
2Prosthodontist & Oral Implantologist, Chairman of Dental center, King Fahd General Hospital, KSA, Director of Dental services MOH
3Assistant Professor of Restorative Dentistry, Al-Farabi Dental College, Consultant of Restorative Dentistry, KSA
OSA is caused by repeated airway obstruction during sleep as a result of narrowing of the respiratory passages [15-17]. This narrowing is often attributed to obesity and anatomical alteration. Over two-thirds of the patients with OSA are most often overweight. Generally, obesity is also associated with larger neck size. If an individual’s neck circumference is greater than 42.5 cm, the chance of apnea increases significantly [16-18]. Craniofacial as well as maxillofacial anomalies can also play an important role in OSA cases. These anatomical alterations include deviated nasal septum, enlarged nasal turbinate, increased size of soft palate and uvula, and bi-maxillary or mandibular retrognathism [16,17]. Micrognathia, acromegaly, and Down's syndrome may also be predisposing conditions [17]. Smoking is a detrimental factor to the physiology of the upper airways. The repeated use of an irritant such as smoking can significantly reduce the patency of the upper airway due to the irritation-inflammation-edema cycle [18]. The role of the genioglossus muscle in the pathogenesis of OSA has also been recently emphasized [19,20]. Decreased tone of this muscle during sleep as well as the pull of gravity in the supine position, further decrease airway size, and significantly contribute to airway obstruction [21].
OSA can be managed by both surgical and non surgical methods. The conservative approaches to treatment include behavioural modification (weight loss, altered sleeping position, reduction in smoking and alcohol consumption), the use nasal continuous positive airway pressure (CPAP), medication, and/or oral devices [22]. It has been postulated that a 50% improvement in the apneic hypopneic index (AHI) or an AHI less than 10 indicates a treatment success [23,24]. Surgical treatment of snoring alone is much easier although there are no guarantees that they work for all or last forever. Several surgical procedures are available to correct the upper airway collapsibility with questionable prognosis. These include, nasal surgeries, such as septoplasty and inferior turbinate resection, uvulopalatopharyngoplasty, Laser-assisted uvuloplasty, Mandibular distraction osteogenesis, and tracheostomy [25-30]. Since 1981, continuous positive airway pressure (CPAP) has been the most commonly prescribed nonsurgical method of treatment for obstructive sleep apnea. CPAP treatment is considered the most effective method to manage obstructive sleep apnea. The most significant effect is enlargement of the airway by dimensional changes of the lateral pharyngeal walls. In addition to structural changes, CPAP augments the tone of the upper airway dilator muscles thereby reducing susceptibility to collapse. Despite of its great efficacy it requires the use of a mask interface, sealed tubing, and a device connected to a power source. This complexity limits its acceptance by patients and leads to suboptimal treatment adherence [31-33].
Oral appliances for treatment of OSA was first described by a French physician called Pierre Robin in 1902. With his monobloc appliance, Robin treated children who suffered from breathing difficulties and glossoptosis due to mandibular hypoplasia. The classical form of an oral appliance that repositioned the mandible in an adult patient with OSA was not reported until 1980 [34]. Treatment of obstructive sleep apnea in dentate patients with oral appliances (OAs) is well documented, the objective of oral appliances is to advance the mandible and tongue base, increasing the space between the base of the tongue and the posterior pharyngeal wall. The tongue may also be advanced with the use of a tongue-retaining device. These appliances improve upper airway collapsibility during sleep. Subsequently assist in reducing the obstruction [35,36]. Prosthodontists have recently become one of the general team in the field of sleep medicine. However, it is very important that the dentist should not provide the primary care of the patient; instead he has to work through a medical team work. Most of the treatment options are medical in nature, the problem often ranges far beyond that of a dental condition, and it often requires multiple medical studies. Consequently, the role of dentist in treating that case should be linked to a team which include a thoracic physician, oral and maxillofacial surgeon ear, nose, and throat surgeon, restorative dentist, and an orthodontist. Therefore, it is imperative that the patient be referred to a physician for examination, appropriate studies, diagnosis, and course of treatment [37,38].
TRD was first described by Carwright and Samelson [41]. The TRD appliance is especially useful in patients who have macroglossia. Because the TRD does not depend in its retention on the presence of good healthy natural dentition, it is considered an effective alternate to mandibular advancement prostheses in edentulous patients or in patients with compromised dentition. Moreover, OSA patients who are not capable of advancing the mandible for whatever reason can use the TRD safely [42]. The TRD is a custom-made appliance with a flange which fits between lips and teeth and an anterior soft plastic bulb that by means of negative pressure holds the tongue forward during sleep [43]. For those patients with blocked nasal passages, a modified TRD with lateral airway tubes to permit mouth breathing is also available. However, the use of TRD poses many disadvantages as it forces the nasal breathing and it locks the jaw in a single position which is not usually tolerated by the patients [44]. The TRD appears useful either alone or in conjunction with other treatments to improve patients with a wide range of apnea severity provided that the apnea is more severe in the supine position and the patient’s weight is not greater than 50% above the ideal [38]. The effects of the TRD on baseline tongue muscle activity have been studied. Ono., et al. [45] found that the TRD has different effects on the awake genioglossus muscle activity in control subjects and OSA patients. In awake OSA patients, the TRD reduces genioglossus muscle activity and corrects the delayed timing of the muscle before an apneic period during sleep. The TRD may counteract fatigue in the tongue muscles and fluctuations in the activity of the genioglossus muscle. In addition, the TRD may provide a pneumatic splint to enlarge the upper airway similar to that seen with nasal CPAP [45].
In the last decade there has been an explosion of interest in using oral appliances especially the MRAsto treat OSA. The development of this prosthetic treatment option represents an important step in the management of this disease. They are generally appealing because they are simple to use, reversible, portable, and appear to be quite safe [46-48]. Randomized controlled clinical trials [49-51] have shown oral appliances to be an effective and well-established treatment option for patients with mild or moderate OSA and for patients with severe OSA who are unable to tolerate nasal CPAP. MRA is a removable dental prosthesis that creates a different, yet temporary, dental occlusal position that guides the mandible to close into a predetermined and altered position [52]. A great deal of studies have paid attention to the horizontal relation between the mandible and maxilla produced by the appliance and consequently, the optimum amount of mandibular protrusion required to achieve better results which was estimated to be approximately 60% of maximum protrusion [53]. However, the optimum vertical dimension of an oral appliance required to achieve a successful treatment outcome in patients with OSA has been an issue of debate. Some authors [54] believe that the vertical dimension should be determined according to the individual patient tolerance and acceptance. Others [55] believe that acceptable treatment outcome cannot be obtained without increasing the vertical dimension by the appliance. In a randomized, controlled crossover study, Bloch., et al. [56] compared two groups of patients who received oral appliances with identical amount of mandibular protrusion and different amount of vertical opening. The authors reported better improvement with the group of patients who received an oral appliance with greater amount of vertical opening. However, possible contributors to this result are the difference in the appliance design itself between the two groups since one group received a Herbst appliance while the other received a Monobloc fixed device. Furthermore, the results of this study may be also questionable because of the between-subject variability due to the parallel group study design. In another trial, Pitsis., et al. [57] tried to systematically evaluate two predetermined specific levels of mouth opening among patients who received the same oral appliance and with identical protrusion level. However, the evaluation parameters were not sufficient to draw a conclusive result. A more recent study [58] suggests that the fabrication of oral appliances used to treat the OSA should be made with the minimal vertical opening required to accommodate those appliances since increasing the vertical dimension does not markedly affect the treatment outcome.
Despite the effectiveness of surgical intervention in the treatment of some cases of OSA, there may be contraindications for such techniques as in medically unfit patients for general anaesthesia, and patient's refusal. Therefore attempts have been made to employ oral appliances alternatively. The aim of such modality is to advance the mandible and subsequently enlarges the antero-posterior diameter of the retro-glossal space thus reduces the pharyngeal collapsibility. Of particular interest in this context are the mandibular advancement prostheses, which are capable of advancing the lower jaw [38]. There are other possible mechanisms of oral appliances in reducing OSA. The forward jaw position is said to induce stretching and increased stiffness of the lateral pharyngeal walls and pillars. Movement of the tongue forward can also prevent any likelihood of seal forming between the tongue/soft palate/pharyngeal wall. Moreover stabilization of the mandible and hyoid bone prevent posterior rotation of the jaw and retro-lapse of the tongue during sleep. Eventually, the altered anatomic relationship induces a stretch-induced neurosensory stimulation that influences the motor tone and collapsibility of the airway [63,64]. Three dimensional imaging and (supine) cephalometric studies demonstrated that mandibular repositioning increases oropharyngeal, hypopharyngeal and velopharyngeal dimensions [65]. Endoscopic studies have demonstrated that mandibular advancement results in, particularly, an increased cross-section of the lateral dimension of the velopharynx [66].
Although side-effects are frequently reported with MRA therapy, these are usually mild and acceptable, with most symptoms subsiding when treatment is continued. Tenderness of the teeth and jaws, myofacial pain, gum irritation, excessive salivation, and xerostomia are commonly reported in the initial period of use. In exceptional cases, treatment may be complicated by involuntary removal of the device, an exaggerated gag reflex, periodontal damage, or fractured teeth and fillings [71]. It has been suggested that advancement of the mandible for considerable periods may have adverse effects on the stomatognathic system. Mild complaints of pain and strain of the masticatory muscles and the temporomandibular joint frequently occur at the initiation of treatment [72]. Some studies have observed an increase in bruxism in response to MRA therapy. In the long term, MRA treatment has been suggested to initiate or aggravate temporomandibular joint disease in individual patients [73]. A temporary bite change in the morning after removal of the appliance occurs in almost all patients. In individual cases, permanent occlusal alterations have been observed after long-term treatment periods [74].
The splint consists of maxillary and mandibular vacuum formed splints over which heat polymerized clear acrylic resin blocks were attached (vent holes in middle of acrylic resin blocks were placed). The blocks were attached together by auto-polymerizing acrylic resin [75]. This splint is fabricated to achieve protrusion of the mandible (75% of maximum protrusion) without increasing the vertical dimension of occlusion. Therefore, there is no difficulty in inserting and removing the splint from the mouth, and the patient does not find the splint formidable to wear. This assists in improving patient compliance. It is indicated in patients with well formed ridges. Adequate retention could be obtained by making a mandibular impression with a properly extended lingual flange [75].
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