Clinical Oral Investigations

, Volume 14, Issue 3, pp 339–345 | Cite as

Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea

  • Ghizlane AarabEmail author
  • Frank Lobbezoo
  • Hans L. Hamburger
  • Machiel Naeije
Original Article


The aim of the study was to assess the influence of four mandibular protrusion positions, at a constant vertical dimension, on obstructive sleep apnea (OSA). Seventeen OSA patients (49.2 ± 8.5 years) received an adjustable mandibular advancement device (MAD). The patients underwent four polysomnographic recordings with their MAD in situ at, in random order, 0%, 25%, 50%, and 75% of the maximum protrusion. The mean apnea–hypopnea index (AHI) values of the patients differed significantly between the protrusion positions (P < 0.000). The 25% protrusion position resulted in a significant reduction of the AHI with respect to the 0% position, while in the 50% and 75% positions, even lower AHI values were found. The number of side effects was larger starting at the 50% protrusion position. We therefore recommend coming to a weighted compromise between efficacy and side effects by starting a MAD treatment in the 50% protrusion position.


Obstructive sleep apnea Oral appliance Mandibular advancement device Protrusion Vertical dimension 



The authors would like to thank the staff of the Center for Sleep–Wake Disorders of Slotervaart Medical Center in Amsterdam, The Netherlands for their assistance with this work. The Netherlands Institute for Dental Sciences (IOT) supported this work.

Conflict of interest

All authors declare that they have no conflict of interest in this study.


  1. 1.
    Aarab G, Lobbezoo F, Wicks DJ, Hamburger HL, Naeije M (2005) Short-term effects of a mandibular advancement device on obstructive sleep apnoea: an open-label pilot trial. J Oral Rehabil 32:564–570CrossRefPubMedGoogle Scholar
  2. 2.
    American Academy of Sleep Medicine Task Force (1999) Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep 22:667–689Google Scholar
  3. 3.
    Cartwright RD (1984) Effect of sleep position on sleep apnea severity. Sleep 7:110–114PubMedGoogle Scholar
  4. 4.
    Dworkin SF, LeResche L (1992) Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord 6:301–355PubMedGoogle Scholar
  5. 5.
    Engleman HM, McDonald JP, Graham D, Lello GE, Kingshott RN, Coleman EL, Mackay TW, Douglas NJ (2002) Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Am J Respir Crit Care Med 166:855–859CrossRefPubMedGoogle Scholar
  6. 6.
    Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W (2006) Oral appliances for snoring and obstructive sleep apnea: a review. Sleep 29:244–262PubMedGoogle Scholar
  7. 7.
    Fritsch KM, Iseli A, Russi EW, Bloch KE (2001) Side effects of mandibular advancement devices for sleep apnea treatment. Am J Respir Crit Care Med 164:813–818PubMedGoogle Scholar
  8. 8.
    Gagnon Y, Mayer P, Morisson F, Rompré PH, Lavigne GJ (2004) Aggravation of respiratory disturbances by the use of an occlusal splint in apneic patients: a pilot study. Int J Prosthodont 17:447–453PubMedGoogle Scholar
  9. 9.
    George PT (2001) Selecting sleep-disordered-breathing appliances: biomechanical considerations. J Am Dent Assoc 132:339–347PubMedGoogle Scholar
  10. 10.
    Giles T, Lasserson T, Smith B, White J, Wright J, Cates C (2006) Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev Issue 3:CD001106Google Scholar
  11. 11.
    Gotsopoulos H, Chen C, Qian J, Cistulli PA (2002) Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, controlled trial. Am J Respir Crit Care Med 166:743–748CrossRefPubMedGoogle Scholar
  12. 12.
    Hoekema A, Stegenga B, de Bont LG (2004) Efficacy and co-morbidity of oral appliances in the treatment of obstructive sleep apnea–hypopnea: a systematic review. Crit Rev Oral Biol Med 15:137–155CrossRefPubMedGoogle Scholar
  13. 13.
    Hoffstein V (2007) Review of oral appliances for treatment of sleep-disordered breathing. Sleep Breath 11:1–22CrossRefPubMedGoogle Scholar
  14. 14.
    Holm S (1979) A simple sequentially rejective multiple test procedure. Scand J Statist 6:65–70Google Scholar
  15. 15.
    Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14:540–545PubMedGoogle Scholar
  16. 16.
    Johns MW (1993) Daytime sleepiness, snoring and obstructive sleep apnea: the Epworth sleepiness scale. Chest 103:30–36CrossRefPubMedGoogle Scholar
  17. 17.
    Kato J, Isono S, Tanaka A, Watanabe T, Araki D, Tanzawa H, Nishino T (2000) Dose-dependent effects of mandibular advancement on pharyngeal mechanics and nocturnal oxygenation in patients with sleep-disordered breathing. Chest 117:1065–1072CrossRefPubMedGoogle Scholar
  18. 18.
    Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP, American Academy of Sleep (2006) Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 29:240–243PubMedGoogle Scholar
  19. 19.
    Lobbezoo F, van Selms MK, John MT, Huggins K, Ohrbach R, Visscher CM, van der Zaag J, van der Meulen MJ, Naeije M, Dworkin SF (2005) Use of the research diagnostic criteria for temporomandibular disorders for multinational research: translation efforts and reliability assessments in The Netherlands. J Orofac Pain 19:301–308PubMedGoogle Scholar
  20. 20.
    Lowe AA, Sjöholm TT, Ryan CF, Fleetham JA, Ferguson KA, Remmers JE (2000) Treatment, airway and compliance effects of a titratable oral appliance. Sleep 23:S172–S178PubMedGoogle Scholar
  21. 21.
    McArdle N, Devereux G, Heidarnejad H, Engleman HM, Mackay TW, Douglas NJ (1999) Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med 159:1108–1114PubMedGoogle Scholar
  22. 22.
    Meurice JC, Marc I, Carrier G, Sériès F (1996) Effects of mouth opening on upper airway collapsibility in normal sleeping subjects. Am J Respir Crit Care Med 153:255–259PubMedGoogle Scholar
  23. 23.
    Miyamoto K, Ozbek MM, Lowe AA, Sjöholm TT, Love LL, Fleetham JA, Ryan CF (1999) Mandibular posture during sleep in patients with obstructive sleep apnoea. Arch Oral Biol 44:657–664CrossRefPubMedGoogle Scholar
  24. 24.
    Morin CM (2005) Psychological and behavioral treatments for primary insomnia. In: Kryger MH, Roth T, Dement WC (eds) Principles and practice of sleep medicine, 4th edn. Saunders, Philadelphia, pp 726–737Google Scholar
  25. 25.
    Neill A, Whyman R, Bannan S, Jeffrey O, Campbell A (2002) Mandibular advancement splint improves indices of obstructive sleep apnoea and snoring but side effects are common. N Z Med J 115:289–292PubMedGoogle Scholar
  26. 26.
    Ng AT, Gotsopoulos H, Qian J, Cistulli PA (2003) Effect of oral appliance therapy on upper airway collapsibility in obstructive sleep apnea. Am J Respir Crit Care Med 168:238–241CrossRefPubMedGoogle Scholar
  27. 27.
    Rechtschaffen A, Kales A (1968) A manual of standardized terminology, techniques and scoring systems for sleep stages of human subjects. Brain Information Service/Brain Research Institute, UCLA, Los AngelesGoogle Scholar
  28. 28.
    Roehrs T, Carskadon MA, Dement WC, Roth T (2005) Daytime sleepiness and alertness. In: Kryger M, Roth T, Dement WC (eds) Principles and practice of sleep medicine. Elsevier, Amsterdam, pp 39–50CrossRefGoogle Scholar
  29. 29.
    Strollo PJ, Atwood CW, Sanders MH (2005) Medical therapy for obstructive sleep apnea–hypopnea syndrome. In: Kryger MH, Roth T, Dement WC (eds) Priniciples and practice of sleep medicine, 4th edn. Saunders, Philadelphia, p 1053Google Scholar
  30. 30.
    Tegelberg A, Walker-Engström ML, Vestling O, Wilhelmsson B (2003) Two different degrees of mandibular advancement with a dental appliance in treatment of patients with mild to moderate obstructive sleep apnea. Acta Odontol Scand 61:356–362CrossRefPubMedGoogle Scholar
  31. 31.
    Walker-Engström ML, Ringqvist I, Vestling O, Wilhelmsson B, Tegelberg A (2003) A prospective randomized study comparing two different degrees of mandibular advancement with a dental appliance in treatment of severe obstructive sleep apnea. Sleep Breath 7:119–130CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Ghizlane Aarab
    • 1
    Email author
  • Frank Lobbezoo
    • 1
  • Hans L. Hamburger
    • 2
  • Machiel Naeije
    • 1
  1. 1.Department of Oral FunctionAcademic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University AmsterdamAmsterdamThe Netherlands
  2. 2.Department of Clinical Neurophysiology and Center for Sleep–Wake DisordersSlotervaart Medical CenterAmsterdamThe Netherlands

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