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Objective: To survey potential predictors of success of mandibular advancement device (MAD) therapy in patients with obstructive sleep apnea (OSA), and in particular, to examine anatomical narrowings and sleep-related collapse levels in the upper airway., Methods: This was a prospective study of 62 OSA patients (median apnea-hypopnea index [AHI] of 34), who were treated with a custom-made, monobloc MAD. The upper airway was examined by inspection, nasopharyngoscopy, overnight acoustic reflectometry recording collapses, and cephalometry of soft tissue dimensions (in addition to skeletal parameters). MAD treatment was controlled by polysomnograpy before and after at least five weeks from the beginning of treatment. Independent predictors of actual reduction in AHI and treatment success (reduction in AHI ≥ 50% with residual AHI < 10) were determined, using multivariable linear and logistic regression., Results: Positional OSA (POSA) and nonsupine AHI (adjusted for upper airway narrowness and collapses, together with gender, age, body mass index, neck circumference, and baseline AHI) were the only independent predictors: POSA indicative for success, and nonsupine AHI inversely related to success. Cephalometry was not predictive. Two predictive models were proposed, one based on POSA having a specificity of 70% and sensitivity of 69%, and the other based on nonsupine AHI, generating a receiver operating characteristic (ROC) curve (area under ROC = 0.78). Using the ROC model, specificity could be increased to 80% without lowering sensitivity., Conclusions: Only variables related to sleep position proved to be independent predictors of success with MAD therapy. The results could be explained by the MAD counteracting the mandible from moving backwards when sleeping supine., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Patients with obstructive sleep apnoea (OSA) in long-term treatment with a mandibular advancement device (MAD) to increase the upper airway space may develop changes in the temporomandibular joint (TMJ) and the oro-facial function due to the protruded jaw position during sleep. The aim was to investigate the influence of long-term MAD treatment on the TMJs, oro-facial function and occlusion. This prospective study included 30 men and 13 women (median age 54) with OSA [Apnoea-Hypopnoea Index (AHI): 7-57]. They were examined with the Nordic Orofacial Test Screening (NOT-S), the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and cone beam computed tomography (CBCT) of the TMJs. The examination was performed before MAD treatment (T0), and 3-6 months (T1, no CBCT), 1 year (T2) and 3 years (T3) after treatment start. The results were analysed as long term (T0-T3, n = 14) and short term (T0-T2, n = 24) by t-test, Fisher's exact test and anova. Both long- and short-term analyses revealed a reduction in AHI (P < 0·002). Significant long term were increased scores in the NOT-S Interview (P < 0·045), reduced vertical overbite (P < 0·031) and increased jaw protrusive movement (P < 0·027). TMJ changes were found as joint sounds in terms of reciprocal clicking and crepitus, short term as a decrease and subsequent recurrence (P < 0·053; P < 0·037). No significant radiological changes were found. In conclusion, MAD treatment is beneficial to some OSA patients, but might induce changes in the TMJs, the oro-facial function and the occlusion. However, these changes seemed to be less harmful than previously reported with careful adaptation, control and follow-ups., (© 2017 John Wiley & Sons Ltd.)

Background/objectives: The aim of the study was to assess cephalometric predictive markers in terms of craniofacial morphology including posterior cranial fossa and upper spine morphology for mandibular advancement device (MAD) treatment outcome in patients with obstructive sleep apnoea (OSA)., Material/methods: Twenty-seven OSA patients were treated with MAD for 4 weeks. Apnoea-hypopnoea index (AHI) was recorded before and after MAD treatment. The criteria of treatment success were 75 per cent reduction of AHI. Accordingly, two groups occurred: the success treatment group of 8 patients and the no success treatment group of 19 patients. Before MAD treatment lateral cephalograms were taken and analyses of the craniofacial morphology including the posterior cranial fossa and upper spine morphology were performed. Differences between the groups were analysed by Fisher's exact test, t-test, and multiple regression analysis., Results: Upper spine morphological deviations occurred non-significantly in 25 per cent in the success treatment group and in 42.1 per cent in the no success treatment group. Body mass index (BMI; P < 0.05), maxillary prognathism (S-N-Ss; P < 0.01), mandibular prognathism (S-N-Pg; P < 0.05 and S-N-Sm; P < 0.01), and the distance between sella turcica and the deepest point in posterior cranial fossa (S-D; P < 0.05) was significantly smaller in the success treatment group. The maxillary prognathism (P < 0.05) was the most important factor for the MAD treatment outcome (R (2) = 0.47)., Limitations: Relatively small sample size., Conclusions: The results indicate that BMI, posterior cranial fossa morphology, and retrognathia of the jaws are factors related to MAD treatment outcome. Furthermore, OSA patients with upper spine morphological deviations may respond poorer to MAD treatment., (© The Author 2014. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: Few studies have described morphological deviations in obstructive sleep apnoea (OSA) patients on two-dimensional (2D) lateral cephalograms, and the reliability of 2D radiographs has been discussed. The objective is to describe the morphology of the cervical vertebral column on cone beam CT (CBCT) in adult patients with OSA and to compare 2D lateral cephalograms with three-dimensional (3D) CBCT images., Methods: For all 57 OSA patients, the cervical vertebral column morphology was evaluated on lateral cephalograms and CBCT images and compared according to fusion anomalies and posterior arch deficiency., Results: The CBCT assessment showed that 21.1% had fusion anomalies of the cervical column, i.e. fusion between two cervical vertebrae (10.5%), block fusions (8.8%) or occipitalization (1.8%). Posterior arch deficiency occurred in 14% as partial cleft of C1 and in 3.5% in combination with block fusions. The agreement between the occurrence of morphological deviations in the cervical vertebral column between lateral cephalograms and CBCT images showed good agreement (κ = 0.64)., Conclusions: Prevalence and pattern in the cervical column morphology have now been confirmed on CBCT. The occurrence of morphological deviations in the cervical vertebral column showed good agreement between lateral cephalograms and CBCT images. This indicates that 2D lateral cephalograms (already available after indication in connection with, e.g. treatment planning) are sufficient for identifying morphological deviations in the cervical vertebral column. For a more accurate diagnosis and location of the deviations, CBCT is required. New 3D methods will suggest a need for new detailed characterization and division of deviations in cervical vertebral column morphology.

Cervical column morphology was examined in adult patients with obstructive sleep apnoea (OSA) and compared with the cervical morphology of an adult control group with neutral occlusion, normal craniofacial morphology, and no history of sleep apnoea. The sleep apnoea group consisted of 91 patients, 16 females aged 29-59 years (mean 49.4 years) and 75 males aged 27-65 years (mean 49.0 years). All patients were diagnosed with OSA by overnight polysomnography. The control group consisted of 21 subjects, 15 females aged 23-40 years (mean 29.2 years) and 6 males aged 25-44 years (mean 32.8 years). From each individual, a visual assessment of the cervical column was performed on the radiograph. Differences in the cervical column morphology, between the genders and the groups were assessed by Fisher's exact test and the effect of age by logistic regression analysis. In the OSA group, 46.2 per cent had fusion anomalies of the cervical column and 5.5 per cent a posterior arch deficiency. Fusion anomalies occurred in 26.4 per cent as fusions between two cervical vertebrae. Block fusions occurred in 12.1 per cent and occipitalization in 14.3 per cent. A posterior arch deficiency occurred in 2.2 per cent as a partial cleft of C1 and in 3.3 per cent as dehiscence of C3 and C4. No statistical gender differences were found in the occurrence of morphological characteristics of the cervical column. The fusion anomalies of the cervical column occurred significantly more often in the OSA group. The results indicate that the morphological deviations of the upper cervical vertebrae play a role in the phenotypical subdivision and diagnosis of OSA.

The aim of this trial was to evaluate the efficacy of a mandibular advancement appliance (MAA) for obstructive sleep apnoea (OSA). Ninety-three patients with OSA and a mean apnoea-hypopnoea index (AHI) of 34.7 were centrally randomised into three, parallel groups: (a) MAA; (b) mandibular non-advancement appliance (MNA); and (c) no intervention. The appliances were custom made, in one piece. The MAAs had a mean protrusion of the mandible of 74% (range 64-85%). Outcome measures, assessed after continuous use for 4 weeks, were AHI (polysomnography), daytime sleepiness (Epworth) and quality of life (SF-36). Eighty-one patients (87%) completed the trial. The MAA group achieved mean AHI and Epworth scores significantly lower (P < 0.001 and P < 0.05) than the MNA group and the no-intervention group. No significant differences were found between the MNA group and the no-intervention group. The MAA group had a mean AHI reduction of 14.1 (95% CI 7.4-20.8), and a mean Epworth score reduction of 3.3 (95% CI 1.8-4.8). Eight MAA patients (30%) achieved a reduction in AHI > or = 75% ending with an AHI < 5, half of them having baseline AHI > 30. Sensitivity analyses confirmed these results. MAA had a significant beneficial effect on the vitality domain of SF-36. Four MAA patients (14.8%) and two MNA patients (8%) discontinued interventions because of adverse effects. Our conclusion is that MAA has significant beneficial effects on OSA, including cure in some cases of severe OSA. Protrusion of the mandible is essential for the effect. MNA has no placebo effect. MAA may be a good alternative to CPAP in subsets of OSA patients.