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Introduction Mandibular Advancement Devices (MAD) have been reported to be an alternative treatment to CPAP in moderate to severe obstructive sleep apnea (OSA) cases. The design of MAD has a major influence on its success rate on the patient, and design features that have an influence on efficacy, tolerance, and compliance. The aim of this study was to determine the range of mandibular protrusion at different vertical points; 2, 5, 8 and 11 mm in a young adult population. Methods Fifty two students aged 19 to 23 years (mean 21.3 ± 1.7; 29 females and 23 males), with full permanent dentition participated in the study. The absolute range of maximal mandibular protrusion and retrusion was measured (mm) with the use of the George Gauge. Descriptive statistics, ANOVA and paired t-test using SPSS were used. Results Range of mandibular advancement was possible to be determined for the 4 levels of vertical opening with the gauges: 2 mm fork mean mandibular advance 13,10 mm ± 0.604; 5 mm mean 11.98 mm ± 1.075; 8 mm mean 11.20 mm ± 1.369; 11 mm mean 9.87 mm ± 1.886. No significant differences were found between class I, II, and III. Conclusions There is an impact of increased inter-incisal distance of effective mandibular protrusion when constructing a MAD. As vertical dimension increases the mandible rotates posteriorly and places itself in a more retrusive location, and the range of mandibular advancement reduces (0.3 mm for every 1 mm of vertical increase).

This study aimed to analyze the efficacy of maxillary oral appliance (MOA) designs on respiratory variables during sleep. At baseline, 23 participants underwent a sleep test with a portable device for two nights and were categorized as participants with mild obstructive sleep apnea (mild-OSA) (n = 13) and without OSA (w/o-OSA) (n = 10). Three types of MOAs, standard-OA (S-OA), palatal covering-OA (PC-OA), and vertically increasing-OA (VI-OA), were each worn for three nights, and sleep tests with each MOA were performed with a portable device for two nights. Based on the average of the respiratory event index (REI) values for the two nights for each MOA, w/o-OSA participants with an REI ≥ 5.0 were defined as the exacerbation group and those with an REI < 5.0 as the non-exacerbation group. In mild-OSA participants, an REI ≥ 15.0 or REI ≥ baseline REI × 1.5 were defined as the exacerbation group and those with an REI < 15.0 and REI < baseline REI × 1.5 were defined as the non-exacerbation group. The percentage of the exacerbation and non-exacerbation groups with MOA was evaluated in the w/o-OSA and mild-OSA participants. The maxillary and mandibular dental-arch dimension was compared by dentition model analysis. The exacerbation group in w/o-OSA participants (n = 10) comprised 10.0% participants (n = 1) with S-OA, 40.0% (n = 4) with PC-OA, and 30.0% (n = 3) with VI-OA. The exacerbation group in the mild-OSA participants (n = 13) comprised 15.4% subjects (n = 2) with S-OA, 23.1% (n = 3) with PC-OA, and 23.1% (n = 3) in VI-OA. In the model analysis for w/o-OSA, the posterior dental arch width was significantly greater in the exacerbation group than in the non-exacerbation group wearing S-OA (p < 0.05). In addition, the ratio of the maxillary to mandibular dental arch width (anterior dental arch width) was significantly greater in the exacerbation group than in the non-exacerbation group for both PC-OA and VI-OA (p < 0.05). In mild-OSA, the maxillary and mandibular dental arch lengths and the ratio of maxillary to mandibular dental arch width (posterior dental arch width) were significantly smaller in the exacerbation group than in the non-exacerbation group for S-OA (p < 0.05). This study confirmed that wearing an MOA by w/o-OSA and mild-OSA participants may increase the REI during sleep and that PC-OA and VI-OA may increase the REI more than S-OA. The maxillary and mandibular dental-arch dimensions may affect the REI when using an MOA.

BackgroundModerate and severe obstructive sleep apnea (OSA) have been independently associated with dyslipidemia. The results of metabolic improvement with continuous positive airway pressure (CPAP) have been controversial. Less evidence exists regarding this issue in mild OSA. A current treatment for mild OSA is mandibular advancement device (MAD) therapy, but its effectiveness on the metabolic profile needs to be compared with CPAP. The purpose of this study was to compare MAD vs CPAP vs no treatment on the metabolic profile during 6 and 12 months of follow-up in patients with mild OSA.MethodsThe inclusion criteria were patients with mild OSA, both genders, ages 18 to 65 years, and body mass index (BMI) of < 35 Kg/m2. Patients were randomized in 3 groups (CPAP, MAD, and control). The evaluations included physical examination, metabolic profile, and full polysomnography at baseline, 6 months, and 12 months of follow-up.ResultsSeventy-nine patients with mild OSA were randomized in three treatment groups, with mean age (± SD) of 47 ± 9 years, 54% men, and AHI 9.5 ± 2.9 events/h. MAD and CPAP reduced AHI at 6 and 12 months compared to the control group. MAD adherence was higher than CPAP at 6 and 12 months. Despite lower adherence compared to MAD, CPAP was more effective in reducing total cholesterol over 12 months (baseline 189.3 ± 60.2 mg/dl to 173.4 ± 74.3 mg/dl) and low-density lipoprotein cholesterol (LDL-c, baseline 112.8 ± 54.9 mg/dl to 94.5 ± 67.4 mg/dl).ConclusionsAfter 1 year of treatment, CPAP was superior to MAD in reducing total cholesterol and LDL-c in patients with mild OSA.

Abstract PurposeObstructive sleep apnea (OSA) is a common chronic condition, associated with several conditions that account for leading causes of mortality. Adherence to treatment of a chronic condition is, along with treatment efficacy, a major determinant of treatment outcome. The aim of this study was to test whether or not a multifactorial intervention in addition to standard care increases adherence rates in patients using a titratable oral appliance for OSA.MethodsAll subjects were 18 years old or older, had a diagnosis of OSA, and were treated with an oral appliance with an embedded sensor to measure appliance wear time objectively. The control group received routine care, while the experimental subjects received an additional multifactorial intervention. Comparison of adherence was at 30 days (Phase I) and 90 days (Phase II) after appliance delivery.ResultsData are reported for 82 subjects in Phase I (control 43; experimental 39) and 66 subjects in Phase II (control 36; experimental 30). There were no significant differences for age, sex, body mass index, and apnea-hypopnea index (p > 0.05) between groups. In both Phase I and Phase II, the mean number of nights the appliance was worn 4 or more hours and the mean time the appliance was worn nightly were significantly greater in the experimental than in the control group (p < 0.05).ConclusionsInterventions were well received by subjects and can be carried out by auxiliary personnel. The experimental interventions resulted in clinically important and statistically significant improvements in patient adherence to treatment.

Purpose In order for a mandibular advancement device (MAD) to be efficacious, it must remain seated on the teeth during sleep. Quantitative data on the retentive characteristics of MADs are currently unavailable. The present pilot study is the first to describe an in vitro setup testing the retentive characteristics of different monobloc MADs. Methods A hydraulic cyclic test machine was used with MADs seated on dental casts to measure retention forces upon removal of the MADs. A custom-made monobloc (CM-mono), a thermoplastic monobloc (TP-mono), and a thermoplastic duobloc (TP-duo) configured as a monobloc were tested. Two protrusions were investigated, representing 25 and 65 % of the maximal protrusion. The effects of the type of MAD, duration of the test, and amount of protrusion on removal forces were measured. Results The measured removal forces of all three MADs tested differed significantly, with the TP-duo showing the highest values ( P  < 0.0001). The effects of wear due to the repetitive cyclic loading became obvious by the production of wear particles in all MADs tested. However, only the TP-duo showed a significant reduction in time in removal forces for both protrusion positions ( P  < 0.0001; P  = 0.0011). The effect of the amount of protrusion on the removal forces differed significantly between all three MADs tested ( P  = 0.0074). Conclusions This in vitro pilot study reveals significant differences in retention forces for the MADs tested. The findings are consistent with clinical effects of nightly loss of MADs as reported in the literature and are within the range of reported physiological mouth-opening forces. Future research is needed to determine the key design features of MADs that explain these differences.

Mandibular advancement splints (MAS) are the leading treatment alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA). However, not all patients experience clinical benefit and treatment prediction remains challenging. Understanding the effects of mandibular advancement on pharyngeal collapsibility and muscle function may provide valuable information on the mechanisms of MAS, and thereby help to develop novel approaches for patient selection. Thus, we aimed to determine dose-dependent effects of mandibular advancement on pharyngeal collapsibility and muscle function concurrently in OSA patients undergoing MAS therapy. Twelve (11 male) MAS-naïve patients underwent a detailed physiology sleep study (polysomnography) to quantify pharyngeal collapsibility (PCRIT), pharyngeal muscle responsiveness to negative pharyngeal pressure (via genioglossus intramuscular electromyography and an epiglottic pressure sensor) and effectiveness to restore airflow and minute ventilation (Vi) after 1-minute transient CPAP reductions (induced airflow-limitation) at three mandibular advancement positions: 0% (habitual bite), 50% and 100% of the maximum comfortable mandibular advancement. Standard clinical polysomnography after MAS therapy optimization was performed to determine treatment outcome. Overall, participants were obese with severe OSA (mean ± SD: BMI = 31 ± 4 kg/m2, apnea-hypopnea index [AHI] = 33 ± 14 events/hour). PCRIT decreased with mandibular advancement in a dose-dependent manner (1.8 ± 3.9 vs. -0.9 ± 2.9 vs. -4.0 ± 3.6 cmH2O; p < 0.001). There was no systematic change in genioglossus muscle responsiveness (p = 0.09) or effectiveness to restore peak airflow (p = 0.4) or Vi (p = 0.7) with mandibular advancement. Mandibular advancement reduces pharyngeal collapsibility in a dose-dependent manner without systematically changing genioglossus muscle function in a predominantly obese and severe OSA population. This indicates that the primary mode of action of MAS therapy is via improvement in passive pharyngeal anatomy.

Obstructive sleep apnea (OSA), a common sleep disorder disease, affects millions of people. Without appropriate treatment, this disease can provoke several health-related risks including stroke and sudden death. A variety of treatments have been introduced to relieve OSA. The main present clinical treatments and undertaken research activities to improve the success rate of OSA were covered in this paper. Additionally, guidelines on choosing a suitable treatment based on scientific evidence and objective comparison were provided. This review paper specifically elaborated the clinically offered managements as well as the research activities to better treat OSA. We analyzed the methodology of each diagnostic and treatment method, the success rate, and the economic burden on the world. This review paper provided an evidence-based comparison of each treatment to guide patients and physicians, but there are some limitations that would affect the comparison result. Future research should consider the consistent follow-up period and a sufficient number of samples. With the development of implantable medical devices, hypoglossal nerve stimulation systems will be designed to be smart and miniature and one of the potential upcoming research topics. The transcutaneous electrical stimulation as a non-invasive potential treatment would be further investigated in a clinical setting. Meanwhile, no treatment can cure OSA due to the complicated etiology. To maximize the treatment success of OSA, a multidisciplinary and integrated management would be considered in the future.

Comment on \"Comparative evaluation of the efficacy of customized maxillary oral appliance with mandibular advancement appliance as a treatment modality for moderate obstructive sleep apnea patients.\" Keywords: Sleep apnea, Oral appliance, Mandibular advancement device

Purpose This study aimed to compare the effects of two different mandibular advancement devices on the upper airway volume, polysomnographic parameters, and sleepiness scale scores in patients with obstructive sleep apnea and Temporomandibular disorders (TMD). Materials and methods Monoblock and twinblock mandibular advancement devices were applied to patients with obstructive sleep apnea syndrome for 3 months separated by a wash-out period of 2 weeks. Research Diagnostic Criteria for TMD (RDC/TMD), Polysomnographic parameters and cone-beam computed tomography findings were recorded before and after the use of the mandibular advancement devices. A three-dimensional analysis of the airway was then performed. Results The use of the monoblock device significantly increased the upper airway volume compared with the use of the twinblock device ( p  = 0.032). The polysomnographic parameters similarly improved with the use of the twin-block and monoblock devices. The significant reduction in TMD symptoms was observed. Conclusion The use of the monoblock device increased the retropalatal airway volume. This volume increase may be attributed to the fact that the design of the monoblock device allows less mandibular movement than does that of the twinblock device. Indicates the potential benefits of MAD S treatment in alleviating TMD-related issues. Clinical significance Monoblock MADs have improved effects on respiratory parameters and upper airway dimensions in patients with OSA and mild to moderate TMD.

Oral appliance (OAm) therapy has demonstrated efficacy in treating obstructive sleep apnea (OSA). The aim of this systematic review was to clarify the efficacy of device designs (Mono-block or Bi-block) in OAm therapy for OSA patients. We performed a meta-analysis using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Two studies (Mono-block OAm versus Bi-block OAm) remained eligible after applying the exclusion criteria. When comparing Mono-block OAm and Bi-block OAm, Mono-block OAm significantly reduced the apnea–hypopnea index (2.92; 95% confidence interval (95%CI), 1.26 to 4.58; p = 0.0006), and patient preference for Mono-block OAm was significantly higher (2.06; 95%CI, 1.44 to 2.06; p < 0.0001). Lowest SpO2, arousal index, non-REM stage 3, sleep efficiency, Epworth Sleepiness Scale (ESS), Snoring Scale, and side effects were not significantly different between the two groups (lowest SpO2: −11.18; 95%CI, −26.90 to 4.54; p = 0.16, arousal index: 4.40; 95%CI, −6.00 to 14.80; p = 0.41, non-REM stage 3: −2.00; 95%CI, −6.00 to 14.80; p = 0.41, sleep efficiency: −1.42, 95%CI, −4.71 to 1.86; p = 0.40, ESS: 0.12; 95%CI, −1.55 to 1.79; p = 0.89, Snoring Scale: 0.55; 95%CI, −0.73 to 1.83, p = 0.55, side effects: 1.00, 95%CI, 0.62 to 1.61, p = 1.00). In this systematic review, the use of Mono-block OAm was more effective than Bi-block OAm for OSA patients.