The Most Effective Amount of Forward Movement for Oral Appliances for Obstructive Sleep Apnea: A Systematic Review

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Abstract

This systematic review clarifies the amount of effective protrusion in mandibular advancement devices of oral appliances required for obstructive sleep apnea (OSA). The systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Review Manager 5 and GRADEpro were used to combine trials and analyze data. The present review included three studies. In mild to moderate OSA cases, measured using the apnea–hypopnea index (AHI), 50% protrusion was more effective than 75% protrusion. However, 75% protrusion was more effective for severe cases. Sleep stage, Epworth Sleepiness Scale (ESS), snoring index, and side effects significantly differed between the groups. Additionally, 75% protrusion was more effective (AHI: 0.38, 95% CI: −0.89 to 1.65, p = 0.56; sleep stage 3: −1.20, 95% CI: 9.54–7.14, p = 0.78; ESS: 1.07, 95% CI: −0.09 to 2.24, p = 0.07; snoring index: 0.09, 95% CI: 0.05–0.13, p < 0.05; side effects: RR: 1.89, 95% CI: 0.36–9.92, p = 0.45). As per the AHI, 75% protrusion was effective in severe cases, whereas 50% protrusion was effective in moderate cases. Analysis of different surrogate outcomes indicated that 75% protrusion was more effective. Further, well-designed, larger trials should determine the benefits for patients. Additionally, investigations of adherence and side effects with long-term follow-up are needed.

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Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea.

G Aarab, Hans L Hamburger, Machiel Naeije … (2010)

The aim of the study was to assess the influence of four mandibular protrusion positions, at a constant vertical dimension, on obstructive sleep apnea (OSA). Seventeen OSA patients (49.2 +/- 8.5 years) received an adjustable mandibular advancement device (MAD). The patients underwent four polysomnographic recordings with their MAD in situ at, in random order, 0%, 25%, 50%, and 75% of the maximum protrusion. The mean apnea-hypopnea index (AHI) values of the patients differed significantly between the protrusion positions (P < 0.000). The 25% protrusion position resulted in a significant reduction of the AHI with respect to the 0% position, while in the 50% and 75% positions, even lower AHI values were found. The number of side effects was larger starting at the 50% protrusion position. We therefore recommend coming to a weighted compromise between efficacy and side effects by starting a MAD treatment in the 50% protrusion position.

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A prospective randomized study comparing two different degrees of mandibular advancement with a dental appliance in treatment of severe obstructive sleep apnea.

B Wilhelmsson, Olle Vestling, Ivar Ringqvist … (2003)

The objective of this study was to compare the effect of two different degrees of mandibular advancement (MA), 75% versus 50%, on somnographic variables after 6 months of dental appliance treatment in patients with severe obstructive sleep apnea (OSA). A further purpose was to compare the number of adverse events on the stomatognathic system and the effects of dental appliance treatment on the presence of daytime sleepiness. Eighty-six males with severe OSA (apnea index > or = 20) were randomly allocated to either 75% or 50% MA. Forty patients in the 75% MA group and 37 patients in the 50% MA group completed the 6-month follow-up. The effectiveness of treatment in terms of normalization (apnea index < 5 and apnea/hypopnea index < 10) with 75% MA was 52%, which was significantly higher (p = 0.04) than the 31% achieved with 50% MA. The dental appliance had few adverse events on the stomatognathic system regardless of group, and the number of adverse events did not differ between the two groups. Finally, the mean value of Epworth Sleepiness Scale scores decreased significantly from 11.6 at baseline to 8.0 at follow-up (p < 0.001). No significant difference was observed between the two groups. The results indicate that a dental appliance could be an alternative treatment for some patients with severe OSA.

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Impact of Weight Loss Management in OSA.

Simon A Joosten, Garun Hamilton, Matthew Naughton (2017)

The interaction between obesity and OSA is complex. Although it is often assumed that obesity is the major cause of OSA, and that treatment of the OSA might mitigate further weight gain, new evidence is emerging that suggests this may not be the case. Obesity explains about 60% of the variance of the apnea-hypopnea index (AHI) definition of OSA, mainly in those < 50 years and less so in the elderly. Moreover, long-term treatment of OSA with CPAP is associated with a small but significant weight gain. This weight gain effect may result from abolition of the increased work of breathing associated with OSA. Unfortunately, weight loss by either medical or surgical techniques, which often cures type 2 diabetes, has a beneficial effect on sleep apnea in only a minority of patients. A short jaw length may be predictive of a better outcome. The slight fall in the overall AHI with weight loss, however, may be associated with a larger drop in the nonsupine AHI, thus converting some patients from nonpositional to positional (ie, supine only) OSA. Importantly, patients undergoing surgical weight loss need close monitoring to prevent complications. Finally, in patients with moderate to severe obesity-related OSA, the combination of weight loss with CPAP appears more beneficial than either treatment in isolation.

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Journal

Journal ID (nlm-ta): Int J Environ Res Public Health

Journal ID (iso-abbrev): Int J Environ Res Public Health

Journal ID (publisher-id): ijerph

Title: International Journal of Environmental Research and Public Health

Publisher: MDPI

ISSN (Print): 1661-7827

ISSN (Electronic): 1660-4601

Publication date (Electronic): 04 September 2019

Publication date (Print): September 2019

Volume: 16

Issue: 18

Electronic Location Identifier: 3248

Affiliations

[1 ]Department of Oral Surgery, Hironokogen Hospital, 3-1-1 Kitayamadai Nishi-ku Kobe-shi, Hyogo 6512215, Japan

[2 ]Department of Oral and Maxillofacial Surgery, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 4801103, Japan

[3 ]Division of Medicine for Function and Morphology of Sensor Organ, Dentistry and Oral Surgery, Osaka Medical College. 2-7 Daigaku-machi Takatsuki-shi, Osaka 5698686, Japan

[4 ]Orofacial Pain Management, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima Bunkyo-ku, Tokyo 1138510, Japan

[5 ]Division of Reconstructive Surgery for Oral and Maxillofacial Region, Department of Tissue Regeneration and Reconstruction, Niigata University Graduate School of Medical and Dental Sciences, 2-5274 Gakkocho-Dori, Cyuo-ku, Nigata-shi, Nigata 9518514, Japan

[6 ]Department of Oral Medicine, Oral and Maxillofacial Surgery, Tokyo Dental College, 5-11-13 Sugano Ichikawa-shi, Chiba 2728513, Japan

[7 ]Department of Oral and Maxillofacial Surgery, National Hospital Organization Toyohashi Medical Center, 50 Imure-chou Aza Hamamichi-Ue, Toyohashi-shi, Aichi 4408510, Japan

Author notes

[* ]Correspondence: s.yukioutdoor@ 123456gmail.com ; Tel.: +81-078-994-1155

[†]

These authors contributed equally to this work.

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Kazumichi Sato https://orcid.org/0000-0003-1339-9199

Article

Publisher ID: ijerph-16-03248

DOI: 10.3390/ijerph16183248

PMC ID: 6765823

PubMed ID: 31487920

SO-VID: 8b664243-6def-403b-b530-6467a122d8ed

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Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

The Most Effective Amount of Forward Movement for Oral Appliances for Obstructive Sleep Apnea: A Systematic Review

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Most cited references 13

Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea.

A prospective randomized study comparing two different degrees of mandibular advancement with a dental appliance in treatment of severe obstructive sleep apnea.

Impact of Weight Loss Management in OSA.

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