Sample detailed case report

Patient X

SYNOPSIS

INTRODUCTION:

This patient was a 64-year-old Caucasian female (16/01/1952) with the chief complaint of
snoring. She initially consulted her general medical practitioner regarding her symptoms, who
referred her to a sleep physician. After undergoing a sleep study, Mrs X was diagnosed with
moderate obstructive sleep apnoea/hypopnea, which was severe in the supine position. Her
sleep physician referred her to trial a Mandibular advancement splint (MAS). She presented
to me for a consult on 24/08/2020.

CHIEF COMPLAINT:

The patient’s chief complaint was snoring which disturbed her partner’s sleep. Her partner
rates her snoring as moderately loud, rating it 6/10 on a Numerical Rating Scale (NRS). There
were no reports of witnessed apnoeic events. She reported waking up with a headache once
a week and feeling moderately unrefreshed upon waking most days. Mrs X experiences mild
lethargy during the day and occasional drowsiness with sedentary activities during the day
and evenings. As a result, she felt her general motivation levels were low. She did not report
any mood disturbances.

HISTORY OF PRESENT ILLNESS:

The patient has been aware of her snoring for a number of years, and her partner reported
its progressive worsening. However, she did not suspect obstructive sleep apnoea as she was
unaware of such a diagnosis prior to her complaint of snoring. She initially trialed home-made
positional appliance to reduce her time slept on her back, as her husband noted worse snoring
in the supine position. Unfortunately, she was not able to tolerate it for extended periods of
time and found it resulted in poorer sleep quality. A lab/hospital-based sleep study was
completed on the 6th of July 2020. This revealed an Apnoea- Hypopnoea index (AHI) of 16.6
and the lowest oxygen saturation concentration of 92%. CPAP was initially trialed, but the
patient could not tolerate the sensation from positive pressures and found it restrictive as she
was unable to move around. Additionally, her husband also found the machine to be loud.
After a month of trialing the CPAP, she was non-responsive as she was intolerant of the
machine. As such, a mandibular advancement splint was recommended.

PAST MEDICAL HISTORY:

Address: Level 1, 5 George St, North Strathfield NSW 2137 ABN: 51 138 032 014
Phone: 61 2 9920 1968 email: [email protected] web: www.sleep.org.au
Mrs X weighs 67kg and is 164cm tall, with a BMI of 17.8. She has Wolf-Parkinson-White,
hypothyroidism and asthma, which are well controlled pharmacologically. She had a motor
vehicle accident (MVA) in 2015, which resulted in C6/C7 compression fracture. A cervical
spine fusion was completed. She has resultant chronic left arm and neck pain post-MVA but
does not report interferences with sleeping positions as a result of this.

CLINICAL AND RADIOGRAPHIC EXAMINATION:

The patient had the following missing teeth: 21 and 45. There was a Porcelain fused to metal
(PFM) bridge from the 12-22 (4 units) aimed to replace the missing 21, and PFM crowns on
the 16, 17 and 46. She has completed endodontic treatment on her 16. Her remaining
restorative work was in good condition. There were no periodontal pockets (CPITIN 0,1,0,
0,0,0). Mrs X has a Class II div II occlusion with her midline 2mm to the left. Her maximum
mouth opening was 42mm, right lateral excursion 8mm, left lateral excursion 8mm and she
was able to protrude up to 9mm. There were no masticatory muscles or TMJ tenderness or
pain upon palpation or function. There was no clicking, deviation or deflection noted. She had
a large tongue, medium sized soft palate, medium sized uvula and had her tonsils present.
There were no soft tissue lesions noted.

DIAGNOSIS:

Overnight polysomnogram on the 6th of July 2020 revealed moderate obstructive sleep
apnoea/hypopnoea and mild periodic limb movements. Her AHI was 16.6 and had a lowest
O2 desaturation of 92%. Her obstructive sleep apnoea was considered to be severe in the
supine position and REM sleep, both with an AHI of 38.5.

RATIONALE:

A Somnodent Fusion mandibular advancement appliance was chosen due to its comfort and
ease of use. Patient was motivated and capable of understanding its titration mechanism,
which allowed her to titrate the appliance independently if necessary and able. It also allowed
for vertical movement so patient can breathe through her mouth if required. The acrylic
material allowed for any adjustment if the patient was to undergo dental treatment. Her
starting treatment position was 5mm out of a possible 9mm (55.5%).

RESULTS:

Patient reports subjective improvements in sleep parameters prior to objective sleep

assessment. The success of the appliance was initially compounded by a reduction in
compliance due to maxillary teeth tenderness and its interference in her daily life. However,
after adjustments, patient was able to cope with the appliance which led to large
improvements in subjective symptoms.
Treatment polysomnogram was completed on 24th of January 2021. The treatment sleep
study revealed an AHI of 5.5 and lowest O2 desaturation of 94%. Patient did not sleep supine
in this sleep study. However, AHI in REM sleep improved from 38.5 to 13.6. She was
recommended to continue wearing the appliance nightly at the current treatment position,
which was 6.4mm out of 9mm (71.1%)

FDSM Sample complex case report – © Australasian Sleep Association 2

DISPOSITION:

A treatment sleep study was completed on the 24th of January 2021, which was analyzed by
a sleep physician. It confirmed the success of the appliance, with the physician stating there
was objective improvement in her AHI, with a reduction from 17 to 6 apnoeas/hypopnoeas
per hour of sleep and no significant side effects. Given her improvements in her symptoms
(snoring, decreased morning tiredness, daytime somnolence, sleep disturbances) and
objective reduction of her AHI, she was recommended to continue utilizing her mandibular
advancement appliance to manage her obstructive sleep apnoea. The sleep physician
scheduled no further reviews with her.

FOLLOW UP VISITS

Patient DOB: 16/01/1952

Initial consult: 24/08/2020
Appliance insert: 21/09/2020

DOS: 19/10/2020
• Subjective: Patient has a history of moderate obstructive sleep apnoea and presents
for her 1 month follow up with the use of her Somnodent Fusion mandibular
advancement appliance. Medical history, family history and social remains
unchanged. No significant weight change is reported. Patient reports she her snoring
is 100% improved with the use of the appliance. Patient awakens feeling refreshed on
most days and experiences mild lethargy and occasional drowsiness with sedentary
activities during the day and evenings. The main side effect reported maxillary anterior
teeth soreness in the morning, which can persist for several hours. Patient reports this
interferes with her breakfast and finds this bothersome. She reports avoiding using
the appliances some days because of this pain and as such, feels her symptoms of
tiredness and lethargy has not completely resolved.
• Objective: General appearance remains unchanged. There was mild bilateral
masseter tenderness and no TMJ pain. Maximum mouth opening in increased to
45mm. Right, left and protrusive excursions remain the same (8mm, 8mm and 9mm
respectively). Occlusion remained the same and there were no bite changes or teeth
mobility. There was no clicking, deviation or deflection noted Intra-orally, no
abnormalities were noted in any of the soft tissues. Appliance was titrated at 5.4mm
out of a possible 9mm (60%) and was mechanically sound. Maxillary anterior teeth
were not tender to percussion or sensitive upon testing.
• Assessment: Snoring reportedly resolved and there were improvements in subjective
scores as stated above. Obstructive sleep apnoea has subjectively improved with oral
appliance therapy. Confirmation of oral appliance success will need to be objectively
tested with a treatment sleep study.
• Plan: Recommended patient to continue wearing the appliance nightly and titrate the
appliance bilaterally by 5 turns (0.5mm) on a weekly basis due to her severe sleep
apnoea in supine and REM sleep. The anterior maxillary portion of the appliance was

FDSM Sample complex case report – © Australasian Sleep Association 3

adjusted to better accommodate her maxillary teeth. A follow up was scheduled in 2
months.

DOS: 12/12/2020
• Subjective: Patient has a history of moderate obstructive sleep apnoea and presents
for her 3 month follow up with the use of her Somnodent Fusion mandibular
advancement appliance. Medical history, family history and social history remains
unchanged. No significant weight change was reported. Patient advises she has
maintained her 100% improvement in symptoms. Snoring has completely resolved
according to her partner and she still awakens feeling refreshed. She does not
experience any lethargy. Patient experiences drowsiness with sedentary activities very
occasionally during the day and evenings. She still experiences some maxillary anterior
teeth soreness upon awaking, but it settles soon after waking and is not bothered by
it.
• Objective: General appearance remains unchanged. There was no masticatory muscle
pain or but mild left TMJ discomfort. She attributes this to having a recent flare up of
neck pain. Maximum mouth opening remained unchanged at 45mm. Right lateral
excursion has increased to 10mm and left lateral excursion has increased to 9mm.
Protrusion remains the same at 9mm. There was no clicking, deviation or deflection
noted. Occlusion has remained the same and there were no bite changes or teeth
mobility. Intra-orally, no abnormalities were noted in any of the soft tissues. Appliance
is titrated at 6.4mm out of a possible 9mm (71%) and is mechanically sound.
• Assessment: Snoring has reportedly resolved and subjective symptoms have
drastically improved as well. Obstructive sleep apnoea has subjectively improved with
oral appliance therapy. Confirmation of oral appliance success will need to be
objectively tested with a treatment sleep study.
• Plan: Recommended patient to continue wearing the appliance nightly at this
treatment position. Patient was referred for a treatment sleep study and a follow up
was scheduled in 5 months.

DOS: 22/05/2021
• Subjective: Patient has a history of moderate obstructive sleep apnoea and presents
for her 8 month follow up with the use of her Somnodent Fusion mandibular
advancement appliance. Medical history, family history and social remains
unchanged. No significant weight change is reported. Patient advised a sleep study
was completed, which confirmed the success of the appliance. Patient advises she has
slightly regressed with her symptoms recently but is mainly due to her role as a
caretaker to her young grandchildren on certain days. Her snoring remains resolved
and she still awakens refreshed. She experiences some mild lethargy but does not
experience drowsiness during the day or evenings. She no longer experiences
maxillary anterior teeth soreness upon awaking.
• Objective: General appearance remains unchanged. There was no masticatory muscle
or TMJ pain. Maximum mouth opening remained unchanged at 45mm. Right and left
lateral excursion has remained at 10mm and 9mm respectively. Protrusion remains
the same at 9mm. There was no clicking, deviation or deflection noted. Occlusion has
remained the same and there were no bite changes or teeth mobility. Intra-orally, no

FDSM Sample complex case report – © Australasian Sleep Association 4

abnormalities were noted in any of the soft tissues. Appliance was titrated at 6.4mm
out of a possible 9mm (71%) and is mechanically sound.
• Assessment: Obstructive sleep apnoea has improved to an AHI of 6 as confirmed by
objective testing, including REM sleep (down to 13.6 from 38.5).
• Plan: Recommended patient to continue wearing the appliance nightly at this
treatment position. A follow up was scheduled in 12 months.

PRE-TREATMENT SLEEP STUDY

POST-TREATMENT SLEEP STUDY

FDSM Sample complex case report – © Australasian Sleep Association 5

INTRA-ORAL PHOTOS

FDSM Sample complex case report – © Australasian Sleep Association 6

ANTERIOR VIEW in occlusion

RIGHT LATERAL VIEW in occlusion

FDSM Sample complex case report – © Australasian Sleep Association 7

LEFT LATERAL VIEW in occlusion

ANTERIOR VIEW with appliance

FDSM Sample complex case report – © Australasian Sleep Association 8

OCCLUSAL VIEW of models

OCCLUSAL VIEW of models with MAS

ANTERIOR VIEW of models

FDSM Sample complex case report – © Australasian Sleep Association 9

FDSM Sample complex case report – © Australasian Sleep Association 10
LEFT LATERAL VIEW of models

ANTERIOR VIEW of bite registration

RIGHT LATERAL VIEW of bite registration

FDSM Sample complex case report – © Australasian Sleep Association 11

LEFT LATERAL VIEW of bite registration

FDSM Sample complex case report – © Australasian Sleep Association 12