Obstructive Sleep Apnea and the Use of Cone

Beam Computed Tomography in Airway

Imaging: A Review
John M. McCrillis, Jennifer Haskell, Bruce S. Haskell, Michelle Brammer,
Douglas Chenin, William C. Scarfe, and Allan G. Farman
The use of cone beam computed tomography to permit three-dimensional
visualization of the airway is described. Obstructive sleep apnea is defined in
relation to associated anatomy. Work in progress examining the visualization of airway changes using one treatment modality, a mandibular advancement device, is discussed. (Semin Orthod 2009;15:63-69.) 2009
Elsevier Inc. All rights reserved.

bstructive sleep apnea (OSA) can be defined as a cessation of breathing during

sleep because of a mechanical obstruction such
as a retropositioning of the tongue in the airway,
a large amount of tissue in the upper airway, or
even a partially collapsed trachea. OSA is a common respiratory sleep disorder characterized by
snoring and episodes of breathing cessation or
absence of respiratory airflow (10 seconds)
during sleep and despite respiratory effort.1 A
rising occurrence rate in the general population
rivaling that of asthma and diabetes has been
variously credited to increased awareness, better
diagnostics, and a pandemic of obesity.2-4 Regardless of etiology, identifying the area of airway obstruction has often proven challenging.
Factors bearing on this challenge include the
difficulty in visualizing the airway in three dimensions, the difficulty of visualizing the airway
through its entire length, and the inability to

Private Practice, Louisville Dental Sleep Medicine, Louisville,

KY. Dental Student, School of Dentistry, The University of Louisville, Louisville, KY. Graduate Orthodontics Student, School of
Dentistry, The University of Louisville, Louisville, KY. Anatomage,
In Vivo Dental, San Jose, CA. Department of Radiology, School of
Dentistry, University of Louisville, Louisville, KY.
Address correspondence to: John M. McCrillis, DMD, Louisville
Dental Sleep Medicine, 2902 Taylorsville Road, Louisville, KY
40205. Phone: 502-458-7476; E-mail: drmcf_jm@insightbb.com
2009 Elsevier Inc. All rights reserved.
1073-8746/09/1501-0$30.00/0
doi:10.1053/j.sodo.2008.09.008

visualize the anatomical changes of various treatment methods.

Cone beam computed tomography (CBCT)
scanners have been available for craniofacial imaging since 2001 in the United Sates. Their compact
size and relatively low radiation dosage make the
CBCT scan an imaging modality that helps address
the previously stated challenges effectively and efficiently.5 The resulting volume of digital data
can be manipulated to allow the clinician threedimensional (3D) images that can be rotated in
three axes, can be selectively contrasted, emphasized, or reduced to visualize certain anatomical
structures such as the airway, and can be shared
electronically among any number of remote
sites.

Obstructive Sleep Apnea

The upper airway has three major functions:
ventilation, swallowing, and speech. For ventilation, the upper airway must remain patent, but
for the other functions, it must narrow or close.
In addition, ventilation must be maintained
when the nose is occluded or, alternatively,
when the mouth is closed. Integration of these
conflicting functions in one anatomical region is
complicated, and it is not surprising that intermittent failure of ventilation occurs.6 Additionally, the nose and mouth are the source of large
volumes of secretions that must be cleared via
the pharynx.

Seminars in Orthodontics, Vol 15, No 1 (March), 2009: pp 63-69

63

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J.M. McCrillis et al.

Patency of the pharynx is vital to the ventilation (respiratory) function. With the exception
of the two ends of the airway, that is, the nares
and the small intrapulmonary airways, the pharynx is the only collapsible segment of the respiratory tract. What became apparent only in the
1970s is that some individuals possess an adequate pharyngeal lumen for all respiratory functions while awake but have an obstructed lumen
during sleep.7,8

Anatomical Terms
Anatomical structures describing the various
portions of the pharyngeal airway, superiorly to
inferiorly, include:
Nasopharynx. The uppermost portion of the
airway, mainly the nose. It begins with the nares,
where air enters the nose, and extends back to
the hard palate at the superior portion of the
soft palate. This includes, then, the nasal septum
and the nasal turbinates.
Velopharynx (also known as the retropalatal
area). Extends from the hard palate to the inferior tip of the soft palate. Includes the uvula and
the uppermost segment of the posterior pharyngeal wall. Major muscles include the tensor palatini and levator pallatini, which elevate the soft
palate, and the musculous uvulae providing elevation of the uvula.
Oropharynx (also known as the retroglossal
area). Includes the oral cavity, beginning with the
back portion of the mouth and extending rearward to the base of the tongue. This segment of
the posterior pharyngeal wall includes the tonsils.
In this area are many muscles, both extrinsic and
intrinsic, that control tongue posture: genioglossus, palatoglossus, and the superior longitudinal
and transverse muscles of the tongue as examples.
Hypopharynx. Extends from the tip of the epiglottis to the lowest portion of the airway at the
larynx. A large number of muscles affect this
portion of the airway, often acting in concert
with or opposition to other related muscles.9

Sleep Apnea Events and Terms

OSA events are often described as follows:
Apnea (obstructive apnea), literally no breath. Cessation of airflow for 10 or more seconds.
Hypopnea (partial obstructive apnea), literally
low breath. Reduction of airflow below 70%

for 10 seconds or longer with a 4% or greater

blood oxygen desaturation. Alternatively defined as reduction of airflow below 50% for 10
seconds or longer with a 3% desaturation, or the
event is associated with arousal.10
Respiratory effort-related arousals (RERAs). An
arousal from sleep that follows a 10-second or
longer sequence of breaths that are characterized by increasing respiratory effort but which
does not meet criteria for an apnea or hypopnea.11
Upper airway resistance syndrome (UARS). A form
of sleep disordered breathing (SDB) in which
repetitive increases in resistance to airflow
within the upper airway lead to brief arousals
and daytime somnolence.12 There may be few, if
any, obvious apneas or hypopneas with desaturation, but snoring may be a very prominent
finding.13
Apnea/hypopnea index (AHI). An index of the
severity of the OSA, the AHI is calculated by
adding the total number of apneas and hypopneas observed and dividing by the number of
hours observed.14
Respiratory disturbance index (RDI). Many sleep
diagnostic centers use AHI and RDI interchangeably. While similar, the RDI also includes
respiratory events such as RERAs that do not
technically fit the definitions of apnea or hypopnea but do disrupt sleep.14
Mild, moderate, and severe OSA. Severity of OSA
is generally defined using the AHI/RDI (mild
5 to 15; moderate 16 to 25; severe 26 and
more). Exact boundaries are somewhat fluid,
leading to terms such as mild to moderate and
so forth, to better describe clinical reality. Additionally, it should be noted that the level of
severe is quite open ended with AHI/RDIs
exceeding 100 being well known.

Pathophysiology
OSA events occur when the pharyngeal airway
narrows or closes with respiratory effort during
sleep. Several concepts, among them a balance
of pressures, a modification that adds transmural pressure, and a tube law have been described in explanation of the many and varied
changes in the airway leading to these apneas
and hypopneas.15,16 This challenging and often
incredibly detailed work permits a summary description as follows.

CBCT in Airway Imaging

The pharyngeal airway is unique in having no

rigid support, instead being muscle and ligament formed and supported. During wakefulness, muscle tensions keep the lumen patent.
During sleep, as the muscles relax, the pharyngeal walls become more flexible and more collapsible. In the reclined position, the effects of
gravity distort the pharyngeal walls, especially by
retropositioning the tongue mass when supine,
resulting in a narrowed lumen.
As the desired volume exchange of air remains the same, a higher velocity is required
through the smaller passageway. This flow is turbulent17 and tends to produce vibration and
flutter of the flexible walls and soft palate, producing (often loud) snoring.
The narrower the lumen, the faster the velocity and the lower the pressure.18 At some critical
point, this combination of physical conditions
will result in an occluded airway (sucked shut).
Although breathing effort will continue, with
the diaphragm contracting downward forcefully
enough that the chest walls may be drawn inward, no air will be exchanged until there is
sufficient arousal (lighter level of sleep) to regain some muscle tension and reopen the pharyngeal airway.
This sequence of loud snoring, sudden silence, and loud resuscitative snort is not only
virtually pathognomonic for OSA, but is frequently the last straw that drives the offenders
family to force the individual to seek care.

65

3. Cardiac arrythmias
4. Sudden nocturnal death
5. Other (stroke, pulmonary hypertension)
Social/behavioral.
1.
2.
3.
4.

Drowsy driving/accidents
Decreased work performance
Poor quality of life19
Increased mortality20-22

Use of CBCT in Airway Imaging

Technology
CBCT provides, in a single rotation much like a
dental panoramic radiograph unit, precise, essentially immediate, accurate 3D radiographic
images (Figs 1 and 2). Collimation of the CBCT
primary x-ray beam allows limitation of exposure
to the region of interest or field of view (FOV).
By using megapixel solid state detection devices,
minimal voxel (3D pixel) sizes of 0.09 mm
0.25 mm are achieved, exceeding the highest
grade multislice CT in terms of spatial resolution. Reconstruction of the digital data for viewing is accomplished on a PC in close to real time.
Standard viewing layouts include the display of
coronal, sagittal, and axial data sets concurrently. The views can be rotated on all three

Symptoms and Consequences

Symptoms
1. Loud irregular snoring
2. Snorts, gasps, and other unusual breathing
sounds during sleep
3. Long pauses in breathing during sleep
4. Excessive daytime sleepiness
5. Fatigue
6. Obesity
7. Changes in cognitive functions such as alertness, memory, personality, or behavior
8. Impotence
9. Morning headaches19
Consequences
Cardiovascular.
1. Systemic hypertension
2. Coronary heart disease

Figure 1. Segmentation of airway in relation to hard

tissue using midline cone beam computed tomography ray-sum volume of Digital Imaging and Communications in Medicine data set and Anatomage InVivoDental software (San Jose, CA). (Color version of
figure is available online.)

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J.M. McCrillis et al.

Application

Figure 2. Airway and facial soft tissue surface segmented from 3D volume (Anatomage InVivoDental
software, San Jose, CA). (Color version of figure is
available online.)

axes. Cursor-driven measurement algorithms

provide the clinician with an interactive capability for real-time dimensional assessment.23

Dosimetry
CBCT provides a lower dose, lower cost alternative when compared with conventional medical
CT scans although somewhat more than typical
dental panoramic exposures.24 As noted by
Farman, ALARA (as low as reasonably achievable) still applies.25
Ludlow and coworkers looked at dosimetry of
3 CBCT devices for oral and maxillofacial radiology: CB Mercuray (Hitachi Medical Systems
America, Twinsburg, OH), NewTom 3G (QR,
Verona, Italy), and i-CAT (Imaging Sciences International, Hartfield, PA).
Utilizing thermoluminescent dosimeter chips
(TLDs) in a tissue-equivalent phantom (RANDOradiation analog dosimetry system; Nuclear Associates, Hicksville, NY), Ludlow and coworkers reported widely varying exposure levels depending
on not only the exposure settings but also the field
of view (FOV), which can range from 6

to 12

.
Dose levels reported were 4 to 77 times greater
than comparable panoramic examination doses.
Reductions in dose were seen with reduction in
field size and with mA and kV technique factors.24

In a review of medical therapy for OSA, Veasey

and coworkers state: OSA is a highly prevalent
syndrome that is associated with substantial morbidity and increased mortality. Positive air pressure (PAP) is the most uniformly effective therapy . . . However, approximately 25-50% of
patients with OSA will either refuse the offer of
PAP therapy, or will not tolerate it. Oral appliances and surgical procedures to improve upper
airway patency are successful in certain subsets
of patients, but a notable proportion of patients
do not receive adequate clinical benefit from
these approaches.26
Any technology that would enhance clinicians ability to visualize where in the airway
obstruction occurs would help identify those
subsets of patients who may or may not benefit
from a choice of treatment modalities. CBCT,
with its 3D presentation of the airway and its
surrounding structures, offers this increased visualization of both untreated obstruction tendencies and potentially of changes in the airway
by treatment modality.
Ogawa and coworkers demonstrated the utility of diagnosis of anatomy with the 3D airway
imaging with CBCT. They noted the ability to
describe significant group differences in total
airway volume and the anteroposterior dimension of the oropharyngeal airway between OSA
and gender-matched controls.27
The same group published additional findings notable in the use of a CBCT capable of
supine position imaging (Newtom QR DVT
9000; QA sri, Via Silvestrini 20, 37,135 Verona,
Italy). In this study of 10 OSA and 10 non-OSA
patients, statistically significant differences
were reported in: the anterior-posterior dimension of the minimum cross-section segment; the minimum cross-section area; and in
the percentage incidence of location of the
minimum cross-section above or below the occlusal plane. The OSA group presented a concave or elliptic shaped airway and the nonOSA group presented a concave, round, or
square-shaped airway.28
Shi and coworkers utilized anonymous
CBCT data sets from subjects imaged for conditions unrelated to the airway to evaluate
both a manual segmentation and an automated segmentation algorithm in measuring

CBCT in Airway Imaging

certain airway dimensions and airway volume.

They found no clinical significant difference
in the manual versus automated algorithms,
opening the door to further automated analysis of CBCT data sets.29
In a follow-up article, Farman and coworkers
demonstrated the immense flexibility of CBCT
in a highly visible Education in the Round
setting at the 148th American Dental Association
(ADA) Annual Session in San Francisco, September 26-30, 2007. Image production, processing, and export to third-party software was performed in real time. Multiple add-on services,
including model and positioning stent preparation from CBCT data sets, and 3-D photograph
production (3dMD, Atlanta, GA) were also
shown.30

67

In work in progress, Farman and coworkers

examine the possibilities of using different software packages to analyze changes in the upper
airway with and without placement of a mandibular advancement device (MAD). Image J, a
noncommercial software (National Institutes of
Health, Bethesda, MD), was used to look at horizontal plane file sets for cross-sectional area
changes. Anatomage (InVivoDental, San Jose,
CA) used the entire Digital Imaging and Communications in Medicine (DICOM) multifile
data sets to produce a color-contrasted blended
view of the airway changes with and without the
MAD in place (Figs 3 and 4). Excellent segmentation was achieved and it was possible to make
airway minimum cross-sectional area and volumetric assessment.31

Figure 3. Subtraction radiography using Anatomage InVivoDental software (San Jose, CA) to demonstrate
improvement in airway patency following placement of a mandibular advancement device. (Color version of
figure is available online.)

68

J.M. McCrillis et al.

Figure 4. Subtraction radiography using Anatomage InVivoDental software (San Jose, CA) to demonstrate
improvement in airway patency following placement of a mandibular advancement device. (Color version of
figure is available online.)

Summary
CBCT technology provides 3D images that provide the third dimension in dental/airway imaging. The rapid growth in numbers of new CBCT
imaging units being readied for the marketplace
evidences the interest of industry in this sector of
medical imaging.32 Further studies are required
to correlate the visualized airway characteristics
with clinical outcomes by treatment modality,
hence then to the possibility of treatment modality choice based on predictable outcomes.

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