This presentation is intended for educational purposes only. Statements of facts and opinions expressed are those of the educator/doctor individually, and unless expressly stated to the contrary, are not the opinion of the course sponsor, Vivos Therapeutics, Inc.

Origins of Sleep Apnea – How Did We Get Here?

Presenter Name: Dr. Ben Miraglia, DDS

This presentation is intended for educational purposes only. Statements of facts and opinions expressed are those of the educator/doctor individually, and unless expressly stated to the contrary, are not the opinion of the course sponsor, Vivos Therapeutics, Inc.

Statements of facts and opinions expressed are those of the educator/doctor individually, and unless expressly stated to the contrary, are not the opinion of Vivos Therapeutics, Inc.

Any use of the Vivos appliances outside of or “off label” from the FDA Cleared and/or Registered Indication(s) for use is the sole responsibility of the treating dentist at her/his clinical discretion and is not the teachings, guidelines, or recommendation of Vivos Therapeutics, Inc.

Vivos does not have an appliance to treat children diagnosed with Sleep Disordered Breathing. Any use of the Vivos appliances outside of or “off label” from the FDA Cleared and/or Registered Indication(s) for use is the sole responsibility of the treating dentist at her/his clinical discretion and is not the teachings, guidelines, or recommendation of Vivos Therapeutics, Inc.

HIPAA Please do not photograph or record any of the minor patients in this

presentation.

All patients shown are treated by Dr. Ben Miraglia

Any reproduction and use of the patient case content is a violation ofHIPAA

“This presentation is intended for educational purposes only. Statements of facts and opinions expressed are those of the educator/doctor individually, and unless expressly stated to the contrary, are not the opinion of the course sponsor, Vivos Therapeutics, Inc.”

WHY ARE WE HERE?

For the overall growth, development, health and longevity of our young

patients.

5

Children are struggling with symptoms…

ADHD

Bedwetting

Upper respiratoryinfections

Ear infections/tubes

Night terrors

Academic struggles

Hyperactivity

Aggressive behavior

Clenching/Grinding

Restless sleep/wakes

Asthma

Small/Delayed growth

Anxiety

Depression

Daytime sleepiness

Overweight

Obesity

Night sweats

GI distress/reflux

Emotional instability

Sensory issues

Snoring

Mouth breathing6

How did this child get here?What do we see?

How did this child get here?What do we see?

The most common orthodontic problem is a crowded malocclusion.

1. Improper Arch Form

Causes of Crowded Malocclusion

10

Causes of Crowded Malocclusion Improper vs. Proper Arch Form

1. Improper Arch Form

2. Improper Arch Width

1. Transverse Measurement

2. The Eyes

Causes of Crowded Malocclusion

12

Improper Arch Width

2. Improper Arch Width

Transverse Measurement

The shortest distance between teeth 3 and 14.

Children who develop naturally without orthodontic intervention become adults who achieve a 35-39mm transverse measurement.

14

Transverse Measurement - Arch Width

Boley Gauge Cotton Roll

15

Transverse Measurement Arch Width

Boley Gauge Cotton Roll

37mm

PRIMARY TEETH

The Eyes

Venous Pooling - purple/blue discolorationunder the eyes

CO2 is a vasodilator

Mouth breathing reduces blood CO2

Less CO2 means less vasodilation or morevasoconstriction

The inferior orbital vein is a superficial vessel,when it contricts we see…

VENOUS POOLING

17

VENOUS POOLING

LET’S PUT SOME PIECES TOGETHER

Improper arch form and width are the result of underdevelopment of themaxilla and mandible.

I.E: An underdeveloped maxilla and mandible is the cause ofmalocclusion

An underdeveloped maxilla has an adverse effect on the position of themandible. It traps the mandible in a retruded position.

Craniofacial Growth & Development Normal growth is wide, forward and downward

Abnormal growth is narrow, backward and downward

Abnormal growth is underdevelopment

Professionally known as Craniofacial Deficiency

Ideal Craniofacial Growth & Development

21

Ideal Craniofacial Development – Age 5

1. A significant space between all primary teeth2. A full view of the lower teeth when closed3. Forward growing

Ideal Craniofacial Development – Age 5

23

Ideal Craniofacial Development - Age 5

Ideal Craniofacial Development - Age 5

UNICORN

Ideal Craniofacial Development – Age 12

38mm

Ideal Craniofacial Development – Age 12

Craniofacial Growth & Development

When do we get our maxillary and mandibular growth?

29

% OF MM GROWTH ACHIEVED AGE MALE FEMALE AVERAGE

INCREASE

0-2 54% 54% 54%2-4 73% 78% 21%5

6

7

8

9

10

11

12

% OF MM GROWTH ACHIEVED AGE MALE FEMALE AVERAGE

INCREASE

0-2 54% 54% 54%2-4 73% 78% 21%5 76% 81% 3%6 79% 84% 3%7 81% 85% 2%8 83% 87% 2%9 84% 89% 2%10 86% 91% 2%11 88% 93% 2%12 89% 94% 1%

Craniofacial Deficiency

Next question…

Why are the maxilla and mandible underdeveloped?

Anthropology Research

Four researchers: Dr. James Sim Wallace

Dr. Westin A. Price

Dr. Robert Corruccini

Dr. Jerome Rose

What do we tell parents when we see crowded/tight primary teeth?

35

“An early SOFT DIET prevents the development of the

muscle fibers of the TONGUE resulting in a WEAKER

TONGUE which can not drive the primary dentition out

into a spaced relationship with fully developed ARCHES

which will lead to more crowding of the permanent

teeth.”

JAMES SIM WALLACE, DDS - 1900’s

WESTON A. PRICE, DDS BORN IN 1870 RESEARCH DONE DURING THE EARLY 1900’S

10 YEAR PERIOD OF TRAVEL

14 COUNTRIES

100’S OF CITIES

LOOKING FOR SECRETS OF HEALTHY PEOPLES

STUDIED ISOLATED, PRIMITIVE GROUPS LIVING ON INDIGENOUS FOODS

ESKIMOS, NATIVE AMERICANS, AFRICAN TRIBES, AUSTRALIAN ABORIGINALS, POLYNESIANS ETC.

THE PEOPLE HE OBSERVED… DISPLAYED PHYSICAL EXCELLENCE

HAD PERFECT JAWS AND TEETH

EMOTIONAL STABILITY

NO ALLERGIES

COMMONALITIES BREASTFEEDING FOLLOWED BY A GRITTY, HARD DIET AT AN EARLY

AGE

NATURAL FOODS FROM SEA, PLANT AND MEAT

MOSTLY A RAW DIET WITH LITTLE COOKING OF THE FOOD

MEATS ARE DRIED AND CURED, SOME SALT

NO SUGAR, NO PRESERVATIVES, NO CHEMICALS,

NO CANNED OR PROCESSED FOODS

CHANGES OCCUR ONCE ISOLATION IS BROKEN

ESKIMOS DISPLAYED PERFECT OCCLUSION WITH EXCELLENT MAXILLARY

WIDTH

AFTER CONTACT WITH INDUSTRIALIZED SOCIETIES – A SHIFT TOSOFT FOODS AND REFINED SUGARS

MALOCCLUSION RATES ROSE TO OVER…

50% IN THE FIRST GENERATION!

WESTON A. PRICE, DDS All documented is his book

Nutrition and Physical Degeneration

Dr. Robert S. Corruccini

He wrote the book…

Mentor, Colleague, Friend…

Dr. Robert S. Corruccini ANTHROPOLOGIST

30+ YEARS OF RESEARCH

7 BOOKS

HUNDRES OF JOURNAL ARTICLES

FOSSIL STUDIES

POPULATION STUDIES

ANIMAL TESTING

PRIOR TO 400 YEARS AGO…

LITTLE TO NO EVIDENCE OF MALOCCLUSION

POPULATION STUDIES DR. CORRUCCINI TRAVELED THE WORLD

STUDIED ISOLATED RURAL PEOPLES

BREASTFEEDING

ALL HAD A HARD DIET

LITTLE TO NO INCIDENCE OF MALOCCLUSION OR OTHER DEGENERATIVE DISEASES

LITTLE TO NO VARIATION

ALSO STUDIED SEVERAL POPULATIONS AS THEY BECAME EXPOSED TO WESTERN CULTURES

ANIMAL STUDIES DECADES WORTH OF HARD-SOFT DIET STUDIES

RESULTS ALWAYS THE SAME:

SOFT-DIET ANIMALS

SMALLER BODY MASS

LESS DENSE BONE

SMALLER, WEAKER ORAL MUSCULATURE

NARROWER MAXILLA

SMALLER MANDIBLE

THINNER ALVEOLUS

SMALLER CONDYLES

BROKEN ISOLATION MALOCCLUSION SHOWS UP IN THE FIRST

GENERATION AFTER EXPOSURE TO PREPARED, PROCESSED AND PRESERVED FOODS

50%

MALOCCLUSION RATES RISE DRAMATICALLY INTO THE SECOND GENERATION

70%

AND THIRD GENERATION

85%

AND FOURTH GENERATION

>90%

VARIATION ALSO INCREASES

CONCLUSIONS BREASTFEEDING RESULTS IN PROPER TRAINING AND

DEVELOPMENT OF THE TONGUE

THEN THE EARLY HARD DIET CONTINUES THE PROCESS

WHEN THE TONGUE POSTURES, SWALLOWS AND SPEAKS PROPERLY, WEGET IDEAL GROWTH

MOST MALOCCLUSIONS ARE ACQUIRED, NOT INHERITED

MALOCCLUSION IS A DISEASE OF WESTERN SOCIETY

DR. CORRUCCINI “DIETARY CONSISTENCY AND TOUGHNESS PROMOTE PROPER

BONE GROWTH AND PROPER PERMANENT TOOTH ERUPTION, BRINGING ABOUT IDEAL OCCLUSION; WHEN NONRESISTANT PROCESSED FOODS BECOME UBIQUITOUS AFTER INDUSTRIALIZATION, AND THE ERUPTION AND CUSPAL COORDINATION OF TEETH LOSE THE CRITICAL PATHFINDER INFLUENCE OF VIGOROUS MASTICATORY PRESSURES, MALOCCLUSION SHOWS A RAPID RISE.” from: How Anthropology Informs the Orthodontic Diagnosis of Malocclusion’s Causes

Dr. Scott Bolding, Dr. Jerome Rose, Me

Dr. Jerome Rose

“95% of all malocclusions are acquired. Genetics play a role in only 5% of malocclusions. This is indisputable.”

Breastfeeding Trends in the USA The current rate is 70%

Drops to 50% at 6 months – partial/pumping

Bottle feeding/jar or blended food is different(soft)

Results:

Tongue is not trained properly – poor function

Tongue musculature is weaker – poor growth

Child misses the optimal growth and development of the maxilla and mandible during the first 2 years of life

56

Graduates ‘Puffs’. The nutritious snack that melts in baby’s mouth.

A BETTER CHOICE…

57

Craniofacial Deficiency Next question…

WHAT ARE THE RESULTS OF HAVING AN UNDERDEVELOPED MAXILLA AND MANDIBLE?

WE NEED TO LOOK AT OUR ANATOMY FOR THE ANSWERS.

MAXILLA

61

AIRWAY ANATOMY

Airway Anatomy

THE UNDERDEVELOPED MAXILLA AND MANDIBLE RESULT IN A CHILD WITH A

COMPROMISED…

AIRWAY

AGE 10 - AIRWAY

63

AGE 10 – AIRWAY?

64

CLASS I COMPARISON

AGE 10 AGE 10

Genetics

Twin Studies

COMPARE

12 MONTHS LATER

12 MONTHS LATER

12 MONTHS LATER

Airway Anatomy

Our airway anatomy is directly related to our craniofacial growth anddevelopment

The more ideal the craniofacial growth and development, the larger theairway space

Craniofacial deficiency includes airway compromise/deficiency

Airway compromise/deficiency results in compensation

NASAL BREATHING VS.

MOUTH BREATHING

77

DR. EGIL HARVOLD

• Director – Center for Craniofacial Anomalies –UCSF

• Research – Primate Center – UC – Davis• Rhesus monkeys• Blocked monkey’s noses with cotton rolls• Conducted airway studies• Nasal obstruction > mouth breathing >

lower tongue posture > malocclusion

Dr. Sten Linder-Aronson Dr. Sten Linder-Aronson – children

Research focus was the difference between nasalbreathing kids and mouth breathing kids

Same results – mouth breathers developdifferently

MOUTH BREATHING + POOR TONGUEPOSITION/FUNCTION = HIGH RATES OFMALOCCLUSION

FUNCTIONS OF THE NASAL CAVITY FILTER

HUMIDIFY

WARM

ACCELERATE

One Purpose:

Prepare the air for the lungs

PROPER NASAL BREATHING LIPS TOGETHER AND AT REST

TONGUE AT THE ROOF OF THE MOUTH

INVISIBLE

SILENT

NO MOVEMENT OF LIPS AND CHEEKS DURING SUBCONSCIOUS SWALLOW

END RESULT: NON-RESISTANT AIRFLOW

NASAL BREATHING DIAPHRAGMATIC BREATHING FILLS THE LUNGS WITH IDEAL AIR

LEADS TO OPTIMAL CO2, O2, NO BALANCE

END RESULT: A PROPERLY OXYGENATED, WELL BALANCED,HEALTHY CHILD

The perfect person breathes as if they do not breathe.

Sixth century B.C. philosopher

Lao Tzu

82

MOUTH BREATHERS DEVELOP POORLY

MOUTH BREATHERS INCREASE IN UPPER RESPIRATORY INFECTIONS

INCREASE IN ENT INFECTIONS

INCREASE IN ASTHMA

WHY?

MOUTH BREATHING COMPENSATION

OVERBREATHING, AKA HYPERVENTIALTING

DECREASED CO2 – CHEST BREATHING

DOES NOT FILL THE LUNGS WITH IDEAL AIR

IMBALANCE IN CO2, O2, NO

END RESULT: A POORLY OXYGENATED, IMBALANCED, ANDUNHEALTHY CHILD

MOUTH BREATHING

VENOUS POOLING

CO2 HAS A VASODILATORY EFFECT

MOUTH BREATHING REDUCES BLOOD CO2

INFERIOR ORBITAL VEIN CONSTRICTS

THE RESULT IS VENOUS POOLING

ALSO

NASAL BREATHING RELEASES NITRIC OXIDE FROM THE PARANASAL SINUSES

MOUTH BREATHERS REDUCE BLOOD NO

INFERIOR ORBITAL VEIN CONSTRICTS

THE RESULT IS VENOUS POOLING and…

87

MOUTH BREATHERS INCREASE IN UPPER RESPIRATORY INFECTIONS

INCREASE IN ENT INFECTIONS

INCREASE IN ASTHMA

WHY?

The decrease in NO

NO is antibacterial, antiviral and antifungal

Connecting the Dots…

“Mouth breathing has been linked to oral conditions such as craniofacial deformity, malocclusion and obstructive sleep apnea.”

García Triana, B., Hibatulla Ali, A., & Grau León, I. (2016). Mouth breathing and its relationship to some oral and medical conditions: physiopathological mechanisms involved. Revista Habanera De Ciencias MéDicas, 15(2).

Recuperadode

Connecting the Dots… “A narrow maxilla with high arched palate characterizes a phenotype of patients

with obstructive sleep apnea. This is associated with increased nasal airflow resistance and posterior displacement of the tongue.”

Johal A, Conaghan C. Maxillary morphology in obstructive sleep apnea: a cephalometric and model study. Angle Orthod. 2004;74:648-656.

Abdullantif J, Certal V, Zaghi S, et al. Maxillary expansion and maxillomandibular expansion for adult OSA: a systematic review and meta-analysis. J Craniomaxillofac Surg. 2016;44:574-578

90

Connecting the Dots… “Snoring is associated with straight profiles, V-shaped palatal morphology,

increased neck circumference, decreased upper arch length, and decreasedinter-first upper premolar distance.”

Al-Madani GH, Banabihl SM, El-Sakhawy MM. Prevalence of snoring and facial profile type, malocclusion class and dental archmorphology among snorer and nonsnorer university population. J Orthodont Sci 2015;4:108-12.

91

CONNECTING THE DOTS… “Patients with OSA had significantly narrower maxillary and mandibular arch

widths when compared to control groups. These findings support the notionthat a narrow maxilla or mandible may lead to airway obstruction because of

inadequate space for the tongue. Thus when the space in the oral cavity is inadequate, it is possible that a normal sized tongue can gravitate to the back of

the oro-pharynx.”

Banabilh SM, Suzina AH, et al. Dental arch morphology in south-east Asian adults withobstructive sleep apnoea: geometric morphometrics. Journal of Oral Rehabilitation 2009;36:184-

192.

92

ADENOIDS AND TONSILS

Tonsils

Class 3 Adenoid

Dr. Christian Guillemenault Stanford University

Childhood Sleep Disordered Breathing Research

Tonsil & Adenoid removal research

Unsuccessful 9-12 months post removal

Mouth vs. Nose

Conclusion: Nose breathing is the ultimate outcome

Connecting the Dots… In 98% of patients with OSAS, the condition is due to abnormal

anatomical features of the soft tissues and/or the structures of themaxillomandibular skeleton that cause a “disproportionate anatomy” of the airway,4,5 and in only 2% of adult patients is the condition due

to a space-occupying lesion, such as adenoidal, tonsillar or uvula hypertrophy, in which case resection would be curative.

Barceló X, Mirapeix RM, Bugés J, Cobos A, Domingo C. Oropharyngeal Examination to Predict Sleep ApneaSeverity. Arch Otolaryngol Head Neck Surg. 2011;137(10):990–996. doi:10.1001/archoto.2011.176

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SLEEP DISORDERED BREATHING

99

SLEEP DISORDERED BREATHING (SDB)

Karen Bonuck, PhD.

Published research in 2012 that followed 11,000 kids for 6 years

Objective

Examine statistical effects of SDB symptom trajectories from 6 months to 7 years on subsequent behavior.

Youtube -Dr. Karen Bonuck Sleep Disordered Breathing Children

Results of Dr. Bonucks Research “A STRONG AND PERSISTENT ASSOCIATION BETWEEN

SLEEP DISORDERED BREATHING AND DIMINISHED IQ”

SLEEP DISORDERED BREATHING INCREASED THE RISKOF ADD/ADHD BY 50%

SLEEP DISORDERED BREATHING KIDS WERE 40-100%MORE LIKELY TO HAVE NEURO-BEHAVIORAL ISSUES

SDB/OSA ASSOCIATED WITH

INCREASED FACE HEIGHT

DECREASED NOSE PROMINENCE

DECREASED NOSE WIDTH

RETROGNATHIC MANDIBLE

THIS IS THE FACE OF SDB/OSA

SDB/OSA ASSOCIATED WITH NARROW ARCHES

HIGH VAULT

ELONGATED SOFT PALATE

RETROGNATHIC MAXILLA

RETRUDED MANDIBLE

THIS IS THE ORAL CAVITY OF SDB/OSA

“Hi, my name is Olaf and I like warm hugs.”

“I also wear a CPAP to bed. Can I get some nostrils?”

SLEEP DISORDERED BREATHING• Mouth breathing - Snoring - UARS - OSA

• Increased nasal airflow resistance

• Sympathetic Nervous System activation

• Altered biochemistry and physiology during sleep

• End result: sleep fragmentation or disruption of the reparative sleep

cycle delivers an unhealthy child who will grow up to be an unhealthy

adult

TONGUE TIE

Ankyloglossis

AKA – tongue-tie

Abnormal shortness of the lingual frenum causing limited movement of the tongue

TONGUE TIE RELATED TO DEVELOPMENT

“Restricted tongue mobility was associated with narrowing of themaxillary arch and elongation of the soft palate. These findings suggestthat variations in tongue mobility may affect maxillofacial development.”

Yoon AJ, Zaghi S, Ha S, Law CS, GuilleminaultC, Liu SY. Ankyloglosisas a risk factor for maxillary hypoplasia and soft palate elongation: A functional-morphological study. Orthod Craniofac Res.

2017;00:1-8.

ONE STEP FURTHER…

“Soft palate length is significantly greater in OSA patients and it is wellestablished that increased soft palate length is a prominent risk factor forupper airway collapsibility.”

Shigeta Y, Ogawa T, Tomoko I, Clark GT, Enciso R. Soft palate length and upper airway relationship in OSA and non-OSA subjects. Sleep Breath. 2010;14:353-358.

Sforza E, Bacon W, Weiss T, Thibault A,Petiau C, Krieger J. Upper airway collapsibility and cephalometric variables in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2000;161:347-352.

TIE it all together… “Children with untreated short frenulum developed abnormal tongue

function early in life with secondary impact on orofacial growth and sleep disordered breathing(SDB).”

“Short lingual frenulum may lead to abnormal orofacial growth early in life, a risk factor for development of SDB.”

Huang YS, Quo S, Berkowski JA, Guilleminault C (2015) Short Lingual Frenulum and Obstructive Sleep Apnea in Children. Int J Pediatr Res 1:003

PACIFIERS

Worth a Thousand Words?

NON-NUTRITIVE SUCKING

PACIFIER

FINGERS

SIPPY CUPS

STRAWS

119

NON-NUTRITIVE SUCKING FORM FOLLOWS FUNCTION

TONGUE

FACIAL MUSCLES

RESULTS OF NON-NUTRITIVE SUCKING

IMPROPER ARCH FORM

IMPROPER ARCH WIDTH

NARROW AND HIGH VAULTED PALATE

I.E. UNDERDEVELOPMENT

I.E. AIRWAY COMPROMISE

Behavior

Patient 3

Cognitive Development

Referred by pediatrician

Thumb habit

Struggling

Patient 4

Summary

The early soft diet results in muscle weakness and dysfunction

The soft tissue weakness and dysfunction results in underdevelopment

Craniofacial deficiency includes airway deficiency/compromise

Airway compromise leads to sleep disordered breathing

SDB results in sleep fragmentation

Ultimately compensatory breathing and sleep fragmentation deliverunhealthy children who struggle with a long symptom list

An unhealthy child grows up to be an unhealthy adult

Better to treat the craniofacial deficiency early

“It is evident that the next great step in medical progress in the line of preventive medicine should be made by the dentists.

The question is will they do it?”

Dr. Charles H. Mayo, M.D. (1865-1939)

THANK YOU!