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An Overview of Oral

Appliances and Managing the


Airway in Obstructive Sleep Apnea
Mimi Yow
The literature supporting the efficacy and use of oral appliances in the
management of obstructive sleep apnea (OSA) has grown enormously in the
last two decades. The data gleaned from the studies of many researchers
and practitioners have led to a better understanding of the role of oral
appliances in managing patients with OSA, their clinical effectiveness and
side effects, outcome predictors, tolerability and compliance formulated on
evidence-based outcomes. This article gives an overview on the use of oral
appliances in managing airway patency of pediatric and adult patients with
OSA. (Semin Orthod 2009;15:88-93.) 2009 Elsevier Inc. All rights reserved.

French stomatologist, Pierre Robin, first


used oral appliances in the early 1900s for
managing life-threatening upper airway obstruction in neonates born with the craniofacial disorder that was named after him. In addition to a cleft
palate and hypoplastic mandible, a Pierre Robin
patient has glossoptosis with risk of asphyxiation
from the tongue positioned posteroinferiorly in a
small oropharynx. Following the mechanical principles of managing airway obstructions, Pierre
Robin sequence patients are positioned prone,
with or without a monobloc appliance, a one-piece
acrylic oral appliance, to posture the mandible
forwards so that the tongue is protracted forwards
and away from occluding the oropharyngeal airway. Severe cases are managed surgically.1 Over
the years, mandibular advancement appliances
were developed for use as functional appliances in
the dentofacial orthopedic treatment of growing
children with hypoplastic and/or retrognathic
mandibles.2

Department of Orthodontics, National Dental Centre, Singapore.


Address correspondence to Mimi Yow, Department of Orthodontics, National Dental Centre, 5 Second Hospital Avenue, Singapore
168938. E-mail: mimi.yow@ndc.com.sg
2009 Elsevier Inc. All rights reserved.
1073-8746/09/1502-0$30.00/0
doi:10.1053/j.sodo.2009.01.006

88

Oral Appliances and Pediatric


Obstructive Sleep Apnea (OSA)
OSA in children has complex etiologies with multifactorial interplay between the neuromuscular
system, airway, and anatomical structures, which
result in partial or complete obstruction of the
upper airway. OSA is not graded in children. There
are no distinctions between mild, moderate, or
severe pediatric OSA. An apnea-hypopnea index
(AHI) of 1 or greater indicates OSA in children.
Input from several specialists is needed in the evaluation of children with OSA. The otolaryngologist,
orthodontist, neurologist, pediatrician, and sleep
technologist all play a part in diagnosing and identifying the causes for appropriate management.
Sleep breathing problems in children commonly
result from adenotonsillar hypertrophy. Neuromuscular conditions and/or craniofacial anomalies may compound the problem.3
Adenotonsillar hypertrophy frequently presenting in children at 2 to 8 years of age, and concomitant with certain craniofacial morphometrics, may
compromise the pediatric airway.4 Dentofacial
characteristics that are closely associated with
OSA in children include a narrow upper airway,
hypoplastic maxilla, a retrognathic mandible
with steep mandibular plane angle, narrow dental arches, high palatal vault, long soft palate,
and an increased lower anterior facial height.
Craniocervical angulation and lower anterior
face height are larger than norm in children

Seminars in Orthodontics, Vol 15, No 2 (June), 2009: pp 88-93

Oral Appliances and Managing the Airway in OSA

with OSA.5-8 The head tilts backwards at the atlas


to enlarge a structurally limited oropharynx at
the tongue base and epiglottis. This increases a
structurally limited airway. Adaptive changes in
head postures to overcome compromised upper
airways could influence facial growth and occlusal development in a growing child.9,10
Although there is a significant correlation between nasal airway resistance and cephalometric
measurements of the lower anterior facial height,
the influence on dentofacial morphology during
periods of active growth in children may vary according to different facial types. Children with nasal resistance and dolichocephalic facial patterns
are affected more so than brachycephalic children
with strong musculature. A change from nasal to
oral airway is likely when nasal resistance increases
to 2 to 3 times of the norm. Oral respiration leads to
lowering of the tongue and a downward, backward
rotation of the mandible. With an inferiorly positioned tongue, the lateral expansive forces of the
tongue on the palate are lost, and the unopposed
medial forces of the buccinator and masseter muscles lead to development of a narrow, high arched
palate and with posterior buccal crossbite. Retrognathic mandibles, vertical maxillary excess and
open bite malocclusions are common dentofacial
presentations of children with downward and
backward rotating mandibles.11
The basis of therapeutic intervention with
oral appliances in the obstructed pediatric airway is to expand the maxilla and/or advance the
mandible. The oral appliances are no different
from conventional removable orthodontic or
fixed functional appliances; the activator, bionator, Herbst appliance and protraction facemask
are some examples. The increased growth and
forward spatial development of the maxilla and
mandible create more room to accommodate
the tongue, thereby enlarging the retro-lingual
airway space. In patients with a narrow maxilla
and high arched palate, rapid palatal expansion
is ideal. Maxillary expansion increases lateral
arch dimensions, raises the soft palate and widens the nasal airway. The altered relationships of
the nasal floor, palate, tongue and pharyngeal
walls increase space for the tongue. Overall, pharyngeal space is enlarged to accommodate the
adenoids, tonsils and a patent upper airway.12
A short-term randomized controlled study on
non-obese children with OSA, ages 4 to 10 years,
fitted with customized oral appliances to ad-

89

vance the mandible and thereby repositioning


the tongue, reported that 50% of patients had
no respiratory events (AHI 0). The use of oral
appliances also reduced tonsillar hypertrophy in
almost 67% of patients compared with 14% of
children in the control group. Approximately 74%
of the children tolerated the oral appliance treatment well.13 Long-term studies are needed to show
if benefits from oral appliance wear are indeed
long-lasting for children with OSA.

Oral Appliances and OSA in Adults


There are no strict guidelines in the design of oral
appliances for OSA management in adults and
there is a plethora of them in use. There are
1-piece or 2-piece appliances made from soft elastomeric material or hard acrylic. In 2-piece appliances, there are many built-in mechanisms for
titratable mandibular advancement, latitude for temporomandibular joint movement, tongue protrusion, and lifting of the soft palate. Customized 1-piece
monobloc appliances or 2-piece mandibular advancement splints that are closely fitted to the teeth
are preferred to over-the-counter boil and bite thermoplastic splints. The boil and bite appliances are
not recommended to be used as a therapeutic option
or as a screening tool to determine patient-suitability
for mandibular advancement treatment.14

Evidence-Based Oral Appliance Therapy


Since the 1980s, oral appliances were used as a
primary treatment modality for adult patients with
OSA as well as an alternative approach for those
who cannot tolerate nasal continuous positive airway pressure (nCPAP). There has been a great
deal of research in this field and rigorous studies
conducted to determine patient selection, success
criteria, polysomnographic and patient-based outcomes, appliance effectiveness and tolerance of
oral appliance therapy. Two recent well-researched
systematic review articles analyzed a total of 103
studies. The data was pooled and analyzed to study
various parameters which supported evidencebased clinical practice in using oral appliances for
managing mild to moderate OSA.15,16

Mode of Action of Oral Appliance


Systematically reviewed data indicate a direct
relationship between the degree of mandibular

90

M. Yow

advancement and reduction in AHI, suggesting


that mechanical manipulation of airway size has
an effect on reducing apnea by enlarging the airway and/or improving the muscle tone. However,
evidence on tongue protrusion and its effects on
genioglossal tone are conflicting. Placebo studies
using oral appliances suggest that mandibular advancement in apneic patients does result in AHI
reduction and improvement in arterial oxygen saturation. Three-dimensional imaging and endoscopic studies have shown increased cross-sectional
dimensions of the hypo-, oro-, and velopharyngeal
areas with forward mandibular displacement.17
The soft palate, suprahyoid muscles and the genioglossus are displaced anteriorly together with mandibular advancement. Other than positional
changes, mandibular displacement also stretches
the palatoglossal and palatopharyngeal arches
which increases upper airway muscular activity.18

Efficacy of Oral Appliance Therapy


Criteria used for determining success vary in different studies in OSA treatment: AHI, arousal index, level of minimum arterial oxygen saturation
(SaO2) during sleep, multiple sleep latency test, sleep
architecture, maintenance of wakefulness test, and
blood pressure are some of the objective measures used. Snoring, the Epworth Sleepiness
Scale, quality-of-life measures and Functional Outcomes of Sleep Questionnaire (FOSQ) are subjective measures for patient-reported outcomes. Stringent measures of successful outcomes in adult
OSA management are reductions of AHI to less
than 5 events per hour and maintaining lowest
SaO2 at a level of 85% or more. Less stringent
standards equate a successful treatment outcome
with a 50% reduction of pretreatment AHI.
In the systematic reviews of data comparing oral
appliance therapy to nCPAP treatment, oral appliances were less effective than nCPAP in reducing
AHI and apnea index (AI) and in increasing SaO2.
There were no significant differences between
nCPAP and oral appliance therapy in outcomes for cognitive performances, maintenance of wakefulness tasks, or systolic/diastolic
nocturnal blood pressure during a 24-hour period.
A randomized placebo-controlled study reported a
modest reduction in night-time diastolic blood
pressure by 2.2 mm Hg with oral appliance use
over a 3-month period.19 The results suggest beneficial effects of oral appliances on blood pressure

and other cardiovascular outcomes, however, longterm evidence-based studies are required in this
respect. In a randomized controlled study, snoring
frequency and intensity reduced substantially;
snoring frequency reduced by 40 to 60% and
mean reduction of snoring intensity was 3 decibels.20

Factors in Oral
Appliance Therapy Success
Four factors are attributed to oral appliance effectiveness but the extent to which each factor is
involved is unclear: (1) mild to moderate OSA
severity (AHI 30), (2) large mandibular advancement, (3) supine AHI, and (4) low body
mass index (BMI). Patients with lower values in
baseline AHI and have greater supine than lateral AHI readings demonstrate better outcomes
with oral appliance use. Optimal AHI reductions
with oral appliances are variable in patients with
severe OSA (AHI 30). Fourteen-61% of severe
OSA cases compared with 57-81% of patients
with mild-to-moderate OSA were successfully
treated (AHI 5). There is no significant difference in efficacy with greater or lesser vertical mandibular opening in reducing AHI. Similarly, differences in efficacy of 1-piece or
2-piece mandibular advancement splints were
not demonstrated. A small proportion of patients developed increased AHI after shortterm (6 weeks) and long-term (4 years) use of
oral appliances.21,22 Follow-up sleep studies
are recommended to detect suboptimal reductions of AHI for OSA patients treated with oral
appliances.
Methods for determining treatment predictors and the effective amount of mandibular
advancement for optimal AHI reduction include
sleep nasoendoscopy and overnight polysomnographic titration with remote-controlled mandibular advancement of oral appliances. Sleep
nasoendoscopy identifies the level of and the degree
of obstruction when the patient is asleep. Obstructions are classified as palatal, multilevel, or tonguebased with a grading system: Grade 1palatal snoring; Grade 2palatal level obstruction; Grade
3multisegmental involvement with intermittent
oro- and hypopharyngeal collapse; Grade
4sustained multilevel collapse; and Grade
5tongue base obstruction. Patients with Grade 5 or
tongue base obstruction are likely to benefit from

Oral Appliances and Managing the Airway in OSA

oral appliance therapy.23 Remote-controlled titrations of mandibular advancement (average 11.4


2.4 mm) measured with respiratory events in overnight sleep studies proved promising in developing predictors with a positive predictive value of 90
and a negative predictive value of 89 (sensitivity
90 and specificity 89).24 Predictive cephalometric measurements, for successful or unsuccessful
oral appliance therapy outcomes, were conflicting
and nonconclusive.25,26

Comparison of Oral Appliance


with Other Treatment Modalities
To determine the relative effectiveness of different
OSA treatment modalities, the authors of crossover clinical studies have compared outcomes of
oral appliance treatment versus uvulopalatopharyngoplasty (UPPP) and oral appliance treatment
versus nCPAP in mild-to-moderately severe OSA
cases. Oral appliance treatment showed significant
effectiveness in reducing AHI against UPPP. Oral
appliances are useful in adjuvant treatment after
unsuccessful UPPP surgery. Subjective measures of
daytime sleepiness and quality of life initially favored the UPPP procedure over use of oral appliances for the short term. After 1 year of follow-up,
there was no significant difference in subjective
scores of patients with oral appliance treatment compared to UPPP.27,28 Pooled data of 6
clinical studies that compared oral appliance
and nCPAP treatment concluded that nCPAP
resulted in significantly better AHI reduction.
There was no significant difference in daytime
sleepiness between the oral appliance treatment
and nCPAP groups. There are conflicting polysomnographic outcomes for arousal index, oxygen
desaturation frequency and intensity between
treatment with oral appliance and nCPAP. The
advantage of nCPAP is an in-built AHI recorder for
self-monitoring. Oral appliance treatment, like
UPPP, requires follow-up sleep studies to determine long-term efficacy.29

Side Effects of Oral Appliances


Side effects are common and acute in the initial
phase of treatment. Transient pain of the upper
and lower incisors occurs in 33% of patients after
waking. Thirty-eight-50% of patients reported excessive salivation and 28-46% reported mouth dryness after oral appliance use. Twenty percent of

91

patients reported gingival soreness. Temporomandibular joint discomfort and noises were experienced by 12.5-33% of patients, and 12.5% reported headaches and bruxism.
Changes in occlusion are commonly reported
in the first few hours of waking. These changes are
transient and disappear with use. Long-term side
effects develop after 6 to 30 months of treatment
with oral appliances. Intraoral changes affect the
occlusion and positions of teeth: overjet and overbite reduced (mean 1-3 mm) with retroclination
of upper incisors (mean 1.9) and proclination
of lower incisors (mean 2.8).
Long-term users may experience dislodged or
fractured fillings, cracked or fractured teeth and
periodontal disease with mobile teeth. Skeletal
changes affect the mandible; it is relocated downwards and forwards, with increased lower anterior
face height. The occurrence of skeletal changes is
largely attributed to a greater mandibular advancement.30-33

Patient-Reported
Outcomes, Tolerance, and Compliance
In this study,19 it was reported that nCPAP and
oral appliance therapy as were effective in reducing subjective daytime sleepiness (EES). However,
there was no improvement in maintenance of
wakefulness test for both nCPAP and oral appliance treatment groups.
Compared with a placebo appliance, the oral
appliance improved quality of life for OSA patients measured by the FOSQ in mean score and
social outcome domain. nCPAP treatment improved overall score and activity level of the
FOSQ as well as mean score and well-being as
assessed by the Medical Outcomes Study Short
Form-36 (SF-36).
Patient-groups using the 1-piece or 2-piece
oral appliance indicated a preference for the
1-piece appliance.34 The compliant patient-population decreased to 82% after a year and to
62% after 4 years of oral appliance use.35 Compliance with patients using oral appliances with
either tongue retaining or soft palate lifting
components is even lower because of poor tolerance. Some factors need to be studied in order
to foster optimal long-term compliance; they are
appliance design, side-effects from oral appliance usage, attenuation in efficacy of treatment
over time, frequency and types of follow-up pro-

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M. Yow

cedures and, in particular, patient-characteristics. It is necessary to address each patients


needs on an individual basis and equally important to follow-up over the long-term for clinical
responses to treatment, attenuation of oral appliance effectiveness, adherence to the appliance, appliance deterioration, oral health effects
and occlusal changes.
There is a role for oral appliances in managing OSA in both children and adults. Oral appliances for children are not unlike functional
appliances. With appropriate proper diagnosis
and management, they alleviate compromised
pediatric airways, and correct malocclusions and
change dentofacial structures in growing children. The key to success in managing adult OSA
patients with oral appliances is accurate diagnosis and localization of the site(s) of obstruction.
Although there is a likelihood of permanent
skeletal and dental changes occurring after longterm use of oral appliances by adults, these
changes are minor and the benefits far outweigh
the side effects.
In an American Academy of Sleep Medicine
report,36 standard best practices for oral appliance treatment in OSA patients are (1) to
establish the presence or absence of OSA, using standard diagnostic criteria that include
polysomnography before the decision to prescribe oral appliances and (2) to treat OSA
patients to the desired outcomes of AHI 5
events per hour and arterial oxyhemoglobin
saturation levels 85% with resolution of clinical signs and symptoms. Follow-up clinical reviews on the efficacy of and compliance with
oral appliance treatment are recommended
for good patient care. If signs and symptoms of
OSA worsen or recur, a follow-up polysomnography will be necessary.

Acknowledgments
The author thanks Dr. C.T. Kwa and Dr. Eric K.W. Lye for their
constructive suggestions in the preparation of this article. Special thanks are also due to Ms Roslinda bte Sabani for her
efficiency and help in sourcing the reference material.

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