Sleep and Breathing

, Volume 11, Issue 4, pp 225–231 | Cite as

Titratable mandibular repositioner appliances for obstructive sleep apnea syndrome: are they an option?

  • Marco Antonio Cardoso MachadoEmail author
  • Ligia Juliano
  • Marcel Taga
  • Luciane Bizari Coin de Carvalho
  • Lucila Bizari Fernandes do Prado
  • Gilmar Fernandes do Prado
Original Article


Mandibular repositioning appliances (tMRAs) designed with a titratable mechanism are effective to treat obstructive sleep apnea syndrome (OSAS) but are not widely used, although many studies have proven their value. The aim of the present study was to evaluate the efficacy of tMRAs in the treatment of OSAS on the criteria of the American Academy of Sleep Medicine (AASM; apnea/hypopnea index [AHI] < 5). Three hundred consecutive patients with a polysomnographic diagnosis of OSAS were referred for treatment with tMRAs between 2000 and 2003. Thirty-eight patients were excluded, and 262 concluded the titration protocol with tMRA that lasted 4 months. After titration, the patients were referred for a medical reassessment, and 83 patients (70 men) participated in the new polysomnographic exam with tMRA in place to access tMRA’s efficacy. The mean pre- and post-treatment AHI were 26 ± 17.7 and 4.8 ± 5.3 events per hour, respectively (p < 0.00005). Fifty-three (62.6%) of the 83 patients were treated successfully (AHI < 5). Twenty-three patients had severe OSAS, and 12 of them (52.1%) were treated successfully (AHI < 5). Forty patients had moderate OSAS, and 26 of them (65%) were treated successfully. Twenty patients had mild OSAS, and 15 (75%) were successfully treated. Even when applying more rigid criteria such as those of the AASM, the expressive success rate obtained with the treatment of different degrees of OSAS indicates that tMRAs are an additional valuable option even for cases of severe apnea in which the patient does not tolerate continuous positive airway pressure or cannot afford this treatment, a fact quite common in Brazil and other developing countries.


Sleep apnea OSAS Snoring Oral appliances Adults 



We would like to thank Mr. David George Elliff for the English translation.


  1. 1.
    Peppard PE, Young T, Palta M, Skatrud J (2000) Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 342(19):1378–1384PubMedCrossRefGoogle Scholar
  2. 2.
    Hoffstein V, Rubinstein I, Mateka S, Slutsky AS (1988) Determinants of blood pressure in snorers. Lancet 29:992–994CrossRefGoogle Scholar
  3. 3.
    Becker HF, Jerrentrup A, Ploch T et al (2003) Effect of nasal continuous positive airway treatment on blood pressure in patients with obstructive sleep apnea. Circulation 107:68–73PubMedCrossRefGoogle Scholar
  4. 4.
    The report of an 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
  5. 5.
    Stepnowsky CJ, Marler MR, Ancoli-Israel S (2002) Determinants of nasal CPAP compliance. Sleep Med 3:239–247PubMedCrossRefGoogle Scholar
  6. 6.
    Kribbs NB, Pack AI, Kline LR et al (1993) Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 147(4):887–895PubMedGoogle Scholar
  7. 7.
    Yaggi HK, Concato J, Kernan WN et al (2005) Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 353(19):2034–2041PubMedCrossRefGoogle Scholar
  8. 8.
    Mayer G, Meier-Ewert K (1995) Cephalometric predictors for orthopaedic mandibular advancement in obstructive sleep apnoea. Eur J Orthod 17:35–43PubMedGoogle Scholar
  9. 9.
    Ivanhoe JR, Attanasio R (2001) Sleep disorders and oral devices. Dent Clin North Am 45(4):733–758PubMedGoogle Scholar
  10. 10.
    De Almeida FR, Lowe AA, Otsuka R et al (2006) Long-term sequelae of oral appliance therapy in obstructive sleep apnea patients. Part 2: study model analysis. Am J Orthod Dentofac Orthop 129(2):205–213CrossRefGoogle Scholar
  11. 11.
    Kato J, Isono S, Tanaka A et al (2000) Dose-dependent effects of mandibular advancement on pharyngeal mechanics and nocturnal oxygenation in patients with sleep-disordered breathing. Chest 117(4):1065–1072PubMedCrossRefGoogle Scholar
  12. 12.
    Ferguson KA, Lowe AA (2005) Oral appliances for sleep-disordered breathing. In: Kryger MH, Roth T, Dement WC (eds) Principles and practice of sleep medicine, 4th edn. Elsevier Saunders, Philadelphia, USA, pp 1098–1108Google Scholar
  13. 13.
    Ng AT, Gotsopoulos H, Qian J, Cistulli PA (2003) Effect of oral appliance therapy on upper airway collapsibility in OSA. Am J Respir Crit Care Med 168:238–241PubMedCrossRefGoogle Scholar
  14. 14.
    Engleman HM, McDonald JP, Graham D (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 166:855–859PubMedCrossRefGoogle Scholar
  15. 15.
    Gotsopoulos H, Chen C, Qian J, Cistulli PA (2002) Oral appliance therapy improves symptoms in OSAS: a randomized, controlled trial. Am J Respir Crit Care Med 166:743–748PubMedCrossRefGoogle Scholar
  16. 16.
    Rechtschaffen A, Kales A (1968) A manual of standardized terminology, techniques and scoring system for sleep stages of human subjects. NIH Publication 204. US Government printing office, Department of Health Education welfare, WashingtonGoogle Scholar
  17. 17.
    Machado MA, Carvalho LB, Juliano ML et al (2006) Clinical co-morbidities in obstructive sleep apnea syndrome treated with mandibular repositioning appliance. Respir Med 100(6):988–995 (Jun)PubMedCrossRefGoogle Scholar
  18. 18.
    Lowe AA, Sjoholm TT, Ryan CF et al (2000) Treatment, airway and compliance effects of a titratable oral appliance. Sleep 23:172–178Google Scholar
  19. 19.
    Machado MAC, Carvalho LBC, Francisco S et al (2004) Quality of life of patients with obstructive sleep apnea syndrome treated with an intraoral mandibular repositioner. Arq Neuro-Psiquiatr 62:222–225CrossRefGoogle Scholar
  20. 20.
    Neter J, Kutner MH, Nashtsheim CJ, Wasserman W (1996) Applied linear statistical models, 4th edn. McGraw-Hill, Boston, pp 1408Google Scholar
  21. 21.
    Barnes M, McEvoy RD, Banks S et al (2004) Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 170:656–664PubMedCrossRefGoogle Scholar
  22. 22.
    Ferguson KA, Ono T, Lowe AA (1996) A randomized crossover study of an oral appliance vs CPAP in the treatment to mild–moderate OSAS. Chest 109:1269–1275PubMedGoogle Scholar
  23. 23.
    Ferguson KA, Ono T, Lowe AA et al (1997) A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnea. Thorax 52:362–368PubMedCrossRefGoogle Scholar
  24. 24.
    O’Sullivan RA, Hillman DR, Mateljan R et al (1995) Mandibular advancement splint: an appliance to treat snoring and obstructive sleep apnea. Am J Respir Crit Care Med 151:194–198PubMedGoogle Scholar
  25. 25.
    Clark GT, Blumenfeld I, Yoffe N et al (1996) A crossover study comparing the efficacy of CPAP with anterior mandibular positioning devices on patients with OSA. Chest 109:1477–1483PubMedGoogle Scholar
  26. 26.
    Randerath WJ, Heise M, Hinz R, Ruehle KH (2002) An individually adjustable oral appliance vs CPAP in mild-to-moderate OSAS. Chest 122:569–575PubMedCrossRefGoogle Scholar
  27. 27.
    Engleman HM, Kingshott RN, Wraith PK et al (1999) Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep apnea hypopnea syndrome. Am J Respir Crit Care Med 159:461–467PubMedGoogle Scholar
  28. 28.
    Pancer J, Al-Faifi S, Al-Faifi M, Hoffstein V (1999) Evaluation of variable mandibular advancement appliance for treatment of snoring and sleep apnea. Chest 116(6):1511–1518PubMedCrossRefGoogle Scholar
  29. 29.
    Walker-Engstrom ML, Tegelberg A, Wilhelmsson B, Ringqvist I (2002) 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea. Chest 121(3):739–746PubMedCrossRefGoogle Scholar
  30. 30.
    Marklund M, Sahlin C, Stenlund H et al (2001) Mandibular advancement device in patients with OSAS: long term effects on apnea and sleep. Chest 120:162–169PubMedCrossRefGoogle Scholar
  31. 31.
    Reeves-Hoche MK, Meck R, Zwillich CW (1994) Nasal CPAP: an objective evaluation of patient compliance. Am J Respir Crit Care Med 149(1):149–154PubMedGoogle Scholar
  32. 32.
    Fransson AM, Tegelberg A, Leissner L et al (2003) Effects of a mandibular protruding device on the sleep of patients with obstructive sleep apnea and snoring problems: a 2-year follow-up. Sleep Breath 7(3):131–141PubMedCrossRefGoogle Scholar
  33. 33.
    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(4):1270–1278PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Marco Antonio Cardoso Machado
    • 1
    Email author
  • Ligia Juliano
    • 1
  • Marcel Taga
    • 1
  • Luciane Bizari Coin de Carvalho
    • 1
  • Lucila Bizari Fernandes do Prado
    • 1
  • Gilmar Fernandes do Prado
    • 1
  1. 1.Departments of Neurology and Internal MedicineFederal University of São PauloSão PauloBrazil

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