. The PI measures cerebral intravascular resistance. Physiologic balance of the whole body was also tested while the subjects were in both jaw positions using the y-excursion balance test* and by videotape. Results: (i) Cerebral blood flow. On the natural teeth, the MFV dropped from baseline to clenching position (mean drop -2.6±7.7 cm/second, whereas, the MFV was slightly enhanced with the physiologic rest position (PRP) [mean enhancement is 0.82±3.7 cm/second (P=0.07)]. At baseline on natural teeth, the PI dropped slightly from baseline to clenching (mean drop 0.015±0.19). Whereas with PRP, the PI dropped by mean of 0.059±0.072 (P=0.15). (ii) Balance. The mean balance measurement while using the PRP was 119.54±12.56 cm (P=0.001), whereas the mean balance measurement on natural teeth was 110.72±9.47 cm. Balance improved subjectively in both MS patients on videotape. Conclusion: The physiologic rest position of the mandible might have an effect on balance by showing a trend (demonstrating a tendency) in enhancing cerebral blood flow as measured by transcranial Doppler. Further studies are needed to confirm this study's finding.