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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4538_Библиотеки_им_академика_М_И_Перельмана
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12 Dentistry inObstructive Sleep Apnea
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morphology, the oral oor, and their relationship with the bone structure is possible.
In addition, Dynamic sleep MRI can reliably characterize the actual site of dynamic
airway obstruction and has the potential of improving predictions of successful surgical outcomes in OSA patients [14, 15].
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12.3 Oral Appliances
Oral appliances have been described as an efcacious treatment for OSA.In a paper
called “Dening an Effective Intraoral Device for the Treatment of Snoring and
Obstructive Sleep Apnea Syndrome: 2019in the Journal or Dental Sleep Medicine
Update,” ve major changes were made concerning the effectiveness of the intraoral
device. These changes focused on the physical characteristics and functions of an
oral appliance (OA)
1. An Oral Appliance must be made of materials that meet the physical needs of
patients.
An OA must be made of biocompatible materials to be considered safe for
patient use [16]. In addition, the materials must be suitable for the oral structure
and physical needs of an individual patient. For example, such physical needs
may include the need for nonmetallic materials for those with metal
hypersensitivity.
Approximately 10%–15% of the population is hypersensitive to metals [17].
Therefore, alternative, biocompatible materials should be used when fabricating
intraoral devices for such patients. OA materials that were previously fabricated
with metal can now be made with other materials. For example, the connecting
mechanisms in Bibloc devices can be made of elastics, plastics, or even magnets [18].
2. A custom-fabricated (customized) Oral Appliance may include a prefabricated
component.
Current evidence indicates that custom-made oral appliances are superior to
prefabricated devices [19–24]. In addition, custom-made appliances have been
associated with patient comfort and treatment adherence [25] as well as reduced
apnea–hypopnea index (AHI), improved daytime sleepiness, improved endothelial function, and increased muscle activity [25–35].
3. The Oral Appliance (OA) mechanism is not limited to xed mechanical hinges or
metallic materials.
OA designs now feature connection mechanisms that are nonmetallic, for
those who suffer from hypersensitivity to metals.
As technology has progressed, several hingeless devices have been shown to
be effective in treating OSA.However, there is still some controversy as some
studies show improvements in AHI by protruding the mandible using elastics
connected to Adams clasps [36]. Another study of OA’s with elastic bands (to
control mouth opening) compared to the same appliance without bands found no
signicant difference in AHI after use [37].
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Other appliances (Bibloc) that are connected and tted using nonmetallic
exible rods have been associated with signicant improvements in OSA symptoms. In one study, 76% of patients were effectively treated with this device
(AHI decrease ≥50%), and 64% achieved a complete response to treatment [30].
Another study with this OA showed that 56% of patients using the device
achieved a response to treatment [38].
In other studies, devices using ball clasps to protrude the mandible signicantly reduced AHI.These studies found that 57% of patients achieve an AHI
<10 per hour and 31% an AHI <5 per hour. Overall, they concluded that the
devices were successful in treating OSA in 58% of patients, excessive daytime
sleepiness in 56% and snoring in 76% [31]. Therefore, connecting mechanisms
other than xed mechanical hinges can effectively treat snoring and OSA.
4. An oral appliance must prevent dislodgement
An effective OA must have retention in one or both arches [6, 39]. Lack of
adequate stability of the oral appliance can lead to worse outcomes. For example, it has been suggested that the Monobloc may be less effective than Bibloc
devices due to poor stability (among other factors) [40]. Therefore, the OA must
have good tooth retention and prevent dislodgement.
5. Life of an oral appliance
The original denition included a clause stating that an effective intraoral device
must “maintain its structural integrity for a minimum of 3years.” In this update
(JDSM 2019), it was determined that there was very little evidence outside of the
AADSM denition that a device should last at least 3years to be effective. Therefore,
this aspect was removed from the denition.
L. D. AneybaLópez et al.
12.3.1 Types ofOral Appliances
Currently, there are a many Oral Appliances (OA) designs available on the market.
These Oral Appliances vary in attachment design, mode of fabrication and activation, titration capability, degree of vertical opening, and jaw laterality movements.
They also can be of a one-piece (Monobloc) or two-piece (Bibloc) design, either
custom-made or prefabricated [41, 42]. Thermoplastic OA (boil & bite) has been
proposed as a temporary device to be used while repairing a permanent OA, or a
patient’s waiting time is not enough to fabricate a permanent one [43]. It has the
advantage of a feasible a low cost [44, 45].
A dentist with training in Dental Sleep Medicine should be the only one to provide OA therapy. The critical treatment approach includes coordination and communication (in writing) with the referring physician regarding the treatment plan
and long-term follow-up.
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12.3.2 Monobloc
These are OA (Fig.12.5) composed of a single body and span both arches, mostly
nonadjustable. It has been recommended that the dental pieces are totally or partially encapsulated inside the device to avoid dental overeruption or any other
movement.
12.3.3 Bibloc
They are OA composed of two bodies (upper and lower arch) that interact with each
other through different types of connectors. They are adjustable (depending on the
connector type), making it possible for the dentist to have complete control of the
protrusion during treatment. There are several designs worldwide; some examples
of those are Somnomed Avant®, Telescopic/Herbst (Fig. 12.6), Elastic Device/
EMA, Dorsal Fin (Fig.12.7), OrthoApnea Classic® (Fig.12.8), and the DreamTAP®
(Fig.12.9).
Fig. 12.5 Monobloc
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Fig. 12.6 Telescopic/
herbst
L. D. AneybaLópez et al.
Fig. 12.7 Dorsal n
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Fig. 12.8 OrthoApnea
®
Classic
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Fig. 12.9 DreamTAP
®
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12.3.4 Telescopic/Herbst
12.3.5 Dorsal Fin
L. D. AneybaLópez et al.
12.3.6 OrthoApnea Classic
12.3.7 DreamTAP
®
®
12.3.8 Thermoplastics (Boil andBite)
These are prefabricated devices (Fig.12.10) that are not custom-made, and their
durability is not predictable. Instead, adaptation is made directly at the moment,
either in the ofce or by the patient at home.
There are both monobloc and bibloc, adjustable, and nonadjustable.
There are also the tongue retainer devices (Fig.12.11) among these intraoral
devices, which are an alternative for those partially or edentulous patients. All of
them are prefabricated, and the most common design is the one shown below:
Finally, emphasize that technological and innovative advances in Intraoral
Devices have occurred in recent years by elaborating them using 3D Printing and
CAD-CAM technology such as OrthoApnea NOA® (Fig.12.12) and ProSomnus®
(Fig.12.13). At the same time, more and more markers or “chips” are being incorporated into the devices, where we can receive information about the threedimensional position, time of use, patient’s temperature, etc.
Fig.
12.10 Thermoplastics
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Fig. 12.11 Tongue
retainer device
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Fig.
12.12 OrthoApnea NOA
Fig. 12.13 ProSomnus
®
®
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L. D. AneybaLópez et al.
12.3.9 OrthoApnea NOA
12.3.10 ProSomnus
®
®
12.3.11 Effectiveness ofanOral Appliance
An Intraoral Device aims to treat obstructive sleep apnea, primary snoring, and
associated symptoms. Historically, the most frequently measured outcomes in therapeutic efcacy and effectiveness of OSA treatment have been the apnea–hypopnea
index (AHI) to measure the severity of OSA and the Epworth Sleepiness Scale
(ESS) to assess daytime sleepiness. However, as OA research has matured, the
results have expanded to include the effect on cardiovascular function, neurocognitive behavior, and quality of life.
12.3.12 Improvements in Respiratory Variables and
Daytime Sleepiness
The efcacy and effectiveness of Oral Appliances therapy have been conrmed by
several high-quality studies, including randomized controlled trials, systematic
reviews, and meta-analyses [38, 46–60]. Through nocturnal polysomnography
(PSG), these studies have validated the usefulness of MA (mandibular advancement) in decreasing the frequency and/or duration of Apneas, Hypopneas RERAS
and/or snoring, as well as in improving nocturnal oxygenation. As a measure of
daytime sleepiness, the ESS score has normalized or improved by 2–4 points [54].
In one of the rst reports of a study conducted comparing pre- and postpolysomnographic recordings using Oral Appliances Yoshida demonstrated that posttreatment AHI was signicantly reduced by more than 50% from pretreatment values
[61]. Polysomnographic parameters did not normalize, but these ndings showed
that intraoral device therapy can improve sleep-disordered breathing signicantly.
Subsequently, Marklund reported that in 72% of patients with mild to moderate
obstructive sleep apnea, AHI was reduced to <10. In the severe group, AHI signicantly improved from a mean of 53 to 14 [62]. Other reports corroborated these
early ndings and demonstrated longitudinal stability of improvement in sleep
parameters with OA [63–69].
In perhaps the most extensive study to date, Holley and colleagues described the
results of their retrospective study in a sample of 497 OSA patients with all levels
of disease severity, all treated with Oral Appliance therapy [70]. OA therapy reduced
mean AHI from 30.0 to 8.4, and ESS was signicantly improved. In addition, there
is a comparison of PSG parameters between OA therapy and CPAP therapy of the
397 subjects. OA therapy demonstrated equivalent efcacy relative to CPAP in the
mild subjects (p=0.15), where treatment successfully reduced AHI <5in 76% of
the CPAP and 62% of the oral appliance group. In the moderate and severe groups,
CPAP was more effective than OA in reducing AHI <5 (71% vs. 51% in the moderate group and 63% vs. 40% in the severe group). However, when comparing the
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magnitude of reduction in AHI between treatments, the decrease in AHI was signicant only for the severe group, where CPAP decreased AHI by an additional 5.9
events/h (p<0.001). The amount of reduction in AHI by both treatments in the mild
and moderate groups differed by less than 2 events/h and was not statistically
signicant.
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12.3.13 Effect onCardiovascular Function
There was an improvement in High blood pressure [71–77] and cardiovascular function [78, 79] in addition to respiratory and daytime sleepiness improvements. The
effect of OA therapy on hypertension has been summarized in Iftikhar’s systematic
review and meta-analysis of seven randomized controlled observational studies [74].
A reduction of approximately 2mm in systolic, diastolic, and mean blood pressure was reported among the 399 pooled participants who met the inclusion criteria
for these studies. In another study, an evaluation of the impact of OA therapy on
blood pressure revealed a signicant improvement in overnight diastolic blood pressure compared to CPAP [72]. In addition, Lam studied the effect of OA therapy on
blood pressure and found a signicant improvement in systolic blood pressure
maintained after 1year of follow-up [75]. Gotsopoulos demonstrated a reduction in
24-h mean diastolic blood pressure in patients with AHI>10 and concluded that
these ndings mirrored those found with CPAP [58]. Otsuka reported a signicant
reduction in mean arterial pressure and diastolic blood pressure during monitoring
over a 20-h period, and signicant reductions in systolic, diastolic, and mean arterial pressure during sleep [76].
12.3.13.1 Impact onQuality ofLife andNeurocognitive Behavior
The overall quality of life [71, 80–86] and neurobehavioral outcomes [73, 80, 81,
85, 87] have improved with OA therapy. Walker-Engstrom examined three dimen-
sions of quality of life (vitality, satisfaction, and sleep quality) in randomized subjects between patients with uvulopalatopharyngoplasty or intraoral device therapy
[86]. One year after the intervention, both treatment groups demonstrated signicant improvements in all three dimensions of quality of life. Levendowski etal.
studied quality of life in patients who underwent OA therapy after failing CPAP
therapy [81]. They found statistically signicant reductions in sleepiness (76% of
subjects) and depression (73% of subjects), as well as improvements in the diseasespecic quality of life index (60% of subjects).
In addition, Saletu designed a study to examine respiratory variables and different outcomes of OA therapy in a group of patients with all levels of disease [85].
Active and inactive oral appliances were used to compare the effects on morning
mood, subjective impression of sleep quality, and cognitive and psychophysiological performance. All respiratory variables improved in the active OA group compared to the sham appliance group. In addition, subjects demonstrated a signicant
benet in sleep quality, morning cognitive performance, ne motor activity, and
reaction time.
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L. D. AneybaLópez et al.
Fig. 12.14 MyTAP PAP
®
12.3.14 Potential forImproved CPAP Adherence
Finally, Oral Appliances may offer improvements in CPAP efcacy. Using phrenic
nerve stimulation to assess the dynamic properties of the upper airway, Borel etal.
established that continuous use of CPAP (nasal mask) in conjunction with an OA
reduces velopharyngeal resistance to a greater extent than using CPAP alone [83].
When OA’s were used with nasal CPAP, peak ow velocity was signicantly
improved. Take for example: MyTAP PAP® (Fig.12.14).
12.3.15 MyTAP PAP
®
The simultaneous use of OA therapy with CPAP is a relatively new concept in dental sleep medicine. While preliminary studies are promising, further research is warranted to validate the improved effectiveness.
12.4 Dental Side Effects ofOral Appliances (Mandibular
Advance Devices Mad)
Mandibular advancement devices aim to advance and stabilize the mandibular during sleep, allowing the passage of air through the upper airway without obstruction.
This forward position of the lower jaw can cause discomfort with pressure and
sometimes pain in the muscle, the joint and, the teeth. Extreme circumstances can
lead to the failure of the therapy.
Managing side effects depends on the dentist clinical expertise and sensibility to
identify and establish the best approach.
Oral appliances are attached to the teeth, and therefore, this therapy is highly
dependent on a healthy dentition [88, 89].
The clinical relevance of dental occlusal side effects is strictly related to the
baseline dental occlusion [90].
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