Avaliação clínica e polissonográfica do aparelho BRD no tratamento da Síndrome da Apneia Obstrutiva do Sono

Mandibular advancement device in obstructive sleep apnea treatment: what happens to the condyle position and patient response?

BACKGROUND

This study aims primarily to assess the mandibular condyles and patient response to MAD therapy using cone-beam computed tomography (CBCT). Also, the study proposes to analyze whether variations in condylar position, OSA severity and mandibular protrusion influence patient response.

METHODS

23 patients diagnosed with mild/moderate OSA and treated with MAD comprised the sample. Clinical, CBCT, and PSG assessments were conducted at baseline and with MAD in therapeutic protrusion (4-6 months of MAD use). The condyle position was vertically and horizontally evaluated at baseline and at the therapeutic protrusion.

RESULTS

The condyle position significantly changed with MAD, showing anterior (7.3 ± 2.8 mm; p < 0.001) and inferior (3.5 ± 1 mm; p < 0.001) displacement. Patients with mild OSA required more protrusion (p = 0.02) for improvement. Responders exhibited a significantly prominent (p = 0.04) anterior baseline condyle position. A negative modest correlation was found between treatment response and baseline condyle anterior position (p = 0.03; r=-0.4), as well as between OSA severity and the percentage of maximum protrusion needed for therapeutic protrusion (p = 0.02; r=-0.4). The patient protrusion amount did not predict condylar positional changes. Neither condyle position, OSA severity, nor therapeutic protrusion were predictors of MAD treatment response.

CONCLUSION

MAD resulted in anterior and inferior condylar displacement, and the amount of protrusion did not predict condylar positional changes. Responders showed a more anterior baseline condyle position. OSA severity and mandibular protrusion did not predict treatment response.

Evaluation of condylar and mandibular movements on the upper airway during the use of mandibular advancement device for obstructive sleep apnea treatment

OBJECTIVES

To evaluate the temporomandibular joint (TMJ), condylar and mandibular movements in obstructive sleep apnea (OSA) patients treated with mandibular advancement device (MAD) and to identify the influence of these anatomic factors on upper airway (UA) volume and polysomnographic outcomes after treatment.

MATERIALS AND METHODS

Twenty OSA patients were prospectively treated with MAD. Clinical examinations, cone-beam computed tomography, and polysomnography were performed before MAD treatment and after achieving therapeutic protrusion. Polysomnographic variables and three-dimensional measurements of the TMJ, mandible, and upper airway were statistically analyzed.

RESULTS

Condylar rotation, anterior translation, and anterior mandibular displacement were directly correlated with total UA volume, while vertical mandibular translation was inversely correlated with the volume of the inferior oropharynx. MAD treatment resulted in an increase in the volume and area of the superior oropharynx. There was no statistically significant correlation between condylar rotation and translation and polysomnographic variables. With MAD, there was a significant increase in vertical dimension, changes in condylar position (rotation and translation), and mandibular displacement. The central and medial lengths of the articular eminence were inversely correlated with condylar rotation and translation, respectively. The lateral length of the eminence was directly correlated with condylar translation, and the lateral height was directly correlated with condylar rotation and translation.

CONCLUSION

Condylar and mandibular movements influenced UA volume. The articular eminence played a role in the amount of condylar rotation and translation.

CLINICAL RELEVANCE

Individualized anatomical evaluation of the TMJ proves to be important in the therapy of OSA with MAD.

Three-dimensional comparison between the effects of mandibular advancement device and maxillomandibular advancement surgery on upper airway

BACKGROUND

The efficacy of mandibular advancement devices (MAD) and maxillomandibular advancement (MMA) in improving upper airway (UA) patency has been described as being comparable to continuous positive airway pressure (CPAP) outcomes. However, no previous study has compared MAD and MMA treatment outcomes for the upper airway enlargement. This study aimed to evaluate three-dimensionally the UA changes and mandibular rotation in patients after MAD compared to MMA.

METHODS

The sample consisted of 17 patients with treated with MAD and 17 patients treated with MMA matched by weight, height, body mass index. Cone-beam computed tomography from before and after both treatments were used to measure total UA, superior/inferior oropharynx volume and surface area; and mandibular rotation.

RESULTS

Both groups showed a significant increase in the superior oropharynx volume after the treatments (p = 0.003) and the MMA group showed greater increase (p = 0.010). No statistical difference was identified in the MAD group considering the inferior volume, while the MMA group showed a significantly gain (p = 0.010) and greater volume (p = 0.024). Both groups showed anterior mandibular displacement. However, the mandibular rotation were statistically different between the groups (p < 0.001). While the MAD group showed a clockwise rotation pattern (-3.97 ± 1.07 and - 4.08 ± 1.30), the MMA group demonstrated a counterclockwise (2.40 ± 3.43 and 3.41 ± 2.79). In the MAD group, the mandibular linear anterior displacement was correlated with superior [p = 0.002 (r=-0.697)] and inferior [p = 0.004 (r = 0.658)] oropharynx volume, suggesting that greater amounts of mandibular advancement are correlated to a decrease in the superior oropharynx and an increase in the inferior oropharynx. In the MMA group, the superior oropharynx volume was correlated to mandibular anteroposterior [p = 0.029 (r=-0.530)] and vertical displacement [p = 0.047 (r = 0.488)], indicating greater amounts of mandibular advancement may lead to a lowest gain in the superior oropharynx volume, while a great mandibular superior displacement is correlated with improvements in this region.

CONCLUSIONS

The MAD therapy led to a clockwise mandibular rotation, increasing the dimensions of the superior oropharynx; while a counterclockwise rotation with greater increases in all UA regions were showed in the MMA treatment.

Methodological parameters for upper airway assessment by cone-beam computed tomography in adults with obstructive sleep apnea: a systematic review of the literature and meta-analysis

BACKGROUND

A reliable method for analyzing the upper airway (UA) remains a challenge. This study aimed to report the methods for UA assessment using cone-beam computed tomography (CBCT) in adults with obstructive sleep apnea (OSA).

METHODS

We performed a systematic review (PROSPERO #CRD42021237490 and PRISMA checklist) that applied a search strategy to seven databases and grey literature.

RESULTS

In 29 studies with moderate-to-high risk of bias, investigators mostly reported the body position during CBCT (upright or supine) and hard tissue references, diverging in UA delimitation and terminologies. The meta-analysis showed two subgroups (upright and supine), and no statistical differences were identified (p = 0.18) considering the UA area. The volume in the OSA group was smaller than that in the control group (p < 0.003 and Cohen's d =  - 0.81) in the upright position. Patients with OSA showed smaller anteroposterior dimensions than the control group and were not affected by the position during image acquisition (p = 0.02; Cohen's d =  - 0.52). The lateral measurements were also lower in the OSA group (supine) (p = 0.002; Cohen's d =  - 0.6).

CONCLUSIONS

Patients with OSA showed smaller UA measurements in the upright (volume) and supine (lateral dimension) positions. The anteroposterior dimension was also reduced in patients with OSA compared to the control group, regardless of the position during CBCT acquisition.

Three-dimensional craniofacial characteristics associated with obstructive sleep apnea severity and treatment outcomes

OBJECTIVES

This study aims to assess craniofacial dimensions in obstructive sleep apnea (OSA) patients treated with a mandibular advancement device (MAD) and to identify anatomic influences on OSA severity and MAD therapy outcomes.

MATERIALS AND METHODS

Twenty patients with OSA were prospectively treated with MAD. Clinical, cone-beam computed tomography, and polysomnography exams were performed before treatment and 4-6 months after achieving the MAD therapeutic position. Polysomnographic exams and three-dimensional maxillary, mandibular, and upper airway (UA) measurements were evaluated. Pearson's correlation and t-tests were applied.

RESULTS

Before MAD treatment, the transverse width measured at the frontomaxillary suture and the angle between the mandibular ramus and Frankfurt horizontal were statistically correlated with apnea and the hypopnea index (AHI), while the gonial angle was correlated with therapeutic protrusion. After MAD treatment, all patients showed a significant AHI reduction and an improvement in minimum oxyhemoglobin saturation. The UA total volume, superior and inferior oropharynx volume, and area were statistically correlated with MAD therapeutic protrusion. The UA total area showed a statistical correlation with the improvement in AHI, and the superior oropharynx volume and area increased significantly.

CONCLUSIONS

The transversal frontomaxillary suture width and the mandibular ramus facial angle may influence OSA severity. The gonial angle, volume, and area of all UA regions may indicate the amount of protrusion needed for successful MAD treatment.

CLINICAL RELEVANCE

The craniofacial characteristics reported as important factors for OSA severity and MAD treatment outcomes impact therapy planning for OSA patients, considering individual anatomic characteristics, prognosis, and cost benefits.

The treatment of mild OSA with CPAP or mandibular advancement device and the effect on blood pressure and endothelial function after one year of treatment

STUDY OBJECTIVES

To evaluate and compare the effects of continuous positive airway pressure (CPAP), use of a mandibular advancement device (MAD), and no treatment on 24-hour ambulatory blood pressure monitoring and peripheral arterial tonometry at 6 and 12 months follow-up in individuals with mild obstructive sleep apnea (OSA), and in a subgroup who had an apnea-hypopnea index of < 5 events/h and adherence of ≥ 4 hours per night (effective-treatment subgroups).

METHODS

The inclusion criteria were individuals with mild obstructive sleep apnea, any sex, age between 18 and 65 years, and a body mass index of ≤ 35 kg/m². Patients were randomized into CPAP, MAD, and no-treatment groups. The evaluations included physical examination, full polysomnography, 24-hour ambulatory blood pressure monitoring, and peripheral arterial tonometry at baseline and after 6 and 12 months. A generalized linear mixed model was used for comparisons.

RESULTS

The CPAP and MAD groups had lower apnea-hypopnea indexes than the control group at 6 and 12 months, and the CPAP group had higher blood oxygen levels (SpO₂) than the MAD group. The MAD group had more hours of treatment per night and better adaptation to treatment than the CPAP group (MAD: 5.7 ± 2.7 h/night; CPAP: 3.8 ± 3.4 h/night; MAD: 16% did not adapt; CPAP: 42% did not adapt). No differences were found in the total sample and effective treatment in relation to peripheral arterial tonometry or 24-hour ambulatory blood pressure monitoring outcomes.

CONCLUSIONS

Treatment of mild obstructive sleep apnea with CPAP or MAD did not improve blood pressure or endothelial function after 1 year, even in patients with effective treatment.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Continuous Positive Airway Pressure and Oral Appliances Treatments in Mild Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT01461486; Identifier: NCT01461486.

The effects of continuous positive airway pressure and mandibular advancement therapy on metabolic outcomes of patients with mild obstructive sleep apnea: a randomized controlled study

BACKGROUND

Moderate and severe obstructive sleep apnea (OSA) have been independently associated with dyslipidemia. The results of metabolic improvement with continuous positive airway pressure (CPAP) have been controversial. Less evidence exists regarding this issue in mild OSA. A current treatment for mild OSA is mandibular advancement device (MAD) therapy, but its effectiveness on the metabolic profile needs to be compared with CPAP. The purpose of this study was to compare MAD vs CPAP vs no treatment on the metabolic profile during 6 and 12 months of follow-up in patients with mild OSA.

METHODS

The inclusion criteria were patients with mild OSA, both genders, ages 18 to 65 years, and body mass index (BMI) of < 35 Kg/m². Patients were randomized in 3 groups (CPAP, MAD, and control). The evaluations included physical examination, metabolic profile, and full polysomnography at baseline, 6 months, and 12 months of follow-up.

RESULTS

Seventy-nine patients with mild OSA were randomized in three treatment groups, with mean age (± SD) of 47 ± 9 years, 54% men, and AHI 9.5 ± 2.9 events/h. MAD and CPAP reduced AHI at 6 and 12 months compared to the control group. MAD adherence was higher than CPAP at 6 and 12 months. Despite lower adherence compared to MAD, CPAP was more effective in reducing total cholesterol over 12 months (baseline 189.3 ± 60.2 mg/dl to 173.4 ± 74.3 mg/dl) and low-density lipoprotein cholesterol (LDL-c, baseline 112.8 ± 54.9 mg/dl to 94.5 ± 67.4 mg/dl).

CONCLUSIONS

After 1 year of treatment, CPAP was superior to MAD in reducing total cholesterol and LDL-c in patients with mild OSA.

Long term oral appliance therapy decreases stress symptoms in patients with upper airway resistance syndrome

STUDY OBJECTIVES

To evaluate the long-term effects of a mandibular advancement device (MAD) on stress symptoms and cognitive function in patients with upper airway resistance syndrome (UARS) compared with placebo.

METHODS

This study was a randomized placebo-controlled clinical trial. Thirty UARS patients were randomized into 2 groups: placebo and MAD groups. UARS criteria were the presence of sleepiness (Epworth Sleepiness Scale ≥ 10) and/or fatigue (Modified Fatigue Impact Scale ≥ 38) associated with an apnea-hypopnea index ≤ 5 events/h and a respiratory disturbance index > 5 events/h of sleep, and/or flow limitation in more than 30% of total sleep time. All patients completed the Rey Auditory-Verbal Learning Test, the Logical Memory test, the Stroop Color Test, the Trail Making Test, the Digit Symbol Substitution Test, and Inventory of Stress Symptoms. Cognition protocol was defined based on the most used neuropsychological tests in the literature. Evaluations were performed before and after 1.5 years of treatment.

RESULTS

Mean adherence to placebo and to MAD was 6.6 ± 2.6 and 6.1 ± 2.4 h/night, respectively. Side effects reported by MAD group were minor and short-term. There was no statistically significant difference in Rey Auditory-Verbal Learning Test, Logical Memory test, Stroop Color Test, Trail Making Test, and Digit Symbol Substitution Test before and after 1.5 years of treatment in both groups. Inventory of Stress Symptoms score decreased at the alert phase and the resistance phase after 1.5 years of MAD treatment compared to the placebo.

CONCLUSIONS

Mandibular advancement devices were effective in decreasing stress symptoms in UARS patients after 1.5 years of treatment.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Efficacy of Oral Appliance for Upper Airway Resistance Syndrome; URL: https://clinicaltrials.gov/ct2/show/record/NCT02636621; Identifier: NTC02636621.

Impact of upper airway abnormalities on the success and adherence to mandibular advancement device treatment in patients with Obstructive Sleep Apnea Syndrome

Introduction

The mandibular advancement device (MAD) is a option to treat patients with Obstructive Sleep Apnea Syndrome (OSAS).

Objective

To assess the influence of upper airway abnormalities on the success of and adherence to MAD in patients with OSAS.

Methods

Prospective study with 30 patients with mild to moderate OSAS and indications for MAD. The protocol included questionnaires addressing sleep and nasal complaints, polysomnography, and upper airway assessment. The analyzed parameters of patients who showed therapeutic success and failure and those who exhibited good and poor treatment adherence were compared.

Results

28 patients completed the protocol; 64.3% responded successfully to treatment with MAD, and 60.7% exhibited good adherence to treatment. Factors associated with greater success rates were younger age (p = 0.02), smaller cervical circumference (p = 0.05), and lower AHI at baseline (p = 0.05). There was a predominance of patients without nasal abnormalities among patients treated successfully compared to those with treatment failure (p = 0.04), which was not observed in relation to adherence. Neither pharyngeal nor facial skeletal abnormalities were significantly associated with either therapeutic success or adherence.

Conclusion

MAD treatment success was significantly lower among patients with nasal abnormalities; however, treatment adherence was not influenced by the presence of upper airway or facial skeletal abnormalities.

Multidisciplinaridade na apneia do sono: uma revisão de literatura

Síndrome da Apneia/Hipopneia Obstrutiva do sono (SAHOS) é uma doença crônica, evolutiva que pode ocasionar graves repercussões comportamentais, cardiovasculares e neurológicos ao paciente.O objetivo deste estudo é realizar uma revisão sistematizada sobre a importância da abordagem multidisciplinar no diagnóstico e tratamento da Síndrome da Apneia e Hipopnéia Obstrutiva do sono. Vários profissionais da área de saúde podem atuar no diagnóstico e tratamento desta síndrome, destacando-se atuação dos médicos, dentistas, fisioterapeutas e fonoaudiólogos.

Mandibular advancement device and CPAP upon cardiovascular parameters in OSA

PURPOSE

This study aims to compare the effects of a mandibular advancement device (MAD) with continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA) on blood pressure (BP), oxidative stress, and heart rate variability (HRV) in a randomized, crossed-over, single-blind, and controlled trial.

METHODS

Twenty-nine moderate-to-severe adult OSA patients underwent MAD, CPAP, and placebo oral appliance treatment. Polysomnography, Epworth sleepiness scale, 24-h ambulatory BP monitoring, oxidative stress parameters (malondialdehyde, catalase, superoxide dismutase, vitamins C, E, B6, B12, folate, homocysteine, uric acid), and HRV were assessed at baseline and after 1 month of each treatment. Diaries were used to evaluate compliance for devices and a pressure-time meter for CPAP.

RESULTS

Both active treatments resulted in decreases in apnea and hypopnea index and Epworth sleepiness scale; CPAP showed a greater effect. Frequency of diastolic BP dipping was higher in the MAD group compared with the CPAP group. A significant drop from baseline levels for catalase activity was observed after MAD. For HRV, there was a significant decrease in total power at night with CPAP and MAD compared with POA, and a decrease in index of sleep autonomic variation with MAD compared with baseline levels. Compliance rates were higher with MAD rather than CPAP.

CONCLUSIONS

Even though CPAP proved to be more effective at attenuating OSA, better compliance with MAD favored the reduction of one of the enzymes which participates in oxidative stress and better autonomic modulation during sleep.