The effectiveness of oral appliances for obstructive sleep apnea syndrome: A meta-analysis

The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study

STUDY OBJECTIVES

To prospectively validate drug-induced sleep endoscopy with mandibular advancement maneuvers as a prediction tool for treatment success of oral appliance treatment (OAT).

METHODS

Seventy-seven patients diagnosed with moderate obstructive sleep apnea were included and underwent drug-induced sleep endoscopy. The upper airway collapse was assessed using the VOTE classification. Additionally, three mandibular advancement maneuvers were performed to predict treatment success of OAT. If the maneuver was negative, the level and degree and configuration of the persistent collapse was described according to the VOTE classification. All patients were treated with OAT and completed a follow-up sleep study with OAT in situ without regard to their anticipated response to treatment.

RESULTS

Sixty-four patients completed 6-month follow up. A positive jaw thrust maneuver proved to be significantly associated with favorable OAT response, whereas the chin lift maneuver and the vertical chin lift maneuver were not. Additionally, a persistent lateral oropharyngeal collapse when performing any mandibular advancement maneuver was significantly associated with unfavorable OAT response.

CONCLUSIONS

The current findings suggest that a jaw thrust maneuver should be preferred over the chin lift maneuver for predicting OAT response. Patients with a positive jaw thrust maneuver should be counseled toward favorable OAT response, whereas those with persistent lateral oropharyngeal collapse should be advised about the likelihood of unfavorable OAT response. A negative jaw thrust maneuver did not prove to be a significant predictor for unfavorable response to OAT. Consequently, uncertainties arise regarding the justification of performing drug-induced sleep endoscopy solely for predicting the efficacy of OAT. However, the results of the current study could be influenced by heterogeneity in the assessment of respiratory parameters, variability in the performance of the mandibular advancement maneuvers, and the instability of bolus technique sedation.

CLINICAL TRIAL REGISTRATION

Registry: Netherlands Trial Register; Name: Drug-induced Sleep Endoscopy: a prediction tool for success rate of oral appliance treatment; Identifier: NL8425; URL: https://www.onderzoekmetmensen.nl/en/trial/20741.

CITATION

Veugen CCAFM, Kant E, Kelder JC, Schipper A, Stokroos RJ, Copper MP. The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study. J Clin Sleep Med. 2024;20(3): 353-361.

Effectiveness of Titratable Oral Appliance in Management of Moderate to Severe Obstructive Sleep Apnea-A Prospective Clinical Study with Acoustic Pharyngometry

To assess effectiveness of titratable Oral Appliance (OA) in management of moderate to severe cases of Obstructive Sleep Apnea (OSA). Thirty Polysomnography (PSG) diagnosed cases of moderate to severe OSA were subjected to a thorough cranio-facial-dental evaluation, a detailed sleep history and three dimensional assessment of upper airway geometry utilising Acoustic Pharyngometry (AP) (Eccovision, sleep group solutions). A titratable OA was delivered to all patients for mandibular advancement. Apnea Hypopnea Index (AHI), Oxygen Saturation (SPO2), Epworth's Sleepiness Scale (ESS), Mean area and volume of upper airway were recorded at Baseline (T0) and after 08 weeks of appliance delivery (T1). The mean AHI & ESS scores were significantly lower and SPO2 was significantly higher at T1 compared to T0 (P-value < 0.05 for all). The mean area and volume of upper airway at T1 were significantly higher compared to values at T0 (P-value < 0.05 for both). The mean area showed 19.51% increase at T1 whereas mean volume increased by 18.55%. OA therapy is highly efficacious in cases with moderate to severe OSA, especially, in those with retrognathic mandible. This modality should be considered as an effective alternate to Continuous Positive Airway Pressure (CPAP) therapy in non-compliant patients rather than no treatment. AP is an effective modality to predict airway changes after advancement with OA, to ascertain follow up changes and is highly recommended in routine clinical practice. Large scale, multicenter studies are recommended to elaborate the findings of the present study and to add better quality evidence in this regard.

Is the response rate of oral appliance therapy for subjects with and without position-dependent obstructive sleep apnoea different?

Objective To compare the effect of oral appliance (OA) treatment on non-position-dependent obstructive sleep apnoea (non-POSA) and position-dependent obstructive sleep apnoea (POSA).Methods The investigational sample was 205 patients with obstructive sleep apnoea at baseline and they were classified as non-POSA and POSA. Polygraphic registration was employed to compare the proportion of treatment responders between non-POSA and POSA groups at eight-week and one-year follow-ups. The treatment responder was defined as apnoea-hypopnoea index (AHI) <10 and/or ≥50% reduction in AHI.Results At the eight-week follow-up, the proportions of responders were 56% and 69% for the non-POSA and POSA groups (not significant), respectively. The responder proportions were increased to 68% and 77% for the two groups, respectively, at the one-year follow-up (not significant between the two groups). At the two follow-ups, there was no significant difference in absolute change in overall AHI between the two groups. However, the decrease in supine AHI was significantly greater in the POSA group, while the decrease in non-supine AHI was significantly greater in the non-POSA group.Conclusions The response rate for OA treatment did not differ between POSA and non-POSA groups. However, greater decreases in supine AHI and non-supine AHI were found among POSA and non-POSA patients, respectively.

Pilot Study of a New Mandibular Advancement Device

This study was conducted to determine the efficacy of a customized mandibular advancement device (MAD) in the treatment of obstructive sleep apnea (OSA). Eight patients (M = 3; F = 5; mean age = 56.3 ± 9.4) with a diagnosis of OSA confirmed by polysomnography (PSG) were recruited on the basis of the following inclusion criteria: apnea-hypopnea index (AHI) > 5, age between 18 and 75 years, body mass index (BMI) < 25, and PSG data available at baseline (T0). All were treated with the new NOA® MAD by OrthoApnea (NOA®) for at least 3 months; PSG with NOA in situ was performed after 3 months of treatment (T1). The following parameters were calculated at T0 and T1: AHI, supine AHI, oxygen desaturation index (ODI), percentage of recording time spent with oxygen saturation <90% (SpO2 < 90%), and mean oxygen desaturation (MeanSpO2%). Data were submitted for statistical analysis. The baseline values were AHI = 21.33 ± 14.79, supine AHI = 35.64 ± 12.80, ODI = 17.51 ± 13.5, SpO2 < 90% = 7.82 ± 17.08, and MeanSpO2% = 93.45 ± 1.86. Four patients had mild OSA (5 > AHI < 15), one moderate OSA (15 > AHI < 30), and three severe OSA (AHI > 30). After treatment with NOA®, statistically significant improvements in AHI (8.6 ± 4.21) and supine AHI (11.21 ± 7.26) were recorded. OrthoApnea NOA® could be an effective alternative in the treatment of OSA: the device improved the PSG parameters assessed.

One-Stage Multilevel Surgery for Treatment of Obstructive Sleep Apnea Syndrome

We report the results of one-stage multilevel upper airway surgery for patients who could not tolerate continuous positive airway pressure (CPAP). Patients treated with multilevel surgery at a University Hospital in 2015–2019 were identified from a prospectively maintained database. The inclusion criteria were aged 18–70 years, body mass index (BMI) < 35 kg/m², apnea–hypopnea index (AHI) > 20, and lingual tonsil hypertrophy grade 3 or 4. Drug-induced sleep endoscopy was performed before surgery in all patients. Multilevel surgery was performed in one stage and included expansion sphincter pharyngoplasty (ESP), coblation tongue base reduction (CTBR), and partial epiglottectomy (PE) as required. The outcome measures were postoperative AHI, time percentage oxygen saturation < 90%, and Epworth Sleepiness Scale (ESS) score. A total of 24 patients were included: median age 49.1 years, average BMI 27.26 kg/m², and 90% men. Ten patients received ESP plus CTBR plus PE, eight received ESP plus CTBR, and six received ESP plus PE. The mean preoperative AHI was 33.01 at baseline and improved to 17.7 ± 13 after surgery (p < 0.05). The ESS score decreased from 11 ± 5.11 to 7.9 ± 4.94 (p < 0.05). The surgical success rate according to Sher’s criteria was 82.3%. The median follow-up was 23.3 months (range 12–36). These findings suggest that multilevel surgery is a safe and successful treatment of OSAHS.

Efficacy of a Trial Oral Appliance in OSAS Management: A New Protocol to Recognize Responder/Nonresponder Patients

Oral appliances (OAs) of various types have shown variable success in the treatment of mild-to-moderate obstructive sleep apnoea (OSA). In an OSA sample, this study evaluated the efficacy of a diagnostic trial OA (myTAP™); the efficacy of a definitive custom-fitted mandibular advancement device (MAD) (SomnoDent Flex™); and whether a trial device can be used to distinguish treatment responder from nonresponder patients. Patients underwent overnight home sleep recordings prior to and after fitting of these appliances in order to objectively assess their sleep quality in terms of polysomnographic (PSG) respiratory measures: apnoea-hypopnoea index (AHI), oxygen desaturation index (ODI), and minimum oxygen saturation (LowSpO₂). 40 patients with symptomatic OSAS were enrolled, 33 males and 7 females, with a mean age of 55.6 ± 12.73 years and an initial (T0) AHI of 26.51 ± 14.79. Trial devices were used in 16 patients (AHI: 29.9 ± 19.97, ODI: 21.06 ± 16.05, and LowSpO₂: 82 ± 10.22 at T0) and definitive MADs in 28 (AHI: 23.90 ± 9.19, ODI: 16.27 ± 11.34, and LowSpO₂: 82.87 ± 6.04 at T0). Statistically significant decreases in AHI (9.59 ± 8.94, p < 0.0023) and ODI (8.20 ± 9.67, p < 0.0129) were observed after treatment with the trial device. Only 8 of the patients in the trial device group went on to use the definitive device. Treatment with the definitive MAD produced statistically significant decreases in AHI (11.46 ± 9.65, p < 0.0001) and ODI (9.10 ± 8.47, p < 0.0016) and a significant improvement in LowSpO₂ (85.09 ± 6.86, p < 0.0004). Thus, both types of device proved effective in improving the PSG parameters. This study showed that introducing an easy-to-make and low-cost trial device into the therapeutic pathway of OSAS patients can circumvent the problem of individual responses to treatment by allowing effective classification of patients: in short, it allows a first distinction to be drawn between responders and nonresponders to treatment.

Clinical Evidence in the Treatment of Obstructive Sleep Apnoea with Oral Appliances: A Systematic Review

Background

Recent clinical guidelines have extended indications for oral appliances to subjects affected by moderate-to-severe obstructive sleep apnoea (OSA). The aim of this systematic review covering this important issue for public health is twofold: updating and summarizing the best available scientific evidence by selecting RCTs of quality only, and identifying the therapeutic pathways that can be transferred to the current clinical practice.

Methods

All the abstracts which were published before February 18, 2019, have been identified in three electronic databases (PubMed, Web of Science, and Cochrane). The Cochrane Collaboration's tool for assessing risk of bias was used as an assessment tool in order to evaluate the quality of the selected studies.

Results

The search strategy yielded 2,260 studies. After removing duplicates and studies that did not comply with the inclusion criteria, 32 full-text articles were assessed for eligibility, and 17 RCTs were finally included in the qualitative synthesis. The 17 selected studies were very heterogeneous in the type of included RCTs in terms of patient inclusion criteria, sample size, distribution of the two genders in the various groups, duration of treatment, and definition of primary and secondary outcomes, without any restriction on the definition of the control group. A common finding was the positive responsiveness of oral appliance treatment in subjects affected by mild-to-moderate OSA with some evidence for cases of severe OSA.

Conclusion

Higher-quality studies are needed in order to provide additional useful guidelines for dental clinicians for OSA management.

The effectiveness of mandibular advancement devices in the treatment of obstructive sleep apnoea in adults: a methodological quality assessment of systematic reviews

BACKGROUND AND OBJECTIVES

There is growing interest in the use of mandibular advancement devices (MADs) for the treatment of obstructive sleep apnoea (OSA). Many systematic reviews (SRs) have investigated their effectiveness, but the applicability of SR results is affected by their methodological quality. This study critically appraises the methodological quality of SRs on this topic using a more detailed and updated version of A MeaSurement Tool to Assess systematic Reviews (AMSTAR).

MATERIALS AND METHODS

The literature was searched for SRs on MAD effectiveness in adults (≥18 years of age) for OSA treatment as compared with other non-surgical or surgical interventions or no intervention. Any objective or subjective measures of treatment outcome were considered eligible. AMSTAR2 was used to assess methodological quality.

RESULTS

The literature search yielded 64 potential reports; 10 met the eligibility criteria. All SRs had more than one critical flaw in AMSTAR2, so their methodological quality was rated as critically low. The most common issues included non-registration of study protocol, absence of list of excluded studies, no acknowledgment of fundings of included studies, no impact of risk of bias on SR results or interpretation and discussion of results, and data extraction not in duplicate.

LIMITATIONS

If a SR was not clearly identified by title or abstract as a SR or meta-analysis, it may have been missed during the screening process.

CONCLUSIONS

The methodological quality of SRs was suboptimal and warrants further improvement in order to provide strong evidence of MAD effectiveness and increase applicability of SR results for clinical decision-making.

Effect of Multilevel Upper Airway Surgery vs Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea: The SAMS Randomized Clinical Trial

IMPORTANCE

Many adults with obstructive sleep apnea (OSA) use device treatments inadequately and remain untreated.

OBJECTIVE

To determine whether combined palatal and tongue surgery to enlarge or stabilize the upper airway is an effective treatment for patients with OSA when conventional device treatment failed.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, parallel-group, open-label randomized clinical trial of upper airway surgery vs ongoing medical management. Adults with symptomatic moderate or severe OSA in whom conventional treatments had failed were enrolled between November 2014 and October 2017, with follow-up until August 2018.

INTERVENTIONS

Multilevel surgery (modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction; n = 51) or ongoing medical management (eg, advice on sleep positioning, weight loss; n = 51).

MAIN OUTCOMES AND MEASURES

Primary outcome measures were the apnea-hypopnea index (AHI; ie, the number of apnea and hypopnea events/h; 15-30 indicates moderate and >30 indicates severe OSA) and the Epworth Sleepiness Scale (ESS; range, 0-24; >10 indicates pathological sleepiness). Baseline-adjusted differences between groups at 6 months were assessed. Minimal clinically important differences are 15 events per hour for AHI and 2 units for ESS.

RESULTS

Among 102 participants who were randomized (mean [SD] age, 44.6 [12.8] years; 18 [18%] women), 91 (89%) completed the trial. The mean AHI was 47.9 at baseline and 20.8 at 6 months for the surgery group and 45.3 at baseline and 34.5 at 6 months for the medical management group (mean baseline-adjusted between-group difference at 6 mo, -17.6 events/h [95% CI, -26.8 to -8.4]; P < .001). The mean ESS was 12.4 at baseline and 5.3 at 6 months in the surgery group and 11.1 at baseline and 10.5 at 6 months in the medical management group (mean baseline-adjusted between-group difference at 6 mo, -6.7 [95% CI, -8.2 to -5.2]; P < .001). Two participants (4%) in the surgery group had serious adverse events (1 had a myocardial infarction on postoperative day 5 and 1 was hospitalized for observation following hematemesis of old blood).

CONCLUSIONS AND RELEVANCE

In this preliminary study of adults with moderate or severe OSA in whom conventional therapy had failed, combined palatal and tongue surgery, compared with medical management, reduced the number of apnea and hypopnea events and patient-reported sleepiness at 6 months. Further research is needed to confirm these findings in additional populations and to understand clinical utility, long-term efficacy, and safety of multilevel upper airway surgery for treatment of patients with OSA.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12614000338662.

A Procedure for Analyzing Mandible Roto-Translation Induced by Mandibular Advancement Devices

Background: Sleep-Related Breathing Disorders are characterized by repeated episodes of complete or partial obstruction of the upper airway during sleep. Mandibular advancement devices represent a non-invasive treatment in reducing the number of respiratory events and in decreasing symptoms. The advancement extent of these devices is responsible for the mandibular roto-translation and its effects on the temporomandibular joint. Methods: This study defined a systematic method to assess the mandible roto translation that is caused by MADs according to a scan-to-CAD approach. Starting from a closed mouth position and simulating the oral appliance at different settings it was possible to define a local reference system that is useful for the evaluation of the mandibular roto-translation. This latter was then applied to evaluate the movements of the condyle and the mandibular dental arch. Results: MAD1 resulted in a reduced mouth opening and protrusion, while MAD2 enabled a higher degree of motion of the mandible useful for patients who need an important protrusion. Conclusions: The two devices present different dynamics. Results that are achievable employing this method can be directly used by practitioners in comparing MADs, as well as by researchers in evaluating MADs effects.

Review of systematic reviews on mandibular advancement oral appliance for obstructive sleep apnea: The importance of long-term follow-up

The purpose of this review was to present the currently available information on oral appliance (OA) therapy for dentists, especially clinic-based dentists, to aid them in performing this treatment for the management of symptoms of obstructive sleep apnea (OSA). The clinical research evidence comprised of systematic reviews concerned with the mandibular advancement oral appliance (OAm). Continuous positive airway pressure (CPAP) is superior to OA therapy in improving OSA symptoms. It is necessary to survey the adherence of patients who stopped CPAP therapy to OAm therapy. There is little evidence supporting the theory that OAm therapy prevents cardiovascular disease or improves prognosis. There is still room to investigate the types of OAm. OAm therapy has clear dental and skeletal side effects with long-term use, and these are important for dentists. However, a certain percentage of patients discontinue consultations. Regarding consultation rate for follow-up and repair/adjustments of OAm, there are advantages for the clinic-based dentists treating OSA with OAm. We believe that enhancing under-graduate and post-graduate education on sleep medicine, and establishing a specialist system could be the strategies for enabling the dentists to handle OAm therapy in dental clinics.

Long-Term Objective Adherence to Mandibular Advancement Device Therapy Versus Continuous Positive Airway Pressure in Patients With Moderate Obstructive Sleep Apnea

STUDY OBJECTIVES

Comparable health effects of mandibular advancement device (MAD) and continuous positive airway pressure (CPAP) therapy have been attributed to higher adherence with MAD compared with CPAP therapy. The objective of this study was to make a direct comparison of the objective adherence between MAD and CPAP in patients with moderate obstructive sleep apnea (OSA).

METHODS

Adherence was monitored for 12 months in 59 patients with moderate OSA (apnea-hypopnea index 15-30 events/h) as part of a randomized controlled trial. Objective adherence with MAD was assessed using the TheraMon microsensor. Objective adherence with CPAP was assessed using the built-in registration software with readout on SD card. Self-reported adherence with both therapies was assessed using a questionnaire.

RESULTS

Forty patients (68%) completed the study with the therapy to which they were randomly assigned. Median (interquartile range) objective adherence (h/night) in the 3rd month was 7.4 (5.2-8.2) for MAD and 6.8 (5.7-7.6) for CPAP (P = .41), compared to 6.9 (3.5-7.9) with MAD and 6.8 (5.2-7.6) with CPAP (P = .85) in the 12th month. There were no significant changes between the 3rd and 12th month for both MAD (P = .21) and CPAP (P = .46). Changes in adherence were not significantly different between MAD and CPAP (P = .51). Self-reported adherence was significantly higher with MAD than CPAP at all follow-ups. Self-reported adherence with CPAP was lower than objective CPAP adherence at the 6th and 12th month (P = .02).

CONCLUSIONS

Objective adherence with MAD and CPAP is comparable and consistent over time. Self-reported adherence is higher with MAD than with CPAP giving rise to interesting discrepancy between objective and self-reported adherence with CPAP.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Identifier: NCT01588275.

Clinical- and Cost-Effectiveness of a Mandibular Advancement Device Versus Continuous Positive Airway Pressure in Moderate Obstructive Sleep Apnea

STUDY OBJECTIVES

Limited evidence exists on the cost-effectiveness of mandibular advancement device (MAD) compared to continuous positive airway pressure (CPAP) therapy in moderate obstructive sleep apnea (OSA). Therefore, this study compares the clinical and cost-effectiveness of MAD therapy with CPAP therapy in moderate OSA.

METHODS

In a multicentre randomized controlled trial, patients with an apnea-hypopnea index (AHI) of 15 to 30 events/h were randomized to either MAD or CPAP. Incremental cost-effectiveness and cost-utility ratios (ICER/ICUR, in terms of AHI reduction and quality-adjusted life-years [QALYs, based on the EuroQol Five-Dimension Quality of Life questionnaire]) were calculated after 12 months, all from a societal perspective.

RESULTS

In the 85 randomized patients (n = 42 CPAP, n = 43 MAD), AHI reduction was significantly greater with CPAP (median reduction AHI 18.3 [14.8-22.6] events/h) than with MAD therapy (median reduction AHI 13.5 [8.5-18.4] events/h) after 12 months. Societal costs after 12 months were higher for MAD than for CPAP (mean difference €2.156). MAD was less cost-effective than CPAP after 12 months (ICER -€305 [-€3.003 to €1.572] per AHI point improvement). However, in terms of QALY, MAD performed better than CPAP after 12 months (€33.701 [-€191.106 to €562.271] per QALY gained).

CONCLUSIONS

CPAP was more clinically effective (in terms of AHI reduction) and cost-effective than MAD. However, costs per QALY was better with MAD as compared to CPAP. Therefore, CPAP is the first-choice treatment option in moderate OSA and MAD may be a good alternative.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Identifier: NCT01588275.

Systematic reviews in orthodontics: Impact of the PRISMA for Abstracts checklist on completeness of reporting

INTRODUCTION

This study evaluated and compared the completeness of reporting of abstracts of orthodontics systematic reviews before and after the publication of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Abstracts Checklist (PRISMA-A).

METHODS

Abstracts of systematic reviews and meta-analyses in orthodontics published in PubMed, Latin American and Caribbean Health Sciences Literature, and the Cochrane Database of Systematic Reviews databases before March 23, 2018, that met the predefined inclusion and exclusion criteria, were evaluated using the 12 items of PRISMA-A, scoring each item from 0 to 2. Abstracts were classified into 2 groups: before and after publication of the PRISMA-A checklist. Three calibrated evaluators (intraclass correlation coefficient and kappa > 0.8) assessed the scores for compliance with the checklist. The number of authors, country of affiliation of the first author, performance of meta-analysis, and topic of the article were recorded. A regression analysis was performed to assess the associations between abstract characteristics and the PRISMA-A scores.

RESULTS

Of 1034 abstracts evaluated, 389 were included in the analysis. The mean PRISMA-A score was 53.39 (95% CI, 51.83-54.96). The overall score for studies published after the publication of the checklist was significantly higher than for studies published before (P ≤ 0.0001). The components returning significantly higher scores after publication of PRISMA-A were title (P = 0.024), information from databases (P = 0.026), risk of bias (P ≤ 0.0001), included studies (P ≤ 0.0001), synthesis of results (P ≤ 0.0001), interpretation of results (P = 0.035), financing and conflict of interest (P ≤ 0.0001), and registration (P ≤ 0.0001). These results showed the positive effect of PRISMA-A had on the quality of reporting of orthodontics systematic reviews. Nevertheless, the poor adherence revealed that there is still need for improvement in the quality of abstract reporting.

CONCLUSIONS

The quality of reporting of abstracts of orthodontic systematic reviews and meta-analyses increased after the introduction of PRISMA-A.

Long-term dental and skeletal effects of mandibular advancement devices in adults with obstructive sleep apnoea: A systematic review

OBJECTIVE

This systematic review aimed to clarify whether there are any significant long-term sequelae to wearing mandibular advancement devices focusing on dental and skeletal effects in adults with OSA.

MATERIALS AND METHODS

Databases, including PubMed, Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and SAGE Journals. Hand searches and grey literature were also used. A piloted data collection form was used to extract the appropriate data.

RESULTS

Twenty-three reports of 19 studies were included. Five had serious risk of bias while 18 had moderate risk of bias. Meta-analysis revealed a significant change in overbite and overjet. I-squared analysis showed a high level of statistical heterogeneity. A moderate correlation was found between wear time and amount of change.

CONCLUSION

Mandibular advancement devices will cause a small but statistically significant change in the dentition of long-term wearers. Skeletal changes are generally secondary to dental changes.

Long-term Results for Maxillomandibular Advancement to Treat Obstructive Sleep Apnea: A Meta-analysis

Objective

To examine outcomes in the intermediate term (1 to <4 years), long term (4 to <8 years), and very long term (≥8 years) for maxillomandibular advancement (MMA) as treatment for obstructive sleep apnea (OSA).

Data Sources

The Cochrane Library, Google Scholar, Embase, Cumulative Index to Nursing and Allied Health, and PubMed/MEDLINE.

Review Methods

Three authors systematically reviewed the international literature through July 26, 2018.

Results

A total of 445 studies were screened, and 6 met criteria (120 patients). Thirty-one patients showed a reduction in apnea-hypopnea index (AHI) from a mean 48.3 events/h (95% CI, 42.1-54.5) pre-MMA to 8.4 (95% CI 5.6, 11.2) in the intermediate term. Fifty-four patients showed a reduction in AHI from a mean 65.8 events/h (95% CI, 58.8-72.8) pre-MMA to 7.7 (95% CI 5.9, 9.5) in the long term. Thirty-five showed a reduction in AHI from a mean 53.2 events/h (95% CI 45, 61.4) pre-MMA to 23.1 (95% CI 16.3, 29.9) in the very long term. Improvement in sleepiness was maintained at all follow-up periods. Lowest oxygen saturation improvement was maintained in the long term.

Conclusion

The current international literature shows that patients with OSA who were treated with MMA maintained improvements in AHI, sleepiness, and lowest oxygen saturation in the long term; however, the mean AHI increased to moderate OSA in the very long term. Definitive generalizations cannot be made, and additional research providing individual patient data for the intermediate term, long term, and very long term is needed.

Long-term effectiveness and side effects of mandibular advancement devices on dental and skeletal parameters

INTRODUCTION

Continuous positive airways pressure, generally used to treat obstructive sleep apnea-hypopnea syndrome (OSAHS), is not tolerated well by many patients. An alternative is to treat OSAHS with mandibular advancement devices (MAD). This research assesses the long term (> 2 years) effectiveness and the side effects on dental and skeletal parameters of these devices.

MATERIAL AND METHODS

We selected 24 patients with moderate to severe OSAHS. All were treated with MADs for at least 2 years. We gathered cephalometric teleradiographs in centric relation and sleep recordings before and after the patients were treated. We evaluated the patients' apnea-hypopnea indexes (AHI) as well as their Epworth sleepiness scale (ESS) scores. We measured the inclination of the central incisors and the positions of the upper and lower jaws.

RESULTS

Mandibular advancement devices were used for more than 2 years (3.9 ± 1.9 years). We observed a statistically significant decrease of the patients' AHI and their ESS scores. We also observed a modification of the inclination of the lower central incisors (+0.521; P = 0.047) and of the position of the maxilla (-0.287; P = 0.039).

DISCUSSION

We demonstrated the clinical effectiveness of mandibular advancement devices for treating OSAHS, with a very low rate of side effects on dental and skeletal positions.

Papageorgiou S. Oral Interventions for Obstructive Sleep Apnea

BACKGROUND

The effectiveness of intraoral appliances (IOA), maxillary expansion (ME), and maxillomandibular advancement (MMA) in the treatment of children and adults with obstructive sleep apnea (OSA) has not yet been adequately assessed.

METHODS

An umbrella review was performed based on established guidelines for evidence-based medicine. Data synthesis was performed only from randomized controlled trials with Paule-Mandel random-effects meta-analyses / meta-regressions using mean differences (MDs) and 95% confidence intervals (CIs) and was followed by the qualitative evaluation of the meta-evidence.

RESULTS

29 systematic reviews were included, 7 of which provided quantitative data. IOA were effective in improving apnea hypopnea index (AHI) compared to both, placebo appliances (12 trials; 525 patients; MD = -11.70; 95% CI: [-15.38; -8.01]; p<0.001) and no treatment (1 trial; 24 patients; MD = -14.30; [-21.59; -7.01]; p<0.001). Only the former comparison was supported by robust meta-evidence. Effectiveness of IOA as measured by the Epworth Sleepiness Scale, on the other hand, was not supported by robust meta-evidence. No randomized or prospective controlled trials were found on the effectiveness of ME (conventional or surgically assisted) and MMA.

CONCLUSION

Intraoral appliances are effective in reducing AHI and their use is substantiated by robust evidence. There is no evidence from high-quality research to support treatment with ME (conventional or surgically assisted) or MMA in patients with OSA.

A systematic review on the effectiveness of titratable over nontitratable mandibular advancement appliances for sleep apnea

Background

Mandibular advancement appliances are being tested for use in patients with obstructive sleep apnea (OSA). However, the effectiveness of titration of these appliances does not have conclusive evidence. Systematic reviews help us to compile all available clinical evidence using statistical principles. Hence, the aim of this systematic review is to identify the effectiveness of titratable over nontitratable mandibular advancement appliances in patients with mild to moderate OSA. This review objective is to identify if titration of these appliances produce significant benefits over fixed appliances.

Materials and Methodology

Electronic databases were searched to identify eligible studies based on set inclusion criteria. Data extraction form was created and the data were extracted. The participants were mild to moderate OSA patients who received mandibular advancement appliances. Studies included a comparison between titratable and nontitratable mandibular advancement appliance.

Results

Of the five included studies, three were observational and two were a randomized trial. All these studies were conducted in adults. The outcome attributes were polysomnographic readings and apnea-hypopnea index (AHI). A significant heterogeneity was seen between the eligible studies and hence a meta-analysis could not be performed.

Conclusion

The results from this systematic review did not show significant advantages of titratable appliances, although titratable appliances performed better from individual studies as regards to reduction in AHI and polysomnography. The reason is the lack of sufficient clinical trials on the same. More high quality randomized controlled trials comparing titratable and fixed appliances have to be initiated to get to conclusive evidence.

Rapid Maxillary Expansion in Obstructive Sleep Apnea in Young Patients: Cardio-Respiratory Monitoring

OBJECTIVE(S)

Obstructive sleep apnea syndrome (OSAS) is a respiratory disorder which affects from 1 to 3 % of people during development. OSAS treatment may be pharmacological, surgical or based on application of intraoral devices to increase nasal respiratory spaces. The purpose of this study was to determine the efficacy of the Rapid Maxillary Expander in OSAS young patients by measuring cardio-respiratory monitoring parameters (AHI, the average value of complete and incomplete obstructed respiration per hour of sleep, and SAO₂, the percentage of oxygen saturation).

STUDY DESIGN

The study was conducted on 11 OSAS young subjects (mean age 6.9±1.04 years), all treated with rapid maxillary expansion (RME). Cardio-respiratory monitoring (8-channel Polymesam) was performed at the beginning (diagnostic, T0) and after 12 months of treatment.

RESULTS

The mean values of cardio-respiratory parameters at TO were: AHI=6.09±3.47; SAO₂=93.09%±1.60. After 12 months of treatment, the mean values of the same polysomnographic parameters were: AHI=2.36 ± 2.24;SAO₂=96.81% ±1.60. These changes were associated with an improvement in clinical symptoms, such as reduction of snoring and sleep apnea.

CONCLUSION(S)

This study confirms the therapeutic efficacy of RME in OSAS young patients. This orthopedic-orthodontic treatment may represent a good option in young patients affected by this syndrome.