Mandibular advancement splint

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Mandibular advancement splint
Mandibular advancement splint.jpg
A mandibular advancement splint for treatment of sleep apnea
Other namesMAS

A mandibular splint or mandibular advancement splint is a prescription custom-made medical device worn in the mouth used to treat sleep-related breathing disorders including: obstructive sleep apnea (OSA), snoring, and TMJ disorders. These devices are also known as mandibular advancement devices, sleep apnea oral appliances, oral airway dilators, and sleep apnea mouth guards .

Contents

The American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) recommend that sleep physicians should prescribe sleep apnea oral appliances for adult patients who need treatment for their primary snoring (without obstructive sleep apnea) rather than no treatment and for patients who have obstructive sleep apnea but are intolerant to CPAP therapy or otherwise prefer alternate therapy. [1]

Vanderveken et al (2008) researched prescription custom-made splints head-to-head with thermoplastic over-the-counter splints: "Our results suggest that the thermoplastic device cannot be recommended as a therapeutic option nor can it be used as a screening tool to find good candidates for mandibular advancement therapy." [2]

Usage

A different style of mandibular advancement splint Avance mandibular.jpg
A different style of mandibular advancement splint
A mandibular splint produced by 3D printing from titanium coated with a medical grade plastic. A 3D scanner was used to map a patient's mouth. The output tube has two separate airways that allow air to flow through to the back of the throat, avoiding obstructions from the nose, the back of the mouth and tongue. 3D printed mouthpeace.jpg
A mandibular splint produced by 3D printing from titanium coated with a medical grade plastic. A 3D scanner was used to map a patient's mouth. The output tube has two separate airways that allow air to flow through to the back of the throat, avoiding obstructions from the nose, the back of the mouth and tongue.

The splint treats snoring and sleep apnea by moving the lower jaw forward slightly, which tightens the soft tissue and muscles of the upper airway to prevent obstruction of the airway during sleep. The tightening created by the device also prevents the tissues of the upper airway from vibrating as air passes over them—the most common cause of snoring.[ citation needed ]

Mandibular advancement splints are widely used in the United States and are beginning to be used in the UK. According to the current American Academy of Sleep Medicine treatment guidelines, [1] oral appliances should be considered for patients with snoring or minor to moderate sleep apnea, or as an alternative to CPAP in non compliant patients with severe obstructive sleep apnea. Where appropriate, they are considered a good therapy choice as they are non-invasive, easily reversible, quiet, and generally well accepted by the patient. The focus of improvement in appliance design is in reducing bulk, permitting free jaw movement (permitting yawning, speaking, and drinking), and allowing the user to breathe through the mouth (early "welded gum shield"-type devices prevented oral breathing).[ citation needed ]

Evidence is accumulating to support the use of oral devices in the treatment of OSA, and studies demonstrating their efficacy [3] have been underpinned by increasing recognition of the importance of upper airway anatomy in the pathophysiology of OSA. [4] Oral devices have been shown to have beneficial effects relating to several areas. These include the polysomnographic indexes of OSA, subjective and objective measures of sleepiness, blood pressure, aspects of neuropsychological functioning, and quality of life.[ citation needed ] Elucidation of the mechanism of action of oral devices has provided insight into the factors that predict treatment response and may improve the selection of patients for this treatment modality. [4]

A 2008 study published in Sleep on the influence of nasal resistance (NAR) on oral device treatment outcome in OSA demonstrates the need for an interdisciplinary approach between ENT surgeons and sleep physicians to treating OSA. The study suggests that higher levels of NAR may negatively affect outcome with MAS [5] and subsequently methods to lower nasal resistance may improve the outcome of oral device treatment.

They are generally more successful at treating mild and moderate sleep apnea and less effective at treating severe sleep apnea, even though good success was measured even in severe sleep apnea. [6] They may bring the level of apnea a patient experiences down significantly but fail to eliminate it.[ citation needed ]

A meta-analysis of 51 randomized controlled trials investigating the effects of CPAP and oral devices on blood pressure found that oral devices were equally effective as continuous positive airway pressure (CPAP) devices in lowering the blood pressure of patients with OSA. [7] The medical dental sleep appliance, or MDSA, was clinically proven to conclusively show in a large and complex randomized controlled study that CPAP and MAS are effective in treating sleep-disordered breathing in subjects with AHI 5–30. CPAP was thought to be more effective, but randomised control evidence (such as that reviewed in 2013) suggests splints may be as effective in patients with a range of severities of obstructive sleep apnoea. [8] Both methods appear effective in alleviating symptoms, improving daytime sleepiness, quality of life and some aspects of neurobehavioral function, with CPAP usage being less than self-reported MAS usage. More test subjects and their domestic partners felt that CPAP was the most effective treatment, although MAS was easier to use. Nocturnal systemic hypertension was shown to improve with MAS but not CPAP, although the changes are small. [9]

Drawbacks

In a survey study of patients, many discontinued use because of discomfort, lack of efficacy or switching to CPAP, and frequent side-effects such as dry mouth, tooth pain, dental discomfort and jaw pain. [10] [11] Long-term use is not associated with temporamandibular disorders but was associated with permanent changes in how the upper and lower teeth meet, and the appliances needed about 0.8 repairs/relines per year. [12] Some patients can find these devices somewhat uncomfortable, although many patients find them less bothersome than CPAP mask treatment, so patients are more likely to wear them consistently and comply with treatment [13] CPAP manufacturers claim that improperly fitted devices may cause teeth to shift over time, like with CPAP, but cite no evidence to support these claims.[ citation needed ] Patients may pay around $1900 out of pocket to secure these devices, and, in the US, some health plans do not cover these costs. [14] The high price for prescription devices has led to a proliferation of lower cost non-prescription devices that are unproven and some sleep specialists suggest may be dangerous. [15]

Adherence to oral appliance is strongly associated with patient reservations regarding the effects of the device on teeth, possible lack of efficacy, and discomfort. [16]

See also

Related Research Articles

<span class="mw-page-title-main">Sleep apnea</span> Disorder involving pauses in breathing during sleep

Sleep apnea is a sleep-related breathing disorder in which repetitive pauses in breathing, periods of shallow breathing, or collapse of the upper airway during sleep results in poor ventilation and sleep disruption. Each pause in breathing can last for a few seconds to a few minutes and occurs many times a night. A choking or snorting sound may occur as breathing resumes. Common symptoms include daytime sleepiness, snoring, and non restorative sleep despite adequate sleep time. Because the disorder disrupts normal sleep, those affected may experience sleepiness or feel tired during the day. It is often a chronic condition.

<span class="mw-page-title-main">Snoring</span> Vibratory sound made while asleep

Snoring is the vibration of respiratory structures and the resulting sound due to obstructed air movement during breathing while sleeping. The sound may be soft or loud and unpleasant. Snoring during sleep may be a sign, or first alarm, of obstructive sleep apnea (OSA). Research suggests that snoring is one of the factors of sleep deprivation.

<span class="mw-page-title-main">Obesity hypoventilation syndrome</span> Condition in which severely overweight people fail to breathe rapidly or deeply enough

Obesity hypoventilation syndrome (OHS) is a condition in which severely overweight people fail to breathe rapidly or deeply enough, resulting in low oxygen levels and high blood carbon dioxide (CO2) levels. The syndrome is often associated with obstructive sleep apnea (OSA), which causes periods of absent or reduced breathing in sleep, resulting in many partial awakenings during the night and sleepiness during the day. The disease puts strain on the heart, which may lead to heart failure and leg swelling.

<span class="mw-page-title-main">Positive airway pressure</span> Mechanical ventilation in which airway pressure is always above atmospheric pressure

Positive airway pressure (PAP) is a mode of respiratory ventilation used in the treatment of sleep apnea. PAP ventilation is also commonly used for those who are critically ill in hospital with respiratory failure, in newborn infants (neonates), and for the prevention and treatment of atelectasis in patients with difficulty taking deep breaths. In these patients, PAP ventilation can prevent the need for tracheal intubation, or allow earlier extubation. Sometimes patients with neuromuscular diseases use this variety of ventilation as well. CPAP is an acronym for "continuous positive airway pressure", which was developed by Dr. George Gregory and colleagues in the neonatal intensive care unit at the University of California, San Francisco. A variation of the PAP system was developed by Professor Colin Sullivan at Royal Prince Alfred Hospital in Sydney, Australia, in 1981.

Upper airway resistance syndrome (UARS) is a sleep disorder characterized by the narrowing of the airway that can cause disruptions to sleep. The symptoms include unrefreshing sleep, fatigue, sleepiness, chronic insomnia, and difficulty concentrating. UARS can be diagnosed by polysomnograms capable of detecting Respiratory Effort-related Arousals. It can be treated with lifestyle changes, functional orthodontics, surgery, mandibular repositioning devices or CPAP therapy. UARS is considered a variant of sleep apnea, although some scientists and doctors believe it to be a distinct disorder.

<span class="mw-page-title-main">Mouthguard</span> Protective device for the teeth and gums to avoid injury to them

A mouthguard is a protective device for the mouth that covers the teeth and gums to prevent and reduce injury to the teeth, arches, lips and gums. An effective mouthguard is like a crash helmet for teeth and jaws. It also prevents the jaws coming together fully, thereby reducing the risk of jaw joint injuries and concussion. A mouthguard is most often used to prevent injury in contact sports, as a treatment for bruxism or TMD, or as part of certain dental procedures, such as tooth bleaching or sleep apnea treatment. Depending on the application, it may also be called a mouth protector, mouth piece, gumshield, gumguard, nightguard, occlusal splint, bite splint, or bite plane. The dentists who specialise in sports dentistry fabricate mouthguards.

<span class="mw-page-title-main">Polysomnography</span> Multi-parameter study of sleep and sleep disorders

Polysomnography (PSG) is a multi-parameter type of sleep study and a diagnostic tool in sleep medicine. The test result is called a polysomnogram, also abbreviated PSG. The name is derived from Greek and Latin roots: the Greek πολύς, the Latin somnus ("sleep"), and the Greek γράφειν.

<span class="mw-page-title-main">Non-invasive ventilation</span> Breathing support administered through a face mask

Non-invasive ventilation (NIV) is the use of breathing support administered through a face mask, nasal mask, or a helmet. Air, usually with added oxygen, is given through the mask under positive pressure; generally the amount of pressure is alternated depending on whether someone is breathing in or out. It is termed "non-invasive" because it is delivered with a mask that is tightly fitted to the face or around the head, but without a need for tracheal intubation. While there are similarities with regard to the interface, NIV is not the same as continuous positive airway pressure (CPAP), which applies a single level of positive airway pressure throughout the whole respiratory cycle; CPAP does not deliver ventilation but is occasionally used in conditions also treated with NIV.

<span class="mw-page-title-main">Obstructive sleep apnea</span> Sleeping and breathing disorder

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, which – in combination with disturbances in blood oxygenation – is thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime.

<span class="mw-page-title-main">Somnology</span> Scientific study of sleep

Somnology is the scientific study of sleep. It includes clinical study and treatment of sleep disorders and irregularities. Sleep medicine is a subset of somnology.

Oral myology is the field of study that involves the evaluation and treatment of the oral and facial musculature, including the muscles of the tongue, lips, cheeks, and jaw.

Hypopnea is overly shallow breathing or an abnormally low respiratory rate. Hypopnea is defined by some to be less severe than apnea, while other researchers have discovered hypopnea to have a "similar if not indistinguishable impact" on the negative outcomes of sleep breathing disorders. In sleep clinics, obstructive sleep apnea syndrome or obstructive sleep apnea–hypopnea syndrome is normally diagnosed based on the frequent presence of apneas and/or hypopneas rather than differentiating between the two phenomena. Hypopnea is typically defined by a decreased amount of air movement into the lungs and can cause oxygen levels in the blood to drop. It commonly is due to partial obstruction of the upper airway.

<span class="mw-page-title-main">Continuous positive airway pressure</span> Form of ventilator which applies mild air pressure continuously to keep airways open

Continuous positive airway pressure (CPAP) is a form of positive airway pressure (PAP) ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person. The application of positive pressure may be intended to prevent upper airway collapse, as occurs in obstructive sleep apnea, or to reduce the work of breathing in conditions such as acute decompensated heart failure. CPAP therapy is highly effective for managing obstructive sleep apnea. Compliance and acceptance of use of CPAP therapy can be a limiting factor, with 8% of people stopping use after the first night and 50% within the first year.

<span class="mw-page-title-main">Sleep medicine</span> Medical specialty devoted to the diagnosis and therapy of sleep disturbances and disorders

Sleep medicine is a medical specialty or subspecialty devoted to the diagnosis and therapy of sleep disturbances and disorders. From the middle of the 20th century, research has provided increasing knowledge of, and answered many questions about, sleep–wake functioning. The rapidly evolving field has become a recognized medical subspecialty in some countries. Dental sleep medicine also qualifies for board certification in some countries. Properly organized, minimum 12-month, postgraduate training programs are still being defined in the United States. In some countries, the sleep researchers and the physicians who treat patients may be the same people.

<span class="mw-page-title-main">Catathrenia</span> Sleep-related breathing disorder

Catathrenia or nocturnal groaning is a sleep-related breathing disorder, consisting of end-inspiratory apnea and expiratory groaning during sleep. It describes a rare condition characterized by monotonous, irregular groans while sleeping. Catathrenia begins with a deep inspiration. The person with catathrenia holds his or her breath against a closed glottis, similar to the Valsalva maneuver. Expiration can be slow and accompanied by sound caused by vibration of the vocal cords or a simple rapid exhalation. Despite a slower breathing rate, no oxygen desaturation usually occurs. The moaning sound is usually not noticed by the person producing the sound, but it can be extremely disturbing to sleep partners. It appears more often during expiration REM sleep than in NREM sleep.

Nasal expiratory positive airway pressure is a treatment for obstructive sleep apnea (OSA) and snoring.

A sleep-related breathing disorder is a sleep disorder in which abnormalities in breathing occur during sleep that may or may not be present while awake. According to the International Classification of Sleep Disorders, sleep-related breathing disorders are classified as follows:

Sleep surgery is a surgery performed to treat sleep disordered breathing. Sleep disordered breathing is a spectrum of disorders that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea. These surgeries are performed by surgeons trained in otolaryngology, oral maxillofacial surgery, and craniofacial surgery.

Hyoid suspension, also known as hyoid myotomy and suspension or hyoid advancement, is a surgical procedure or sleep surgery in which the hyoid bone and its muscle attachments to the tongue and airway are pulled forward with the aim of increasing airway size and improving airway stability in the retrolingual and hypopharyngeal airway. The horseshoe shaped hyoid bone sits directly below the base of tongue with the arms of the bone flanking the airway. Hyoid suspension is typically performed as a treatment for obstructive sleep apnea (OSA). This procedure is frequently performed with a uvulopalatopharyngoplasty (UPPP) which targets sites of obstruction higher in the airway. Typically, a hyoid suspension is considered successful when the patient's apnea-hypopnea index is significantly reduced after surgery.

Oral pressure therapy (OPT) is a treatment for obstructive sleep apnea (OSA) that uses negative pressure in the mouth to shift the soft palate and tongue forward. The negative pressure is created by a bedside console connected by a small tube to a mouthpiece worn inside the mouth during sleep. The device is successful in between a quarter and a third of people.

References

  1. 1 2 Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD (July 2015). "Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015". J Clin Sleep Med. 11 (7): 773–827. doi:10.5664/jcsm.4858. PMC   4481062 . PMID   26094920.
  2. ↑ Vanderveken, Olivier M.; Devolder, Annick; Marklund, Marie; Boudewyns, An N.; Braem, Marc J.; Okkerse, Walter; Verbraecken, Johan A.; Franklin, Karl A.; De Backer, Wilfried A. (2008-07-15). "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. doi:10.1164/rccm.200701-114OC. ISSN   1073-449X. PMID   17673699.
  3. ↑ Rose E. (2004). "Identifying the Ideal Oral Appliance Candidate". Journal of Orofacial Orthopedics. 65: 6.
  4. 1 2 Chan AS, Lee RW, Cistulli PA (August 2007). "Dental appliance treatment for obstructive sleep apnea". Chest. 132 (2): 693–9. CiteSeerX   10.1.1.675.8333 . doi:10.1378/chest.06-2038. PMID   17699143.
  5. ↑ Zeng B, Ng AT, Qian J, Petocz P, Darendeliler MA, Cistulli PA (2008). "Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea". Sleep . 31 (4): 543–547. doi:10.1093/sleep/31.4.543. PMC   2279749 . PMID   18457242.
  6. ↑ Haviv Y, Bachar G, Aframian DJ, Almoznino G, Michaeli E, Benoliel R (April 2015). "A 2-year mean follow-up of oral appliance therapy for severe obstructive sleep apnea: a cohort study". Oral Dis. 21 (3): 386–92. doi:10.1111/odi.12291. PMID   25207802.
  7. ↑ Bratton DJ, Gaisl T, Wons AM, Kohler M (December 2015). "CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-analysis". JAMA. 314 (21): 2280–93. doi: 10.1001/jama.2015.16303 . PMID   26624827.
  8. ↑ Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ, Marks GB, Cistulli PA (April 2013). "Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial". Am. J. Respir. Crit. Care Med. 187 (8): 879–87. doi:10.1164/rccm.201212-2223OC. PMID   23413266.
  9. ↑ Barnes M, McEvoy RD, Banks S, Tarquinio N, Murray CG, Vowles N, Pierce RJ (September 2004). "Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea". Am. J. Respir. Crit. Care Med. 170 (6): 656–64. doi:10.1164/rccm.200311-1571OC. PMID   15201136.
  10. ↑ de Almeida FR, Lowe AA, Tsuiki S, Otsuka R, Wong M, Fastlicht S, Ryan F (April 2005). "Long-term compliance and side effects of oral appliances used for the treatment of snoring and obstructive sleep apnea syndrome". J Clin Sleep Med. 1 (2): 143–52. doi: 10.5664/jcsm.8978 . ISSN   1550-9389. PMID   17561628.
  11. ↑ Pantin CC, Hillman DR, Tennant M (March 1999). "Dental side effects of an oral device to treat snoring and obstructive sleep apnea". Sleep. 22 (2): 237–40. doi: 10.1093/sleep/22.2.237 . ISSN   1550-9109. PMID   10201069.
  12. ↑ Martínez-Gomis J, Willaert E, Nogues L, Pascual M, Somoza M, Monasterio C (January 2010). "Five years of sleep apnea treatment with a mandibular advancement device. Side effects and technical complications". Angle Orthod. 80 (1): 30–6. doi:10.2319/030309-122.1. hdl: 2445/20727 . ISSN   0003-3219. PMC   8978723 . PMID   19852636.
  13. ↑ Glos M, Penzel T, Schoebel C, Nitzsche GR, Zimmermann S, Rudolph C, Blau A, Baumann G, Jost-Brinkmann PG, Rautengarten S, Meier JC, Peroz I, Fietze I (May 2016). "Comparison of effects of OSA treatment by MAD and by CPAP on cardiac autonomic function during daytime". Sleep Breath. 20 (2): 635–46. doi:10.1007/s11325-015-1265-0. PMC   4850173 . PMID   26463420.
  14. ↑ "Managing a Sleep Disorder Long-Term: Will Insurance Cover Your Expenses?". Health.com. Retrieved 28 June 2016.
  15. ↑ Woolston, Chris (2011-02-28). "Over-the-counter devices probably won't help sleep apnea". Los Angeles Times. ISSN   0458-3035 . Retrieved 2016-08-06.
  16. ↑ Haviv Y, Zini A, Almoznino G, Keshet N, Sharav Y, Aframian DJ (July 2017). "Assessment of interfering factors in non-adherence to oral appliance therapy in severe sleep apnea". Oral Dis. 23 (5): 629–635. doi:10.1111/odi.12633. PMID   28054437.
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