Predictors of Success in the Treatment of Obstructive Sleep Apnea
                    Syndrome with Mandibular Repositioning Appliance: A Systematic
                    Review

Saffer, Fernanda; Lubianca Neto, José Faibes; Rösing, Cassiano; Dias, Caroline; Closs, Luciane

doi:10.1055/s-0034-1393957

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International Archives of Otorhinolaryngology

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Systematic Reviews • Int. Arch. Otorhinolaryngol. 19 (1) • Jan-Mar 2015 • https://doi.org/10.1055/s-0034-1393957 copy

Predictors of Success in the Treatment of Obstructive Sleep Apnea Syndrome with Mandibular Repositioning Appliance: A Systematic Review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction

Obstructive sleep apnea syndrome affects up to 4% of middle-aged men and 2% of adult women. It is associated with obesity.

Objective

The objective of this article is to review the literature to determine which factors best correlate with treatment success in patients with obstructive sleep apnea syndrome treated with a mandibular repositioning appliance.

Data Synthesis

A search was performed of the PubMed, Cochrane, Lilacs, Scielo, and Web of Science databases of articles published from January 1988 to January 2012. Two review authors independently collected data and assessed trial quality. Sixty-nine articles were selected from PubMed and 1 from Cochrane library. Of these, 42 were excluded based on the title and abstract, and 27 were retrieved for complete reading. A total of 13 articles and 1 systematic review were considered eligible for further review and inclusion in this study: 6 studies evaluated anthropomorphic and physiologic factors, 3 articles addressed cephalometric and anatomic factors, and 4 studies evaluated variables related to mandibular repositioning appliance design and activation. All the studies evaluated had low to moderate methodologic quality and were not able to support evidence on prediction of treatment success.

Conclusion

Based on this systematic review on obstructive sleep apnea syndrome treatment, it remains unclear which predictive factors can be used with confidence to select patients suitable for treatment with a mandibular repositioning appliance.

systematic review; sleep apnea syndrome; obstructive sleep apnea syndrome

Author	Defined treatment success
Barnes et al¹⁷17 Barnes M, McEvoy RD, Banks S, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 2004;170(6):656-664	Mild to moderate disease severity. In patients with mild to moderate OSAS, authors found that CPAP and MRA effectively treated sleep-disorder breathing and sleepiness; however, the expected response in neurobehavioral function was incomplete. This may be due to MRA having a lesser therapeutic effect and CPAP being poorly tolerated (used less in this patient group).
Engelman et al¹⁸18 Engleman HM, McDonald JP, Graham D, et al. Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Am J Respir Crit Care Med 2002;166(6): 855-859	Mixed disease severity. Objective sleepiness, cognitive performance, and preference for treatment were not different. In patients treated with CPAP versus MRA experiencing a mild form of the syndrome (AHI < 15, n = 18), symptoms, treatment efficacy satisfaction, and subjective sleepiness were better with CPAP than MRA. These results do not support the MRA as first-line treatment for patients with OSAS.
Hoekema et al¹⁹19 Hoekema A, Stegenga B, Wijkstra PJ, van der Hoeven JH, Meinesz AF, de Bont LGM. Obstructive sleep apnea therapy. J Dent Res 2008; 87(9):882-887	Mixed disease severity. MRA therapy was less effective in individuals with severe disease (AHI > 30). Because these patients could be at particular risk for cardiovascular disease, primary MRA therapy appears to be supported only for those with nonsevere apnea.
Metha et al²⁰20 Mehta A, Qian J, Petocz P, Darendeliler MA, Cistulli PA. A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med 2001;163(6): 1457-1461	Mixed disease severity. MRA used in this study was well tolerated, at least in the short term, and was associated with substantial subjective and objective improvements in a significant proportion of patients. These results support the use of MRA even in some of the patients with more severe forms of OSAS.
Tan et al²¹21 Tan YK, L'Estrange PR, Luo Y-M, et al. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial. Eur J Orthod 2002;24(3):239-249	Mild to moderate disease severity. (1) MRA may be a suitable alternative to nasal CPAP in patients with mild to moderate OSAS; (2) larger studies on the long-term efficacy of the MRA will be required before MRA can be offered as definitive alternative to nasal CPAP; (3) MRAs were well tolerated and preferred by the majority of patients.
Wilhemson et al²²22 Wilhelmsson B, Tegelberg A, Walker-Engström ML, et al. A prospective randomized study of a dental appliance compared with uvulopalatopharyngoplasty in the treatment of obstructive sleep apnoea. Acta Otolaryngol 1999;119(4):503-509	Mild to moderate disease severity. Findings suggest that the MRA is useful in the treatment of mild to moderate OSAS.

Factors related to MRA only		Anthropometric and physiologic factors and MRA		Cochrane Systematic Review
Author	Description	Author	Description	Author	Description
Araab et al²³23 Aarab G, Lobbezoo F, Hamburger HL, Naeije M. Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial. Respiration 2011;81(5):411-419	In patients with mild to moderate condition titratable during PSG, the authors found no differences in excessive daytime sleepiness improvements (MRA x nCPAP). This would indicate that the larger improvements in AHI in the nCPAP group are not clinically relevant. nCPAP patients may show more problems in accepting nCPAP than MRA patients.	Gagnodoaux et al²⁶26 Gagnadoux F, Fleury B, Vielle B, et al. Titrated mandibular advancement versus positive airway pressure for sleep apnoea. Eur Respir J 2009;34(4):914-920	Titrated MRA is an effective therapy in moderately sleepy and overweight patients with OSAS. Although less effective than CPAP, successfully titrated MRA was very effective at reducing the AHI and was associated with a higher reported compliance. Both treatments improved functional outcomes to a similar degree. One night of titration of MRA had a low negative predictive value for treatment success.	Lim et al⁵5 Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep apnoea. Cochrane Database Syst Rev 2006;(1): CD004435	The review found 16 studies that met the inclusion criteria, comparing treatment with oral appliances. The authors suggest that future research should recruit patient with more severe symptoms, to establish whether the response to therapy differs between subgroups.
Araab et al²⁴24 Aarab G, Lobbezoo F, Heymans MW, Hamburger HL, Naeije M. Long-term follow-up of a randomized controlled trial of oral appliance therapy in obstructive sleep apnea. Respiration 2011; 82(2):162-168	No clinically relevant difference was found between MRA and nCPAP in the treatment of mild/moderate OSA when both treatment modalities are titrated objectively;	Petri et al²⁷27 Petri N, Svanholt P, Solow B, Wildschiødtz G, Winkel P. Mandibular advancement appliance for obstructive sleep apnoea: results of a randomised placebo controlled trial using parallel group design. J Sleep Res 2008;17(2):221-229	MRA had significantly beneficial effects on OSA, including cure in some cases of severe OSA. Protrusion of the mandible is essential for the effect. MRA had no placebo effect and may be a good alternative to CPAP.
Pitsis et al²⁵25 Pitsis AJ, Darendeliler MA, Gotsopoulos H, Petocz P, Cistulli PA. Effect of vertical dimension on efficacy of oral appliance therapy in obstructive sleep apnea. Am J Respir Crit Care Med 2002;166(6): 860-864	The amount of bite opening induced by MRA does not have a significant impact on treatment efficacy but does have an impact on patient acceptance.	Tegelberg et al²⁸28 Tegelberg A,Walker-EngströmML, Vestling O, Wilhelmsson B. Two different degrees of mandibular advancement with a dental appliance in treatment of patients with mild to moderate obstructive sleep apnea. Acta Odontol Scand 2003;61(6):356-362	MRA recommended for patients of mild to moderate OSAS but recommended to not start the treatment by more than 50% of mandibular advancement.
		Walker-Engstron et al²⁹29 Walker-Engström ML, Ringqvist I, Vestling O, Wilhelmsson B, Tegelberg A. A prospective randomized study comparing two different degrees of mandibular advancement with a dental appliance in treatment of severe obstructive sleep apnea. Sleep Breath 2003;7(3):119-130	MRA could be an alternative treatment for some patients with severe OSAS.

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[1] Address for correspondence Caroline Dias, Department of Orthodontics, School of Dentistry, ULBRA, Av. Farroupilha, 8001, Canoas 92425-900, Brazil (e-mail: carolinedias@terra.com.br).