HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Reprinted by permission of Laryngoscope. 2016; 126(2):507-514.

The Laryngoscope V C 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Systematic Review

Effectiveness of Mandibular Advancement Appliances in Treating Obstructive Sleep Apnea Syndrome: A Systematic Review

Sara Serra-Torres, DDS; Carlos Bellot-Arcıs, DDS, PhD; Jose M. Montiel-Company, DDS, MD, PhD; Jaime Marco-Algarra, MD, PhD; Jose M. Almerich-Silla, MD, PhD

Objectives/Hypothesis: Mandibular advancement devices are an alternative to continuous positive airway pressure for patients with mild or moderate obstructive sleep apnea/hypopnea syndrome (OSAHS). The main aim of this review was to assess the effectiveness of different devices in treating OSAHS, based on polysomnographic measurements such as the apnea/ hypopnea index (AHI) and oxygen saturation, and on changes in the upper airway and improvements in the most common symptoms: snoring and somnolence. Their adverse effects were also noted. Study Design: Systematic review. Methods: Following an exhaustive search in the Medline, Scopus, and Cochrane Library databases, 22 articles published in the past 10 years met the quality and inclusion criteria. Results: Using mandibular advancement devices during the hours of sleep helps to prevent snoring and excessive day- time sleepiness, reduce the AHI significantly, and bring about beneficial changes in the upper airway. Adjustable and custom- made mandibular advancement devices give better results than fixed and prefabricated appliances. Monobloc devices give rise to more adverse events, although these are generally mild and transient. Conclusions: Mandibular advancement devices increase the area of the airway. They bring the soft palate, tongue, and hyoid bone forward and activate the masseter and submental muscles, preventing closure. All these effects reduce the AHI, increase the oxygen saturation, and improve the main symptoms of OSAHS. Key Words: Obstructive sleep apnea, mandibular advancement splints, mandibular advancement appliance, mandibular advancement device. Level of Evidence: NA Laryngoscope , 126:507–514, 2016

INTRODUCTION Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a respiratory sleep disorder, listed in the International Classification of Sleep Disorders, that consists of recurrent episodes of total or partial blockage of the passage of air. 1 It occurs because an anatomical or functional narrowing of the upper airway can lead to its closure, causing decreased oxyhemoglobin saturation and repeated miniawakenings that give rise to daytime sleepiness and to neuropsychiatric, respiratory, and cardiac disorders. 2–5 It is the most common respiratory disorder to be recognized as a serious public health problem. 4 It affects 4% to 6% of men and 2% to 4% of women, with higher incidences in obese persons. 3 OSAHS From the Stomatology Department ( S . S .- T ., C . B .- A ., J . M . M .- C ., J . M . A .- S .); and Otorhinolaryngology Unit, University Clinical Hospital ( J . M .- A .), Fac- ulty of Medicine and Dentistry, University of Valencia, Valencia, Spain. Editor’s Note: This Manuscript was accepted for publication June 18, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Carlos Bellot-Arcıs, Departamento de Estomatologıa, Unidad docente de Preventiva, Clınica Odontologica, C/ Gasco Oliag No. 1, CP: 46010, Valencia, Spain. E-mail: bellot.arcis@ gmail.com

is classified by the number of pauses in breathing per hour of sleep (the apnea/hypopnea index [AHI]) as mild (AHI 5 5–15), moderate (AHI 5 16–30), or severe (AHI > 30). 3 The symptoms occur both at night and during the day. The most common are snoring, asphyxial episodes, abnormal movements, diaphoresis, frequent awakenings, nightmares, restless sleep, insomnia, dribbling, bruxism, dry mouth, night sweats, excessive daytime sleepiness, chronic tiredness, morning headaches, irritability, depres- sion, and difficulty in concentrating. Excessive daytime sleepiness, measured by subjective methods such as the Epworth Sleepiness Scale (ESS), is the most prevalent day- time symptom. 6 The method of choice for diagnosing OSAHS is polysomnography, which assesses the quantity and quality of sleep and identifies the different respiratory events. 6 Part of the treatment consists of changing dietary habits, cutting out alcohol and tobacco, and sleeping in a different position. 6 Although surgical procedures such as maxillomandibular advancement or uvulopalatopharyngo- plasty are available, 2 continuous positive airway pressure (CPAP) is the treatment of choice for OSAHS. CPAP increases the area of the upper airway, preventing it from closing, 4,7,8 but it is very uncomfortable for the patient and presents numerous adverse effects such as nasal congestion and dryness of the mucosa. 2

DOI: 10.1002/lary.25505

Laryngoscope 126: February 2016

Serra-Torres et al.: Oral Appliances for Sleep Apnea

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