Sleep and Breathing

, Volume 16, Issue 1, pp 47–58 | Cite as

Cephalometry and prediction of oral appliance treatment outcome

  • Andrew Tze Ming Ng
  • M. Ali Darendeliler
  • Peter Petocz
  • Peter A. Cistulli
Original Article



Predicting which patients with obstructive sleep apnea (OSA) will be successfully treated with mandibular advancement splints (MAS) remains elusive. Developing simple daytime measurements and tests to predict treatment outcome would enhance MAS treatment.


The purpose of this study was to assess the clinical utility of anthropomorphic measurements and cephalometric X-rays in the prediction of MAS treatment outcome in OSA.


Anthropomorphic measurements and cephalometric X-rays from 72 OSA patients who had presented to a tertiary referral sleep clinic were analyzed retrospectively.


Treatment response was defined as ≥50% reduction in Apnea/Hypopnea Index (AHI; criterion 1); ≥50% reduction and residual AHI less than 20/h (criterion 2); ≥50% reduction in AHI and residual AHI less than 10/h (criterion 3); and ≥50% reduction in AHI and residual AHI less than 5/h (criterion 4). This was done to reflect the differences in the clinical definition of treatment success in the literature. A good response occurred in 56% (40 patients) according to criterion 1; 54% (39 patients) according to criterion 2; 46% (33 patients) according to criterion 3; or 39% (28 patients) according to criterion 4. Age and gender were found to be significant predictors for criteria 1 and 2. Age and soft palate length were found to be significant predictors for criteria 3 and 4. Equations to predict MAS treatment response were derived as equations were to predict final AHI.


Certain cephalometric and anthropomorphic measurements impact on MAS treatment outcome. This study adds to the current literature and implies that MAS success is (to some degree) related to anatomical characteristics.


Obstructive sleep apnea Mandibular advancement splint Oral appliance Prediction 



We wish to thank Dr Jin Qian, sleep laboratory manager of the Centre for Sleep Disorders and Respiratory Failure at St. George Hospital, for his assistance with sleep studies and data processing.

Conflict of interest

PAC contributed to the development of the oral appliance used on this study, which is being commercialized by SomnoMed Ltd, and was a consultant for the company 2004–2006. His department has received in-kind and/or financial support for sleep apnea research from SomonMed Ltd., ResMed Inc, and ExploraMed Inc.


  1. 1.
    Riley R, Guilleminault C, Herran J, Powell N (1983) Cephalometric analyses and flow volume loops in obstructive sleep apnea patients. Sleep 6:304–317Google Scholar
  2. 2.
    Haponik EF, Smith PL, Bohlman ME, Allen RP, Goldman SM, Bleecker ER (1983) Computerized tomography in obstructive sleep apnea: correlation of airway size with physiology during sleep and wakefulness. Am Rev Respir Dis 127:221–226PubMedGoogle Scholar
  3. 3.
    Crumley RL, Stein M, Gamsu G, Golden J, Dermon S (1987) Determination of obstructive site in obstructive sleep apnea. Laryngoscope 97:301–308PubMedCrossRefGoogle Scholar
  4. 4.
    Abbey NC, Block AJ, Green D, Mancuso A, Hellard DW (1989) Measurement of pharyngeal volume by digitized magnetic resonance imaging. Effect of nasal continuous positive airway pressure. Am Rev Respir Dis 140:717–723PubMedGoogle Scholar
  5. 5.
    Chan AS, Sutherland K, Schwab RJ, Zeng B, Petocz P, Lee RWW, Darendeliler MA, Cistulli PA (2010) The effect of mandibular advancement on upper airway structure in obstructive sleep apnoea. Thorax 65:726–732PubMedCrossRefGoogle Scholar
  6. 6.
    Suratt PM, Dee R, Atkinson RL, Armstrong P, Wilhoit SC (1983) Fluoroscopic and computed tomographic features of the pharyngeal airway in obstructive sleep apnea. Am Rev Respir Dis 127:487–492PubMedGoogle Scholar
  7. 7.
    Rivlin J, Hoffstein V, Kalbfleisch J, McNicholas W, Zamel N, Bryan AC (1984) Upper airway morphology in patients with idiopathic obstructive sleep apnea. Am Rev Respir Dis 129:355–360PubMedGoogle Scholar
  8. 8.
    Millman RP, Carlisle CC, Rosenberg C, Kahn D, McRae R, Kramer NR (2000) Simple predictors of uvulopalatopharyngoplasty in the treatment of obstructive sleep apnea. Chest 118:1025–1030PubMedCrossRefGoogle Scholar
  9. 9.
    Mehta A, Qian J, Petocz P, Darendeliler MA, Cistulli PA (2001) A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med 163:1457–1461PubMedGoogle Scholar
  10. 10.
    Eveloff SE, Rosenberg CL, Carlisle CC, Millman RP (1994) Efficacy of a Herbst mandibular advancement device in obstructive sleep apnea. Am J Respir Crit Care Med 149:905–909PubMedGoogle Scholar
  11. 11.
    Mayer G, Meier-Ewert K (1995) Cephalometric predictors for orthopaedic mandibular advancement in obstructive sleep apnoea. Eur J Orthod 17:35–43PubMedGoogle Scholar
  12. 12.
    Gotsopoulos H, Chen C, Qian J, Cistulli PA (2002) Oral appliance therapy improves symptoms in obstructive sleep apnea. Am J Respir Crit Care Med 166:743–748PubMedCrossRefGoogle Scholar
  13. 13.
    Naismith S, Winter V, Gotsopoulos H, Hickie I, Cistulli PA (2004) Neurobehavioral functioning in obstructive sleep apnea: differential effects of sleep quality, hypoxemia and subjective sleepiness. J Clin Exp Neuropsychol 26:43–54PubMedCrossRefGoogle Scholar
  14. 14.
    Chan AS, Cistulli PA (2009) Oral appliance treatment of obstructive sleep apnea: an update. Curr Opin Pulm Med Aug 25 (in press)Google Scholar
  15. 15.
    Guilleminault C, Riley R, Powell N (1984) Obstructive sleep apnea and abnormal cephalometric measurements. Chest 86:793–794PubMedCrossRefGoogle Scholar
  16. 16.
    Jamieson A, Guilleminault C, Partinen M, Quera-Salva MA (1986) Obstructive sleep apneic patients have craniomandibular abnormalities. Sleep 9:469–477PubMedGoogle Scholar
  17. 17.
    Houston WJ (1983) The analysis of errors in orthodontic measurements. Am J Orthod 83:382–390PubMedCrossRefGoogle Scholar
  18. 18.
    Zeng B, Ng AT, Darendeliler MA, Petocz P, Cistulli PA (2007) Use of flow-volume curves to predict oral appliance treatment outcome in obstructive sleep apnea. Am J Respir Crit Care Med 175:726–730PubMedCrossRefGoogle Scholar
  19. 19.
    Marklund M, Franklin KA, Stenlund H, Persson M (1998) Mandibular morphology and the efficacy of a mandibular advancement device in patients with sleep apnoea. Eur J Oral Sci 106:914–921PubMedCrossRefGoogle Scholar
  20. 20.
    Liu Y, Zeng X, Fu M, Huang X, Lowe AA (2000) Effects of a mandibular repositioner on obstructive sleep apnea. Am J Orthod Dentofacial Orthop 118:248–256PubMedCrossRefGoogle Scholar
  21. 21.
    Linder-Aronson S (1970) Adenoids, their effects on mode of breathing and nasal airflow and their relationship to characteristics of their facial skeleton and the dentition. A biometric, rhino-manometric and cephalometro-radiographic study on children with and without adenoids. Acta Otolaryngol 265:1–132Google Scholar
  22. 22.
    Solow B, Siersbaek-Nielson S, Greve E (1984) Airway adequacy, head posture, and craniofacial morphology. Am J Orthod 86:214–223PubMedCrossRefGoogle Scholar
  23. 23.
    Tomes CS (1873) The bearing of the development of the jaws on irregularities. Dent Cosmos 115:292–296Google Scholar
  24. 24.
    Linder-Aronson S (1985) The physiologic basis of functional appliances: the role of respiration. In: Grabe TM (ed) Physiologic principles of fundamental appliances. CV Mosby Co, St Louis, pp 5–11Google Scholar
  25. 25.
    Guilleminault C, Partinen M, Praud JP, Saby MA, Chambille B, Dehan M, Gaultier C (1989) Morphometric facial changes and obstructive sleep apnea in adolescents. J Pediatr 114:997–999PubMedCrossRefGoogle Scholar
  26. 26.
    Vargervik K, Harvold EP (1987) Experiments on the interaction between orofacial function and morphology. Ear Nose Throat J 66:201–208PubMedGoogle Scholar
  27. 27.
    Vargervik K, Miller AJ, Chierici G, Harvold E, Tomer BS (1984) Morphologic response to changes in neuromuscular patterns experimentally induced by altered modes of respiration. Am J Orthod 85:115–124PubMedCrossRefGoogle Scholar
  28. 28.
    Liu Y, Lowe AA, Fleetham JA, Park YC (2001) Cephalometric and physiological predictors of the efficacy of an adjustable oral appliance for treating obstructive sleep apnea. Am J Orthod Dentofacial Orthop 120:639–647PubMedCrossRefGoogle Scholar
  29. 29.
    Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA (2004) Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Med Rev 8:443–457PubMedCrossRefGoogle Scholar
  30. 30.
    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
  31. 31.
    Marklund M, Stenlund H, Franklin KA (2004) Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring: tolerability and predictors of treatment success. Chest 125:1270–1278PubMedCrossRefGoogle Scholar
  32. 32.
    O'Sullivan RA, Hillman DR, Mateljan R, Pantin C, Finucane KE (1995) Mandibular advancement splint: an appliance to treat snoring and obstructive sleep apnea. Am J Respir Crit Care Med 151:194–198PubMedGoogle Scholar
  33. 33.
    Schmidt-Nowara WW, Lowe A, Wiegand L, Cartwright R, Perez-Guerra F, Menn S (1995) Oral appliances for the treatment of snoring and obstructive sleep apnea: a review. Sleep 18:501–510PubMedGoogle Scholar
  34. 34.
    Lowe AA (2000) Oral appliances for sleep breathing disorders. In: Kryger MH, Roth T, Dement WC (eds) Principles and practice of sleep medicine, 3rd edn. WB Saunders Co, Philadelphia, pp 929–939Google Scholar
  35. 35.
    Clark GT, Arand D, Chung E, Tong D (1993) Effect of anterior mandibular positioning on obstructive sleep apnoea. Am Rev Respir Dis 147:624–629PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Andrew Tze Ming Ng
    • 1
  • M. Ali Darendeliler
    • 2
  • Peter Petocz
    • 3
  • Peter A. Cistulli
    • 4
  1. 1.Centre for Sleep Disorders and Respiratory FailureSt. George HospitalSydneyAustralia
  2. 2.Faculty of DentistryUniversity of SydneySydneyAustralia
  3. 3.Department of StatisticsMacquarie UniversitySydneyAustralia
  4. 4.Centre for Sleep Health and Research, Department of Respiratory MedicineRoyal North Shore HospitalSydneyAustralia

Personalised recommendations