Human spend one-third of their lives sleeping. #1 sleep disorder is insomnia, #2 obstructive sleep apnea (OSA) OSA is intermittent closure of the upper airway that results in oxygen desaturation. Prevalence 9% to 38%. #1 cause in adult is obesity. Other factors retrognathia and poor muscular tone. Diagnosed by polysomnography (PSG). Mild OSA is AHI 5-15 events/hour. Moderate 15-30, severe > 30 per hour.
Main treatment is continuous positive airway pressure (CPAP) keeps airway open through continuous airway pressure, high efficacy; however, compliance is poor due to mouth dryness, chest discomfort, difficulty in nasal breathing, and inconvenience. There is BIPAP. An alternative option for the treatment of OSA is oral appliances (OAs), such as mandibular advancement devices (MADs).
Case Presentation
34-year-old male “I need a mouthpiece to treat my snoring and sleep apnea”. Height 190 cm, weight 99 kg, BMI 27.4 kg/m2. Symptoms snoring, morning headache, excessive daytime sleepiness, unrefreshed sleep, fatigue, and low mood throughout the day. AHI 71/hour, REM AHI 109/hour. No central apnea events. During sleep study, on CPAP pressure of 8 cmH2O, AHI dropped to 2/hour. However, patient was intolerant to CPAP. Alternative were MAD and surgical options such as uvulopalatopharyngoplasty (UPPP) and maxillo-mandibular advancement (MMA). The patient preferred the option of non-surgical MAD.
Baseline PSG. AHI 71/hr REM AHI 109/hr
On CPA. AHI 2/hr. REM AHI 6.5
POn MAD AHI 2/hr RM AHI 1/hr
Straight profile with short chin-to-throat length. Upper and lower lips were retruded to the esthetic line. Mild facial asymmetry, mandible shifted to right. Neck circumference increased. Class I molar relationship on the left side, right side was in class III relationship (Figure 1). Both canines in class I. Anterior crossbite between teeth #12 and #43. Lower midline shifted to right. Overbite was relatively deep with 70% overlap of the lower incisors. Lower teeth were severely crowded. Tooth #46 was missing and tooth #17 was over-erupted. Indentations on the sides of tongue, reflecting relative macroglossia. The protrusion range of mandible was 12 mm.
The panoramic radiograph showed upper posterior crowding at the upper left third molar area, missing tooth #47 and impaction of the lower left third molar
Patient request to manage OSA and postpone treatment of malocclusion. Mandibular advancement device design with starting protrusion of mandible 60% of the protrusion range, using a 17 mm blue elastic strap.
After one week, patient reported improvement; however, there were remaining snoring reported by his bed partner. Further advancement using a 16 mm clear strap. After three weeks, OSA symptoms disappeared. No more snoring or daytime symptoms such as morning headache, excessive daytime sleepiness, fatigue, or low mood. Follow-up PSG to confirm the improvement in sleep quality.
Figure 3: The elastomeric mandibular advancement device used to position the mandible in a forward position.
Figure 4: The normal and protruded position of the mandible with the EMA device
EMA: Elastomeric Mandibular Advancement
Patient’s weight increased from 99 kg to 108 kg, the follow-up PSG showed AHI dropped from 71/hour to 2/hour with similar efficacy as the 8 cmH2O CPAP. REM-AHI dropped from 109/hour to 1/hour. The patient was scheduled for a yearly follow-up to fabricate a new appliance if needed.
Periodic follow-up to ensure effectiveness and observe side effects of MADs (proclination of the lower incisors, retroclination of the upper incisors, and posterior open bite) common during treatment. To decrease these by using morning repositioning splint (MRS) worn by the patient for 15-30 minutes in the morning after waking up. Other side effects of MADs including jaw muscle discomfort and sore teeth, transient and decrease with time.
Factors contributed to successful management of severe OSA. Locate the position of obstruction, such as drug-induced sleep endoscopy (DISE). A basic assessment by an ENT indicated no nasal obstruction. Our patient had retruded mandible with macroglossia. The amount of protrusion range; our patient has 12-13 mm of protrusion range that allowed for forward positioning of mandible during sleep. Amount of advancement was just 7-8 mm. Other factors, include use of titratable devices, periodic follow-ups, a relatively young patient, and a low BMI.