Abstract
Mandibular advancement splint (MAS) therapy is the leading alternative to continuous positive airway pressure (CPAP) therapy for the treatment of obstructive sleep apnoea. A MAS is an oral appliance which advances the mandible in relation to the maxilla, thus increasing airway calibre and reducing collapsibility. Although it is less effective than CPAP in reducing the apnoea-hypopnoea index (AHI), it has demonstrated equivalence to CPAP in a number of key neurobehavioural and cardiovascular health outcomes, perhaps due to increased tolerability and patient adherence when compared to CPAP. However, response to MAS is variable, and reliable prediction tools for patients who respond best to MAS therapy have thus far been elusive; this is one of the key clinical barriers to wider uptake of MAS therapy. In addition, the most effective MAS devices are custom-made by a dentist specialising in the treatment of sleep disorders, which may present financial or accessibility barriers for some patients. MAS devices are generally well tolerated but may have side effects including temporomandibular joint (TMJ) dysfunction, hypersalivation, tooth pain and migration as well as occlusal changes. A patient-centred approach to treatment from a multidisciplinary team perspective is recommended. Evidence-based clinical practice points and areas of future research are summarised at the conclusion of the chapter.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Almeida, F. R., Henrich, N., Marra, C., et al. (2013). Patient preferences and experiences of CPAP and oral appliances for the treatment of obstructive sleep apnea: A qualitative analysis. Sleep & Breathing, 17(2), 659–666. https://doi.org/10.1007/s11325-012-0739-6
Amin, S., Weber, H. P., Finkelman, M., El Rafie, K., Kudara, Y., & Papaspyridakos, P. (2017). Digital vs. conventional full-arch implant impressions: A comparative study. Clinical Oral Implants Research, 28(11), 1360–1367. https://doi.org/10.1111/clr.12994
Bamagoos, A. A., Sutherland, K., & Cistulli, P. A. (2016). Mandibular advancement splints. Sleep Medicine Clinics, 11(3), 343–352. https://doi.org/10.1016/j.jsmc.2016.04.002
Bamagoos, A. A., Cistulli, P. A., Sutherland, K., et al. (2019a). Dose-dependent effects of mandibular advancement on upper airway collapsibility and muscle function in obstructive sleep apnea. Sleep, 42(6), zsz049. https://doi.org/10.1093/sleep/zsz049
Bamagoos, A. A., Cistulli, P. A., Sutherland, K., et al. (2019b). Polysomnographic endotyping to select patients with obstructive sleep apnea for oral appliances. Annals of the American Thoracic Society, 16(11), 1422–1431. https://doi.org/10.1513/AnnalsATS.201903-190OC
Bamagoos, A. A., Eckert, D. J., Sutherland, K., Ngiam, J., & Cistulli, P. A. (2020). Dose-dependent effects of mandibular advancement on optimal positive airway pressure requirements in obstructive sleep apnoea. Sleep & Breathing, 24(3), 961–969. https://doi.org/10.1007/s11325-019-01930-3
Basyuni, S., Barabas, M., & Quinnell, T. (2018). An update on mandibular advancement devices for the treatment of obstructive sleep apnoea hypopnoea syndrome. Journal of Thoracic Disease, 10(Suppl 1), S48–S56. https://doi.org/10.21037/jtd.2017.12.18
Bratton, D. J., Gaisl, T., Wons, A. M., & Kohler, M. (2015). CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: A systematic review and meta-analysis. JAMA, 314(21), 2280–2293. https://doi.org/10.1001/jama.2015.16303
Brown, E. C., Cheng, S., McKenzie, D. K., Butler, J. E., Gandevia, S. C., & Bilston, L. E. (2013). Tongue and lateral upper airway movement with mandibular advancement. Sleep, 36(3), 397–404. https://doi.org/10.5665/sleep.2458
Brown, E. C., Jugé, L., Knapman, F. L., et al. (2021). Mandibular advancement splint response is associated with the pterygomandibular raphe. Sleep, 44(4), zsaa222. https://doi.org/10.1093/sleep/zsaa222
Chan, A. S., Lee, R. W., Srinivasan, V. K., Darendeliler, M. A., Grunstein, R. R., & Cistulli, P. A. (2010). Nasopharyngoscopic evaluation of oral appliance therapy for obstructive sleep apnoea. The European Respiratory Journal, 35(4), 836–842. https://doi.org/10.1183/09031936.00077409
Chan, A. S. L., Sutherland, K., & Cistulli, P. A. (2020). Mandibular advancement splints for the treatment of obstructive sleep apnea. Expert Review of Respiratory Medicine, 14(1), 81–88. https://doi.org/10.1080/17476348.2020.1686978
Chen, H., Eckert, D. J., van der Stelt, P. F., et al. (2020). Phenotypes of responders to mandibular advancement device therapy in obstructive sleep apnea patients: A systematic review and meta-analysis. Sleep Medicine Reviews, 49, 101229. https://doi.org/10.1016/j.smrv.2019.101229
Dal-Fabbro, C., Garbuio, S., D’Almeida, V., Cintra, F. D., Tufik, S., & Bittencourt, L. (2014). Mandibular advancement device and CPAP upon cardiovascular parameters in OSA. Sleep & Breathing, 18(4), 749–759. https://doi.org/10.1007/s11325-014-0937-5
Dieltjens, M., Braem, M. J., Vroegop, A., et al. (2013). Objectively measured vs self-reported compliance during oral appliance therapy for sleep-disordered breathing. Chest, 144(5), 1495–1502. https://doi.org/10.1378/chest.13-0613
Dieltjens, M., Braem, M. J., Op de Beeck, S., et al. (2019). Remotely controlled mandibular positioning of oral appliance therapy during polysomnography and drug-induced sleep endoscopy compared with conventional subjective titration in patients with obstructive sleep apnea: Protocol for a randomized crossover trial. Trials, 20(1), 615. https://doi.org/10.1186/s13063-019-3698-4
Dissanayake, H. U., Colpani, J. T., Sutherland, K., et al. (2021). Obstructive sleep apnea therapy for cardiovascular risk reduction-Time for a rethink? Clinical Cardiology, 44(12), 1729–1738. https://doi.org/10.1002/clc.23747
Edwards, B. A., Andara, C., Landry, S., et al. (2016). Upper-airway collapsibility and loop gain predict the response to oral appliance therapy in patients with obstructive sleep apnea. American Journal of Respiratory and Critical Care Medicine, 194(11), 1413–1422. https://doi.org/10.1164/rccm.201601-0099OC
Edwards, B. A., Redline, S., Sands, S. A., & Owens, R. L. (2019). More than the sum of the respiratory events: Personalized medicine approaches for obstructive sleep apnea. American Journal of Respiratory and Critical Care Medicine., 200(6), 691–703. https://doi.org/10.1164/rccm.201901-0014TR
Hoekema, A., Stegenga, B., Bakker, M., et al. (2007). Simulated driving in obstructive sleep apnoea-hypopnoea; effects of oral appliances and continuous positive airway pressure. Sleep & Breathing, 11(3), 129–138. https://doi.org/10.1007/s11325-006-0093-7
Johal, A., Haria, P., Manek, S., Joury, E., & Riha, R. (2017). Ready-made versus custom-made mandibular repositioning devices in sleep apnea: A randomized clinical trial. Journal of Clinical Sleep Medicine, 13(2), 175–182. https://doi.org/10.5664/jcsm.6440
Kato, J., Isono, S., Tanaka, A., et al. (2000). Dose-dependent effects of mandibular advancement on pharyngeal mechanics and nocturnal oxygenation in patients with sleep-disordered breathing. Chest, 117(4), 1065–1072. https://doi.org/10.1378/chest.117.4.1065
Kribbs, N. B., Pack, A. I., Kline, L. R., et al. (1993). Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. The American Review of Respiratory Disease, 147(4), 887–895. https://doi.org/10.1164/ajrccm/147.4.887
Kuhn, E., Schwarz, E. I., Bratton, D. J., Rossi, V. A., & Kohler, M. (2017). Effects of CPAP and mandibular advancement devices on health-related quality of life in OSA: A systematic review and meta-analysis. Chest, 151(4), 786–794. https://doi.org/10.1016/j.chest.2017.01.020
Lim, J., Lasserson, T. J., Fleetham, J., & Wright, J. (2006). Oral appliances for obstructive sleep apnoea. The Cochrane Database of Systematic Reviews, 2006(1), Cd004435. https://doi.org/10.1002/14651858.CD004435.pub3
Marklund, M., Carlberg, B., Forsgren, L., Olsson, T., Stenlund, H., & Franklin, K. A. (2015). Oral appliance therapy in patients with daytime sleepiness and snoring or mild to moderate sleep apnea: A randomized clinical trial. JAMA Internal Medicine, 175(8), 1278–1285. https://doi.org/10.1001/jamainternmed.2015.2051
Marklund, M., Braem, M. J. A., & Verbraecken, J. (2019). Update on oral appliance therapy. European Respiratory Review: An Official Journal of the European Respiratory Society, 28(153). https://doi.org/10.1183/16000617.0083-2019
MartÃnez-Gomis, J., Willaert, E., Nogues, L., Pascual, M., Somoza, M., & Monasterio, C. (2010). Five years of sleep apnea treatment with a mandibular advancement device. Side effects and technical complications. The Angle Orthodontist, 80(1), 30–36. https://doi.org/10.2319/030309-122.1
McEvoy, R. D., Antic, N. A., Heeley, E., et al. (2016). CPAP for prevention of cardiovascular events in obstructive sleep apnea. New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1606599
Nabavi, S., Debbarma, S., & Bhadra, S. (2020). A smart mandibular advancement device for intraoral cardiorespiratory monitoring. Annual International Conference of the IEEE Engineering in Medicine and Biology Society, 2020, 4079–4084. https://doi.org/10.1109/embc44109.2020.9176520
Ng, A. T., Gotsopoulos, H., Qian, J., & Cistulli, P. A. (2003). Effect of oral appliance therapy on upper airway collapsibility in obstructive sleep apnea. American Journal of Respiratory and Critical Care Medicine., 168(2), 238–241. https://doi.org/10.1164/rccm.200211-1275OC
Op de Beeck, S., Dieltjens, M., Verbruggen, A. E., et al. (2019). Phenotypic labelling using drug-induced sleep endoscopy improves patient selection for mandibular advancement device outcome: A prospective study. Journal of Clinical Sleep Medicine, 15(8), 1089–1099. https://doi.org/10.5664/jcsm.7796
Op de Beeck, S., Dieltjens, M., Azarbarzin, A., et al. (2021). Mandibular advancement device treatment efficacy is associated with polysomnographic endotypes. Annals of the American Thoracic Society, 18(3), 511–518. https://doi.org/10.1513/AnnalsATS.202003-220OC
Peker, Y., Glantz, H., Eulenburg, C., Wegscheider, K., Herlitz, J., & Thunstrom, E. (2016). Effect of positive airway pressure on cardiovascular outcomes in coronary artery disease patients with nonsleepy obstructive sleep apnea. The RICCADSA randomized controlled trial. American Journal of Respiratory and Critical Care Medicine, 194(5), 613–620. https://doi.org/10.1164/rccm.201601-0088OC
Penzel, T., Glos, M., & Fietze, I. (2021). New trends and new technologies in sleep medicine: Expanding accessibility. Sleep Medicine Clinics, 16(3), 475–483. https://doi.org/10.1016/j.jsmc.2021.05.010
Phillips, C. L., Grunstein, R. R., Darendeliler, M. A., et al. (2013). Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: A randomized controlled trial. American Journal of Respiratory and Critical Care Medicine., 187(8), 879–887. https://doi.org/10.1164/rccm.201212-2223OC
Piskin, B., Uyar, A., Yuceer, M., et al. (2021). Fabrication of a mandibular advancement device using a fully digital workflow: A clinical report. Journal of Prosthodontics, 30(3), 191–195. https://doi.org/10.1111/jopr.13297
Pliska, B. T., Nam, H., Chen, H., Lowe, A. A., & Almeida, F. R. (2014). Obstructive sleep apnea and mandibular advancement splints: Occlusal effects and progression of changes associated with a decade of treatment. Journal of Clinical Sleep Medicine, 10(12), 1285–1291. https://doi.org/10.5664/jcsm.4278
Quinnell, T. G., Bennett, M., Jordan, J., et al. (2014). A crossover randomised controlled trial of oral mandibular advancement devices for obstructive sleep apnoea-hypopnoea (TOMADO). Thorax, 69(10), 938–945. https://doi.org/10.1136/thoraxjnl-2014-205464
Ramar, K., Dort, L. C., Katz, S. G., et al. (2015). Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: An update for 2015. Journal of Clinical Sleep Medicine, 11(7), 773–827. https://doi.org/10.5664/jcsm.4858
Remmers, J., Charkhandeh, S., Grosse, J., et al. (2013). Remotely controlled mandibular protrusion during sleep predicts therapeutic success with oral appliances in patients with obstructive sleep apnea. Sleep, 36(10), 1517–1525, 1525a. https://doi.org/10.5665/sleep.3048
Remmers, J. E., Topor, Z., Grosse, J., et al. (2017). A feedback-controlled mandibular positioner identifies individuals with sleep apnea who will respond to oral appliance therapy. Journal of Clinical Sleep Medicine, 13(7), 871–880. https://doi.org/10.5664/jcsm.6656
Sanchez-de-la-Torre, M., Sanchez-de-la-Torre, A., Bertran, S., et al. (2020). Effect of obstructive sleep apnoea and its treatment with continuous positive airway pressure on the prevalence of cardiovascular events in patients with acute coronary syndrome (ISAACC study): A randomised controlled trial. The Lancet Respiratory Medicine, 8(4), 359–367. https://doi.org/10.1016/S2213-2600(19)30271-1
Schwartz, M., Acosta, L., Hung, Y. L., Padilla, M., & Enciso, R. (2018). Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: A systematic review and meta-analysis. Sleep & Breathing, 22(3), 555–568. https://doi.org/10.1007/s11325-017-1590-6
Sharples, L. D., Clutterbuck-James, A. L., Glover, M. J., et al. (2016). Meta-analysis of randomised controlled trials of oral mandibular advancement devices and continuous positive airway pressure for obstructive sleep apnoea-hypopnoea. Sleep Medicine Reviews, 27, 108–124. https://doi.org/10.1016/j.smrv.2015.05.003
Sutherland, K., Takaya, H., Qian, J., Petocz, P., Ng, A. T., & Cistulli, P. A. (2015). Oral appliance treatment response and polysomnographic phenotypes of obstructive sleep apnea. Journal of Clinical Sleep Medicine., 11(8), 861–868. https://doi.org/10.5664/jcsm.4934
Sutherland, K., Ngiam, J., & Cistulli, P. A. (2017). Performance of remotely controlled mandibular protrusion sleep studies for prediction of oral appliance treatment response. Journal of Clinical Sleep Medicine, 13(3), 411–417. https://doi.org/10.5664/jcsm.6492
Sutherland, K., Dalci, O., & Cistulli, P. A. (2021a). What do we know about adherence to oral appliances? Sleep Medicine Clinics, 16(1), 145–154. https://doi.org/10.1016/j.jsmc.2020.10.004
Sutherland, K., Almeida, F. R., Kim, T., et al. (2021b). Treatment usage patterns of oral appliances for obstructive sleep apnea over the first 60 days: A cluster analysis. Journal of Clinical Sleep Medicine. https://doi.org/10.5664/jcsm.9288
Terrill, P. I., Edwards, B. A., Nemati, S., et al. (2015). Quantifying the ventilatory control contribution to sleep apnoea using polysomnography. The European Respiratory Journal, 45(2), 408–418. https://doi.org/10.1183/09031936.00062914
Trzepizur, W., Cistulli, P. A., Glos, M., et al. (2021). Health outcomes of continuous positive airway pressure versus mandibular advancement device for the treatment of severe obstructive sleep apnea: An individual participant data meta-analysis. Sleep, 44(7), zsab015. https://doi.org/10.1093/sleep/zsab015
Tsai, W. H., Vazquez, J. C., Oshima, T., et al. (2004). Remotely controlled mandibular positioner predicts efficacy of oral appliances in sleep apnea. American Journal of Respiratory and Critical Care Medicine., 170(4), 366–370. https://doi.org/10.1164/rccm.200310-1446OC
Vanderveken, O. M., Devolder, A., Marklund, M., et al. (2008). Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. American Journal of Respiratory and Critical Care Medicine, 178(2), 197–202. https://doi.org/10.1164/rccm.200701-114OC
Vanderveken, O. M., Dieltjens, M., Wouters, K., De Backer, W. A., Van de Heyning, P. H., & Braem, M. J. (2013). Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing. Thorax, 68(1), 91–96. https://doi.org/10.1136/thoraxjnl-2012-201900
Vena, D., Azarbarzin, A., Marques, M., et al. (2020). Predicting sleep apnea responses to oral appliance therapy using polysomnographic airflow. Sleep, 43(7), zsaa004. https://doi.org/10.1093/sleep/zsaa004
Zhou, N., Ho, J. T. F., de Vries, N., Bosschieter, P. F. N., Ravesloot, M. J. L., & de Lange, J. (2021). Evaluation of drug-induced sleep endoscopy as a tool for selecting patients with obstructive sleep apnea for maxillomandibular advancement. Journal of Clinical Sleep Medicine. https://doi.org/10.5664/jcsm.9802
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2022 The Author(s), under exclusive license to Springer Nature Switzerland AG
About this chapter
Cite this chapter
Mohammadieh, A.M., Sutherland, K., Chan, A.S.L., Cistulli, P.A. (2022). Mandibular Advancement Splint Therapy. In: Penzel, T., Hornero, R. (eds) Advances in the Diagnosis and Treatment of Sleep Apnea . Advances in Experimental Medicine and Biology, vol 1384. Springer, Cham. https://doi.org/10.1007/978-3-031-06413-5_22
Download citation
DOI: https://doi.org/10.1007/978-3-031-06413-5_22
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-031-06412-8
Online ISBN: 978-3-031-06413-5
eBook Packages: Biomedical and Life SciencesBiomedical and Life Sciences (R0)