Long-term oral appliance therapy in obstructive sleep apnea syndrome: a controlled study on dental side effects Dental and occlusal changes during mandibular advancement splint therapy in sleep disordered patients. Effects and adverse events of a dental appliance for treatment of obstructive sleep apnoea. Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up. Dental and skeletal changes after 4 years of obstructive sleep apnea treatment with a mandibular advancement device: a prospective, randomized study. Long-term oral appliance therapy in obstructive sleep apnea syndrome: a controlled study on temporomandibular side effects Long-term oral-appliance therapy in obstructive sleep apnea: a cephalometric study of craniofacial changes.
Objectives This study aim ed to assess possible dental side effects associated with long-term use of an adjustable oral appliance compared with continuous positive airway pressure ( CPAP ) in patients with the obstructive sleep apnea syndrome and to study the relationship between these possible side effects and the degree of m and ibular protrusion associated with oral appliance therapy . Material s and methods As part of a previously conducted RCT , 51 patients were r and omized to oral appliance therapy and 52 patients to CPAP therapy .  At baseline and after a 2-year follow-up , dental plaster study models in full occlusion were obtained which were thereupon analyzed with respect to relevant variables . Results Long-term use of an oral appliance result ed in small but significant dental changes compared with CPAP . In the oral appliance group , overbite and overjet decreased 1.2 ( ±1.1 ) mm and 1.5 ( ±1.5 ) mm , respectively . Furthermore , we found a significantly larger anterior – posterior change in the occlusion ( −1.3 ± 1.5 mm ) in the oral appliance group compared to the CPAP group ( −0.1 ± 0.6 mm ) . Moreover , both groups showed a significant decrease in number of occlusal contact points in the (pre)molar region . Linear regression analysis revealed that the decrease in overbite was associated with the mean m and ibular protrusion during follow-up [ regression coefficient ( β ) = −0.02 , 95 % confidence interval ( −0.04 to −0.00 ) ] . Conclusions Oral appliance therapy should be considered as a lifelong treatment , and there is a risk of dental side effects to occur . Clinical relevance Patients treated with the oral appliance need a thorough follow-up by a dentist or dental-specialist experienced in the field of dental sleep medicine The aims of this longitudinal , observational study were two-fold : first , to determine in adults with sleep disorders the extent of dental and occlusal changes following the use of a m and ibular advancement splint ( MAS ) and , second , to determine the time course of these changes . One hundred adult subjects ( 87 males , 13 females ) diagnosed with obstructive sleep apnoea ( OSA ) and /or asymptomatic snoring were treated with non-adjustable MAS . At the outset each subject was r and omly assigned to a group and review ed 6 , 12 , 18 , 24 or 30 months after placement of a splint . There were 20 subjects in each group . Craniofacial changes were measured on lateral cephalometric radiographs taken at the initial and review appointments . When the changes in all subjects were examined , the SNA , ANB angles , ANS-PNS length and face height increased , and the m and ibular first molars and the maxillary first premolars significantly overerupted . Significant retroclination of the maxillary incisors and proclination of the m and ibular incisors were accompanied by reductions in maxillary arch length , overbite and overjet . When the changes over time were determined , the m and ibular symphysis was significantly lower at all review periods . An increase in face height and reductions in overbite and overjet were evident at 6 months , and over-eruption of the maxillary first premolars and m and ibular first molars , and proclination of the lower incisors were found at 24 months . Significant positive correlations were also found between the amount of anterior opening by the appliances and changes in overbite at 24 and 30 months . The appliance used produced small , unpredictable changes in the occlusion that tended to occur after 24 months ' wear . It is postulated that the changes in overbite might be lessened by keeping the bite opening to a minimum In a prospect i ve study , 95 patients with mild to moderate obstructive sleep apnoea ( OSA ) were r and omised to receive either surgical treatment , uvulopalatopharyngoplasty , ( 4 - 6 patients ) or treatment with a nocturnal dental appliance for m and ibular advancement  ( 49 patients ) . Of the 49 dental appliance patients , 37 completed the 12-month follow-up . The aim of this study was to evaluate the effects and adverse events of dental appliance treatment from a one-year perspective . Somnography was employed to measure treatment effects before and 12 months post-treatment . At the 12-month control , somnography was performed twice : the first time with the dental appliance and the second time without it . Adverse events were recorded 2 weeks and 3 , 6 , and 12 months after treatment was initiated . The patients used the dental appliance on average 6 nights/week . After 12 months of treatment , the apnoea , apnoea/hypopnoea , oxygen desaturation , and snoring indices decreased significantly . Ninety-five per cent of the patients reduced their apnoea index by > or = 50 % and 78 % of the patients were normalised following treatment . At the somnographic registration without the dental appliance , the values were found comparable to what they were before treatment . M and ibular mobility and occlusion were constant throughout the study . The adverse events result ing from using the dental appliance were relatively minor and infrequent , and no serious complications were observed except for two patients who reported pain from the temporom and ibular joint . In conclusion , the dental appliance has been shown to be a valuable treatment method for mild to moderate OSA with few adverse events in the stomatognathic system or other complications STUDY OBJECTIVES Oral appliance therapy has emerged as an important alternative to continuous positive airway pressure ( CPAP ) in treating patients with obstructive sleep apnea syndrome ( OSAS ) . In this study we report about the subjective and objective treatment outcome of oral appliance therapy and CPAP in patients with OSAS . DESIGN Cohort study of a previously conducted r and omized clinical trial . SETTING University Medical Center , Groningen , The Netherl and s. PATIENTS OR PARTICIPANTS One hundred three patients with OSAS . INTERVENTIONS CPAP and oral appliance therapy ( Thornton Adjustable Positioner type-1 , Airway Management , Inc. , Dallas , TX , USA ) . MEASUREMENTS AND RESULTS Objective ( polysomnography ) and subjective ( Epworth Sleepiness Scale , Functional Outcomes of Sleep Question naire , Medical Outcomes Study 36-item Short Form Health Survey [ SF-36 ] ) parameters were assessed after 1 and 2 years of treatment . Treatment was considered successful when the apnea-hypopnea index ( AHI ) was < 5 or showed substantial reduction , defined as reduction in the index of at least 50 % from the baseline value to a value of < 20 in a patient without OSAS symptoms while undergoing therapy . Regarding the proportions of successful treatments , no significant difference was found between oral appliance therapy and CPAP in treating mild to severe OSAS in a 2-year follow-up . More patients ( not significant ) dropped out under oral appliance therapy ( 47 % ) compared with CPAP ( 33 % ) . Both therapies showed substantial improvements in polysomnographic and neurobehavioral outcomes . However , CPAP was more effective in lowering the AHI and showed higher oxyhemoglobin saturation levels compared to oral appliance therapy ( P < 0.05 ) . CONCLUSIONS Oral appliance therapy should be considered as a viable treatment alternative to continuous positive airway pressure ( CPAP ) in patients with mild to moderate obstructive sleep apnea syndrome ( OSAS ) . In patients with severe OSAS , CPAP remains the treatment of first choice . CLINICAL TRIAL INFORMATION The original r and omized clinical trial , of which this study is a 2-year follow-up , is registered at IS RCT N.org ; identifier : IS RCT N18174167 ; trial name : Management of the obstructive sleep apnea-hypopnea syndrome : oral appliance versus continuous positive airway pressure therapy ; URL : http://www.controlled-trials.com/IS RCT N18174167 The aim of this prospect i ve , r and omized study was to analyze dental and skeletal side effects after 4 years of treating obstructive sleep apnea ( OSA ) patients with a m and ibular advancement device ( MAD ) compared with uvulopalatopharyngoplasty ( UPPP ) . With the appliance in position , the m and ible was advanced 50 % of maximum protrusion capacity ( ie , 4 - 6 mm ) ; the vertical opening between the incisal edges was , on average , 3 mm . Thirty patients in the MAD group and 37 in the UPPP group completed the 4-year follow-up . There were no differences between the MAD and the UPPP groups in any of the dental or skeletal variables measured after the 4-year treatment period . In the MAD group , small but statistically significant changes were found : there was a posterior rotation of the m and ible ( m and ibular line [ML]/nasion-sella line [ NSL ] ) ( mean 0.5 degrees [ 95 % confidence interval ( CI ) 0.1 - 0.8 degrees ] ) . Correlated to the posterior rotation of the m and ible , the distances incision superius ML , incision superius-NSL , and incision inferius-NSL increased by means ( 95 % CI ) of 0.7 ( 0.5 - 1.2 ) , 0.8 ( 0.4 - 1.1 ) , and 1.3 ( 0.8 - 1.8 ) mm , respectively . Overjet and overbite did not change significantly , nor was there a significant change in the m and ibular length . The observed changes were considered clinical ly insignificant because overbite and overjet stayed within normal limits . Only the vertical position of the maxillary incisors in relation to ML changed to the extent that the 95 % CI of the mean for the change was outside that of the mean of the change in the UPPP group and measurement error . Treatment of OSA with a dental appliance is probably a lifelong process , and long-term follow-up studies should therefore be undertaken to control both the treatment effect on OSA and the side effects on the masticatory system The objective of this study was to assess variations in the occurrence of temporom and ibular disorders ( TMDs ) and the risk of developing pain and function impairment of the temporom and ibular complex in obstructive sleep apnea syndrome ( OSAS ) patients treated with either an oral appliance ( m and ibular advancement device )  or continuous positive airway pressure ( CPAP )  in a 2-year follow-up study . In addition , we assessed the relationship between the mean m and ibular protrusion and the frequency of wearing the appliance during follow-up with the occurrence of pain and function impairment of the temporom and ibular complex . Fifty-one patients were r and omized to oral appliance therapy and 52 patients to CPAP therapy .  TMDs ( diagnosed according to the Axis I Research Diagnostic Criteria for TMD ) , pain intensity and disability and m and ibular function impairment were recorded at baseline , after 2 months , 1 year and 2 years of therapy . Only in the initial period of treatment the occurrence of pain-related TMDs was considerably higher ( 24 % ) in the oral appliance group compared to CPAP ( 6 % ) . Oral appliance therapy furthermore result ed in more temporom and ibular pain compared to CPAP ( odds ratio 2.33 , 95 % confidence interval ( 1.22–4.43 ) ) . However , there were no limitations in m and ibular function in both groups during the ( entire ) follow-up period . Although generally not serious and of transient nature , oral appliance therapy results in more pain-related TMDs in the initial period of use compared with CPAP therapy . Oral appliance therapy is associated with increased pain in the temporom and ibular complex in the initial period of use . Because of the transient nature , this pain is not a reason to contra-indicate an oral appliance in OSAS patients . Moreover , TMDs and the risk of developing pain and function impairment of the temporom and ibular complex appear limited with long-term oral appliance use OBJECTIVES The aim of this r and omized controlled study was to cephalometrically assess possible changes in craniofacial morphology associated with long-term use of an adjustable oral-appliance compared with continuous positive airway pressure ( CPAP ) in patients with the obstructive sleep apnea/hypopnea syndrome ( OSAHS ) . In addition , we wanted to study the relationship between these possible changes and the degree of m and ibular protrusion associated with oral-appliance therapy . METHODS Fifty-one patients were r and omized to oral-appliance therapy and 52 patients to CPAP therapy .  At baseline and after follow-up ( 2.3±0.2 years ) , a lateral cephalogram of all patients was made in maximum intercuspation to determine relevant cephalometric variables . Both baseline and follow-up cephalograms were traced digitally whereupon cephalometric variables were compared . Changes in craniofacial morphology between the oral-appliance- and CPAP group were evaluated with a linear regression analysis . RESULTS Compared with CPAP , long-term use of an oral-appliance result ed in small but significant ( dental ) changes . Overbite and overjet decreased , 1.0 (±1.5)mm and 1.7 (±1.6)mm , respectively . Furthermore we found a retroclination ( -2.0 ( ±2.8 ) ° ) of the upper incisors and a proclination ( 3.7 ( ±5.4 ) ° ) of the lower incisors . Moreover , the lower- and total anterior facial height increased significantly , 0.8 (±1.5)mm and 0.9 (±1.4)mm , respectively . No changes in skeletal variables were found . Linear regression analysis revealed that the decrease in overbite was associated with the mean m and ibular protrusion during follow-up ( B=-0.029 , SE=0.014 , p<0.05 ) . CONCLUSIONS Oral-appliance therapy should be considered as a life long treatment , and there is a risk of craniofacial changes to occur . Therefore , patients treated with an oral-appliance , need a thorough follow-up by a dentist or dental-specialist experienced in the field of dental sleep medicine
ABSTRACT Introduction : Occlusal side effects or development of pain and /or functional impairment of the temporom and ibular complex are potential reasons for poor compliance or ab and onment of m and ibular advancement splints treatment for snoring and obstructive sleep apnea .
Objective : This study aim ed at providing a comprehensive review evaluating the craniofacial side effects of oral appliance therapy for snoring and obstructive sleep apnea .