Mandibular Repositioning Appliance Research Articles

Effect of the Mandibular Repositioning Appliance (MARA) on Posterior Airway Space (PAS)

Aim of the study was to show the effect of skeletal Class II treatment with the mandibular anterior repositioning appliance (MARA) on the sagittal posterior airway space (PAS) diameter. A total of 53 patients were selected retrospectively: 26 male patients (median 13 years, age span 10–19 years) and 27 female patients (median 14 years, age span 11–47 years). All patients had lateral cephalograms taken at T1 (before MARA treatment) and at T2 (after MARA treatment). Average treatment took 13.1 ± 7.5 months (Group 1) and 10.5 ± 4.5 months (Group 2), respectively. The following PAS parameters were obtained at T1 and T2: TI (Tangent Point 1), Me/Gn (menton/gnathion), DW (dorsal wall). Additionally, Björk‘s sum angle, SNA, SNB and ANB were determined. The male patients showed a higher increase in the anteroposterior diameter of the PAS (+27.5%) compared to female patients (+11.6%). Male participants had a significantly higher PAS (p = 0.006) than female participants (p = 0.09). Although not significantly, Björk‘s sum angle decreased in both groups. In general, compared to female patients, male patients showed a greater decrease between T1 and T2. SNA and SNB exhibited varied behavior between T1 and T2, with some individuals reporting a decrease and others reporting an increase. SNA tended to decrease in general. In terms of ANB, the male participants displayed a decrease from T1 to T2. Treatment of a skeletal Class II malocclusion with the mandibular anterior repositioning appliance (MARA) caused an increase in the sagittal posterior airway space (PAS) diameter and, thereby, might be effective against obstructive sleep apnea.

MARPE for the treatment and cure of OSAS: Aruba experience

Obstructive sleep apnea syndrome (OSAS) is defined as “the stoppage of ventilation or incidence of significant hypoventilation during sleep, which is characterized by episodes of partial or complete upper airway obstruction related with hypoxemia and/or hypercarbia. There have been many treatments reported for this syndrome including Mandibular repositioning appliance (MRA), continuous positive airway pressure (CPAP), weight loss, exercise, intraoral appliance therapy, soft tissue procedures, and maxillomandibular advancement (MMA) surgery. Present study is an attempt where three patients of OSAS have been treated withMiniscrew-assisted rapid palatal expansion (MARPE). The results of BMI, AHI index showed the promising effect. Even the use of MARPE has improved the air flow and increased the rapid palatal area.

Tongue Function: An Underrecognized Component in the Treatment of Obstructive Sleep Apnea with Mandibular Repositioning Appliance

Obstructive sleep apnea (OSA) is a common but still underrecognized disorder. A mandibular repositioning appliance (MRA) is used to treat OSA by advancing the mandible and thereby reducing the collapsibility of the upper airway. It has been found that an MRA increases the volume of the upper airway, especially the velopharyngeal area, in OSA patients. We hypothesize that this increase in the velopharyngeal volume is associated with an anterior displacement of the tongue, but likely not with a stretching of the soft tissue connecting the soft palate, lateral pharynx, palatopharyngeal arch, and mandible. Since the function and structure of the genioglossus and hypoglossal nerve are always abnormal in patients with OSA, the tongue does not always move simultaneously with the mandible when an MRA is being used. Oropharyngeal exercises, especially tongue exercises, can improve the quality of life of OSA patients, including reduction of daytime sleepiness and snoring, better quality of sleep, and partial decrease in the AHI. Further, in animal models, tongue exercise is also found to be effective in tongue function recovery and in the remodeling of the hypoglossal nucleus. We suggest that a combination of tongue exercises along with MRA is a promising approach for patients who do not respond to an MRA alone.

Predictors of success for mandibular repositioning appliance in obstructive sleep apnea syndrome.

The characteristics of non-obese patients with mild to moderate Obstructive Sleep Apnea Syndrome (OSAS) who will present with a good response to Mandibular Repositioning Appliance (MRA) treatment have not yet been well established in the literature. The aim of this study is to assess whether polysomnographic (PSG), demographic, anthropometric, cephalometric, and otorhinolaryngological parameters predict MRA success in the treatment of OSAS. Forty (40) males with mild and moderate OSAS were assessed pretreatment and 2-months post-treatment after wearing an MRA. Demographic, anthropometric, otorhinolaryngological (ENT), cephalometric, and polysomnographic parameters, including continuous positive airway pressure (CPAP) titrated pressure, dental models, Epworth Sleepiness Scale, quality of life (Short Form SF-36), and mood state (Profile of Mood States - POMS), were assessed. The responders exhibited fewer oropharyngeal alterations, increased upper pharyngeal space, reduced lower airway space, and increased mandibular intercanine width, and they had milder disease. Nevertheless, no predictive factors of MRA success could be found. MRA was more successful among men with a more pervious airway, a larger interdental width and milder OSAS. However, a combined [1] functional and structural assessment is needed to successfully predict the [2] effectiveness of MRA treatment of OSA.

Effect of Mandibular Repositioning Appliances on Inspiratory and Expiratory Total Air

Abstract: Obstructive Sleep Apnoea / Hypopnoea Syndrome (OSAHS) is associated with obstruction of the upper airway and occurs as a result of repeated closure of the upper airway during sleep, either by anatomical or patho-physiological factors. During these episodes, the diaphragm and chest muscles involved in breathing work actively to re-open the occluded airway and suck air into the lungs. The aim of this study is to clinically investigate the changes in inspira-tory and expiratory total air when a mandibular repositioning appliance (MRA) was used for the treatment of OSAHS and to suggest possible improvement in research technology when using the MRA. A twenty three OSAHS white Caucasian male patients were randomly selected and evaluated against twenty three non-apnoeic subjects matched for race and sex from Fife region, Scotland. Anthropometric comparison is done for the body mass index (BMI) and the percentage of pre-dicted neck circumference (PPNC). Rhinomanometer tests were used for the OSAHS patients and control before wearing the appliance and for the OSAHS group before and after wearing the MRA. Significant improvements of inspiratory and expiratory total air have resulted. MRA is useful alternative or adjunct to the use of Continuous Positive Airway Pressure (CPAP) devices in selected patients with snoring and mild to moderate (OSAHS).

Remotely Controlled Mandibular Protrusion during Sleep Predicts Therapeutic Success with Oral Appliances in Patients with Obstructive Sleep Apnea

The present study addresses the need for a validated tool that prospectively identifies favorable candidates for oral appliance therapy in treatment of obstructive sleep apnea. The objective of the study was to evaluate the ability of a mandibular titration study, performed with a remotely controlled mandibular positioner (RCMP), to predict treatment outcome with a mandibular repositioning appliance (MRA) and to predict an effective target protrusive position (ETPP). A prospective, blinded, outcome study. Standard clinical care with tests performed in the polysomnographic laboratory. Consecutive patients (n = 67) recruited from a sleep center or a dental practice using broad inclusion criteria (age 21-80 years; AHI > 10/h; BMI < 40 kg/m(2)). Therapeutic outcome with a mandibular protruding oral appliance was predicted following a mandibular protrusive titration study in the polysomnographic laboratory using a remotely controlled positioner and prospectively established predictive rules. An ETPP was also prospectively determined for participants predicted to be therapeutically successful with MRA therapy. All participants were blindly treated with a MRA, at either the predicted ETPP or a sham position, and therapeutic outcome was compared against prediction. At the final protrusive position, standard predictive parameters (sensitivity, specificity, positive and negative predictive values) showed statistically significant predictive accuracy (P < 0.05) in the range of 83% to 94%. The predicted ETPP provided an efficacious protrusive position in 87% of participants predicted to be therapeutically successful with MRA therapy (P < 0.05). Using prospectively established rules for interpreting the polysomnographic data, the mandibular titration study predicted mandibular repositioning appliance therapeutic outcome with significant accuracy, particularly with regard to accurately predicting therapeutic success. As well, among the participants predicted to be therapeutically successful with mandibular repositioning appliance therapy, the effective target protrusive position provided efficacious mandibular protrusion in the majority.

A randomized crossover study comparing two mandibular repositioning appliances for treatment of obstructive sleep apnea

The purpose of this study was to determine whether treatment outcomes vary according to the design of the mandibular repositioning appliance (MRA). Two titratable MRA's were compared. The designs differ in advancement hardware and configuration of acrylic both in bulk and interocclusal contact. The primary treatment outcome was the Respiratory Disturbance Index (RDI). Other outcomes that were compared included Sleep Apnea Quality of Life Index (SAQLI), Epworth Sleepiness Scale, oxygen saturation, and subjective feedback regarding experiences with the appliances. Twenty-four subjects were recruited from consecutive referrals for MRA therapy following diagnosis of obstructive sleep apnea (OSA) by polysomnography. Subjects were randomly assigned to a treatment arm of the crossover study. Each subject underwent an initial sleep study with a type III home monitor to establish a baseline RDI. Subjects were then treated with one of the two MRAs determined by random assignment. The MRA self-titration phase was monitored until a treatment position was determined, and the home sleep study was repeated. After a 2-week period without any OSA treatment, subjects received the second MRA and the self-titration treatment protocol was repeated. At completion of treatment with each appliance, subjects answered questionnaires and underwent a sleep study with the type III monitor. The outcome data for each appliance were compared using analysis of variance. Eighteen subjects completed the treatment protocol. There were no significant statistical differences in treatment outcomes between the two appliances. There was a statistically significant (p ≤ 0.05) preference for a MRA design with minimal coverage of teeth and palate. The subjects' appliance selection was consistent with a corresponding reduction in SAQLI score for the selected appliance. Although no statistically significant difference was observed between the two appliances in the outcomes measured, there was a trend toward greater improvement with the appliance with less acrylic resin bulk and less interocclusal contact. MRA selection should favor titratable, unobtrusive designs with appropriate construction to promote acceptance and adherence to MRA therapy.

Drug-induced sleep endoscopy in adults with sleep-disordered breathing: Technique and the VOTE Classification system

Drug-induced sleep endoscopy (DISE) offers an unique evaluation of the upper airway. After pharmacologic induction of unconscious sedation, it is possible to evaluate endoscopically the structures contributing to upper airway obstruction in sleep disordered breathing. The authors describe DISE techniques and the VOTE classification system for reporting of DISE findings. The VOTE classification focuses on the primary structures that contribute to upper airway obstruction and represents a common language to describe the patterns of obstruction during DISE. The latter can facilitate the scientific evaluation of DISE, including its role in directing treatment.

One hundred consecutive patients undergoing drug-induced sleep endoscopy: Results and evaluation

Polysomnography (PSG) is mandatory in the diagnostic workup of obstructive sleep apnea (OSA); drug-induced sleep endoscopy (DISE) is a valid addition. DISE is a dynamic, safe, easy-to-perform technique that visualizes the anatomic sites of snoring or apneas and guides the making of a tailor-made treatment plan in individual cases. The aim of this prospective study was to document the results of 100 consecutive DISE procedures and investigate associations between PSG and DISE findings. This prospective, single-center, observational study enrolled 100 consecutive patients between June and August 2010. All 100 patients eligible for sleep surgery or a mandibular repositioning appliance (MRA) underwent PSG and DISE (using midazolam or propofol). DISE findings were reported using the VOTE classification system; site, degree of airway narrowing, and configuration of obstruction were reported. Associations were analyzed between PSG results, patient characteristics, and DISE findings. Our results suggest that a multilevel collapse, a complete collapse, and a tongue-base collapse are statistically significantly associated with higher apnea hypopnea index values. A tongue base collapse or epiglottal collapse is associated with positional OSA. Complete concentric collapse is statistically significantly associated with an increased body mass index. The results of this small-scale study help us understand the pathogenesis of OSA and the various associations between PSG outcomes and DISE results, as well as assisting the sleep surgeon in tailoring surgery for the patient.

The Value of a Mandibular Repositioning Appliance for the Treatment of Nonapneic Snoring

In this evidence-based case report, the authors addressed the following clinical question: What is the effect of a mandibular repositioning appliance (MRA) in patients with nonapneic snoring on the snoring loudness, partners' sleep disturbance, and quality of life? The authors retrieved relevant publications from Embase, PubMed, Cinahl, CENTRAL, and Web of Science. They used title and abstract field searches with relevant synonyms for the domain, patients with nonapneic snoring, and for the determinant, MRA. The search yielded 499 records. After selection based on relevance and validity, 2 articles remained for answering the authors' clinical question. The authors pooled the data for the level of snoring. MRA as compared to placebo resulted in a reduction of snoring loudness in 38% of patients with nonapneic snoring and in an improvement of sleep disturbance in 54% of the partners. No effect on quality of life and daytime sleepiness of partners was found. Furthermore, evidence for sustained long-term effects and complete recovery is lacking.

Anatomical and functional changes in the upper airways of sleep apnea patients due to mandibular repositioning: A large scale study

The obstructive sleep apnea-hypopnea syndrome (OSAHS) is a sleep related breathing disorder. A popular treatment is the use of a mandibular repositioning appliance (MRA) which advances the mandibula during the sleep and decreases the collapsibility of the upper airway. The success rate of such a device is, however, limited and very variable within a population of patients. Previous studies using computational fluid dynamics have shown that there is a decrease in upper airway resistance in patients who improve clinically due to an MRA. In this article, correlations between patient-specific anatomical and functional parameters are studied to examine how MRA induced biomechanical changes will have an impact on the upper airway resistance. Low-dose computed tomography (CT) scans are made from 143 patients suffering from OSAHS. A baseline scan and a scan after mandibular repositioning (MR) are performed in order to study variations in parameters. It is found that MR using a simulation bite is able to induce resistance changes by changing the pharyngeal lumen. The change in minimal cross-sectional area is the best parameter to predict the change in upper airway resistance. Looking at baseline values, the ideal patients for MR induced resistance decrease seem to be women with short airways, high initial resistance and no baseline occlusion.

Effect of a Titration Polysomnogram on Treatment Success with a Mandibular Repositioning Appliance

Mandibular repositioning appliance (MRA) therapy is a treatment option for patients with mild to moderate sleep apnea and for patients who do not tolerate continuous positive airway pressure. Titration of MRAs consists of sequential mandibular advancement guided by symptom improvement. The goal of the study was to determine if patients with an elevated apnea hypopnea index (AHI), despite the use of a subjectively optimized MRA, could achieve better results with additional titration during polysomnography (PSG). Patients were enrolled if they had an AHI > or = 15/h and were referred for MRA therapy. The MRAwas advanced until symptoms improved. During the PSG, the technologist monitored the patient's sleep and increased mandibular protrusion until the AHI was improved. There was a significant improvement in AHI, minimum oxygen saturation, and total sleep time with the MRA before further advancement. At the final PSG, 65.2% of patients had an AHI < or = 10 associated with at least a 50% reduction in AHI. The incomplete responders had their appliance further titrated, and this improved the results of MRA therapy by 30.4% to a total success rate of 95.6%. This study shows that it is possible to improve the results of MRA therapy by further advancing the appliance during a titration PSG in patients with an incomplete response. The titration night improved the results of the usual clinical advancement of the MRA with substantially more patients achieving a successful outcome.

Effects of a Mandibular Repositioning Appliance on Sleep Structure, Morning Behavior and Clinical Symptomatology in Patients with Snoring and Sleep-Disordered Breathing

Background: Mandibular repositioning appliances (MRAs) have become an established treatment for snoring and sleep-disordered breathing – though most studies only focused on the evaluation of respiratory variables. Methods: This single-blind, placebo-controlled case-series study investigated the effects of an individually adjustable MRA on psychopathology, macro-/microstructure of sleep, periodic leg movements, morning performance, mood/affect and psychophysiology. Fifty patients (37 males) aged 59.7 ± 10.3 years, suffering from primary snoring (7), mild (22), moderate (15) and severe apnea (6), spent 4 nights in the sleep laboratory (adaptation, placebo, drug and MRA night). The drug night is not subject of the present paper. Results: Confirmatory statistics showed an improvement of the snoring index by 72%. Descriptively, the apnea index and the apnea-hypopnea index normalized. A clinical improvement was seen in the Pittsburgh Sleep Quality Index, the Zung Anxiety/Depression Scales and the Epworth Sleepiness Scale. The restless legs syndrome also improved. Polysomnographically, sleep stages REM and 4 as well as REM latency increased, stage 3, movement time, stage shifts and periodic leg movements decreased, as did all arousal measures. Subjectively, morning well-being, drive, affectivity and wakefulness improved. Objectively, attention, motor and reaction time performance, critical flicker frequency as well as muscular strength increased, diastolic blood pressure and the pulse rate decreased. Conclusion: Apart from its good therapeutic effects on snoring and respiratory variables (snoring showed complete or partial response in 68%, the apnea-hypopnea index in 67% of the apnea patients), the MRA also improved psychopathology, objective and subjective sleep and awakening quality.

Oral Appliances and Maxillomandibular Advancement Surgery: An Alternative Treatment Protocol for the Obstructive Sleep Apnea-Hypopnea Syndrome

The present study comprises a retrospective evaluation of the potential application of mandibular repositioning appliance (MRA) therapy preceding maxillomandibular advancement (MMA) surgery in the treatment of the Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS). Our initial experiences with a new surgical protocol, in which MRA therapy serves as a predictor for success of MMA surgery, are reported. Forty-three consecutive patients with OSAHS treated with MRA therapy were considered for inclusion (mean+/-SD; Apnea-Hypopnea Index [AHI]=27+/-20; age=53+/-9 years). All patients displaying a substantial improvement in their AHI with MRA therapy (ie,>50% reduction) who preferred surgical rather than "prosthetic" advancement of the mandible were offered MMA surgery. Accordingly, 4 out of 43 patients were treated with MMA surgery. The AHI was used as the primary outcome measure, with MMA surgery being considered successful in case of a postoperative AHI <5. All 4 patients included displayed substantial improvement in their AHI following MRA therapy. Moreover, in 3 patients MRA therapy resulted in a post-treatment AHI <or=5. With respect to the primary outcome measure, successful OSAHS management was attained in all 4 patients following MMA surgery. Results from the 4 patients included in the present study suggest that MRA therapy might be a good predictor for the success of MMA surgery in OSAHS management. Although confirmation in a larger study sample is indicated, we conclude that patients with a substantial reduction in baseline AHI with MRA therapy appear to be candidates for MMA surgery.

Mandibular advancement and obstructive sleep apnoea: a method for determining effective mandibular protrusion

The objectives of the study were to test the hypotheses that it is possible, during routine polysomnography (PSG), to prospectively identify favourable candidates for mandibular repositioning appliance (MRA) therapy in the treatment of obstructive sleep apnoea (OSA) and to accurately estimate an optimal protrusive distance at which to fabricate the MRA. A series of subjects underwent a remotely controlled mandibular positioner (RCMP) test during PSG monitoring. The ability of the RCMP test to eliminate OSA and the target protrusion at which that occurred was compared with the success of a custom oral MRA in the 33 subjects who completed the protocol. The RCMP test was a success in 15 subjects and a failure in 18 subjects. Appliance therapy was initiated in 38 subjects and completed in 33. MRA therapy was successful at target protrusion in 80% of subjects who had a successful RCMP test and failed in 78% of those who failed the RCMP test. In conclusion the remotely controlled mandibular positioner test outcome demonstrated a statistically significant association with mandibular repositioning appliance outcome. The target protrusion determined during the remotely controlled mandibular positioner test was the effective therapeutic protrusion in subjects with a successful remotely controlled mandibular positioner test.