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Comparative efficacy of mandibular advancement devices in obstructive sleep apnea: a network meta-analysis

  • Sleep Breathing Physiology and Disorders • Original Article
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Abstract

Purpose

To analyze relative efficacies of mandibular advancement devices (MAD) in sleep apnea treatment.

Methods

From eligible randomized controlled trials (RCT), MADs were classified based on their mechanistic designs. Data on apnea–hypopnea index (AHI), Epworth sleepiness scale (ESS), nadir oxygen saturation (minSaO2), and sleep efficiency (SE%) from RCTs were then analyzed in network meta-analyses, and relative ranking of different MADs was computed based on P scores (a method of ranking similar to SUCRA). Similar analyses were conducted based on the different brands of MADs.

Results

There were no statistically significant differences between MADs in any of the outcomes analyzed. However, the P-scores, based on the point estimates and standard errors of the network estimates, ranked some MADs higher than others in some of the outcomes. Of the different mechanistic designs, the highest P scores were achieved for attached midline traction (P score = 0.84) and unattached bilateral interlocking (P score = 0.78) devices for AHI reduction, attached bilateral traction (P score = 0.78) and unattached bilateral interlocking (P score = 0.76) for ESS, monobloc (P score = 0.91) and unattached bilateral interlocking (P score = 0.64) for minSaO2, and unattached bilateral interlocking (P score = 0.82) and attached bilateral traction (P score = 0.77) for SE%. Notable findings in the network meta-analyses based on MAD brands, of the limited number of studies that specified them were the effects of SomnoDent Flex™, TAP™, and IST® in their effects on AHI reduction, with P scores of 0.94, 0.83, and 0.82, respectively. Monobloc decreased supine-AHI the most (− 44.46 [− 62.55; − 26.36], P score = 0.99), and unattached bilateral interlocking had the greatest effect on REM-AHI (− 11.10 [− 17.10; − 5.10], P score = 0.87).

Conclusions

Findings from this study show clinically (but not statistically) significant differences between MADs in terms of their relative efficacy when analyzed for different sleep apnea treatment outcomes and sleep apnea phenotypes.

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Data availability

On reasonable request, data can be made available.

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Author information

Authors and Affiliations

  1. Department of Medicine, Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University School of Medicine, Atlanta, USA

    Imran H. Iftikhar

  2. Atlanta Veterans Affairs Medical Center, Atlanta, USA

    Imran H. Iftikhar

  3. Sleep Research Group, Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, Australia

    Peter A. Cistulli

  4. Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, Australia

    Peter A. Cistulli

  5. Ministry of Health, Manama, Bahrain

    Haitham Jahrami

  6. College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain

    Haitham Jahrami

  7. Department of Preventive Dental Science, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

    Khalid A. Alamoud

  8. King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

    Khalid A. Alamoud

  9. Dental College, HITEC Institute of Medical Sciences, Rawalpindi, Pakistan

    Maarij Saeed

  10. Sleep Apnea & Snoring Solutions (Private Practice), North Druid Hills Georgia, Atlanta, USA

    Andrew P. Soulimiotis

  11. The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia

    Ahmed S. BaHammam

  12. Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia (08-MED511-02), Riyadh, Saudi Arabia

    Ahmed S. BaHammam

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  1. Imran H. Iftikhar
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  2. Peter A. Cistulli
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  4. Khalid A. Alamoud
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Contributions

IHI had full access to all extracted data in the network meta-analysis and takes responsibility for the integrity of the data and the accuracy of the data analysis. IHI conceptualized and designed the study protocol, extracted data, conducted the analyses, and wrote the first draft manuscript. HJ contributed to the study quality assessment. KA contributed to the database search. All authors contributed substantially to the interpretation of analyses and in revisions of the manuscript. All authors have seen and approved the manuscript.

Corresponding author

Correspondence to Imran H. Iftikhar.

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Conflict of interest

IHI, ASB, JH, MS, AS, and KA have nothing to disclose. PAC has an appointment to an endowed academic Chair at the University of Sydney that was created from ResMed funding. He has received research support from ResMed, SomnoMed, Zephyr Sleep Technologies, and Bayer. He is a consultant/adviser to ResMed, SomnoMed, and Signifier Medical Technologies. He has a pecuniary interest in SomnoMed related to a previous role in R&D (2004). This study was not sponsored by any funding agency or pharmaceutical company.

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Iftikhar, I.H., Cistulli, P.A., Jahrami, H. et al. Comparative efficacy of mandibular advancement devices in obstructive sleep apnea: a network meta-analysis. Sleep Breath 27, 1365–1381 (2023). https://doi.org/10.1007/s11325-022-02744-6

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