Mandibular advancement device in obstructive sleep apnea treatment: what happens to the condyle position and patient response?

BACKGROUND: This study aims primarily to assess the mandibular condyles and patient response to MAD therapy using cone-beam computed tomography (CBCT). Also, the study proposes to analyze whether variations in condylar position, OSA severity and mandibular protrusion influence patient response. METHODS: 23 patients diagnosed with mild/moderate OSA and treated with MAD comprised the sample. Clinical, CBCT, and PSG assessments were conducted at baseline and with MAD in therapeutic protrusion (4-6 months of MAD use). The condyle position was vertically and horizontally evaluated at baseline and at the therapeutic protrusion. RESULTS: The condyle position significantly changed with MAD, showing anterior (7.3 ± 2.8 mm; p < 0.001) and inferior (3.5 ± 1 mm; p < 0.001) displacement. Patients with mild OSA required more protrusion (p = 0.02) for improvement. Responders exhibited a significantly prominent (p = 0.04) anterior baseline condyle position. A negative modest correlation was found between treatment response and baseline condyle anterior position (p = 0.03; r=-0.4), as well as between OSA severity and the percentage of maximum protrusion needed for therapeutic protrusion (p = 0.02; r=-0.4). The patient protrusion amount did not predict condylar positional changes. Neither condyle position, OSA severity, nor therapeutic protrusion were predictors of MAD treatment response. CONCLUSION: MAD resulted in anterior and inferior condylar displacement, and the amount of protrusion did not predict condylar positional changes. Responders showed a more anterior baseline condyle position. OSA severity and mandibular protrusion did not predict treatment response.

Preventive medicine in OSA-A systematic review and a call to action.

STUDY OBJECTIVES: The purpose of this systematic review is to evaluate the modifiable risk factors associated with OSA and analyze extant publications solely focused on prevention of the disease. METHODS: Studies focused on prevention strategies for OSA and modifiable risk factors were eligible for inclusion. A detailed individual search strategy for each of the following bibliographic databases was developed: Cochrane, EMBASE, MEDLINE, PubMed and LILACS. The references cited in these articles were also crosschecked and a partial grey literature search was undertaken using Google Scholar. The methodology of selected studies was evaluated using the 14-item Quality Assessment Tool for Diagnostic Accuracy Studies. RESULTS: Search resulted in 720 publications examining risk factors and prevention of OSA, as well as lifestyle modifications. Of these, a thorough assessment of the abstracts and content of each of these manuscripts led to the rejection of all but four papers, the latter being included in this systematic review. In contrast, a search regarding 'Therapeutics' showed that 23,674 articles on OSA were published, clearly illustrating the imbalance between the efforts in prevention and those focused on therapeutics. CONCLUSIONS: Notwithstanding the importance and benefits of technological advances in medicine, consideration of the needs of people with OSA and its consequences prompts advocacy for the prevention of the disease. Thus, despite the economic interests that focus only on diagnosis and treatment, strategies preferentially aimed at overall avoidance of OSA emerge as a major priority. Thus, public and healthcare provider education, multidimensional prevention, and early diagnosis of OSA should be encouraged worldwide.

Smart mandibular advancement devices for obstructive sleep apnea: a systematic literature review.

PURPOSE: The goal of this review is to provide sleep physicians, dentists, and researchers with an evidence-based overview of the literature on smart mandibular advancement devices (MADs) for the treatment of obstructive sleep apnea. METHODS: A systematic literature search was conducted by two blinded reviewers and an information specialist. A smart MAD was defined as any MAD with additional functionality besides mandibular protrusion. The bibliographic databases Medline, Embase, and Scopus were used to identify relevant publications. Studies were included if they described any stage of development of smart MADs. A total of 3162 titles and abstracts were screened for their relevance. In total, 58 articles were selected for full-text screening, 26 of which were included in this review. RESULTS: The overall quality of the available literature was low. Most of the studies were observational, clinical or applied-research articles. The authors classified MADs into two main groups: passive and active. Passive MADs measured patient data, most commonly patient compliance. Active MADs adjusted protrusion of the mandible in response to patient data and were found in various phases of technological readiness (in development, demonstration, or deployment). CONCLUSION: Innovations in smart mandibular advancement devices most frequently track patient compliance. Devices measuring other health parameters and active, feedback-controlled, devices are increasingly reported on. However, studies demonstrating their added benefit over traditional methods remain sparse. With further study, smart mandibular advancement devices have the potential to improve the efficiency of obstructive sleep apnea treatment and provide new treatment possibilities.

Effects of Oral Appliances for Obstructive Sleep Apnoea in Reduced Periodontium: A Finite Element Analysis.

BACKGROUND AND OBJECTIVE: In the literature, no studies correlate the effects of mandibular advancement devices (MADs) with different titration systems to periodontitis. Through a finite element analysis (FEA), this study investigates the effects generated on periodontal ligaments (PDLs) and teeth by four commercial MADs in periodontal health and with 15% bone resorption. METHODS: Four MADs (Somnodent Flex™, Somnodent Avant™, Orthoapnea™, and Herbst™) were digitalised starting from the impressions of a patient's dental arches. A force of 11.18 N, representing an advancement of 9.5 mm, was applied, and a FEA was subsequently performed. After measuring the stresses and displacements on the PDLs and teeth in healthy periodontal conditions, the vertical dimension of the alveolar bone was reduced by 15%, and measurements were repeated. RESULTS: In terms of PDL stress, Herbst™ is the device which guarantees a more uniform increment in case of the first stage of periodontitis (+7% for mandibular and maxillary PDLs compared to the healthy condition). For Somnodent™ devices, the PDLs stress increment is almost null for mandibular PDLs but much higher than Herbst™ for maxillary PDLs (+17% and +21% for Flex™ and Avant™). Orthoapnea™ determines a PDL stress augmentation between the other devices (+16% and +7%, respectively, for maxillary and mandibular PDLs). Concerning teeth movement, Herbst™ and Orthoapnea™ determine a lower and more uniform displacement than Somnodent devices. CONCLUSIONS: The stress distribution and teeth displacement are strictly related to MAD geometry. Since its minor effects on teeth and PDLs, the Herbst™ could be more appropriate in patients with periodontitis.

Temporomandibular Disorders in Relation to Mandibular Advancement Devices for Treating Obstructive Sleep Apnea.

Mandibular advancement devices (MADs) keep the upper airways patent by holding the mandible and attached soft tissues forward via altered position of its condyles relative to the articulating surfaces of the temporal bones. During the first weeks of MAD therapy, pain may occur in the area of the temporomandibular joints, masticatory muscles, and/or teeth with a tendency of spontaneous resolution. In patients reporting temporomandibular disorder (TMD) symptoms prior to therapy, the MAD-related anterior condylar position during sleep may result in a reduction of TMD signs and symptoms.

Oral appliance therapy vs. positional therapy for managing positional obstructive sleep apnea; a systematic review and meta-analysis of randomized control trials.

AIM: To assess the efficacy of positional therapy and oral appliance therapy for the management of positional obstructive sleep apnea. METHODS: We searched PubMed, Web of Science, Cochrane, and SCOPUS for relevant clinical trials. Quality assessment of the included trials was evaluated according to Cochrane's risk of bias tool. We included the following outcomes: The apnea-hypopnea index (AHI), AHI non-supine, AHI supine, sleep efficiency, percentage of supine sleep, Adherence (≥ 4 h/night, ≥ 5 days/week), Oxygen desaturation Index, Arousal Index, Epworth Sleepiness Scale score (ESS), Mean SpO2, and Functional Outcomes of Sleep Questionnaire. RESULTS: The AHI non-supine and the ESS scores were significantly lower in the OAT cohort than in the PT cohort. The PT cohort was associated with a significantly decreased percentage of supine sleep than the OAT cohort (MD= -26.07 [-33.15, -19.00], P = 0.0001). There was no significant variation between PT cohort and OAT cohort regarding total AHI, AHI supine, ODI, sleep efficiency, arousal index, FOSQ, adherence, and mean SpO2. CONCLUSION: Both Positional Therapy and Oral Appliance Therapy effectively addressed Obstructive Sleep Apnea. However, Oral Appliance Therapy exhibited higher efficiency, leading to increased supine sleep percentage and more significant reductions in the Apnea Hypopnea Index during non-supine positions, as well as lower scores on the Epworth Sleepiness Scale.

A mandibular advancement device attenuates the abnormal morphology and function of mitochondria from the genioglossus in obstructive sleep apnea-hypopnea syndrome rabbits.

BACKGROUND: Obstructive sleep apnea hypopnea syndrome (OSAHS) is a serious and potentially life-threatening disease. Mandibular advancement device (MAD) has the characteristics of non-invasive, comfortable, portable and low-cost, making it the preferred treatment for mild-to-moderate OSAHS. Our previous studies found that abnormal contractility and fibre type distribution of the genioglossus could be caused by OSAHS. However, whether the mitochondria participate in these tissue changes is unclear. The effect of MAD treatment on the mitochondria of the genioglossus in OSAHS is also uncertain. OBJECTIVE: To examine the morphology and function of mitochondria from the genioglossus in a rabbit model of obstructive sleep apnea-hypopnea syndrome (OSAHS), as well as these factors after insertion of a mandibular advancement device (MAD). METHODS: Thirty male New Zealand white rabbits were randomised into three groups: control, OSAHS and MAD, with 10 rabbits in each group. Animals in Group OSAHS and Group MAD were induced to develop OSAHS by injection of gel into the submucosal muscular layer of the soft palate. The rabbits in Group MAD were fitted with a MAD. The animals in the control group were not treated. Further, polysomnography (PSG) and cone-beam computed tomography (CBCT) scan were used to measure MAD effectiveness. CBCT of the upper airway and PSG suggested that MAD was effective. Rabbits in the three groups were induced to sleep for 4-6 h per day for eight consecutive weeks. The genioglossus was harvested and detected by optical microscopy and transmission electron microscopy. The mitochondrial membrane potential was determined by laser confocal microscopy and flow cytometry. Mitochondrial complex I and IV activities were detected by mitochondrial complex assay kits. RESULTS: OSAHS-like symptoms were induced successfully in Group OSAHS and rescued by MAD treatment. The relative values of the mitochondrial membrane potential, mitochondrial complex I activity and complex IV activity were significantly lower in Group OSAHS than in the control group; however, there was no significant difference between Group MAD and the control group. The OSAHS-induced injury and the dysfunctional mitochondria of the genioglossus muscle were reduced by MAD treatment. CONCLUSION: Damaged mitochondrial structure and function were induced by OSAHS and could be attenuated by MAD treatment.

Gender differences in oral appliance treatment of obstructive sleep apnea.

PURPOSE: Although overall success rates for treating obstructive sleep apnea (OSA) with an oral appliance (OA) are high, they are significantly higher among females. To verify published data, the study's purpose was to evaluate a participant sample after one year of OA use. The primary outcome was treatment response, with responders defined as having an apnea-hypopnea index (AHI) < 10 at follow-up and/or reduced by ≥50% of baseline. Secondary measures were from standardized questionnaires. METHODS: A sample of 314 participants, predominately with moderate-to-severe OSA, were enrolled and instructed to use an OA every night. At baseline and one-year follow-up, polygraphic recordings and questionnaires, including sleepiness (measured using the Epworth sleepiness scale) and quality-of-life (measured using the Functional Outcomes of Sleep Questionnaire), were collected. RESULTS: Among the 314 participants, 192 completed the one-year evaluation: 51 females (27%) and 141 males (73%). Overall, OA treatment resulted in 78% and 77% responders among females and males, respectively. Neither the difference in improvement nor the absolute change in AHI differed significantly based on gender, at any OSA severity level. There were no significant gender differences in sleepiness or quality of life. Treatment-related adverse reactions were more common among females. CONCLUSION: Both females and males with OSA respond well to OA therapy, with nonsignificant gender differences in outcomes. Thus, the hypothesis that females respond better to OA treatment is rejected.

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

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

Relationship between OSA pathophysiological phenotypes and treatment response to mandibular advancement devices: a pilot study.

STUDY OBJECTIVES: To assess whether critical pathophysiological phenotypes predict treatment response in patients with obstructive sleep apnea (OSA) using a mandibular advancement device (MAD). METHODS: Thirty-one OSA patients were treated with a MAD. Individuals were categorized and graded into four pathophysiological phenotypes based on polysomnographic features (anatomical, ventilatory control, arousal threshold and muscle responsiveness). Morphoanthropometric data were additionally assessed. Patients were classified as responders or nonresponders. Associations between polysomnographic phenotypes and treatment response were documented, as was morphoanthropometric data and their impact on therapeutic success. RESULTS: There was a male predominance (64.5%), with a median age of 49 years (25p:40; 75p:55), BMI=27.4 kg/m2 (26; 28.8) and apnea-hypopnea index (AHI) of 18.2 (25p:11.7; 75p: 27.6). The majority of patients treated with a MAD (58%) were good responders (68.0% mild and moderate versus 16.7% severe). Treatment response was associated with shorter intermolar and interpremolar distances in the lower arch (p = 0.0092 and 0.0129). Rapid eye movement sleep AHI (REMAHI) and MAD-related treatment response were inversely correlated (p = 0.0013). Favorable anatomical (p = 0.0339) and low muscle response (p = 0.0447) phenotypes were correlated with outcomes. CONCLUSIONS: According to our results, a favorable response occurred in a better 'anatomical phenotype' and in the worse 'muscular responsiveness phenotype' according to polysomnographic data. Furthermore, other favorable predictors, such as a REMAHI <16 and a smaller distance between lower molars and premolars, were found. These findings indicate that clinical and polysomnographic aspects can discriminate phenotypes that may guide decisions on MAD treatment for OSA.

Mandibular Advancement vs CPAP for Blood Pressure Reduction in Patients With Obstructive Sleep Apnea.

BACKGROUND: Hypertension guidelines recommend diagnosis and treatment of obstructive sleep apnea (OSA) in patients with hypertension. The mandibular advancement device (MAD) is an oral appliance therapy for patients who decline or cannot tolerate continuous positive airway pressure (CPAP). OBJECTIVES: We compared the relative effectiveness of MAD vs CPAP in reducing 24-hour ambulatory blood pressure (BP). METHODS: In an investigator-initiated, randomized, noninferiority trial (prespecified margin 1.5 mm Hg), 321 participants aged ≥40 years with hypertension and increased cardiovascular risk were recruited at 3 public hospitals for polysomnography. Of these, 220 participants with moderate-to-severe OSA (apnea-hypopnea index ≥15 events per hour) were randomized to either MAD or CPAP (1:1). The primary outcome was the difference between the 24-hour mean arterial BP at baseline and 6 months. RESULTS: Compared with baseline, the 24-hour mean arterial BP decreased by 2.5 mm Hg (P = 0.003) at 6 months in the MAD group, whereas no change was observed in the CPAP group (P = 0.374). The between-group difference was -1.6 mm Hg (95% CI: -3.51 to 0.24, noninferiority P < 0.001). The MAD group demonstrated a larger between-group reduction in all secondary ambulatory BP parameters compared with the CPAP group, with the most pronounced effects observed in the asleep BP parameters. Both the MAD and CPAP improved daytime sleepiness, with the between-group difference similar (P = 0.384). There were no between-group differences in cardiovascular biomarkers. CONCLUSIONS: MAD is noninferior to CPAP for reducing 24-hour mean arterial BP in participants with hypertension and increased cardiovascular risk. (Cardiosleep Research Program on Obstructive Sleep Apnea, Blood Pressure Control and Maladaptive Myocardial Remodeling-Non-inferiority Trial [CRESCENT]; NCT04119999).

Comorbid Insomnia and Sleep Apnea: Challenges and Treatments.

Insomnia and obstructive sleep apnea (OSA) are 2 of the most prevalent sleep disorders and frequently co-occur. Cognitive behavioral therapy for insomnia is the first line treatment for insomnia and has been shown to improve compliance with positive airway pressure therapy. Other alternatives to OSA treatment may have higher acceptance in those with comorbid insomnia and sleep apnea (COMISA). Surgery, particularly hypoglossal nerve stimulation, appears to be well tolerated and may improve insomnia in those with COMISA. Otolaryngologists must be cognizant of the common presentation of COMISA in patients seeking surgical treatment and utilize a multidisciplinary approach.

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.

Role of NF-κB in cardiac changes of obstructive sleep apnoea rabbits treated by mandibular advancement device.

BACKGROUND: Obstructive sleep apnoea (OSA) is an independent risk factor for cardiovascular diseases. We aimed to investigate the role of nuclear factor-kappa B (NF-κB) in the changes of cardiac structures in OSA rabbits treated by mandibular advancement device (MAD). METHODS: Eighteen male New Zealand white rabbits aged 6 months were randomly divided into three groups: control group, group OSA and group MAD. Hyaluronate gel was injected into the soft palate of the rabbits in group OSA and group MAD to induce OSA. The cone beam computer tomography (CBCT) of the upper airway and polysomnography (PSG) was performed to ensure successful modelling. CBCT and PSG were applied again to detect the effects of MAD treatment. All animals were induced to sleep in a supine position for 4-6 h a day for 8 weeks. Then the levels of NF-κB, Interleukin 6 (IL-6), Interleukin 10 (IL-10) and the proportion of myocardial fibrosis (MF) were detected. RESULTS: The higher activation of NF-κB, IL-6 and IL-10 were found in the OSA group than in the control group, leading to the increase of collagen fibres compared with the control group. Furthermore, the apnoea-hypopnea index (AHI) was positively correlated with the above factors. There were no significant differences between group MAD and the control group. CONCLUSION: The NF-κB pathway was activated in the myocardium of OSA rabbits, which accelerated the development of MF. Early application of MAD could reduce the activation of NF-κB in the myocardium and prevent the development of MF.

Mandibular Jaw Movement Automated Analysis for Oral Appliance Monitoring in Obstructive Sleep Apnea: A Prospective Cohort Study.

Rationale: Oral appliances are second-line treatments after continuous positive airway pressure for obstructive sleep apnea (OSA) management. However, the need for oral appliance titration limits their use as a result of monitoring challenges to assess the treatment effect on OSA. Objectives: To assess the validity of mandibular jaw movement (MJM) automated analysis compared with polysomnography (PSG) and polygraphy (PG) in evaluating the effect of oral appliance treatment and the effectiveness of MJM monitoring for oral appliance titration at home in patients with OSA. Methods: This observational, prospective study included 135 patients with OSA eligible for oral appliance therapy. The primary outcome was the apnea-hypopnea index (AHI), measured through in-laboratory PSG/PG and MJM-based technology. Additionally, MJM monitoring at home was conducted at regular intervals during the titration process. The agreement between PSG/PG and MJM automated analysis was revaluated using Bland-Altman analysis. Changes in AHI during the home-based oral appliance titration process were evaluated using a generalized linear mixed model and a generalized estimating equation model. Results: The automated MJM analysis demonstrated strong agreement with PG in assessing AHI at the end of titration, with a median bias of 0.24/h (limits of agreement, -11.2 to 12.8/h). The improvement of AHI from baseline in response to oral appliance treatment was consistent across three evaluation conditions: in-laboratory PG (-59.6%; 95% confidence interval, -59.8% to -59.5%), in-laboratory automated MJM analysis (-59.2%; -65.2% to -52.2%), and at-home automated MJM analysis (-59.7%; -67.4% to -50.2%). Conclusions: Incorporating MJM automated analysis into the oral appliance titration process has the potential to optimize oral appliance therapy outcomes for OSA.

Efficacy of Oral Appliance for Mild, Moderate, and Severe Obstructive Sleep Apnea: A Meta-analysis.

OBJECTIVE: Oral appliances (OA) are the recommended first-line option for mild-to-moderate obstructive sleep apnea (OSA)-hypopnea. However, there is a lack of evidence to compare the effectiveness of OA in different severities of OSA. The purpose of this study was to investigate the therapeutic effects of preferred OA (tongue retention devices [TRD] and mandibular advancement device [MAD]) in different severities of OSA. DATA SOURCES: PubMed/MEDLINE, The Cochrane Library, and Web of Science. REVIEW METHODS: Concentrating on the efficacy of OA, 2 authors searched 3 databases up to November 10, 2022, independently and systematically, following the requirements and steps of the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: Ultimately, 42 studies with 2265 patients met the criteria for inclusion in OA. Overall, the apnea-hypopnea index improved by 48% (5.6), 67% (14.92), and 62% (32.1) in mild, moderate, and severe OSA, respectively. Subgroup analysis showed a significant difference between MAD and TRD efficacy in mild OSA (58% vs 21%). However, no significant difference was seen between MAD and TRD efficacy in moderate (67% vs 66%) and severe OSA (66% vs 51%). There was no significant difference across groups in the Epworth Sleepiness Scale, oxygen desaturation index (ODI), and lowest oxygen saturation (LSAT). CONCLUSION: Overall, both TRD and MAD are effective treatments for moderate and severe OSA. MAD is efficacious in mild OSA, while TRD requires further validation. Furthermore, mild-moderate and severe OSA received similar improvements in sleepiness, ODI, and LSAT. This study complements the evidence for the efficacy of OA.

Mandibular advancement devices decrease systolic pressure during the day and night in patients with obstructive sleep apnea: A systematic review and meta-analysis.

The aim of this systematic review and meta-analysis was to analyze whether or not mandibular advancement devices (MADs) produce changes in blood pressure in patients with obstructive sleep apnea (OSA) in relation to use time and if the device is used at night or day. MATERIALS AND METHOD: A systematic review of the literature and meta-analysis was carried out in accordance with PRISMA guidelines. In the bibliographic search, a total of four databases were consulted: PubMed-Medline, Scopus, Web of Science, and Cochrane. Of the 622 articles initially revealed, 160 duplicates were eliminated. After applying the selection criteria, 17 articles were included for the qualitative analysis and 4 for the meta-analysis. The studies were combined using a random effects model with the inverse method of variance, determining the mean differences in systolic and diastolic pressure before and after treatment using the MAD splint as the effect size. Day/night circadian effect and treatment time were analyzed using meta-regression with a mixed-effects model. RESULTS: MAD treatment was not found to affect diastolic pressure. By combining the four studies with the control group in a meta-analysis (I2 = 75%; z = - 0.15; p-value = 0.882), the mean difference in diastolic pressure between the MAD group and the control group was estimated at - 0.06 (- 0.86; 0.74). The meta-regression also showed no significant effect of day/night (p = 0.560) or treatment time (p = 0.854) on diastolic pressure. When combining the four studies with the control group (I2 = 84%%; z = - 1.47; p-value = 0.142), a non-significant mean difference in systolic pressure between the MAD group and the control group of - 0.99 (- 2.31; 0.33) was estimated in the meta-analysis. However, when assessing the effect of day/night or treatment time on systolic blood pressure using a meta-regression, the latter showed significant covariates that reduce systolic blood pressure values in the model at night (p < 0.001) and in relation to treatment time (p < 0.001). CONCLUSIONS: Only systolic pressure appears to be affected by the use of the MAD in patients with OSA, and this decrease in systolic pressure is greater at night and when treatment time is longer.

Effects of mandibular advancement devices on the evolution of obstructive sleep apnea.

PURPOSE: Mandibular advancement devices (MADs) are a treatment for obstructive sleep apnea (OSA). Titration is a necessary component of proper fitting of MADs, yet little is known about what happens at each step of the titration. The objectives of this study were to determine the clinical and paraclinical evolution of OSA at every mm of MAD advancement. METHODS: Volunteers were fitted with MADs set to 50% of maximum advancement. MAD clinical and paraclinical results were recorded at every additional mm-titration, including apnea-hypopnea index (AHI), as well as symptoms of sleepiness and fatigue. RESULTS: In 20 volunteers with OSA, the MAD had a significant effect on every polygraphic parameter at the onset of use. The mean AHI with MAD fell by 15.2/h (p < 0.001). The mean Epworth Sleepiness Score and Pichot Fatigue questionnaire with MAD fell by 2.0 (p = 0.0687) and 2.4 (p = 0.1073) respectively. There was no proportionality between clinical gains (drowsiness and fatigue) and AHI improvements. CONCLUSIONS: MADs led to a significant improvement in AHI and other polygraphic parameters from the onset of use. The decrease of clinical symptoms (drowsiness and fatigue) was more complex to interpret because of the small decreases observed. The absence of concordance between AHI improvement and clinical symptoms was nevertheless objectively quantified and symptoms were alleviated with advancements. The findings suggest that it may be appropriate to use clinical symptoms as a main aim of titration, since the improvement in AHI is reached at the onset of MAD use.

Evaluation of condylar and mandibular movements on the upper airway during the use of mandibular advancement device for obstructive sleep apnea treatment.

OBJECTIVES: To evaluate the temporomandibular joint (TMJ), condylar and mandibular movements in obstructive sleep apnea (OSA) patients treated with mandibular advancement device (MAD) and to identify the influence of these anatomic factors on upper airway (UA) volume and polysomnographic outcomes after treatment. MATERIALS AND METHODS: Twenty OSA patients were prospectively treated with MAD. Clinical examinations, cone-beam computed tomography, and polysomnography were performed before MAD treatment and after achieving therapeutic protrusion. Polysomnographic variables and three-dimensional measurements of the TMJ, mandible, and upper airway were statistically analyzed. RESULTS: Condylar rotation, anterior translation, and anterior mandibular displacement were directly correlated with total UA volume, while vertical mandibular translation was inversely correlated with the volume of the inferior oropharynx. MAD treatment resulted in an increase in the volume and area of the superior oropharynx. There was no statistically significant correlation between condylar rotation and translation and polysomnographic variables. With MAD, there was a significant increase in vertical dimension, changes in condylar position (rotation and translation), and mandibular displacement. The central and medial lengths of the articular eminence were inversely correlated with condylar rotation and translation, respectively. The lateral length of the eminence was directly correlated with condylar translation, and the lateral height was directly correlated with condylar rotation and translation. CONCLUSION: Condylar and mandibular movements influenced UA volume. The articular eminence played a role in the amount of condylar rotation and translation. CLINICAL RELEVANCE: Individualized anatomical evaluation of the TMJ proves to be important in the therapy of OSA with MAD.