Use of a mandibular advancement device in obstructive sleep apnoea

The present study investigated the effectiveness of an intra-oral mandibular advancement device in the treatment of patients with obstructive sleep apnoea (OSA) who could not tolerate or who had failed to comply with continuous positive airway pressure (CPAP). Thirty-five patients diagnosed by sleep study as suffering from OSA, who had either been unable to tolerate or had been non-compliant with CPAP treatment, were included in the study. The subjects completed an Epworth sleep questionnaire. The subjects then had an oral appliance made. After using the appliance for 3 months, the patients repeated the questionnaires and had a repeat sleep study performed with the oral appliance in situ. Thirty-one subjects completed the investigation. Mean AHI pre- and post-study were 26.64 and 24.06, respectively (P > 0.05). Mean Epworth scores pre- and post-study were 16.32 and 14.64, respectively (P > 0.05). Those patients with a pre-study AHI < 20 (n = 23), however, did significantly better with the appliance (P < 0.0001). Those patients with a pre-study AHI > 20 did not benefit from this device (P > 0.05). The main problems encountered were initial jaw discomfort in 18 patients and dry mouth in 11 patients (both of which improved with continued usage). It was concluded that the type of appliance used in this study can be recommended for those with mild OSA who are unable to tolerate CPAP.     

Clinical guidelines for oral appliance therapy in the treatment of snoring and obstructive sleep apnoea

The purpose of this review is to provide guidelines for the use of oral appliances (OAs) for the treatment of snoring and obstructive sleep apnoea (OSA) in Australia. A review of the scientific literature up to June 2012 regarding the clinical use of OAs in the treatment of snoring and OSA was undertaken by a dental and medical sleep specialists team consisting of respiratory sleep physicians, an otolaryngologist, orthodontist, oral and maxillofacial surgeon and an oral medicine specialist. The recommendations are based on the most recent evidence from studies obtained from peer reviewed literature. Oral appliances can be an effective therapeutic option for the treatment of snoring and OSA across a broad range of disease severity. However, the response to therapy is variable. While a significant proportion of subjects have a near complete control of the apnoea and snoring when using an OA, a significant proportion do not respond, and others show a partial response. Measurements of baseline and treatment success should ideally be undertaken. A coordinated team approach between medical practitioner and dentist should be fostered to enhance treatment outcomes. Ongoing patient follow‐up to monitor treatment efficacy, OA comfort and side effects are cardinal to long‐term treatment success and OA compliance.     

Oral appliance treatment in moderate and severe obstructive sleep apnoea patients non‐adherent to CPAP

The aim of this retrospective study was to evaluate the effect of individually adjusted custom‐made mandibular advancement device/oral appliance (OA) in treatment of patients with moderate and severe obstructive sleep apnoea (OSA), who were non‐adherent to continuous positive airway pressure (CPAP) therapy. During 2007‐2013, 116 patients with moderate (n = 82) and severe (n = 34) OSA non‐adherent to CPAP treatment were referred for dental management with an individually adjusted OA at a specialist sleep clinic. Ten of the participants (8·6%) were lost to follow‐up, leaving the data set to consist of 106 patients (71 men/35 women, mean age 57 year, range 28‐90). Nocturnal respiratory polygraphic recordings were performed at baseline and follow‐up. Average time between baseline polygraphy and follow‐up was 12 months. A successful OA treatment outcome was based on polygraphy at the follow‐up and divided into three groups: 1 = AHI <5; 2 = 5 ≤ AHI <10 and >50% reduction in baseline AHI; and 3. >50% reduction in baseline AHI. If there was a ≤ 50% reduction in baseline AHI at the follow‐up, the treatment was considered as a failure. The overall treatment success rate was 75%. There was no significant difference in success rates between patients in the moderate and severe categories (69% and 77%, respectively). Low oxygen saturation (SpO_{2 nadir)} had a high predictive value for OA treatment failure. OA treatment of patients non‐adherent to CPAP is efficient and especially promising for the severe OSA group who are at greatest risks for developing serious comorbidities, if left untreated.     

The effect of raising the bite without mandibular protrusion on obstructive sleep apnoea

It has recently been suggested that wearing a maxillary occlusal splint (i.e. a hard acrylic resin dental appliance that covers the occlusal surfaces of the maxillary dentition and that is being indicated for the treatment of, e.g. temporomandibular pain) may be associated with a risk of aggravating obstructive sleep apnoea (OSA). The present study tested the hypothesis that raising the bite without mandibular protrusion in OSA patients is associated with an increase in the apnoea-hypopnoea index (AHI). Eighteen OSA patients (13 men; 49·5 ± 8·1 years old) received a mandibular advancement device in 0% protrusion of the mandible (0%MAD). The MAD caused a bite rise of 6 mm as measured interincisally. Polysomnographic recordings were obtained at baseline and with the 0%MAD in situ. No statistically significant difference in AHI was noted between the baseline night and the 0%MAD night. However, nine patients had an aggravation in AHI during the night they used the 0%MAD. Taking into account the previously established smallest detectable difference of 12·8 in AHI, the AHI increased in only two of the patients. The outcomes of this study suggest that an increased jaw gape without mandibular protrusion might be associated with a risk of aggravation of OSA for some, but not for all OSA patients. Dental practitioners should be aware of this possible association when treating patients with oral devices that raise the bite.     

A randomised titrated crossover study comparing two oral appliances in the treatment for mild to moderate obstructive sleep apnoea/hypopnoea syndrome

The objective of this study was to compare the efficiency of two oral appliances in patients with mild to moderate obstructive sleep apnoea/hypopnoea syndrome (OSAHS) by the analysis of objective and subjective evaluations and measurement of upper airway parameter. A randomised crossover design trial was carried out on 16 patients with OSAHS. Two different types of oral appliances were tested in each patient, a one‐piece monoblock and the SILENT NITE^® (GlideWell Laboratories, Newport Beach, CA, USA), a two‐piece appliance. Each oral appliance needed to be worn for two 3‐month periods separated by a 2‐week wash‐out period in between. The objective and subjective efficiency and upper airway parameters associated with the oral appliances were assessed. One‐way analysis of variance (anova ) test was performed to compare the changes in upper airway morphology and the treatment efficiency between the appliances. The monoblock and SILENT NITE^® (GlideWell Laboratories) appliances reduced Apnoea Hypopnoea Index (AHI) from 26·38 ± 4·13 to 7·58 ± 2·28 (P < 0·001) and 8·87 ± 2·88 (P < 0·001), respectively. The monoblock appliance was statistically more efficient in reducing AHI and Apnoea Index (AI) than the SILENT NITE^® (GlideWell Laboratories) (P < 0·05). The scores on Epworth's Sleepiness Scale (ESS) and Snoring Scale (SS) were improved significantly by both appliances. The upper airway spaces showed considerable enlargement by both mandibular advancement appliances (MAAs) (P < 0·05), while no significant differences were found between the two appliances (P > 0·05). Both MAAs showed good efficacy in the treatment for mild to moderate OSAHS. Use of the monoblock appliance should be considered when patients with OSAHS choose MAA treatment, as it was more efficient in reducing the AHI and AI compared to the two‐piece appliance and was preferred by most patients. Long‐term efficiency should be evaluated in future prospective studies.     

The effectiveness of oral appliances in elderly patients with obstructive sleep apnoea treated with lorazepam - a pilot study

Summary Obstructive sleep apnoea (OSA) is one of the most common sleep disorders in elderly and represents a special problem for elderly patients. Elderly patients use a large number of drugs that might have an influence on the upper airway structure, anxiolytics or benzodiazepines being the most common. The aim of this study was to examine the effectiveness of mild or moderate OSA treatment with mandibular advance oral appliance in older lorazepam users compared with the age-matched lorazepam-free patients. A total of 40 functionally independent patients with the age of 65-74 were enrolled in the study. All included patients were found to suffer from at least two of the existing OSA symptoms (snoring, sleep fragmentation, daytime sleepiness) and were diagnosed with mild or moderate OSA after nocturnal polysomnography. Patients were divided into two groups. The experimental group consisted of 20 patients who used lorazepam in their daily therapy, and a control group consisted of 20 patients who did not take lorazepam. A mandibular advance appliance was made individually for each patient. Patients involved in the study were not overweight and were suggested to practise sleeping on the side and reduce alcohol consumption during the study. The study has shown that mandibular advance oral appliances were responsible for complete control of the OSA in over 37% of cases (15 patients). Patients have also reported substantial improvement in the symptoms; 80% of them reported that they had snored less, slept better (94%) and have not experienced daytime sleepiness (100%).     

口腔矫治器治疗阻塞性睡眠呼吸暂停综合征的临床研究

目的评价改良口腔矫治器治疗阻塞性睡眠呼吸暂停综合征(OSAS)的临床疗效。方法采用下颌前移式口腔矫治器治疗24例OSAS患者,治疗前后分别经夜间多导睡眠监测(PSG),比较睡眠呼吸暂停指数(AI)、呼吸暂停低通气指数(AHI)、最低血氧饱和度(SaO2)等呼吸紊乱指标的变化。结果治疗前、后患者呼吸暂停指数、呼吸暂停低通气指数、血氧饱和度指标变化差异有显著性(P<0.001),21例呼吸暂停低通气指数下降了50%以上,客观有效率为87.5%。结论改良口腔矫治器是治疗轻、中度阻塞性睡眠呼吸暂停综合征的有效方法。     

Evidence for dental and dental specialty treatment of obstructive sleep apnoea. Part 1: the adult OSA patient and Part 2: the paediatric and adolescent patient

Summary Until recently, obstructive sleep apnoea was a largely unknown condition. Because of the well‐publicised death of some high‐profile people resulting from untreated obstructive sleep apnoea, now mostly everyone has heard of the condition. Following diagnosis, several medical treatment modalities are available to patients. However, the role that dentistry and its various specialties can play in successful treatment for obstructive sleep apnoea should not be overlooked. The common causes for adult and paediatric obstructive sleep apnoea will be presented as well as a review of the more successful forms of dental treatment. Finally, a summary of the current evidence regarding obstructive sleep apnoea treatment will be presented.     

Effects on blood pressure after treatment of obstructive sleep apnoea with a mandibular advancement appliance – a three-year follow-up

Summary  Obstructive sleep apnoea (OSA) is a highly prevalent sleep disorder; it affects 4% of males and 2% of females. Hypertension has been shown to occur in 28–57% of OSA patients. There is a steady increase in evidence linking OSA to long-term cardiovascular morbidity including hypertension. The purpose of this study was to investigate whether mandibular advancement oral appliance (OA) treatment of OSA affects the patient's blood pressure (BP) in a 3-month and a 3-year perspective. Twenty-nine consecutive patients, with verified OSA defined as apnoea index (AI) >5 per hour and/or apnoea/hypopnoea index (AHI) ≥10 per hour, received an OA as treatment. BP was measured on three occasions; before treatment, after 3 months of treatment, and after 3 years of treatment. BP was measured with an electronic blood pressure monitor. The treatment effect of OA was measured after 3 months by repeated somnographic registration while the patient was wearing the OA. A treatment response was defined as AHI < 10; this was achieved in 25 of 29 patients (86%) at the 3-month evaluation. Significant reductions in blood pressure were attained between baseline and the 3-month evaluation ( P  < 0·001) and these changes remained at the 3-year follow-up in both systolic BP of −15·4 ± 18·7 mm Hg and diastolic BP of −10·3 ± 10·0 mm Hg. OA therapy reduced blood pressure in both a 3-month and a 3-year perspective in patients with OSA.     

Reliability of an adherence monitoring sensor embedded in an oral appliance used for treatment of obstructive sleep apnoea

The aim of this study was to test whether digitally registered use of a mandibular advancement device (MAD ) by a built‐in thermal sensor was reliable compared to a self‐reported diary of MAD use. Eighty consecutive patients referred to a specialist outpatient sleep medicine clinic (HUS ) were recruited. Patients of both genders, aged from 25 to 70 years with a diagnosis of mild, moderate or severe, were included. All participants signed a written informed consent when they received the MAD . For the purpose of this reliability study, we found it sufficient to include the first 30 nights of MAD use in the reliability analysis. At the 30th night follow‐up visit, the self‐reported diary with duration of MAD use was returned and data on the duration of MAD use with the built‐in sensor were retrieved. From a total of 2400 nights, complete data from both methods were retrieved for 2108 nights (84.6%). Missing data were largely a result of missing self‐reported diaries, whereas technical failure occurred in 6 nights (0.002%). The relative reliability was very high with ICC _3,1 0.847, and the absolute reliability for digitally registered MAD usage was calculated to ?0.17 (95% CI : 1.47 to ?1.81) hours in decimal conversion. Objectively collected data from built‐in thermal sensors in MAD s are as reliable as those of the self‐report assessments. This opens new possibilities for more accurate measurements of MAD adherence.     

Effective three‐dimensional evaluation analysis of upper airway form during oral appliance therapy in patients with obstructive sleep apnoea

The oral appliance (OA) is considered to be an effective treatment modality for obstructive sleep apnoea (OSA). Upper airway enlargement during OA therapy is critical, and lateral cephalometry has been used for the two‐dimensional evaluation of upper airway form during this therapy. However, this method cannot provide an accurate three‐dimensional (3D) view of upper airway form. To confirm the effects of OA on the upper airway in patients with OSAS, we performed CT in the presence and absence of OA in 15 Japanese patients (12 males, 3 females) who responded to OA therapy. CT in the presence and absence of OA was consecutively performed for each patient, and upper airway cross‐sectional area in six arbitrary planes parallel to the palatal plane was measured. Next, 3D image reconstruction was performed; morphological changes in upper airway form were evaluated, and upper airway volume at three levels from the palatal plane to the deepest point of the epiglottis was measured. The cross‐sectional area of two planes in the posterior soft palate region significantly increased in the presence of OA compared with that in the absence of OA. In the presence of OA, upper airway cross‐sectional area and volume significantly increased in the posterior soft palate region compared with those in the posterior tongue region. 3D CT image reconstruction accurately confirmed morphological changes in the upper airway during OA therapy. Continued use of this 3D evaluation is expected to improve the results of OA therapy in the future.     

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阻塞性睡眠呼吸暂停综合征（obstructive sleep apneasyndrome,OSAS）是在临床中最为常见的一种睡眠呼吸暂停综合征,主要表现为睡眠时打鼾并伴有呼吸暂停和呼吸表浅,夜间反复发生低氧血症、高碳酸血症和睡眠结构紊乱,导致白天嗜睡、心脑肺血管并发症乃至多脏器损害,严重影响患者的生活质量和寿命。随着研究的深入,OSAS的治疗方法取得了很大进展,其中口腔矫治器因其独特的优点及良好的效果而被患者所接受。应用于OSAS治疗的口腔矫治器种类繁多,适用范围及效果也因人而异。本文现将应用于OSAS治疗的各类口腔矫治器的临床效果、作用机制及戴用过程中存在的不良影响等做一综述。     

Treatment of obstructive sleep apnea with the Karwetzky oral appliance

The aims of this retrospective study were to assess the effect of a Karwetzky mandibular protrusion appliance for treating patients with mild, moderate, and severe obstructive sleep apnea. Eighty-one of 116 patients (69.8%) suffering from obstructive sleep apnea were treated with an activator model according to Karwetzky. After 4 months (SD 4.0 months) treatment outcome was controlled by polysomnography. Therapeutic outcome depended on the severity of obstructive sleep apnea. The median apnea-hypopnea index decreased from 10.6 events/h (range 2.0-14.9) to 5.8 events/h (range 0.2-17.3, P<0.01) in the mild group, from 21.7 events/h (range 17.3-28.4) to 7.7 events/h (range 1.0-30.1, P<0.001) in the moderate group, and from 42.1 events/h (range 33.2-64.9) to 18.1 events/h (range 2.4-48.8, P<0.001) in the severe group. Sleep variables did not show consistent improvement except for a trend towards more REM sleep and slow-wave sleep. The numbers of retentive teeth did not statistically influence treatment efficacy. Comparing the pre- and post-treatment polysomnographic variables, it was found that the respiratory events rather than sleep stages were significantly reduced by the Karwetzky appliance investigated.     

Long-term quality of life outcomes of maxillomandibular advancement osteotomy in patients with obstructive sleep apnoea syndrome

This study was performed to evaluate the long-term impact of maxillomandibular advancement (MMA) surgery on the apnoea–hypopnoea index (AHI) and quality of life (QoL) in patients with obstructive sleep apnoea syndrome (OSAS). The medical files of 12 OSAS patients who underwent MMA by one surgeon between 1995 and 1999 were reviewed retrospectively. Patients received a clinical assessment, polysomnography, and QoL questionnaires as part of routine care preoperatively (n = 12), within 2 years postoperative (n = 12), and again in 2016 (n = 9). A successful surgical outcome was defined as an AHI decrease of >50% with <20 events/h. Of the 66.7% (8/12) of patients who were initially cured, 66.7% (4/6) remained stable at a median follow-up of 19 years. Only the two patients with the highest AHI showed abnormal Epworth Sleepiness Scale scores. After convalescence, most patients reported stable symptomatic improvement. Aesthetic changes were found acceptable and all but one patient stated that they would undergo the surgery again. It is concluded that MMA is a safe and effective procedure. Ageing and weight gain might counterbalance the positive effects of surgery in the long term. It is therefore suggested that re-evaluation every 5 years should be scheduled, since a spontaneous AHI increase over time does not seem to be reflected by symptomatic changes.     

Maxillary, mandibular and chin advancement surgery for the treatment of obstructive sleep apnoea

The aim of this retrospective study was to determine the effectiveness of maxillary, mandibular and chin advancement (MMCA) surgery as a treatment for obstructive sleep apnoea and to determine the cephalometric parameters of this surgery. Twenty consecutive adult patients with obstructive sleep apnoea for whom other treatments (constant positive airway pressure, mandibular advancement splint and soft tissue surgery) had failed underwent MMCA surgery. Pre- and post-surgical polysomnography studies measuring the Respiratory Disturbance Index (RDI), minimum blood oxygen saturation (MinSaO2) and Epworth Sleepiness Scale (ESS) were compared. Lateral cephalometric radiographs measuring the pre- and post-surgical posterior airway space (PAS) were also analysed. Regression analysis indicated that the change in PAS at the level of B point largely accounted for the change in the RDI, although it was not significantly related with the postoperative oxygen saturation. MMCA surgery was found to be effective as a treatment for obstructive sleep apnoea, and improved all postoperative measures in this study. There was a significant relationship between B point, the PAS and a reduction in RDI.     

Patient-reported outcome measures following maxillomandibular advancement surgery in patients with obstructive sleep apnoea syndrome

Maxillomandibular advancement (MMA) is an effective treatment for obstructive sleep apnoea syndrome (OSAS) that is refractory to conventional treatment. However, it is a highly invasive procedure with several recognised side effects, and we know of few data on its effect on important patient-reported outcome measures (PROMS). Here we describe a case series of patients selected for MMA through our joint respiratory/maxillofacial surgery clinic, detailing the effect of MMA on objective physiological measurements and important PROMS. Patients with confirmed moderate/severe symptomatic OSAS who could not tolerate continuous positive airway pressure (CPAP) or mandibular advancement devices (MAD) were assessed in the clinic for consideration of MMA. Preoperative and postoperative airway measurements, apnoea/hypopnoea index (AHI), Epworth sleepiness scale (ESS) score, and quality of life (10-point Likert scale), were recorded. A customised questionnaire was administered postoperatively to assess selected psychosocial and functional domains (sleep quality, energy levels, appearance, ability to perform daily activities, and mood) and patient satisfaction using five-point Likert scales. Over an 18 month period, 39 patients were referred for consideration of MMA. Ten patients (7 men and 3 women, mean age 49.9, mean BMI 27.5) underwent surgery, which resulted in significant improvements in ESS, quality of life, AHI, and airway diameters. All patients reported improvements in all psychosocial/functional domains except appearance, in which five reported no change or worsened appearance. All subjects felt that MMA provided better symptom control than CPAP. The most commonly reported side effects were facial/lip numbness (9/10) and affected bite (6/10). MMA resulted in significant improvements in ESS, quality of life, and a range of PROMS, with a high level of patient satisfaction.     

A case of obstructive sleep apnoea with anterior cervical osteophytes

Summary  Osteophytes of the cervical spine are usually seen in elderly adults. When prominent, they have been blamed for dysphagia, cough, dysphonia and dyspnoea. This paper reports on an obstructive sleep apnoea (OSA) patient with cervical spinal osteophytes, one cause of airway obstruction. A 75-year-old male complained of pronounced snoring. The diagnosis was mild OSA, apnoea hypopnoea index was 9·4. Patient reported no restrictions in neck movements, experiences of neck pain or neck trauma. Previously, patient underwent a tonsillectomy due to discomfort in the pharyngeal region. A lateral cephalometric image was taken to observe airway before oral appliance therapy. The image revealed the presence of large osteophytes or sclerotic enthesopathy, lying on anterior surfaces from the fourth to seventh cervical vertebrae. A computed tomography (CT) image revealed the relationship of airway position to the spine. In the reconstructed three-dimensional (3D) image, the airway appeared displaced to the right of the craniomandiblar bone, with the hyoid bone similarly displaced in a manner to that of the airway. The spine also appeared displaced to the left side ofcraniomandiblar bone. Additionally, the 3D image revealed calcification of the stylohyoideum ligament and ligamentum nuchae. This present case highlights the necessity of CT examination for OSA patients. There were several ligament calcifications in the head and neck region. Cervical spine osteophytes, as a component of Forestier's or cervical spine disease, have been associated with dysphagia and dysphonia. It was reported that bilateral vocal cord paralysis was caused by osteophytes compressing the post-cricoid area of larynx.     

Predictors of obstructive sleep apnoea‐hypopnea severity and oral appliance therapy efficacy by using lateral cephalometric analysis

Obstructive sleep apnoea‐hypopnea (OSAH) is a common disorder characterised by repetitive complete or partial closure of the upper airway during sleep, which results in sleep fragmentation and oxygen desaturation. There is growing interest in the use of oral appliances (OAs) to treat OSAH. The purpose of this study was to clarify the cephalometric factors that are associated with OSAH severity and that predict the outcome of OA therapy. Two hundred nine patients with OSAH were recruited and analysed retrospectively. They had a polysomnographically documented apnoea‐hypopnea index (AHI) of more than five respiratory events per hour. Lateral skull radiographs were used for cephalometric analysis. Only 67 of the 209 recruited patients underwent a second polysomnography (PSG) to evaluate the efficacy of OA therapy. In all recruited patients, the angle formed by the subspinal point (A) to the nasion (N) to the supramental point (B) (i.e. ANB angle) and the distance between the mandibular plane and hyoid bone (MP‐H) were predictive factors of OSAH severity. In only 67 patients underwent PSG with an OA, the mean rate of decrease in the AHI was 47·8 ± 29·1%. OA therapy effectively treated OSAH in some patients with a very severe form of OSAH. However, patients who had a high position of the hyoid bone had a poor response to OA therapy. This study suggested that cephalometric analysis is useful for predicting OSAH severity and OA therapy efficacy.     

Risk factors for the efficacy of oral appliance for treating obstructive sleep apnea: A preliminary study

Objective: To identify potential risk factors of response to oral appliance in patients with obstructive sleep apnea (OSA).

Methods: Fifteen OSA patients were enrolled. Clinical characteristics, cephalometric measurements, and the results of home sleep testing were retrospectively obtained at baseline, and a sleep test was done again at the end of treatment.

Results: Twelve subjects were responders and three were non-responders. The diastolic blood pressure, minimum pulse rate, SNA (Angle between sella-nasion and nasion-A point), ANB (Anteroposterior maxilla/mandible discrepancy), and facial convexity of non-responders was higher than those of responders. Unlike AHI, non-responders showed a lower lowest oxygen saturation (%) than responders.

Discussion: Elevated diastolic pressure and minimal pulse rate, higher skeletal convexity and lowered lowest oxygen saturation might be risk factors to oral appliance efficacy in the OSA patients. More research in a large sample is needed to verify the results of the current study.