An update on mandibular advancement devices for the treatment of obstructive sleep apnoea hypopnoea syndrome

Abstract

Continuous positive airway pressure (CPAP) remains the gold standard treatment for obstructive sleep apnoea hypopnoea syndrome (OSAHS). However, the high efficacy of CPAP is offset by intolerance and poor compliance, which can undermine effectiveness. This means that alternatives to CPAP are also necessary. In recent years, oral appliances have emerged as the leading alternative to CPAP. There is now a strong body of evidence supporting their use in OSAHS and clinical guidelines now recommend their use in mild OSAHS and in more severe cases when CPAP fails. These devices are by no means a homogenous group as they differ greatly in both design and action. The most commonly used appliances are mandibular advancement devices (MAD) that increase airway diameter with soft tissue displacement achieved by mandibular protrusion. Despite the growing evidence, there are still barriers to MAD provision. Their effectiveness can be difficult to predict and there is debate about the required level of design sophistication. These uncertainties prevent more widespread inclusion of MAD within clinical sleep services. This review will focus on the efficacy, effectiveness, design features, side-effects of and patient selection for MAD therapy. Comparison will also be made between MAD and CPAP therapy.

Keywords: Obstructive sleep apnoea; mandibular advancement devices (MAD); oral appliances; sleep apnoea.

Figure 1

Graph showing results from papers since 2005 that studied the effect of bespoke mandibular advancement devices on AHI. Complete resolution of OSAHS: AHI <5; partial resolution: ≥50% reduction in AHI. OSAHS, obstructive sleep apnoea hypopnoea syndrome; AHI, apnoea-hypopnoea index.

Figure 2

Examples of mandibular advancement devices. (A) “Boil and bite” device (SleepPro Easifit); (B) typical appearance of a monobloc appliance; (C) example of an adjustable bespoke device (SomnoDent Classic).

Figure 3

Diagrammatic representation of potential incisal side effects. Upper incisors may rotate palatally (retroclination) whilst lower incisors may rotate labially (proclination). A, overjet; B, overbite. Both overjet and overbite may decrease with MAD therapy. MAD, mandibular advancement devices.