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Operative Techniques in Otolaryngology (2012) 23, 72-78

Oral appliance therapy for sleep-related breathingdisorders

Steven D. Bender, DDS

From the North Texas Center for Head, Face, & TMJ Pain, Plano, Texas.

Oral appliances that advance the mandible in relationship to the maxilla offer a relatively simple andviable option in the treatment of sleep-related breathing disorders. Oral appliances are indicated for thetreatment of snoring and mild to moderate sleep apnea or for those who prefer this type of therapy topositive airway pressure therapies. This article will describe the different appliance types, the proposedmechanisms of action, fabrication, and management of adverse events that may occasionally occur withoral appliance therapy.© 2012 Elsevier Inc. All rights reserved.

KEYWORDSOral appliance;Obstructive sleepapnea;Continuous positiveair pressure;Mandibularadvancementappliance;Sleep-relatedbreathing disorders

Oral appliance (OA) therapy for sleep-related breathingdisorders represents a relatively simple alternative for themore traditional positive pressure treatments.1 The practiceparameters of the American Academy of Sleep Medicine(AASM) recommend OA therapy for the treatment of snor-ing and mild-to-moderate obstructive sleep apnea as well asfor patients who prefer this type of therapy over continuouspositive airway pressure (CPAP) equipment, who do notrespond therapeutically to CPAP, who are not suitable fortreatment with CPAP, or for whom treatment attempts withCPAP are unsuccessful.2 Several investigations also haveshown OAs to be effective in cases of severe apnea.3-7

Although the use of CPAP is still considered the mostefficacious treatment modality,8 many patients, especiallyounger ones, find the use of CPAP awkward and haveifficulty complying with this treatment modality. Patientsho have had the opportunity to use both treatment modal-

ties often tend to prefer the OA over CPAP.9 OA therapymay also be used in conjunction with CPAP in patients whoare otherwise recalcitrant to CPAP therapy alone.10 The useof OAs in the care of patients who experience sleep breath-

Address reprint requests and correspondence: Steven D. Bender,DDS, North Texas Center for Head, Face & T.M.J. Pain, Plano, TX 75093.

E-mail address: steve@benderdds.com.

1043-1810/$ -see front matter © 2012 Elsevier Inc. All rights reserved.doi:10.1016/j.otot.2011.06.007

ing disorders provides an excellent opportunity for the den-tist and sleep physician to work together in providing themost comprehensive and effective treatment for these suf-fering patients.

Appliance types

There are 2 main types of OAs used for sleep-related breathingdisorders, ie, those that advance the mandible (MAA) in rela-tion to the maxilla and those that hold the tongue via suction inthe protruded position (tongue-retaining device [TRD]; Figures1A-B and 2). The TRD appliances lack the ability to adjust fortitration, can dislodge because of a lack of suction, and ulti-mately have low compliance because of comfort issues. Unlessdental issues prohibit their use, MAAs are the most commonlyused devices. There are 2 basic types of MAAs; those that arecustom-made for the patient and those that are noncustom. Thenoncustom appliance, sometimes referred to as “boil and bite,”will usually require heating to mold it to the patient’s dentition.These appliances have been shown to be less effective thancustom-fitted appliances and are not recommended for long-term use.11 The noncustom appliance is also difficult to fitcomfortably and is nonadjustable further, limiting its use in

clinical practice.12

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73Bender Oral Appliance Therapy

The custom fabricated appliances can be further dividedto those that are nonadjustable, often called monoblockdevices, and those that are 2 separate pieces fitting on theupper and lower dental arches (Figures 3 and 4). There areurther classifications of MAAs based on the mechanism ofhich they attach the upper and lower segments together asell as titration mechanisms. MAAs depend on an adequateumber of teeth in each dental arch for retention. Theecommended number varies from 6 to 8 teeth per arch.owever, there are several reports of oral implants beingsed to gain retention in edentulous arches.13,14 There are

many custom OAs available that can make selection quitedifficult. Currently, the Centers for Medicare and MedicaidServices requirements for a custom appliance are as fol-lows15:

Figure 1 (A) Mandibular advancement device; neutral. (B)

andibular advancement device; lower jaw protruded.

● have a mechanism that is hinged or jointed at the sides,front or palate;

● have a mechanism that allows the mandible to be ad-vanced;

● are able to protrude the mandible beyond the front teeth atmaximum protrusion; and

● are adjustable by the beneficiary in increments of one mmor less; and

● retain their adjustment setting when removed.

Mechanism of action

The precise mechanism in which OAs facilitate a reductionin sleep disorder breathing events is yet to be fully eluci-dated. The accepted premise is that by various mechanisms,there is a decrease in collapsibility and an increase in thedimensions of the upper airway.16,17 For most OAs, it ishought that by mechanically holding the mandible forwardn relation to the maxilla, the tongue is prevented fromollapsing into the airway during sleep. Ryan et al16 re-orted the effect to be a maintenance of the patency of theelopharynx, particularly, the lateral dimension. Lee et al18

Figure 2 Tongue retaining device.

Figure 3 (SomnoDent© appliance).

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74 Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012

demonstrated increased space in the retropalatal and retro-lingual spaces as well as a decreased length of the softpalate using OAs. OAs have also been shown to increasegenioglossus neuromuscular activity while in use.19 Evelofft al20 demonstrated a potential change in tongue shape via

reduction in the mandibular plane-to hyoid distance.awauchi et al21 reported that advancing the mandible with

OA therapy facilitated spontaneous nasal breathing via adecrease in nasal resistance. Hiyama et al22 demonstrated anincreases in nasal airway patency during mandibular ad-vancement in healthy awake subjects.

Facilitation of nasal breathing may be important as upperairway resistance and obstruction are significantly less prev-alent while breathing nasally rather than orally.23 Fergusonet al24 reported that active tongue protrusion produced amarked increase in upper airway space from the soft palatearea to the hypopharynx. It is generally thought that agreater degree of mandibular advancement equates to amore robust therapeutic benefit of OAs.25-29 An increase ofvertical opening of OAs beyond that which is necessary tofabricate the devices component’s appears to have littleeffect on efficacy yet seems to have a negative consequenceon compliance.30 In cases of macroglossia, a more robustpening may be necessary to increase comfort and compli-nce. Marklund et al31 also demonstrated that advancementf the mandible is more important than the degree of ver-ical opening for treatment success. One caveat to the find-ngs mentioned is that to date, all were demonstrated inubjects who were awake. It is not known if these findingsre also demonstrated during sleep stages, or if other mech-nisms may be involved.

Appliance fabrication

The OA fabrication process by the dentist should begin witha comprehensive history and evaluation. Components of the

Figure 4 TAP 3 appliance.

examination may include study casts of the dentition, ap-

propriate radiographs, and a careful evaluation of the headand neck. The oral evaluation should include a thoroughassessment of the oral soft and hard tissue health. Toothwear may indicate sleep bruxism. In addition, the presenceof scalloping on the oral tongue lateral borders and ridgingof the buccal mucosa is suggestive of sleep bruxism.32-34

The presence of torus mandibularis or palatinus has alsobeen reported as comorbid with oral parafunctional activ-ity.35,36 The condition of the dentition and supporting peri-odontal structures needs to be optimum to prevent unwantedmorbidity. Any pathology should be immediately addressedbefore appliance fabrication.

An assessment of the occlusal classification and maxil-lomandibular relationship should be documented in the pa-tient’s record before treatment. This will help asses anypotential changes that may occur during therapy. A thor-ough evaluation of the temporomandibular joints (TMJs)and associated structures should be included in the pretreat-ment assessment. Palpation of the masseter, temporalis,suprahyoid, and cervical muscle groups by use of themethod previously described by Fischer37 will provide di-gnostic information important in the assessment of thetomatagnathic musculature (Figure 5).

Masseter and temporalis muscle hypertrophy is ofteneen in association with bruxism and TMJ disorders.38-40

The TMJs should be palpated at both the lateral and retrodiscal aspects. The retro discal area can be palpated byhaving the patient open widely and pressing the preauriculararea with light pressure (no more than 5 kg/cm2). Becauseimited range of mouth opening is often seen in patients

Figure 5 Stomatagnathic muscles.

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75Bender Oral Appliance Therapy

with impaired TMJs, the range of motion should be assessedin opening, lateral, and protrusive movements. Normalmandibular opening is thought to be between 40 and 55 mm.Normal lateral and protrusive movements measure approx-imately 7 mm (Figures 6, 7, and 8). 41 The presence andquality of jaw joint noises should also be documented asthey may indicate joint pathology.42 In some cases, intra-rticular disorders may postpone or interfere with OA ther-py. In other individuals, the OA may serve to decreaseromandibular dysfunction during sleep.43

Figure 6 Jaw opening assessment.

iFigure 7 Jaw protrusion assessment.

According to the AASM practice parameters, the fittingand delivery of an OA should be performed by a well-trained and qualified dentist after prescription by the sleepphysician. The dentist should possess expertise in dentalsleep medicine and temporomandibular disorders.44 Thereating dentist should always provide for a very exhaustivenformed consent before initiating therapy (Figure 9). Anccurate impression of the upper and lower dental arches, asell as a recording of the relationship between the 2 arches

s required for the fabrication of the custom OA (Figures 10nd 11). The impressions are poured in dental stone and sento an approved dental laboratory for fabrication. It is helpfulo maintain a second set of the dental cast to monitor dentalcclusal changes that may occur with appliance usage.

The appliance is then placed in the patient’s mouth tonsure comfortable fit and adequate retention on the teeth. Areat deal of care should be given this step to facilitateptimum patient compliance. It should be confirmed that theatient can form and maintain an adequate lip seal to facil-tate nasal breathing as well as reduce potential droolingnd/or dry mouth. The advancement mechanism should beitrated to the most comfortable protrusive position withnstructions given to the patient for continued home titra-ion. Effectiveness of the OA at the titrated position can berst accessed by the use of portable studies such as homeulse oximetry.29,45 Once portable studies indicate success,ollow-up polysomnogram should be used to confirm theesult. Parker et al46 demonstrated a 92% success rate usingortable monitoring combined with polysomnogram confir-ation. Follow-up appointments need to be scheduled with

he dentist to assure adequate fit, compliance, and overallomfort of the appliance. Any potential morbidity should be

Figure 8 Jaw lateral movement assessment.

mmediately addressed at the follow-up appointments.

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76 Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012

Adverse events

Increased salivation, dry mouth, teeth discomfort, bitechanges, as well as jaw joint pain are the most common sideeffects reported by patients using OAs to treat their sleep-related breathing disorders. The reporting of adverse eventswill depend on the survey questions, the number of patientsstudied, and other such variables unique to the study itself.Most side effects dissipate over time and are rarely a con-cern for the patient. It is of benefit to include the potentialadverse events in the consent form to dispel any concernsthat may occur if they do happen. In most cases, adjust-ments can be made by the dentist to the appliance that willsolve the perceived problem.47 In one investigation, authorsheorized about temporomandibular joint degeneration yetong-term changes to the joint complex have not been welltudied to date.48 The most significant factor for non-com-

pliance of OAs is usually because of lack of efficacy ratherthan appliance discomfort. However, in 2 studies investiga-tors have demonstrated that 40%-50% of patients did, infact, discontinue appliance usage because of adverseevents.31,49

Figure 9 Sa

Figure 10 TAP Gauge ©.

For the dentist, the most significant concern is changes tothe occlusion or biting relationship that may occur withOAs. Martinez-Gomis et al50 demonstrated permanent oc-lusal changes after 5 years of continuous appliance usagen most of the 40 patients studied. De Almeida et al49

showed clinically relevant changes in the dental occlusionafter a mean of 7.4 years of appliance use. Ueda et al alsodemonstrated what was termed “dramatic” changes in den-tal occlusion when the appliance was used for 5 years orlonger.51 Not all patients will experience bite changes withOA use, but attention to the possibility by careful monitor-ing should be a part of the treatment protocol. Retainers orpositioners can be fabricated for wear after the sleep period.These devices are fitted to the patient’s teeth and replicatethe bite relationship prior to the initiation of therapy. Inmost cases, the patient will be able to bite comfortably intothe device after approximately 30 minutes of wear.

Future directions

With the growing popularity and evidence of efficacy ofOAs, studies in which the different appliance types are

onsent form.

Figure 11 TAP Gauge ©.

77Bender Oral Appliance Therapy

compared are needed to help guide practitioners through themaze of information now provided by the mostly by theappliance manufacturers. Design features favorable to spe-cific patient parameters would also help the clinician inappliance selection. Criteria for patient selection, predictorsof success and compliance monitoring will ensure that OAsare prescribed in the most appropriate manner and that goodpatient compliance is ultimately achieved. Using new im-aging technology, we soon may realize a better understand-ing of the mechanisms of action of OAs. Future endeavorsneed to focus on achieving an understanding of the effect ofOAs in the sleeping individual to improve outcomes oftherapy. Advocacy efforts to help patients receive favorablereimbursement are also needed to ensure access to care andremove financial barriers for individuals in need of therapy.

Conclusions

OAs provide the clinician and patient a relatively easy andmoderate cost alternative to the more traditional pneumaticsplinting of the airway. Recent research has demonstratedevidentiary support for their use in obstructive sleep apnea.The recently updated practice parameters of the AASMrecommends OAs for use in patients with mild-to-moderatesleep apnea or for patients with severe sleep apnea who arenot able to tolerate CPAP or prefer an OA. This reviewsummarized the currently proposed mechanisms of action,the fabrication and potential adverse effects of OAs forsleep-related breathing disorders. As discussed, most poten-tial adverse events can be managed by the treating dentist ifregular monitoring is maintained.

With OA therapy, as is true with all treatment modalities,a comprehensive informed consent is imperative. It is alsoimportant that doctors who are well trained and experiencedin sleep disorders and TMJ function and dysfunction, leadthe team in the assessment, fitting and monitoring of thepatient who is a candidate OA therapy. Ultimately, thecollaboration of the well-trained dentist and sleep physicianwill provide a cost-effective and therapeutically sound treat-ment alternative for the ever-increasing population of pa-tients who suffer with sleep related breathing disorders.

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