For those of us who treat obstructive sleep apnea (OSA) or those who have tried but run into problems that make you want to throw up your hands, think about the four points of breathing obstruction. Each patient has a different set of obstructions, so decisions on how to choose between the hundreds of appliances to treat breathing disorders are based upon multiple points of obstruction. The best treatment may be combination therapy (hybrid): oral appliance therapy, nasal positive pressure, and nasal surgery. The optimal result is one in which the four points of obstruction are best managed. Triage of options is dependent on a good clinical exam of the tongue and its posture and cone beam computed tomography (CBCT).

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