Oral appliances for the management of snoring and obstructive sleep apnoea.
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BACKGROUND: Although oral appliances are effective in some patients with obstructive sleep apnoea (OSA), they are not universally effective. A novel anterior mandibular positioner (AMP) has been developed with an adjustable hinge that allows progressive advancement of the mandible. The objective of this prospective crossover study was to compare efficacy, side effects, patient compliance, and preference between AMP and nasal continuous positive airway pressure (nCPAP) in patients with symptomatic mild to moderate OSA. METHODS: Twenty four patients of mean (SD) age 44.0 (10.6) years were recruited with a mean (SD) body mass index of 32.0 (8.2) kg/m2, Epworth sleepiness score 10.7 (3.4), and apnoea/hypopnoea index 26.8 (11.9)/hour. There was a two week wash-in and a two week wash-out period and two treatment periods (AMP and nCPAP) each of four months. Efficacy, side effects, compliance, and preference were evaluated by a questionnaire and home sleep monitoring. RESULTS: One patient dropped out early in the study and three refused to cross over so treatment results are presented on the remaining 20 patients. The apnoea/hypopnoea index (AHI) was lower with nasal CPAP 4.2 (2.2)/hour than with the AMP 13.6 (14.5)/hour (p < 0.01). Eleven of the 20 patients (55%) who used the AMP were treatment successes (reduction of AHI to < 10/hour and relief of symptoms), one (5%) was a compliance failure (unable or unwilling to use the treatment), and eight (40%) were treatment failures (failure to reduce AHI to < 10/hour and/or failure to relieve symptoms). Fourteen of the 20 patients (70%) who used nCPAP were treatment successes, six (30%) were compliance failures, and there were no treatment failures. There was greater patient satisfaction with the AMP (p < 0.01) than with nCPAP but no difference in reported side effects or compliance. CONCLUSIONS: AMP is an effective treatment in some patients with mild to moderate OSA and is associated with greater patient satisfaction than nCPAP. (+info)
A modification to enable controlled progressive advancement of the Twin Block appliance.
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A modification of the Twin block appliance has been developed to facilitate controlled gradual advancement of the mandibular position during the treatment of Class II division I malocclusions. This features the incorporation of stainless steel screws with conical heads into the blocks of the upper appliance to provide the inclined plane effect. Advancement is by the addition of polyacetal spacers between the screw heads and the upper blocks. The system is designed to improve the clinical flexibility of the appliance and to enhance patient acceptance in cases where mandibular protrusion is limited initially. Another possible application is gradual reactivation for Class III correction. Other advantages are reduced laboratory and clinical time during reactivation of the appliance, and perhaps a more physiological response to the growth modification process. The design and construction of the advancement system is illustrated, and its clinical use discussed. (+info)
Mandibular advancement oral appliance therapy for obstructive sleep apnoea: effect on awake calibre of the velopharynx.
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BACKGROUND: The mechanisms of action of oral appliance therapy in obstructive sleep apnoea are poorly understood. Videoendoscopy of the upper airway was used during wakefulness to examine whether the changes in pharyngeal dimensions produced by a mandibular advancement oral appliance are related to the improvement in the severity of obstructive sleep apnoea. METHODS: Fifteen patients with mild to moderate obstructive sleep apnoea (median (range) apnoea index (AI) 4(0-38)/h, apnoea-hypopnoea index (AHI) 28(9-45)/h) underwent overnight polysomnography and imaging of the upper airway before and after insertion of the oral appliance. Images were obtained in the hypopharynx, oropharynx, and velopharynx at end tidal expiration during quiet nasal breathing in the supine position. The cross sectional area and diameters of the upper airway were measured using image processing software with an intraluminal catheter as a linear calibration. RESULTS: AI decreased to a median (range) value of 0 (0-6)/h (p<0.01) and AHI to 8 (1-28)/h (p<0.001) following insertion of the oral appliance. The median (95% confidence interval) cross sectional area of the upper airway increased by 18% (3 to 35) (p<0.02) in the hypopharynx and by 25% (11 to 69) (p<0.005) in the velopharynx, but not significantly in the oropharynx. Although in general the shape of the pharynx did not change following insertion of the oral appliance, the lateral diameter of the velopharynx increased to a greater extent than the anteroposterior diameter. Following insertion of the oral appliance the reduction in AHI was related to the increase in cross sectional area of the velopharynx (p = 0.01). CONCLUSIONS: A mandibular advancement oral appliance increases the cross sectional area of the upper airway during wakefulness, particularly in the velopharynx. Assuming this effect on upper airway calibre is not eliminated by sleep, mandibular advancement oral appliances may reduce the severity of obstructive sleep apnoea by maintaining patency of the velopharynx, particularly in its lateral dimension. (+info)
Effect of mandibular advancement splint on psycho-intellectual derangements in patients with sleep apnea syndrome.
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The mandibular advancement splint (MAS) was recently introduced for the management of sleep apnea syndrome (SAS), although its effects on psycho-intellectual functions have not been elucidated yet. We examined psycho-intellectual function before and after treatment with MAS in patients with SAS. Twenty patients with SAS underwent psycho-intellectual function testing before and after treatment with MAS for 3 to 4 weeks. The apnea index significantly decreased from 19.0+/-15.6 to 2.4+/-1.9. The state anxiety score significantly decreased from 44.6+/-12.1 to 33.7+/-11.1, the trait anxiety score significantly decreased from 46.2+/-13.4 to 37.6+/-13.8, and the depression scale score significantly decreased from 39.2+/-11.0 to 30.8+/-9.9 with MAS treatment. By the Cornell Medical Index and the Yatabe-Guilford test, the patients became less neurotic and less eccentric after treatment. By the Uchida-Kraepelin psychodiagnostic test, calculation ability significantly increased from 1247.4+/-402.1 to 1950.2+/-651.9. We conclude that MAS treatment reduces apneic episodes and improves psycho-intellectual derangements in patients with SAS. (+info)
An investigation into the changes in airway dimension and the efficacy of mandibular advancement appliances in subjects with obstructive sleep apnoea.
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This prospective clinical study evaluates a group of 37 male Caucasians with obstructive sleep apnoea for changes in airway dimension and the efficacy associated with the use of mandibular advancement splints. Lateral skull radiographs were obtained with the subjects--upright in occlusion, supine in occlusion, and supine in protrusion. Each radiograph was traced and digitized, and changes in mandibular position, airway dimensions, and hyoid were examined. Subjects were invited to complete pre- and post-treatment questionnaires, and interviewed following fitting of a removable Herbst mandibular advancement splint. Significant changes were recorded in the airway dimensions in response to both a change in position, from upright to supine, and in response to mandibular advancement. A compliance rate of 76 per cent was achieved with no reported serious complications associated with the use of mandibular advancement devices. (+info)
Immediate intraoral adaptation of mandibular advancing appliances of thermoplastic material for the treatment of obstructive sleep apnea.
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BACKGROUND: In the treatment of obstructive sleep apnea (OSA), mandibular advancing devices (MAD) are usually individually fabricated on plaster casts of both jaws from polymethyl-methacrylate. The potential disadvantages of these devices are (1) the costs and (2) the time required to construct the device. OBJECTIVE: In this study, the efficacy and feasibility of a cheap MAD consisting of thermoplastic material (SnorBan((R))), which can be directly moulded intraorally, were evaluated. METHODS: In a prospective study, the effect of an MAD consisting of thermoplastic material was investigated in 22 consecutive patients with OSA [respiratory disturbance index (RDI) 32.6 +/- 18.4/h]. Polysomnographic sleep was recorded prior to treatment and after 3 months of treatment with the MAD. RESULTS: Three of the 22 patients who did not tolerate the MAD were excluded from the analysis, whereas 11 patients were classified as responders. In the responder group, the mean RDI decreased from 27.6 +/-7.3 to 7.3 +/- 2.9 (p < 0. 01), correspondingly the sleep quality and the Epworth Sleepiness Scale improved (p < 0.05). Eight patients proved to be non-responders without relevant changes for the measured parameters. CONCLUSIONS: In 50% (11 of 22) of the patients, the MAD improved the OSA to a clinically relevant degree. In contrast to the majority of established MAD, the MAD investigated is cheap and immediately adaptable and thus a feasible strategy to 'screen' the efficacy of this therapeutic principle. Thus the construction of unnecessary MAD is avoided. (+info)
Craniomandibular status and function in patients with habitual snoring and obstructive sleep apnoea after nocturnal treatment with a mandibular advancement splint: a 2-year follow-up.
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The aim of the investigation was to evaluate the status and function of the temporomandibular joint (TMJ) and masticatory system in patients with habitual snoring and obstructive apnoea after 2 years nocturnal treatment with a mandibular advancement splint. Thirty-two patients participated in the study, ranging from 43.0 to 79.8 years of age (mean 54.4 years, SD 8.78) at the start of treatment. All patients had been referred from the ENT department for treatment with a mandibular advancement splint. The acrylic splint advanced the mandible 50-70 per cent of maximal protrusion, opened 5 mm vertically, and was used 6-8 hours per night and 5-7 nights per week. Overjet, overbite, and molar relationship were measured on dental casts. The patients were asked to answer a questionnaire concerning symptoms of craniomandibular dysfunction (CMD). They were also clinically examined in a standardized manner, including registration of range of mandibular movements, TMJ sounds, pain on movement, and palpatory tenderness of the TMJ and the masticatory muscles. None of the patients showed more than five symptoms of dysfunction either at the start of or after 2 years of treatment. A decrease in the frequency of headache was found for nine of those 18 patients that reported headache (P = 0.004). A minor, but significant decrease in overjet and overbite was found and the molar relationship was also changed. It was concluded that 2 years' treatment with a mandibular advancement splint had no adverse effects on the craniomandibular status and function, but the observed occlusal changes requires further evaluation. (+info)
Quality of life assessment of treatment with dental appliance or UPPP in patients with mild to moderate obstructive sleep apnoea. A prospective randomized 1-year follow-up study.
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The objectives of this study were: to evaluate the change in the three quality of life (QOL) dimensions of vitality, contentment and sleep before intervention and 1 year after treatment with a dental appliance or uvulopalatopharyngoplasty (UPPP); to compare the effect of treatment between these two treatment groups on these three dimensions; and to determine the relation between the QOL scores and somnographic values. Ninety-five patients with mild to moderate obstructive sleep apnoea (OSA) (AI > 5) were randomly allocated to either a dental appliance or UPPP treatment group. Seven patients withdrew after randomization but before treatment, leaving 88 patients eligible for treatment. The patients were examined using somnography and administered the Minor Symptoms Evaluation-Profile (MSE-P), a QOL questionnaire, before and 1 year after intervention. Thirty-seven patients in the dental appliance group and 43 in the UPPP group completed the 1-year follow-up. The mean values for the three dimensions vitality, contentment and sleep improved significantly 1 year after intervention in the dental appliance and UPPP groups. No difference in the QOL scores at baseline was noted between the groups. One year after intervention the UPPP group showed significantly more contentment than the dental appliance group. In contrast, vitality and sleep dimensions did not differ between the two treatment groups. No significant correlations were observed between the QOL scores and somnographic values. In conclusion, quality of life improved significantly in the dental appliance and UPPP groups 1 year after intervention. However, the dental appliance group showed a lower level of contentment than the UPPP group, even though the somnographic values were superior in the former group. (+info)