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12 Dentistry inObstructive Sleep Apnea
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Dental side effects can be clinically minor, but the dentist should be experienced
in dental sleep medicine to inform the patients and to deal with these events. Side
effects may worsen with time and patients need to be monitored over time [90].
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12.4.1 The Device’s Force
Forces will arise on the teeth during appliance use, and there is a risk for bite
changes [88].
Device design will also inuence the risk of bite changes. For example, one
study describes that a device attached mainly to the front teeth will produce a faster
and more signicant change in dental occlusion than a device connected to the
whole dentition.
The advanced position of the jaw during the night will create forces on the teeth,
and patients can experience some discomfort, temporary bite change with the loss
of occlusal contact some hours after taking off the device [89, 91].
A study showed that device materials have no inuence in centric occlusion and
centric relation and no differences were found during the follow-up [92]. However,
side effects were more pronounced in patients using hard acrylic devices and soft
elastomeric devices with a large mandibular protrusion [92].
Some factors, such as a high percentage of advancement and poor oral health
conditions (poor periodontal disease, insufcient bone support) and noncustommade or nonadjustable devices, can lead to increased risk for negative impact and
produce changes [91, 92].
The occlusal and structural changes registered are a consequence of the joint
forces elicited by the MAD on masticatory muscles, which tend to bring the mandible back to its original position, discharging the tension on the teeth [90].
12.4.2 Short-Term Side Effects
OSA treatment with a mandibular advancement device can lead to side effects that
are short-term and reversible in most cases.
Patients can experience bite changes in the early morning after a night using a
MAD, but the occlusion comes normal during the day [92]. Subjective side effects
are common, and the most frequently include temporomandibular joint (TMJ) pain,
myofascial pain, tooth pain, TMJ sounds, gum irritation, and morning-after occlusal
changes [89, 91, 93].
Also, dry mouth and excessive salivation can occur at the beginning of the treatment [6, 91, 93].
With high vertical dimension and advancement, a MAD creates more muscular
and joint discomfort [91].
Puttin etal., in their study, examined the temporomandibular joints and revealed
noises in 9 of the 106 patients (8%) who did not have joint noises before treatment.
There wasn’t a decrease in mouth opening. However, an increase was found in
30 (28%).
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12.4.3 Long-Term Side Effects
With time only tooth movement and bite changes are more prevalent and can lead to
discontinuation of treatment [91].
The overjet, i.e., the horizontal distance between the upper and lower front teeth,
will decrease. Patients may lose antagonistic contact between the molar teeth,
although there might be variability between patients [88, 91].
The initial type of bite is associated with the degree of bite changes. Patients with
a deep bite, i.e., a signicant vertical overlap between the front teeth, may be protected from overjet changes [88]. Those with normal bites or Angle Class III, i.e.,
lower front teeth located anterior to the upper front teeth, seem to be more at risk for
negative bite changes [88, 91, 93].
Patients with Angle Class II, i.e., lower front teeth much posteriorly located from
the upper front, might receive positive orthodontic effects of oral appliance treatment [88, 91, 93].
A study stressed the signicant correlation between the duration of the therapy
and the decrease of overjet, overbite, and U1 inclination, and increase of L1 inclination [90]. During a period between 2 and 11years of therapy, there is a decrease in
overjet from about 0.2 to 2.0mm and a decrease in overbite from about 0.6 to
2.3mm [90].
12.4.4 Changes inDental Occlusion
The bite changes are noticed early during the rst years of treatment and will gradually continue [88].
Although most patients are unaware of bite changes, the changed dental occlusion might inuence the device’s efcacy. For example, the advancement of the
mandible by the device might diminish if the device is left unadjusted in patients
with more considerable bite changes [88].
Some patients could also have skeletal changes by advancing the mandible [88,
91, 93]. After 5years of MAD treatment, patients can experience less overbite and
overjet, and also the mesial relationship of the lower molar [88, 91].
One-third of patients report posterior open bite after 1 or 2years of treatment.
Loss of interproximal contact is usually reported in the cases of attachments to
increase retention of the device, leading to food impaction [91].
Also, the posterior teeth can change with the distal tip of the upper molars and
the mesial tip of lower molars [88, 91].
Some studies describe the yearly migration of central incisors and jawbones, and
patients’ lower central incisors were signicantly tilted forward [94].
Pantin etal., in their study, reveal that the proportion of patients with occlusal
change increased with the use of the mandibular advancement splint for up to
2years. Beyond 2years, the ratio remained relatively constant.
Consequently, bite changes do not necessarily need to be considered disadvantageous to a particular dentition, and, indeed, some patients could benet [88].
12 Dentistry inObstructive Sleep Apnea
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Changes occur in occlusion during snoring and obstructive sleep apnea treatment
with MAD, especially in patients with protrusion below 6mm. Although a follow up after 2 years is recommended as individual patients may experience marked
orthodontic side effects [92].
Same studies refer that occlusal changes were managed conservatively, using
temporary cessation or reduction in the use of the device and remedial exercises
each morning following its removal. With exercises, the occlusal changes resolve
within 2weeks of treatment cessation in most cases [95].
Patin etal. [95] found a satisfactory response of most patients to exercises, either
to treat occlusal change or subsequently as a prophylactic measure, which suggests
that these problems develop because of a failure to reposition the mandible during
the day following use rather than as the result of immutable changes in occlusion
caused by the device overnight.
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12.5 Side Effects Related totheUse ofMandibular
Advancement Devices
(Device selection to prevent dental side effects)
The dental effects attributable to the prolonged use of oral devices for the treatment of obstructive sleep apnea have long been investigated in the literature.
Occlusal modications are found in 86.7% of patients [96]. The authors agree to
observe a reduction of overjet and overbite over time (1.5mm in 7years), and loss
of dental contacts in the posterior region. Maxillary incisors palatal tipping and
mandibular incisor labial tipping were also observed [97].
A recent study analyzed the effects on periodontal ligaments and tooth surfaces
during the use of 4 different oral devices. The analysis was carried out using the
Finite Element Method (FEM). It was developed in synergy between the dental
department of the Università degli Studi di Padova (Italy) and the department of
industrial engineering of the Università Politecnica delle Marche (Italy) [98, 99].
The Finite Element Method is an instrument that simplies a complex physical
object into many simple elements and analyzes these stresses and deformations in
response to different conditions. FEM has been used in numerous medical and dental studies.
A 3D model of the skull of a 29-year-old patient was created from the Cone
Beam CT and Magnetic Resonance. After creating a 3D model of the skull of a
29-year-old patient was based on his Cone Beam CT and Magnetic Resonance
images. After scanning with a laser probe, four different digital models of
Mandibular Advancement Devices were coupled (Fig.12.15).
These MADs were chosen among the most used for OSA therapy and had different advancement mechanisms. (1) OrthoApnea Classic® consists of two splints connected by a reverse connecting anterior rod screw; (2) Somnodent Flex® (Dorsal
Fin) has two advancement screws placed bilaterally on the upper splint that interface with the ns of the lower part. (3) Also, chose a Herbst-type device with telescopic sidearms. (4) Somnodent Avant®, which connects the two splints using a
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Fig. 12.15 3D model of
the skull with MAD
L. D. AneybaLópez et al.
nylon string that hooks anteriorly in a lane placed on the upper splint and in two pins
at the level of the mandibular molars.
Periodontal ligaments were modeled by offsetting each tooth root surface of
0.3mm to ll the space between each tooth and the alveolar socket [100, 101].
A force of 11.18N was applied to the MAD on the connection points of the
splints; equivalent to a device advancement of 9.5mm [102, 103].
OrthoApnea Classic® generated stress with a maximum value of 4.26kPa on the
periodontal ligaments and 600kPa on the tooth surfaces; that affected the teeth of
the upper and lower anterior sector (Fig.12.16).
The Herbst-type device created a maximum of stress corresponding to 3.56kPa
on the ligaments and 302kPa on the dental surfaces; the stress, in this case, was
distributed more homogeneously, with prevalence in the lateral sectors (Fig.12.17).
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Fig. 12.16 Stresses caused by orthopnea
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Fig. 12.17 Stresses caused by telescopic/herbst
Aleta Dorsal/Somnodent Flex® exhibited very similar behavior, presenting the
absolute least lower stresses (maximum values of 3.27kPa on the ligaments and
287kPa on the teeth) that concentrated on the lateral sectors (Fig.12.18).
Somnodent Avant® is the device that presented the most signicant stresses with
intermediate distribution between OrthoApnea Classic® and devices with bilateral
propulsion mechanisms. The maximum stress values were 4.53kPa on the periodontal ligaments and 467 kPa on the tooth surfaces; the stress distribution was
prevalent on the lower molars and in the upper anterior sector (Fig.12.19).
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Fig. 12.18 Stresses caused by Aleta Dorsal/Somnodent Flex
The study also analyzed the deformations to which the teeth are subject during
the use of MAD, using vectors that indicate the direction of movement and the value
expressed in millimeters. The model showed a right-side view, but the left side is
considered symmetrical. The forces tend to move the upper jaw teeth downward and
backward when considering the anterior teeth in all four devices. Conversely, the
deformations of the posterior teeth were directed backward and upward. Regarding
the lower arch teeth, there is a displacement oriented forward.
The images obtained do not reproduce the exact advancement of the devices but
are examples of the tooth movement that derives from the activation forces of the
MAD (Fig.12.20).
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Fig. 12.19 Stresses caused by Somnodent Avant
Fig. 12.20 Examples of the tooth movement that derives from the activation forces of the MAD
®
12 Dentistry inObstructive Sleep Apnea
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The devices that generate the most signicant displacements were OrthoApnea
Classic® and Somnodent Avant®. The deformity mainly concentrated at the incisal level.
According to the authors, the different distribution of tensions was explained by
the various operating mechanisms: OrthoApnea Classic® uses a reverse front connecting rod that enhanced stress. Herbst and Somnodent Flex® exploit a bilateral
propulsion mechanism despite being of different designs (telescopic arm for Herbst
and advance screw for Somnodent Flex®). This explained the lateral stress distribution at the points of application of the propulsion forces. Somnodent Avant® has an
intermediate behavior between OrthoApnea Classic® and Herbst/Somnodent Flex®:
its propulsion mechanism is based on a string that connects from the molar portion
of the lower splint to the anterior part of the upper splint; in this case, the forces are
concentrated in the areas on which the feed mechanism acts. Since there is a single
pin on which the string is anchored below, the point stress values are the greatest
ever; in general, however, it can be assumed to be intermediate between an anterior
activation device such as OrthoApnea Classic® and bilateral propulsion devices.
OrthoApnea Classic® and Somnodent Avant® are the devices that generate more
stress at the anterior level: this derives from the fact that the splints are connected,
unlike Somnodent Flex® which has two independent portions and generates the
absolute lowest stresses.
The results of the analysis are in agreement with a previous study that compared
the differences between Somnodent Flex® and TAP®, which is a device with a completely similar design to OrthoApnea Classic®: it is reported that TAP® generates
more signicant occlusal changes, in response, therefore, to higher stress, compared
to Somnodent [104].
The clinician needs to consider the effects that MAD cause at the periodontal
level, choosing the device that best suits the individual patient.
To summarize, devices with activation with an anterior connecting rod generate
more concentrated and quantitatively signicant stresses in the anterior areas of the
teeth. In contrast, devices with lateral activation cause less intense and more distributed stress.
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12.6 The Relationship Between Obstructive Sleep Apnea
andTemporomandibular Disorders
Temporomandibular disorders (TMDs) are a heterogeneous group of musculoskeletal disorders in the masticatory system that represents chronic orofacial pain’s
most common cause. Prevalence of TMDs has been estimated between 5% and
12%, with higher rates among women [104, 105].
Different biomechanical, neurobiological, neuromuscular, and biopsychosocial
factors may contribute to the presence of TMD.The main risk factors include age,
genetic factors, sex, stress, anxiety, malocclusion, poor posture, rheumatoid or other
systemic arthritis, and breathing sleep-related disorders. TMD develops at a markedly higher rate in individuals with relatively poorer health status, in conjunction
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with the presence of other painful conditions, comorbid diseases, smoking, and
poor sleep quality [106–108].
One plausible risk factor for TMD is the presence of sleep-disordered breathing
(SDB). A preliminary report suggested that around 75% of patients diagnosed with
TMD have clinical characteristics suggestive of SDB, and this last contributes to the
presence of sleep bruxism, a classically considered an etiologic factor for the development of TMD [109–112].
In the OPPERA (Orofacial Pain: Prospective Evaluation and Risk Assessment)
study, which followed subjects for 4–6years, the signs/symptoms of OSA were
associated with a higher risk of incidence of TMD.This large-scale prospective
cohort study, a multicenter study, followed adults age 18–44years at enrollment for
2.8years. The goal was to identify the incidence of rst-onset TMD and potential
risk factors for TMD development. Initially, TMD-free adults with two or more
signs/symptoms of OSA had a 73% greater incidence of rst-onset TMD, in relative
terms, than adults with fewer signs/symptoms independently of confounding demographic, autonomic, and behavioral characteristics [113, 114]. OPPERA subjects at
risk for OSA had 1.7 times TMD incidence over the median 2.8-year follow-up
period, independently of demographic, autonomic, and behavioral characteristics
[110, 113, 115, 116].
Although the ndings indicated a signicant overlap between the OSA and
TMD, further studies are required to dene the nature of this relationship. Because
both OSA and TMD are associated with several comorbidities, the association
between OSA and TMD could be very complex [114].
We need consequently a large-scale cohort study that takes comorbidities into
the analyses.
These OPPERA studies lack OSA diagnosis through PSG which limits the interpretation of the results [110].
A recent case-control study found a higher prevalence of TMD in subjects at
high risk of OSA (30.7%) than with subjects at no risk of suffering OSA (18.5%).
However, the study may be skewed as many participants were classied as having
OSA by a sign or symptom questionnaire and may have milder forms of SDB such
as upper airway resistance syndrome (UARS) [110, 117].
Smith etal. demonstrated in their study that a great majority of their patients with
TMD complaints were diagnosed with at least one sleep disorder through a PSG
study. Insomnia (36%) and OSA (28.6%) showed the highest frequencies. Sleep
bruxism was also a comorbid sleep disorder in this TMD sample, although the frequencies varied from 75% to 17%, dependent of the clinical vs. PSG criteria for the
diagnosis of SB.Surprisingly about 43% of the sample were diagnosed with more
than just one sleep disturbance [118].
Several mechanisms might be underlying the close relationship between OSA
and TMD [119].
1. Disrupted or inadequate sleep in OSA patients might enhance pain sensitivity,
contributing to hyperalgesia, an important feature found in many TMD patients
[120, 121].
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