HSC Section 3 - Trauma, Critical Care and Sleep Medicine

excellent cost/benefit ratio. Consequently, MADs may be considered a treatment of choice for mild/moderate OSAHS. One of the main limitations of a systematic review is selection bias. To avoid missing relevant articles, 3 databases were used (Medline, Cochrane Library Plus, and Scopus), although the strict criteria (CONSORT) adopted to select articles of high methodological quality may occasionally have eliminated an article of interest. In an attempt to avoid as much selection bias as possi- ble, no article was excluded on language grounds. CONCLUSION MADs increase the area of the airway. They bring the soft palate, tongue, and hyoid bone forward and acti- vate the masseter and submental muscles, preventing clo- sure. All these effects reduce the AHI, increase the oxygen saturation, and improve the main symptoms of OSAHS. MADs could be the treatment of choice in patients with mild/moderate OSAHS and in severe cases when the patient does not tolerate CPAP. Adjustable and custom-made MADs give better results than fixed and prefabricated appliances. Mono- bloc appliances cause more adverse effects. Adverse effects are generally mild and transient. They usually increase with mandibular protrusion of 50%. The most frequent are changes in salivation, in taste, and in tooth position, such as reduced overjet and overbite, labioversion of lower incisors, upper inci- sor linguoversion, and lower molar mesialization, as well as muscular and temporomandibular joint discomfort. BIBLIOGRAPHY 1. American Academy of Sleep Medicine. International Classification of Sleep Disorders: Diagnostic and Coding Manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005. 2. Tsuiki S, Lowe AA, Almeida FR, Kawahata N, Fleetham JA. Effects of mandibular advancement on airway curvature and obstructive sleep apnoea severity. Eur Respir J 2004;23:263–268. 3. Lawton HM, Battagel JM, Kotecha B. A comparison of the Twin Block and Herbst mandibular advancement splints in the treatment of patients with obstructive sleep apnoea: a prospective study. Eur J Orthod 2005; 27:82–90. 4. Ahrens A, McGrath C, Hagg U. A systematic review of the efficacy of oral appliance design in the management of obstructive sleep apnoea. Eur J Orthod 2011;33:318–324. 5. Dort L, Remmers J. A combination appliance for obstructive sleep apnea: the effectiveness of mandibular advancement and tongue retention. J Clin Sleep Med 2012;8:265–269. 6. Friedman M. Sleep Apnea and Snoring: Medical and Surgical Treatment. New York, NY: Elsevier, 2009. 7. Hashimoto K, Ono T, Honda E, et al. Effects of mandibular advancement on brain activation during inspiratory loading in healthy subjects: a functional magnetic resonance imaging study. J Appl Physiol 2006;100: 579–586. 8. Sutherland K, Cistulli PA. Mandibular advancement splints for the treat- ment of sleep apnoea syndrome. Swiss Med Wkly 2011;141:w13276. 9. Gagnadoux F, Fleury B, Vielle B, et al. Titrated mandibular advancement versus positive pressure for sleep apnoea. Eur Respir J 2009;4:914–920. 10. Aarab G, Lobbezoo B, Hamburger HL, Naeije M. Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea. Clin Oral Investig 2010;14:339–345. 11. Englemen HM, Martin SE, Deary IJ, Douglas NJ. Effect of continuous pos- itive airway pressure treatment on daytime function in sleep apnea/ hypopnea syndrome. Lancet 1994;343:572–575. 12. Ferguson KA, Ono T, Lowe AA, Al-Majed S, Love LI, Fleetham JA. A short term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnea. Thorax 1997;52:362–368.

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