Mandibular Advancement Device Treatment Research Articles

Mandibular advancement device therapy for obstructive sleep apnea: a prospective study on predictors of treatment success

ObjectiveTo survey potential predictors of success of mandibular advancement device (MAD) therapy in patients with obstructive sleep apnea (OSA), and in particular, to examine anatomical narrowings and sleep-related collapse levels in the upper airway. MethodsThis was a prospective study of 62 OSA patients (median apnea–hypopnea index [AHI] of 34), who were treated with a custom-made, monobloc MAD. The upper airway was examined by inspection, nasopharyngoscopy, overnight acoustic reflectometry recording collapses, and cephalometry of soft tissue dimensions (in addition to skeletal parameters). MAD treatment was controlled by polysomnograpy before and after at least five weeks from the beginning of treatment. Independent predictors of actual reduction in AHI and treatment success (reduction in AHI ≥ 50% with residual AHI < 10) were determined, using multivariable linear and logistic regression. ResultsPositional OSA (POSA) and nonsupine AHI (adjusted for upper airway narrowness and collapses, together with gender, age, body mass index, neck circumference, and baseline AHI) were the only independent predictors: POSA indicative for success, and nonsupine AHI inversely related to success. Cephalometry was not predictive. Two predictive models were proposed, one based on POSA having a specificity of 70% and sensitivity of 69%, and the other based on nonsupine AHI, generating a receiver operating characteristic (ROC) curve (area under ROC = 0.78). Using the ROC model, specificity could be increased to 80% without lowering sensitivity. ConclusionsOnly variables related to sleep position proved to be independent predictors of success with MAD therapy. The results could be explained by the MAD counteracting the mandible from moving backwards when sleeping supine.

Weight gain may affect mandibular advancement device therapy in patients with obstructive sleep apnea: a retrospective study

The aim was to analyze whether or not weight gain influences the treatment outcome of patients with obstructive sleep apnea (OSA) treated with mandibular advancement devices (MAD). As a part of a follow-up study among OSA patients treated with MAD in primary oral health care, a group of 28 patients reporting worsening of daytime or nighttime symptoms of OSA was given closer examination. Altogether, 21 subjects had a complete set of recordings and were enrolled into the study. Only three subjects had lost weight during the study period. The mean weight gain of 3.6kg ± 7.1kg was significant (p = 0.035). According to linear regression, weight gain was independently significantly associated with lower mean peripheral oxygen saturation 92.4 (SD 1.8 (% per hour) (p = 0.019)) and lowest oxygen saturation 80.1 (SD 7.2 (%) (p = 0.024)) scores. Weight gain is detrimentally associated with MAD treatment in patients with OSA. These findings suggest that regular follow-up by an experienced dentist is advisable to assess for possible worsening of OSA. Patient support to encourage weight control may be an important adjunct to MAD treatment for OSA.

Comparison of success criteria based on long-term symptoms and new-onset hypertension in mandibular advancement device treatment for obstructive sleep apnoea: observational cohort study

ObjectiveTo identify adequate criteria to determine the success or failure of mandibular advancement device (MAD) treatment for obstructive sleep apnoea (OSA) based on long-term symptoms and new-onset hypertension.DesignObservational cohort study.SettingA...

Obstructive Sleep Apnea and Neurocognitive Dysfunction in Edentulous Patients.

To record the incidence of cognitive dysfunction in edentulous patients suffering from obstructive sleep apnea (OSA) and establish a plausible hypothesis to explain the correlation of cognitive dysfunction and OSA. In this study, 315 edentulous patients (aged 60 to 65 years) visiting the outpatient department at Saraswati Dental College, Lucknow were recruited from January 2013 to October 2015. Prosthodontic Diagnostic Index (PDI) classification was used to assess the intraoral condition to relate it with the span of edentulousness. The BERLIN questionnaire and Epworth Sleepiness Scales were used to diagnose sleep-disordered breathing, following which the patients were put through all-night polysomnography. The apnea-hypopnea index (AHI) scores were derived. Mild and moderate OSA patients were classified into mild, moderate, and severe cognitive dysfunction based on SGRQ-C and SCD. Data were tabulated according to a new classification (Cognitive Dysfunction of Dental Sleep Medicine Patients [CDDSMP] Classification) designed specifically for this study. Data were analyzed using SPSS v15.0. Scores were tabulated as mean ± SD and median [IQR] values. Change from baseline was analyzed using Wilcoxon signed rank test. Mean scores at different time intervals were 3.03 ± 1.76 (3 months), 2.98 ± 1.80 (6 months), and 2.81 ± 1.84 (9 months). The median [IQR] values of scores at all time intervals except 9 months were 3 [1 to 5]. At 9 months, median [IQR] was 2 [1 to 5]. A significant change in scores was observed in the 3-month interval (p ≤ 0.001). The severity of OSA and neurocognitive dysfunction could be directly related to the PDI classification and the span of edentulousness of the patient and modified mandibular advancement device treatment significantly improved the patients' condition, which was reflective from 3 months post-intervention itself.

Residents' journal review

Residents' journal review

Long-Term Oral Appliance Therapy Improves Daytime Function and Mood in Upper Airway Resistance Syndrome Patients.

To evaluate the long-term effects of an oral appliance on clinical symptoms, respiratory sleep parameters, sleep quality, and sustained attention in patients with upper airway resistance syndrome (UARS) were compared with placebo. This study was a randomized placebo-controlled clinical trial. Thirty UARS patients were randomized in two groups: placebo and mandibular advancement device (MAD) groups. UARS criteria were presence of sleepiness (Epworth Sleepiness Scale ≥ 10) and/or fatigue (Modified Fatigue Impact Scale ≥ 38) associated with an apnea/hypopnea index ≤ 5 and a respiratory disturbance index (RDI) > 5 events/hour of sleep, and/or flow limitation in more than 30% of total sleep time. All patients completed the Pittsburgh Sleep Quality Index (PSQI), the Functional Outcomes of Sleep Questionnaire, the Beck Anxiety and Depression Inventories, underwent full-night polysomnography, multiple sleep latency test, and Psychomotor Vigilance Test (PVT). Evaluations were performed before and after 1.5 years of treatment. RDI, number of respiratory effort-related arousal, percentage of total sleep time with flow limitation, and arousal index significantly decreased after 1.5 years of MAD treatment. PSQI total score improved, severity of depression symptoms decreased, and mean reaction time in the PVT, based on the first measurement taken at 8:00 am, significantly decreased (p = .03) at the end of the protocol. The MAD was effective in decreasing respiratory events in UARS patients. For UARS, 1.5 years of oral appliance therapy also improved sleep quality and sustained attention, and decreased the severity of depression symptoms. Efficacy of Oral Appliance for Upper Airway Resistance Syndrome: Randomized, Parallel, Placebo-Controlled Study, NCT02636621.

Results in the Treatment with Twin Block Polymeric Appliance of the Retrognathic Mandible in Sleep Apnea Patients

Obstructive sleep apnea syndrome (OSAS) in children is characterized by recurrent events of partial or complete upper airway obstruction during sleep. Functional orthopedics has been used for patients who have OSAS and craniofacial anomalies because they change the mandible posture forwards, improving the respiratory function. In present, much attention is accorded to the relationship between respiratory function and facial morphology. This study combines the cephalometric measurements and cardio-respiratory polygraphy, in order to analyze the effects of a modified functional Twin Block polymeric appliance on respiratory variables in OSAS patients. The chief complaints of the included in study patients was the crooked teeth and the teasing about their smile. Pretreatment facial photographs show labial position of anterior teeth, gummy smile, a large overjet, incompetent lips and retrognathic mandible. The patients underwent overnight cardio-respiratory polygraphic tests in the same Sleep Laboratory, before and after mandibular advancement device treatment. At the end of the orthopedic treatment phase, the beneficial result of this study was the mandible correction, the maxilla restrained, over jet decreased, improving the facial profile and reintegration of the patient in the school social environment. The education of the parents and of the small patients to recognize the symptoms of sleep apnea and to apply the available effective treatments with a positive social impact on self-esteem and which recovers the facial aesthetics and functionality is a stringent necessity.

Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial on psychological distress

ObjectivesThe aim of this randomized placebo-controlled trail was to compare the effects of an objectively titrated mandibular advancement device (MAD) with those of nasal continuous positive airway pressure (nCPAP) and an intraoral placebo device on symptoms of psychological distress in OSA patients.Materials and methodsIn a parallel design, 64 mild/moderate OSA patients (52.0 ± 9.6 years) were randomly assigned to an objectively titrated MAD, nCPAP, or an intraoral placebo appliance. All patients filled out the Symptom Checklist-90-Revised twice: one before treatment and one after 6 months of treatment. The Symptom Checklist-90-Revised is a multidimensional symptom inventory designed to measure symptomatic psychological distress over the past week. Linear mixed model analyses were performed to study differences between the therapy groups for the different dimensions of the Symptom Checklist-90-Revised over time.ResultsThe MAD group showed significant improvements over time in the dimensions “somatization,” “insufficiency of thinking and acting,” “agoraphobia,” “anxiety,” “sleeping problems,” and “global severity index” (F = 4.14–16.73, P = 0.048–0.000). These improvements in symptoms of psychological distress were, however, not significantly different from those observed in the nCPAP and placebo groups (P = 0.374–0.953).ConclusionThere is no significant difference between MAD, nCPAP, and an intraoral placebo appliance in their beneficial effects on symptoms of psychological distress.Clinical relevanceThe improvement in psychological distress symptoms in mild/moderate OSA patients under MAD or nCPAP treatment may be explained by a placebo effect.

Novel Positional Devices for the Treatment of Positional Obstructive Sleep Apnea, and How This Relates to Sleep Surgery.

If untreated, obstructive sleep apnea (OSA) develops as a gradual progressive disease. In the early stage of the disease most patients with OSA are positional. The archetypical patient might progress from simple positional snoring via positional early-stage mild disease to less positional moderate and finally nonpositional severe OSA. At first, the apnea-hypopnea index (AHI) is high only in the supine position, and later is high in all sleeping positions. The phenomenon is reversible. After partial effective treatment, patients with severe OSA can reverse to less severe positional OSA or, in other words, the AHI drops more in the lateral position than in supine position. This has been shown for palatal surgery, multilevel surgery, bimaxillary osteotomies, and bariatric surgery. The absence or presence of positional dependency has a great influence on sleep surgery. First, the results of sleep surgery might be worse in positional patients. Second, the addition of positional therapy to sleep surgery might improve the overall outcome and, as such, enhance the indication of sleep surgery as an alternative to continuous positive airway pressure and mandibular advancement device treatment.

Therapeutic Efficacy of Mandibular Advancement Devices in Patients with Severe Sleep Apnea: A Preliminary Report.

Obstructive sleep apnea (OSA) is defined as episodes of upper airway obstructions during sleep. The method of choice in conservative treatment of OSA is the use of devices that produce positive airway pressure (CPAP). In patients with mild-moderate form of OSA, intraoral mandibular advancement devices (MAD) are applied. The aim of the study was to evaluate the therapeutic efficacy of MAD in patients with severe OSA who were unable to use CPAP. In this preliminary study three patients from a group of 25 severe OSA sufferers who failed to use CPAP, were included. The three patients underwent a triple polysomnographic (PSG) investigation: on CPAP, before MAD treatment, and during MAD. The patients completed the Epworth Sleepiness Scale questionnaire twice. We found significant improvements of subjective symptoms and PSG-evaluated variables after application of MAD in all three patients in comparison with both baseline and CPAP-recorded data. We conclude that MAD can be an alternative treatment option for severe OSA patients who are non-compliant with CPAP therapy.

Therapeutic outcomes of mandibular advancement devices as an initial treatment modality for obstructive sleep apnea.

Although continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA), there is a need for alternative treatment options, such as sleep surgeries and mandibular advancement devices (MADs), to overcome the limitations of CPAP.This study aimed to analyze the therapeutic outcomes of OSA subjects who were treated with a MAD, and to estimate the clinical impact of MAD as a first-line treatment for OSA.Forty-seven patients diagnosed with OSA received an adjustable MAD as an initial treatment. Drug-induced sleep endoscopic findings and sleep parameters (both pre-MAD and post-MAD treatment), such as apnea index, oxygen saturation, and degree of daytime sleepiness, were assessed retrospectively.The MAD treatment resulted in a significant reduction in apnea–hypopnea index, and also a significant elevation in lowest oxygen saturation. Satisfactory results of MAD treatment as a first treatment modality were observed in 27 patients, and a successful outcome was reached in approximately 72% of patients. The OSA patients who had lower body mass index and upper airway narrowing at the level of palate and tongue base showed relatively higher rates of a satisfactory outcome even in cases of moderate or severe OSA.These results suggest that the use of a MAD may be an alternative treatment option in OSA patients with retropalatal and retroglossal area narrowing regardless of disease severity. Additionally, MADs can be recommended as an initial treatment modality, and the effectiveness of MADs in achieving success may not be inferior to CPAP.

Predicting Therapeutic Outcome of Mandibular Advancement Device Treatment in Obstructive Sleep Apnoea (PROMAD): Study Design and Baseline Characteristics

Predicting Therapeutic Outcome of Mandibular Advancement Device Treatment in Obstructive Sleep Apnoea (PROMAD): Study Design and Baseline Characteristics

Can treatment with statins have a negative influence on the tolerance of mandibular advancement devices?

Statins are considered the most effective drugs used in the treatment of dyslipidemias. Some of their adverse effects are related to muscle problems. Myalgias produced by statins appear more often during exercise. Mandibular advancement devices (MAD) force the propulsory and elevatory musculature of the mandible to exercise by making the jaw move forward. The aim of this study is to evaluate the incidence of muscular side effects (referred, spontaneous, or under palpation pain, myofascial pain, mandibular rigidity and fatigue, tension and sensitivity of the masticatory muscles) in a group of patients with a diagnosis of obstructive sleep apnea being treated with MAD. This was a prospective study, involving consecutively 104 patients with a diagnosis of OSAS, and who had begun treatment with a custom made oral device. Muscular side effects were collected by anamnesis (verbal request and questionnaires), psychological status and clinical assessment (manual muscle palpation in the masticatory and cervical muscle groups), before and during MAD treatment. Of the total sample, 22.1% presented muscular side effects with the oral device. However, in patients taking statins, this percentage was 57.1%, as opposed to 16.7% of the non-statins patients (p<0.001). The risk of suffering muscular alterations during oral device treatment is higher in statin patients (odds ratio 6.67, p=0.002). Treatment with statins can give rise to the appearance of undesirable side effects among patients being treated with oral devices.

Mandibular Advancement Device as a Comparable Treatment to Nasal Continuous Positive Airway Pressure for Positional Obstructive Sleep Apnea.

Positional obstructive sleep apnea (P-OSA) is a clinically common phenotype of OSA, which can be treated effectively with mandibular advancement devices (MADs). We hypothesized that the efficacy of an MAD is comparable to that of nasal continuous positive airway pressure (nCPAP) in P-OSA patients. Among patients diagnosed with OSA at a single sleep center from January 2008 to May 2014, male subjects with moderate OSA were recruited and stringently categorized as having P-OSA when the ratio of their lateral apnea-hypopnea index (AHI) to supine AHI was ≤ 0.5, their lateral sleep time was > 60 minutes, and their lateral REM sleep time was longer than 10 minutes. Treatment efficacy was compared between P-OSA subjects with an MAD (n = 34) and those with nCPAP (n = 34) after matching for age, body-mass index, and baseline AHI. There were no significant differences in baseline AHI (MAD: nCPAP = 20.6 ± 3.9/h: 21.3 ± 1.7/h, p = 0.35) or in follow-up AHI (MAD: nCPAP = 4.7 ± 3.5/h: 3.4 ± 3.7/h, p = 0.12) between the 2 treatment groups, and hence MADs lowered the AHI to the same extent as nCPAP. These findings suggest that an MAD is as efficacious as nCPAP for P-OSA patients. MAD treatment for this specific phenotype may be a promising patient-tailored and first-line approach to OSA. A commentary on this article appears in this issue on page 1079.

Impact of upper airway abnormalities on the success and adherence to mandibular advancement device treatment in patients with Obstructive Sleep Apnea Syndrome

IntroductionThe mandibular advancement device (MAD) is a option to treat patients with Obstructive Sleep Apnea Syndrome (OSAS). ObjectiveTo assess the influence of upper airway abnormalities on the success of and adherence to MAD in patients with OSAS. MethodsProspective study with 30 patients with mild to moderate OSAS and indications for MAD. The protocol included questionnaires addressing sleep and nasal complaints, polysomnography, and upper airway assessment. The analyzed parameters of patients who showed therapeutic success and failure and those who exhibited good and poor treatment adherence were compared. Results28 patients completed the protocol; 64.3% responded successfully to treatment with MAD, and 60.7% exhibited good adherence to treatment. Factors associated with greater success rates were younger age (p=0.02), smaller cervical circumference (p=0.05), and lower AHI at baseline (p=0.05). There was a predominance of patients without nasal abnormalities among patients treated successfully compared to those with treatment failure (p=0.04), which was not observed in relation to adherence. Neither pharyngeal nor facial skeletal abnormalities were significantly associated with either therapeutic success or adherence. ConclusionMAD treatment success was significantly lower among patients with nasal abnormalities; however, treatment adherence was not influenced by the presence of upper airway or facial skeletal abnormalities.

Cephalometric predictors of treatment outcome with mandibular advancement devices in adult patients with obstructive sleep apnea: a systematic review.

ObjectiveThe efficacy of mandibular advancement devices (MADs) in the treatment of obstructive sleep apnea (OSA) ranges between 42% and 65%. However, it is still unclear which predictive factors can be used to select suitable patients for MAD treatment. This study aimed to systematically review the literature on the predictive value of cephalometric analysis for MAD treatment outcomes in adult OSA patients.MethodsThe MEDLINE, Google Scholar, Scopus, and Cochrane Library databases were searched through December 2014. Reference lists from the retrieved publications were also examined. English language studies published in international peer-reviewed journals concerning the predictive value of cephalometric analysis for MAD treatment outcome were considered for inclusion. Two review authors independently assessed eligibility, extracted data, and ascertained the quality of the studies.ResultsFifteen eligible studies were identified. Most of the skeletal, dental, and soft tissue cephalometric measurements examined were widely recognized as not prognostic for MAD treatment outcome; however, controversial and limited data were found on the predictive role of certain cephalometric measurements including cranial base angle, mandibular plane angle, hyoid to mandibular plane distance, posterior nasal spine to soft-palate tip distance, anterior nasal spine to epiglottis base distance, and tongue/oral cross sectional area ratio thus justifying additional studies on these parameters.ConclusionsCurrently available evidence is inadequate for identification of cephalometric parameters capable of reliably discriminating between poor and good responders to MAD treatment. To guide further research, methodological weaknesses of the currently available studies were highlighted and possible reasons for their discordant results were analyzed.

Influence of craniofacial and upper spine morphology on mandibular advancement device treatment outcome in patients with obstructive sleep apnoea: a pilot study.

The aim of the study was to assess cephalometric predictive markers in terms of craniofacial morphology including posterior cranial fossa and upper spine morphology for mandibular advancement device (MAD) treatment outcome in patients with obstructive sleep apnoea (OSA). Twenty-seven OSA patients were treated with MAD for 4 weeks. Apnoea-hypopnoea index (AHI) was recorded before and after MAD treatment. The criteria of treatment success were 75 per cent reduction of AHI. Accordingly, two groups occurred: the success treatment group of 8 patients and the no success treatment group of 19 patients. Before MAD treatment lateral cephalograms were taken and analyses of the craniofacial morphology including the posterior cranial fossa and upper spine morphology were performed. Differences between the groups were analysed by Fisher's exact test, t-test, and multiple regression analysis. Upper spine morphological deviations occurred non-significantly in 25 per cent in the success treatment group and in 42.1 per cent in the no success treatment group. Body mass index (BMI; P < 0.05), maxillary prognathism (S-N-Ss; P < 0.01), mandibular prognathism (S-N-Pg; P < 0.05 and S-N-Sm; P < 0.01), and the distance between sella turcica and the deepest point in posterior cranial fossa (S-D; P < 0.05) was significantly smaller in the success treatment group. The maxillary prognathism (P < 0.05) was the most important factor for the MAD treatment outcome (R (2) = 0.47). Relatively small sample size. The results indicate that BMI, posterior cranial fossa morphology, and retrognathia of the jaws are factors related to MAD treatment outcome. Furthermore, OSA patients with upper spine morphological deviations may respond poorer to MAD treatment.

Treatment of elderly patients with snoring and obstructive sleep apnea using a mandibular advancement device

The simplicity of oral appliance therapy in the treatment of adult patients with snoring and obstructive sleep apnea (OSA) has resulted in a worldwide interest for this treatment modality. Mandibular advancement devices (MADs) that hold the lower jaw forward during sleep are mainly indicated for patients with milder OSA and those with CPAP intolerance. There has been minor attention on age when suggesting treatment alternatives for patients with OSA. Some studies indicate that there is a weak negative relationship between treatment success from MADs and higher age, but no studies have stratified their samples with respect to age. The present aim was to compare the effects and side effects from MADs between an elderly group of patients (>65years of age) and a younger age group that were extracted from two of our previous studies. The results showed no difference between the elderly and the younger patients in success rate or the degree of bite changes from MAD treatment. These findings indicate that MADs represent an alternative to CPAP irrespective of the age of the patient.

Analysis of the Effects of a Mandibular Advancement Device on Sleep Bruxism Using Polysomnography, the BiteStrip, the Sleep Assessment Questionnaire, and Occlusal Force

This before and after study evaluated the effects of a mandibular advancement device (MAD) on sleep bruxism (SB) activity and its associated signs and symptoms. Nineteen young adults (39.9 ± 12.9 years, 58% women) with a clinical history of SB without sleep or neurologic disorders and no spontaneous temporomandibular disorder pain were selected. SB activity was assessed after a habituation period of 2 weeks. The results of a 3-month treatment with a thermoplastic monoblock MAD were compared to baseline using electromyogram polysomnography and the BiteStrip, a portable EMG device. Sleep disorders were assessed and validated against the polysomnography sleep assessment questionnaire (SAQ). Additionally, common signs and symptoms of SB were evaluated with the research diagnostic criteria for temporomandibular disorders. Occlusal force was compared to baseline using a cross-arch force transducer. There was a significant improvement in both SB activity and sleep scores (including SB episodes per hour) according to the BiteStrip and the SAQ, respectively. There was also a significant reduction in the signs and symptoms of SB, including grinding and/or clenching, temporomandibular joint (TMJ) sounds, muscle pain, and occlusal force. None of the SB subjects experienced MAD breakage, but in 24% of patients, the MAD treatment had to be interrupted due to TMJ/muscle pain and/or discomfort. The MAD treatment resulted in the reduction of SB activity, SB signs and symptoms, sleep disorders, and occlusal force.

Mandibular advancement device and CPAP upon cardiovascular parameters in OSA

This study aims to compare the effects of a mandibular advancement device (MAD) with continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA) on blood pressure (BP), oxidative stress, and heart rate variability (HRV) in a randomized, crossed-over, single-blind, and controlled trial. Twenty-nine moderate-to-severe adult OSA patients underwent MAD, CPAP, and placebo oral appliance treatment. Polysomnography, Epworth sleepiness scale, 24-h ambulatory BP monitoring, oxidative stress parameters (malondialdehyde, catalase, superoxide dismutase, vitamins C, E, B6, B12, folate, homocysteine, uric acid), and HRV were assessed at baseline and after 1month of each treatment. Diaries were used to evaluate compliance for devices and a pressure-time meter for CPAP. Both active treatments resulted in decreases in apnea and hypopnea index and Epworth sleepiness scale; CPAP showed a greater effect. Frequency of diastolic BP dipping was higher in the MAD group compared with the CPAP group. A significant drop from baseline levels for catalase activity was observed after MAD. For HRV, there was a significant decrease in total power at night with CPAP and MAD compared with POA, and a decrease in index of sleep autonomic variation with MAD compared with baseline levels. Compliance rates were higher with MAD rather than CPAP. Even though CPAP proved to be more effective at attenuating OSA, better compliance with MAD favored the reduction of one of the enzymes which participates in oxidative stress and better autonomic modulation during sleep.