The position of the mandible plays a key role for

determining airflow during sleep

Presenter: Le Dong Nhat Nam

Co-authors:
Martinot JB,Melki B,Denison S,Cuthbert V,Borel JC,Pépin JL.
Vertical mandibular mouvement signal amplitude is
associated with obstructive Hypopneas during sleep
Martinot JB et al. Front Neurol. 2017;8:353.
PMID: 28785240
It was hypothesized that mouthopening/closing at arousal is the
consequence of a local recruitment of jaw antagonistics muscles and not
the product of non specific general motor response (Kato et al JCSM 2013) .

To appreciate the importance for controlling vertical mouth opening during

oral appliance therapy which is still being questioned in the literature
(Pitsis et al AJRCCM 2002 ; Milano et al JDSM 2018 ; Martinot et al. Chest 2018 ) .
 Event
Arousal

Flow Flow
Mandibular
tranposition Restoration
VMM

Time

It is known that respiratory events are ASSOCIATED to

a vertical Mandibular Movement.

References
Senny et al IEEE Trans Biomed Eng. 2008
Cheliout-Heraut et al Neurophysiol Clin. 2011
 VMM
Event
(Arousal)
?
Flow Flow

Restoration

Time

Is the recovered Flow conditioned by the Mandibular transposition ?

 A causal inference…
 To establish a Causality: Bradford Hill’s 9 criteria

Austin Bradford Hill. "The Environment and Disease: Association or

Causation?". Proceedings of the Royal Society of Medicine. 1965; 58 (5):
295–300. PMID 14283879
 MM transposition occurs BEFORE the change of
Analogic signal: Masseter EMG nasal flux
Association with changes in Nasal flux ? Method: Sequence analysis, Probability network
Method: Sequence analysis 1

3
Reversibility : Impact of Mouth Compare nasal flux before and after MM
opening / Closing on Nasal flow event:
and Thoracic/Abdominal RIP ? Method: BSTM, Causal impact model
signals ?
Method: t-test Consistency in : Relationship between MM drift and nasal
1) Chronological order flux change
2) Significant causal impact Method: Linear regression
Method: Descriptive analysis
28 patients with OSAS

Random selection of 100 signal blocs with:

An obstructive respiratory event (Hypopnea/Apnea) + Micro arousal
5 signal bands: Masseter surface EMG, Nasal flux, VMM, Abdominal and Thoracic RIPs

Parameter Median IQR 95%CI

Age (year) 54.0 19.5 29.5 – 77.05
BMI (kg/m2) 29.6 11.35 22.19 – 51.825
TST (min) 381 93.15 182.78 – 522.50
AHI (n/h) 34.7 32.9 2.82 - 95.79
AI(n/h) 30.9 23.15 13.95 – 86.06
Automated detection in the fragment using a Binary Segmentation Algorithm
1) Temporality and Analogy
 Flow Baseline
Flow Change
Flow Stabilisation
VMM beginning
Musc. Contraction begin
Musc. Contraction end
VMM ending

Flow Stabilisation

VMM Muscle
 Flow Baseline
Flow Change
Flow Stabilisation
VMM beginning
Musc. Contraction begin
Musc. Contraction end
VMM ending

Flow change

VMM Muscle
 Flux Baseline
Flux Change
Flux Stabilisation
Begin VMM
Begin Musc. Contraction
End Musc. Contraction
End VMM

Flux change

VMM Muscle
 Flux Baseline
Flux Change
Flux Stabilisation
Begin VMM
Begin Musc. Contraction
End Musc. Contraction
End VMM

Flux change

VMM Muscle
 Flux Baseline
Flux Change
Flux Stabilisation
Begin VMM
Begin Musc. Contraction
End Musc. Contraction
End VMM

Flow change

VMM Muscle
2) Causal impact
 We should observe this pattern
If Nothing happen

Nasal flow
signal

We observed a different pattern

But a MM event did occure

Nasal flow
signal
 Observed time series

MM event occur here

Nasal flow
signal

Bayesian structural
time series (BSTM) model Hypothetic synthetized
pattern

H0: No
impact

Causal impact
Null hypothesis testing
Case study showing the instantaneous differences in flow predicted and observed before and after arousal

P_value = 0.001  Very High Probabiliy for a causal impact

Impact Amplitude : + 40% (+25% to +54%)
 Threshold of
Significance: 0.05

Significant causal impact

was observed in 80/100 fragments

Negative impact:
Median p_val = 0.0166

Positive impact:
Median p_val = 0.00103

80 % 20 %

P_value
3) Dose/response, Reversibility and Specificity
Mouth opening

Mouth closing

The more negative the signal is, the more the mandible is going down
 Amplitude / response relationship between VMM and Flux change
Larger transposition  Higher impact

Relative impact on Flux (% baseline)

Duration of VMM (sec)

o sitive
P

ati ve
Neg
Duration of EMG activity (sec)

More opened Mandibule relocation More closed

Longer muscular activity  longer transposition
Conclusion

 The changes in the mandibular position during sleep are responsible for variations in the nasal inspiration
flow pressure and global change in ventilation. The activities of the jaw antagonistic muscles are causally
associated to the transposition of the mandible.

 That suggests the need for controlling Mouth Opening to optimize the effects of oral appliance therapy.