A prospective 10-year cephalometric follow-up study of patients with obstructive sleep apnea and snoring who used a mandibular protruding device

Effect of mandibular advancement appliance use on oral and periodontal health in patients with OSA: a systematic review

STUDY OBJECTIVES

Use of a mandibular advancement appliance (MAA) is an effective treatment option for mild-to-moderate obstructive sleep apnea (OSA). MAA is well-tolerated but undesirable effects may be observed over time. The present systematic review aimed to assess the effect of MAA use on oral and periodontal health in patients with OSA.

METHODS

MEDLINE (PubMed), Cochrane, and Scopus were searched for randomized and non-randomized controlled trials (RCTs, NRCTs), cohorts, and case-control studies reporting on side effects of MAA treatment in OSA patients during a follow-up of at least 6 months.

RESULTS

From a total of 169 articles screened, 28 were selected. The most frequently reported MAA-related effects on oral health were: hypersalivation (weighted mean prevalence, 33.3%), occlusal changes (30.2%), muscle pain (22.9%), tooth discomfort or pain (20.2%), and xerostomia (18.3%). No MAA-related periodontal effect was reported. The periodontal status prior to MAA treatment was rarely assessed and described, but 5 studies (17.8%) stated that periodontitis was an exclusion criterion for MAA. Only one retrospective study specifically evaluated periodontal parameters and reported no significant changes in periodontally healthy patients with OSA using MAA for over 7 years.

CONCLUSION

MAA use is associated with a number of clinical consequences on oral health, but there is no evidence to conclude whether or not MAA affects periodontal health in patients with OSA. This aspect appears to be under-evaluated and should be further investigated in relation to the type of MAA, the duration of treatment, and prior history of periodontitis.

Impact of palatopharyngeal sizes changing on pharyngeal airflow fluctuation and airway vibration in a pediatric airway

Snoring is common in children and is associated with many adverse consequences. One must study the relationships between pharyngeal morphology and snoring physics to understand snoring progression. Although some model studies have provided fluid-structure interaction dynamic descriptions for the correlation between airway size and snoring physics, the descriptions still need to be further investigated in patient-specific airway models. Fluid-structure interaction studies using patient-specific airway structures complement the above model studies. Based on reported cephalometric measurement methods, this study quantified and preset the size of the palatopharynx airway in a patient-specific airway and investigated how the palatopharynx size affects the pharyngeal airflow fluctuation, soft palate vibration, and glossopharynx vibration with the help of a verified FSI method. The results showed that the stenosis anterior airway of the soft palate increased airway resistance and airway resistance fluctuations, which can lead to increased sleep effort and frequent snoring. Widening of the anterior airway can reduce airflow resistance and avoid obstructing the anterior airway by the soft palate vibration. The pharyngeal airflow resistance, mouth inflow proportion, and soft palate apex displacement have components at the same frequencies in all airway models, and the glossopharynx vibration and instantaneous inflow rate have components at the same frequencies, too. The mechanism of this same frequency fluctuation phenomenon can be explained by the fluid-structure interaction dynamics of an ideal coupled model consisting of a flexible plate model and a collapsible tube model. The results of this study demonstrate the potential of FSI in studying snoring physics and clarify to some degree the mechanism of airway morphology affecting airway vibration physics.

A Systematic Review of Oral Modifications Caused by the Prolonged Application of Continuous Positive Airway Pressure (CPAP) and Intraoral Appliances in Patients with Obstructive Sleep Apnea (OSA)

Objective

Prolonged use of oral devices as a substitute for traditional treatments has been studied in relation to the dental and skeletal changes associated with obstructive sleep apnea syndrome (OSA), which is a sleep-breathing disorder.

Materials and Methods

A review of articles indexed in PubMed, Google Scholar, Cochrane Library, Scopus, Web of Sciences, and CINHAL databases in September 2022 based on MeSH-based keywords with "dental and skeletal" and "oral appliance" and "obstructive sleep apnea" was examined to ensure that the keywords alone or cross-linked, depending on which base of the searched data, were used. 16 articles out of 289 articles were included in the research, and 273 articles were excluded due to lack of study.

Conclusions

CPAP treatment has limited dental or skeletal effects in short-term or long-term use. OAs and MADs show significant dental changes with prolonged use. MAS and TSD are more effective in short-term goals than CPAP. OAs' increase may cause dental and skeletal changes. MPD shows notable cephalometric alterations.

Oral appliance influence on jaw function in obstructive sleep apnea

INTRODUCTION

Oral appliance (OA) therapy in obstructive sleep apnea (OSA) could be a risk factor for normal jaw function, given the prolonged effect of an OA in keeping the mandible in a protruded position away from a normal position. This study aimed to assess changes in symptoms and clinical findings related to jaw function after 1 year of treating OSA with an OA.

METHODS

In this follow-up clinical trial, 302 patients with OSA were assigned to treatment with either monobloc or bibloc OA. Baseline and 1-year follow-up assessment included using the Jaw Functional Limitation Scale, self-reported symptoms and signs related to jaw function. The clinical examination of jaw function included mandibular mobility, dental occlusion, and tenderness in the temporomandibular joints and masticatory muscles. Descriptive analyses of variables are presented for the per-protocol population. To evaluate differences between the baseline and the 1-year follow-up, paired Student t tests and the McNemar change test was used.

RESULTS

One-hundred and ninety-two patients completed the 1-year follow-up (male 73%, mean aged 55 ± 11 years). There was no change in the Jaw Functional Limitation Scale score at the follow-up (nonsignificant). The patients described no change in symptoms at the follow-up, except for improvements in morning headache (P <0.001) and increased frequency of difficulties in opening the mouth or chewing on awakening (P = 0.002). Subjectively reported changes in dental occlusion during biting/chewing increased significantly at the follow-up (P = 0.009).

CONCLUSIONS

No changes in measurements of jaw mobility, dental occlusion, or pain on palpation of the temporomandibular joints or masticatory muscles were seen at the follow-up. Thus, using an OA in treating OSA had limited influence on jaw functions and related symptoms. Moreover, the risk of developing pain and functional impairment in the masticatory system was infrequent, indicating that this treatment is safe and can be recommended.

Dental and Skeletal Side Effects of Oral Appliances Used for the Treatment of Obstructive Sleep Apnea and Snoring in Adult Patients—A Systematic Review and Meta-Analysis

Background: Mandibular advancement devices for obstructive sleep apnea treatment are becoming increasingly popular among patients who do not prefer CPAP devices or surgery. Our study aims to evaluate the literature regarding potential dental and skeletal side effects caused by mandibular advancement appliances used for adult OSA treatment. Methods: Electronic databases were searched for published and unpublished literature along with the reference lists of the eligible studies. Randomized clinical trials and non-randomized trials assessing dental and skeletal changes by comparing cephalometric radiographs were selected. Study selection, data extraction, and risk of bias assessment were performed individually and in duplicate. Fourteen articles were finally selected (two randomized clinical trials and 12 non-randomized trials). Results: The results suggest that mandibular advancement devices used for OSA treatment increase the lower incisor proclination by 1.54 ± 0.16°, decrease overjet by 0.89 ± 0.04 mm and overbite by 0.68 ± 0.04 mm, rotate the mandible downward and forward, and increase the SNA angle by to 0.06 ± 0.03°. The meta-analysis revealed high statistical heterogeneity. Conclusions: The MADs affect the lower incisor proclination, overjet, overbite, the rotation of the mandible and the SNA angle. More randomized clinical trials providing high-quality evidence are needed to support those findings.

Oral appliance-generated malocclusion traits during the long-term management of obstructive sleep apnea in adults

OBJECTIVES

To identify malocclusion characteristics generated after using oral appliances (OAs) for at least 5 years for the management of snoring and obstructive sleep apnea (OSA) in adults.

MATERIALS AND METHODS

PubMed, MEDLINE (Ovid), Scopus, CINAHL, and Informit were searched without language restrictions through January 20, 2021. Unpublished literature was searched on ClinicalTrials.gov, the National Research Register, and the Pro-Quest Dissertation Abstracts and Thesis database. Authors were contacted when necessary, and reference lists of the included studies were screened. Risk of bias was assessed through the revised Cochrane Risk of Bias tool for randomized controlled trials (RoB2) and Non-Randomized Studies of Interventions for non-RCTs and uncontrolled before-after studies (ROBINS-I). A random-effects meta-analysis was conducted only on studies that used the same OAs to exclude biomechanical differences. Risk of bias across studies was assessed with the Grading of Recommendations, Assessment, Development and Evaluation tool.

RESULTS

A total of 12 studies were included in the final qualitative synthesis. Eight included studies had high, one had moderate, and three had low risks of bias. Significant progressive decreases of overjet (OJ; -1.43 mm; 95% confidence interval [CI], -1.66 to -1.20) and overbite (OB; -1.94 mm; 95% CI, -2.14 to -1.74) associated with maxillary incisor retroclination and mandibular incisor proclination were reported long term. Although most studies showed no sagittal skeletal changes, some degree of vertical skeletal changes were noted.

CONCLUSIONS

Based on a very low evidence level, inevitable anterior teeth positional changes seem to be a common long-term adverse effect of OAs. The magnitude of those changes could be considered clinically irrelevant for most pretreatment occlusions, but in occlusions with limited OJ and OB, it may be worth clinical consideration.

Long-term dentoskeletal side effects of mandibular advancement therapy in patients with obstructive sleep apnea: data from the Pays de la Loire sleep cohort

OBJECTIVES

Mandibular advancement devices (MADs) are the main therapeutic alternative to continuous positive airway pressure for obstructive sleep apnea. Our aim was to evaluate the long-term dentoskeletal side effects of MADs and to identify the predictive factors for these side effects.

MATERIALS AND METHODS

Patients from the Pays de la Loire cohort treated with a custom-made MAD for at least 1 year were included in this retrospective study. Digital cephalometric analyses were performed at baseline and at follow-up.

RESULTS

We included a total of 117 patients, treated with a MAD for a median [interquartile range] of 4.6 [2.6-6.6] years. The main significant side effects were a decrease in overbite (- 0.5 ± 1 mm), overjet (- 0.7 ± 1 mm) and maxillary incisor inclination (- 2.5 ± 2.8°) and an increase in mandibular incisor inclination (+ 2.2 ± 2.7°). Subjective side effects were not linked to the observed dentoskeletal changes. Current smokers were at higher risk of overjet modifications. A pre-existing anterior open-bite was associated with a greater decrease in overbite. Treatment duration was associated with a more pronounced mandibular incisor proclination. Propulsion was negatively associated with maxillary incisor retroclination.

CONCLUSIONS

Long-term dentoskeletal side effects were mainly moderate dental side effects. Some predictive factors were shown to be associated with more pronounced changes. Subjective side effects did not appear to be reliable tools to detect dentoskeletal side effects.

CLINICAL RELEVANCE

Regular follow-up with clinical examination and regular radiographs is mandatory. The predictive factors could be of interest for a better selection of patients and to individualize follow-up.

Long-term periodontal changes associated with oral appliance treatment of obstructive sleep apnea

STUDY OBJECTIVES

To characterize the mandibular anterior teeth crown height as a marker of periodontal changes and bone loss as a side effect of an oral appliance (OA) worn for a minimum of 4.5 years.

METHODS

This retrospective study conducted on patients with healthy baseline periodontiu m recruited participants from consecutive sleep apnea patients treated with an OA between 2004 to 2014. Eligible participants were recalled for a follow-up visit where a periodontal exam was performed, a lateral cephalogram and dental impressions were obtained. Clinical crown height for mandibular anterior teeth and cephalometric variables were measured and compared before and after treatment. A full periodontal evaluation was performed at the follow-up visit.

RESULTS

21 patients enrolled with a mean treatment length of 7.9±3.3 years. For the mandibular anterior teeth, clinical crown height did not change over the evaluated period. At follow-up, all the periodontal assessed variables were within normal limits, with the mean probing depth of 1.4±0.5 mm, recession 0.6±1.1 mm and Clinical Attachment Loss (CAL) 0.8±1.0 mm. Compared to baseline, there was a significant proclination of mandibular incisors (mean increase of 5.1°) with the continued use of OA. Gingival levels were maintained with clinically insignificant changes during the observation period.

CONCLUSIONS

Inclination of the mandibular incisors increases significantly with the use of an OA in patients with obstructive sleep apnea (OSA). Positional changes in these teeth were not associated with any measured evidence of increase in clinical crown height or gingival recession.