Titratable Mandibular Advancement Device Research Articles

Modifications in Upper Airway Collapsibility during Sleep Endoscopy with a Mandibular Positioner: Study in Snorers and Obstructive Sleep Apnea Patients.

Mandibular advancement devices (MADs) are an effective treatment for patients with sleep-related breathing disorders, with variable response. Increasingly more research points to the predictive value of Drug-Induced Sleep Endoscopy (DISE) in patient selection. This study aims to analyze the changes in upper airway collapsibility using a titratable MAD simulator during DISE. This study included 104 patients with simple snoring and obstructive sleep apnea (OSA). The VOTE scale was used to assess the presence of collapses during the DISE both without and with the MAD simulator. In snorers, there was a decrease in collapses at the level of the soft palate and oropharynx when the advancement was achieved. Patients with mild OSA also showed a decrease in collapses at the base of the tongue. Patients with moderate/severe OSA exhibited significant amelioration at all levels. The levels at which there were residual collapses despite the maneuver were, in order, the velopharynx, oropharynx, epiglottis, and tongue. The MAD simulator reduces collapsibility at all levels and in all severity groups. Residual collapses suitable for combined treatments were able to be identified. This highlights the need for individualized patient selection, as upper airway collapsibility exhibits variable improvement or worsening with the MAD simulator regardless of the severity of the condition.

Upper Airway Characteristics and Morphological Changes by Different MADs in OSA Adult Subjects Assessed by CBCT 3D Imaging.

This study aimed to analyse the effectiveness of four different designs of the Mandibular Advancement Device (MAD) and the morphological changes on upper airway characteristics of Obstructive Sleep Apnea (OSA) patients inducted by each of them, detected by Cone Beam Computer Tomography (CBCT) 3D imaging. Twenty-two patients were recruited after an OSA diagnosis with PSG. Four different customised and titratable MADs were used and an initial CBCT scan was obtained for each patient. Six months after the end of the MAD titration phase, all the subjects performed a second PSG with the MAD in situ; the second PSG showed an Apnoea-Hypopnoea Index (AHI) of <5 or a decrease of 50% in AHI when compared with the initial AHI. Moreover, a second CBCT scan with the MAD in situ was performed. DICOM files were imported into the airway analysis software programme and the pharyngeal area around the oropharynx was highlighted. The area and volume of the oropharynx with and without the device was evaluated. A considerable improvement of the airway was observed (+33.76%), and a significant difference in the enlargement ratio between the posterior soft palate (+32.41%) and the posterior tongue (+36.96%) region was also found. The greatest increase in airway volume was achieved in patients treated with the MAD Forward and TAP (+42.77% and +41.63%, respectively). MAD therapy is effective to treat moderate to severe OSA with an increased upper airway volume. The design of the MAD can influence the effectiveness of the treatment.

The prevalence of treatment-emergent central sleep apnea with mandibular advancement device therapy.

Treatment-emergent central sleep apnea (TECSA) describes the appearance or persistence of central sleep apnea while undergoing treatment for obstructive sleep apnea. TECSA is well studied in continuous positive airway pressure therapy with an estimated prevalence of 8%. Based on a few case reports, mandibular advancement devices (MAD) may also provoke TECSA. This study aims to gain insight into the prevalence of TECSA with MAD therapy. This retrospective study includes a total of 129 patients with moderate to severe obstructive sleep apnea who were treated with a custom-made titratable MAD. Baseline and follow-up sleep studies were compared to identify patients with TECSA. Since different diagnostic criteria to define TECSA are used in literature, prevalence was calculated according to three definitions (TECSA-1, -2, and -3). Demographics, MAD treatment variables, and findings of the diagnostic polysomnography were compared between TECSA and non-TECSA patients to identify possible predictors. Depending on the definition used, TECSA was found in 3.1%-7.8% of patients undergoing MAD therapy. TECSA patients had a higher apnea index (9.2 vs 2.0 events/h, P = .042), central apnea-hypopnea index (4.1 vs 0.2 events/h, P = .045) and oxygen desaturation index (23.9 vs 16.3 events/h, P = .018) at baseline compared to non-TECSA patients. No differences were found in demographics and treatment variables. These findings demonstrate that TECSA also occurs in patients starting MAD treatment. Patients with TECSA had a higher apnea index, central apnea-hypopnea index, and oxygen desaturation index at baseline compared to non-TECSA patients. Hellemans S, Van de Perck E, Braem MJ, Verbraecken J, Dieltjens M, Vanderveken OM. The prevalence of treatment-emergent central sleep apnea with mandibular advancement device therapy. J Clin Sleep Med. 2023;19(12):2035-2041.

Mandibular advancement device therapy in patients with epiglottic collapse.

Epiglottic collapse is a specific sleep-endoscopic finding that can prove challenging to treat in patients with obstructive sleep apnea (OSA). Its effect on mandibular advancement devices (MAD) remains largely unknown. Therefore, this study assessed whetheror not epiglottic collapse affects treatment outcome with MAD. Patients with diagnosed OSAD underwent drug-induced sleep endoscopy (DISE) and were treated with a titratable MAD. Two age- and gender-matched controls were selected for every subject with primary epiglottic collapse (i.e., complete closure without involvement of other upper airway structures). Treatment response was defined as a reduction in oxygen desaturation index (ODI) of ≥ 50% following MAD therapy. Of 101 patients who underwent DISE, twenty (20%) showed primary epiglottic collapse(mean [SD]: 17 men; age 49.8 [10.1]; body mass index 28.3 [2.9] kg/m2; apnea-hypopnea index 27.0 [16.9] events/h). There were no significant differences in baseline clinical characteristics between cases and controls. MAD therapy was equally effective in patients with and without epiglottic collapse (mean [SD]; ODI with MAD, 8.7 [7.7] events/h vs. 7.8 [7.5] events/h, P = .62; ΔODI, 53.3 [29.6]% vs. 50.6 [37.7]%, P = .82; responder status, 10/20 vs. 22/40, P = .79). Logistic regression analysis revealed no associations between epiglottic collapse and treatment outcome. The presence of epiglottic collapse during DISE does not impair the effectiveness of MAD. Therefore, MAD therapy should be considered in patients with predominant epiglottic collapse.

Correlation between Polysomnographic Parameters and Tridimensional Changes in the Upper Airway of Obstructive Sleep Apnea Patients Treated with Mandibular Advancement Devices.

Background. The effectiveness of mandibular advancement devices has been solidly demonstrated in the past. They are considered a valid alternative treatment to continuous positive airway pressure for patients with obstructive sleep apnea. Nevertheless, the relationship between polysomnographic parameters and the increase in the volume of the upper airway in patients with obstructive sleep apnea syndrome has not been clearly established so far. This study aimed to determine the impact of these oral appliances upon the volume of the airway after the device titration phase and correlate it with the degree of mandibular advancement and the improvement of polysomnographic parameters. Methods. All patients were diagnosed by polysomnography and were treated with a customized, titratable mandibular advancement device. Three-dimensional volumetric measurements were performed using cone beam computed tomography. Results. The present study included 45 patients diagnosed with obstructive sleep apnea hypopnea syndrome (mild in 23 patients, moderate in 11 and severe in 11). Forty-four percent of the patients presented with an apnea hypopnea index <5/h at the end of treatment. The volume of the upper airway increased an average of 4.3 ± 5.9 cm3, this represents a percentage increase of 20.9%, which was significantly correlated with an apnea hypopnea index and a minimum oxygen saturation improvement. Conclusions. The mandibular advancement device used was found to be effective in improving polysomnographic parameters. Moreover, the oral appliance was able to significantly increase the tridimensional dimensions of the upper airway. Moreover, this finding was correlated with a reduction in the apnea hypopnea index (p = 0.007) and an increase on minimum oxygen saturation (p = 0.033).

Health outcomes of continuous positive airway pressure versus mandibular advancement device for the treatment of severe obstructive sleep apnea: an individual participant data meta-analysis.

The impact of therapy with continuous positive airway pressure (CPAP) and mandibular advancement device (MAD) has not been directly compared in patients with severe obstructive sleep apnea (OSA). The purpose of this individual participant data meta-analysis was to compare the treatment effects of CPAP and titratable MAD on sleepiness, quality of life, sleep-disordered breathing severity, and sleep structure in patients with severe OSA. Randomized controlled trials (RCTs) that included severe OSA patients were identified in order to compare the impact of the two treatments. Individual data from severe OSA patients were extracted from the databases and pooled for analysis. Of the seven studies identified, three crossover RCT and one parallel-group RCT corresponding to 151 patients and 249 observations (125 in the CPAP treatment arm and 124 in the MAD treatment arm) were included in the analysis. Titratable MAD had a similar impact to CPAP on major patient-centered outcomes (sleepiness and quality of life). CPAP was more effective in reducing AHI and ODI. However, the two treatments had a similar impact on sleep structure with an increase of N3 and REM sleep. Finally, treatment adherence and preference were largely in favor of MAD. This meta-analysis suggests that MAD represents an effective alternative treatment in severe OSA patients intolerant to CPAP or who prefer alternate therapy.

Drug-induced Sleep Endoscopy (DISE) with Simulation Bite to Predict the Success of Oral Appliance Therapy in Treating Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS)

Study objectivesOral appliances have gained their place in the treatment of obstructive sleep apnea (OSA) where custom-made titratable mandibular advancement devices (MAD) have become the oral appliance of choice. This study aimed to asses the value of the drug-induced sleep endoscopy (DISE) using a MAD in the prediction of treatment outcome for OSAHSMethodsThis is a prospective, single-center cohort study that enrolled sixty-six consecutive patients with diagnosed OSA (5 events/h < apnea-hypopnea index (AHI) < 50 events/h) to be treated with a custom-made titratable MAD. The patients were evaluated polysomnographically with the MAD in situ after the adaptation and titration period of 3 months. The associations between findings during DISE and treatment outcome were assessedResultsThe subjects showed a wide range of severity of OSAHS pre-treatment: median AHI was 43.10 with a range from 20.13 to 66.07. The simulation bite was associated with a significant increase in cross-sectional area at level of the velopharynx, tongue base and epiglottis. MAD treatment response in the studied population was 91%, with a mean AHI improving from 43.10 to 12.93.ConclusionsDrug-induced sleep endoscopy with simulation bite is an acceptably reproducible technique for determining the sites of obstruction in OSAHS subjects; it thus offers possibilities as a prognostic indicator for treatment with MAD

Heat-moulded versus custom-made mandibular advancement devices for obstructive sleep apnoea: a randomised non-inferiority trial

RationaleCustom-made mandibular advancement devices (MADs) are reported as providing higher efficacy rates compared with thermoplastic heat-moulded MADs but at the price of higher costs and treatment delays.ObjectiveTo determine whether a...

The use of oral appliances in obstructive sleep apnea: a retrospective cohort study spanning 14years of private practice experience.

In 2005, the American Academy of Sleep Medicine stated, "Oral appliances are indicated for use in patients with mild to moderate obstructive sleep apnea (OSA) who prefer them to CPAP therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP." However, this recommendation is based upon variable results from only six studies with more than 100 participants. These studies have assessed the effectiveness of mandibular advancement devices (MADs) in specific groups (military populations, academic institutions, or hospital settings) with no large study conducted in a fee-for-service private practice where the majority of patients receive MADs for OSA. The purpose of this study is to report outcomes of a board-certified dental sleep practitioner managing mild, moderate, and severe OSA using customized titratable MADs. We hypothesize that patients will demonstrate a significant reduction in apnea-hypopnea index (AHI) scores after adjusting their customized titratable MADs. This is a 14-year retrospective study design with pre- and post-treatment sleep studies. An AHI score < 10 respiratory events per hour with therapy is defined as treatment success. This study was performed by a single private practitioner. Of 2419 patient records analyzed, 544 (22%) had pre- and post-treatment sleep studies (89% polysomnograms). Of 510 patients with complete data, 459 (90%) revealed a decrease in AHI score < 10 respiratory events per hour indicating treatment success. Only 51 of these patients (10%) had a final AHI ≥ 10 and were considered treatment failures. Among the patients who lacked post overnight polysomnogram, 66/1921 (3%) discontinued the MAD due to adverse effects. Considering these patients as treatment failures as well, and therefore adding their number to the patients with complete sleep study data, the total treatment failures were 117/576 or 20%. Of the treatment successes, OSA was categorized by AHI at baseline as mild in 170 (34%), moderate in 181 (36%), and severe in 138 (28%). In patients with evaluable data, there was an 80% success rate for treatment of OSA using a custom-fabricated adjustable MAD including substantial numbers of patients with moderate and severe disease.

Temporomandibular Disorders in Patients Undergoing Mandibular Advancement Device Therapy for Obstructive Sleep Apnea: A Systematic Review

Background: Mandibular advancement device (MAD) therapy is a popular and effective treatment for snoring and obstructive sleep apnea (OSA). However, there have been several reports in the literature of patients developing temporomandibular disorders (TMDs).&#x0D; Objective: The objective of this review is to evaluate the prevalence of TMD, both in the initial phase of therapy and at follow up appointments, amongst patients wearing a MAD for OSA.&#x0D; Methods: The authors conducted a systematic review of published articles in which the presence of TMDs in patients undergoing MAD therapy for OSA was investigated. Eligible studies met the following criteria: a diagnosis of TMD following mandibular advancement using a custom-made and titratable MAD using either the Diagnostic Criteria for TMD (DC/TMD), Helkimo Anamnestic Dysfunction Index or reproducible clinical signs/symptoms.&#x0D; Results: The average prevalence of TMD during the initial phase of MAD therapy was found to be 25%. The prevalence of TMD reduced in the follow up periods. The adherence to MAD, especially long term, appears to be variable and from our results, it appears an average of 20% of patients discontinue MAD therapy over six to one hundred and twenty months, and this number has been reported to be as high as 62.5%.&#x0D; Conclusions: There was some difficulty in comparing the studies due to the differences in follow up time, methodology, sample size and diagnostic criteria. Longer clinical follow-up studies, with an objective method of monitoring patient adherence and with a larger sample size are needed to evaluate the long-term effects of MADs

Temporomandibular Disorders in Patients Undergoing Mandibular Advancement Device Therapy for Obstructive Sleep Apnea: A Systematic Review

Background: Mandibular advancement device (MAD) therapy is a popular and effective treatment for snoring and obstructive sleep apnea (OSA). However, there have been several reports in the literature of patients developing temporomandibular disorders (TMDs). Objective: The objective of this review is to evaluate the prevalence of TMD, both in the initial phase of therapy and at follow up appointments, amongst patients wearing a MAD for OSA. Methods: The authors conducted a systematic review of published articles in which the presence of TMDs in patients undergoing MAD therapy for OSA was investigated. Eligible studies met the following criteria: a diagnosis of TMD following mandibular advancement using a custom-made and titratable MAD using either the Diagnostic Criteria for TMD (DC/TMD), Helkimo Anamnestic Dysfunction Index or reproducible clinical signs/symptoms. Of the thirty-six articles published in this area, eleven were included in this review. These were assessed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Results: The average prevalence of TMD during the initial phase of MAD therapy was found to be 25%. The prevalence of TMD reduced in the follow up periods. The adherence to MAD, especially long term, appears to be variable and from our results, it appears an average of 20% of patients discontinue MAD therapy over six to one hundred and twenty months, and this number has been reported to be as high as 62.5% (over 58 months). Conclusions: There was some difficulty in comparing the studies due to the differences in follow up time, methodology, sample size and diagnostic criteria. Longer clinical follow-up studies, with an objective method of monitoring patient adherence such as home monitoring devices, and preferably with a larger sample size

Drug-induced sleep endoscopy (DISE) for non-CPAP treatment selection in patients with sleep-disordered breathing

Drug-induced sleep endoscopy (DISE) for non-CPAP treatment selection in patients with sleep-disordered breathing