Predictors of long-term orthodontic side effects from mandibular advancement devices in patients with snoring and obstructive sleep apnea

doi:10.1016/j.ajodo.2005.10.004

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 129, Issue 2, February 2006, Pages 214-221

https://doi.org/10.1016/j.ajodo.2005.10.004 Get rights and content

Introduction: Orthodontic side effects can complicate the long-term use of mandibular advancement devices (MADs) in the treatment of patients with snoring and obstructive sleep apnea. The aim of this study was to find predictors of dental side effects from monoblock MADs. Methods: Four hundred fifty patients, who consecutively received treatment with either soft elastomeric or hard acrylic devices, were followed up after 5.4 ± 0.8 years (mean ± SD). The continuing patients responded to questionnaires and had dental examinations and plaster casts made. Results: Twenty-seven patients had moved or died during the follow-up period. Two hundred thirty-six of the remaining 423 patients (56%) continued treatment, and 187 of them reported compliance rates of ≥50% at night. A small reduction in overjet of <1 mm was associated with a deepbite with an overbite of >3 mm and an overjet of ≤3 mm (odds ratio [OR] = 7.5; P = .015), nasal congestion (OR = 2.9; P = .005), or the use of a soft elastomeric device (OR = 2.7; P = .014) controlled for age, sex, treatment time, and mandibular displacement. A small reduction in overbite of <1 mm was related to a small opening of the mandible of <11 mm (OR = 2.5; P = .008). Conclusions: Orthodontic side effects might be predictable on the basis of initial characteristics in dental occlusion and the design of MADs.

Section snippets

Subjects and follow-up

Four hundred fifty patients, consecutively treated by the author, were evaluated in relation to the long-term use of MADs at a 5-year follow-up. At the start of the study, the median age of these patients was 51 years (range, 22-74), with a median apnea-hypopnea index of 13 (range, 0-76) and a median body mass index of 27 kg/m² (range, 19-42). There were 82 women and 368 men in the sample. Patients with periodontal diseases, craniomandibular disorders, few teeth to anchor the appliance, or

Results

The sample of 450 patients is described in Figure 3. At the 5-year follow-up, 27 patients had moved or died, 187 had discontinued treatment, and 236 (56%) were still using their devices. One hundred eighty-seven of these 236 patients (79%) were frequent users, and 51 of them had taken part in a previous 2-year follow-up of orthodontic side effects.

One hundred eighty-seven of the continuing 236 patients were evaluated in terms of dental side effects (Fig 3). Thirty-one patients had initial casts

Discussion

The frequent use of monoblock MADs with full occlusal coverage for 5 years resulted in median reductions in overjet and overbite of 0.6 mm in this sample of patients with snoring and obstructive sleep apnea. Infrequent users had smaller bite changes. Overjet decreased during both the first and second halves of the treatment period, and overbite changes diminished with time. A deepbite, the use of a soft elastomeric device, or nasal congestion were related to a high chance of experiencing only

Conclusions

About half of the patients treated for snoring and sleep apnea were still using their MADs after 5 years. The orthodontic side effects increased with treatment time and more frequent use of the device. Overjet decreased continuously, whereas overbite changes diminished with time. A deepbite and the use of a soft elastomeric device provided protection from large reductions in overjet, and the small vertical displacement of the mandible was related to a small reduction in overbite. Consequently,

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Cited by (106)

Mandibular advancement splints for the treatment of obstructive sleep apnea
2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second Edition
Obstructive sleep apnea (OSA) is a chronic condition which lends itself to a comprehensive chronic disease management model, rather than a device-focused approach, so as to achieve the best possible health outcomes. Oral appliances are the main alternative to continuous positive airway pressure (CPAP) for the treatment of OSA. There has been an expansion of the research evidence to support the use of oral appliances in clinical practice and the clinical use of oral appliances for the treatment of OSA has become a mainstream practice.
Phenotypes of responders to mandibular advancement device therapy in obstructive sleep apnea patients: A systematic review and meta-analysis
2020, Sleep Medicine Reviews
Mandibular advancement device (MAD) therapy is the most commonly used non-continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA). Although OSA patients prefer MAD over CPAP, on average over one third have minimal or no major reduction in OSA severity with MAD therapy. Improved understanding of responder characteristics (or “phenotypes”) to MAD may facilitate more efficient use of limited medical resources and optimize treatment efficacy.
The aim of this review is to describe the baseline phenotypic characteristics of responders to MAD therapy in OSA patients. Pubmed, Web of Science, EMBASE, Scopus were searched for eligible studies published until Feb 2019. A total of 650 studies were identified. 41 studies were included in this review and meta-analysis. The quality of the studies was assessed using the risk of bias assessment tool for non-randomized studies (RoBANS). Based on meta-analysis, the responders to MAD therapy had certain clinical phenotypic characteristics: lower age (95% CI: −4.55 to −1.62, p < 0.00001), female (95% CI: 0.56 to 0.91, p = 0.006), lower body mass index (95% CI: −2.80 to −1.11, p < 0.00001), smaller neck circumference (95% CI: −1.57 to −0.52, p < 0.00001), lower apnea-hypopnea index (95% CI: −7.23 to −1.89, p < 0.00001), a retracted maxilla and mandible, a narrower airway and a shorter soft palate than non-responders. The above-mentioned phenotypic responder characteristics provides useful information for the clinician when considering prescribing MAD therapy for OSA patients.
Long-term side effects of sleep apnea treatment with oral appliances: nature, magnitude and predictors of long-term changes
2019, Sleep Medicine
Oral appliances for the treatment of obstructive sleep apnea (OSA) reduce upper airway collapse by advancing the mandible (OAm) and associated soft tissues. OAm are well tolerated but have side effects, mainly dental movement. It is not yet clear whether there are irreversible skeletal changes associated with treatment. As oral appliance treatment for OSA is a life-long therapy, careful and extended follow-up of patients is required. The objectives of this study were to evaluate the magnitude and progression of the dental and skeletal changes associated with long-term treatment, in addition to determining the predictors of the changes.
Lateral cephalograms of adults treated for primary snoring or mild to severe OSA with a custom-made titratable OAm for a minimum of eight years were retrospectively studied. The magnitude and rate of progression of any changes over time was determined and initial patient and dental characteristics were investigated as possible predictors of the observed side effects.
Records of 62 patients with an average treatment time of 12.6 years (range:8–21 years) were included. Cephalometric analysis revealed significant (p < 0.001) maxillary incisor retroclination (mean of ≈6°) and mandibular incisor proclination (mean of ≈8°) over the observation period. Maxillary incisors demonstrated a constant rate of retroclination –0.5°/year, the rate of mandibular incisors proclination was variable. The number of treatment years was significantly associated with these variables (p < 0.001). A greater body mass index (BMI) and Subspinale, Nasion, Supramentale angle (ANB) were associated with more maxillary and mandibular incisor proclination respectively. Although statistically significant (p < 0.001) skeletal changes were noted over this extended observation period, the difference in the Sella, Nasion, Supramentale point B (SNB) and mandibular plane angles were approximately 1° and were deemed not clinically significant.
This study represents the longest observation period to date examining OAm side effects with up to 21 years of follow up for some patients. It confirms that there are significant and progressive dental changes with prolonged OAm use. Conversely, over the same time period skeletal or postural changes were negligible. Additionally, treatment duration was the predictor consistently associated with the magnitude of the observed side effects.
Long-term dental and skeletal effects of mandibular advancement devices in adults with obstructive sleep apnoea: A systematic review
2019, International Orthodontics
This systematic review aimed to clarify whether there are any significant long-term sequelae to wearing mandibular advancement devices focusing on dental and skeletal effects in adults with OSA.
Databases, including PubMed, Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and SAGE Journals. Hand searches and grey literature were also used. A piloted data collection form was used to extract the appropriate data.
Twenty-three reports of 19 studies were included. Five had serious risk of bias while 18 had moderate risk of bias. Meta-analysis revealed a significant change in overbite and overjet. I-squared analysis showed a high level of statistical heterogeneity. A moderate correlation was found between wear time and amount of change.
Mandibular advancement devices will cause a small but statistically significant change in the dentition of long-term wearers. Skeletal changes are generally secondary to dental changes.
Cette revue systématique visait à déterminer s’il existe des séquelles significatives à long terme liées au port d’orthèses d’avancée mandibulaire en se concentrant sur les effets dentaires et osseux chez des adultes atteints d’apnée obstructive du sommeil (OSA).
Bases de données incluant PubMed, Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials et les revues SAGE. Des recherches manuelles et la littérature grise ont également été utilisées. Une collecte pilotée de données a été utilisée pour extraire les données appropriées.
Vingt-trois rapports de 19 études ont été inclus. Cinq présentaient un risque sérieux de biais, tandis que 18 présentaient un risque modéré de biais. La méta-analyse a révélé un changement significatif du recouvrement et du surplomb. L’analyse du Chi² a montré un niveau élevé d’hétérogénéité statistique. Une corrélation modérée a été constatée entre la durée de port et la quantité de changement.
Les orthèses d’avancée mandibulaire peuvent causer un changement statistiquement significatif bien que léger de la dentition dans le cas de port de longue durée. Les changements osseux sont généralement secondaires aux changements dentaires.
Long-term effectiveness and side effects of mandibular advancement devices on dental and skeletal parameters
2019, Journal of Stomatology, Oral and Maxillofacial Surgery
Continuous positive airways pressure, generally used to treat obstructive sleep apnea-hypopnea syndrome (OSAHS), is not tolerated well by many patients. An alternative is to treat OSAHS with mandibular advancement devices (MAD). This research assesses the long term (> 2 years) effectiveness and the side effects on dental and skeletal parameters of these devices.
We selected 24 patients with moderate to severe OSAHS. All were treated with MADs for at least 2 years. We gathered cephalometric teleradiographs in centric relation and sleep recordings before and after the patients were treated. We evaluated the patients’ apnea-hypopnea indexes (AHI) as well as their Epworth sleepiness scale (ESS) scores. We measured the inclination of the central incisors and the positions of the upper and lower jaws.
Mandibular advancement devices were used for more than 2 years (3.9 ± 1.9 years). We observed a statistically significant decrease of the patients’ AHI and their ESS scores. We also observed a modification of the inclination of the lower central incisors (+0.521; P = 0.047) and of the position of the maxilla (−0.287; P = 0.039).
We demonstrated the clinical effectiveness of mandibular advancement devices for treating OSAHS, with a very low rate of side effects on dental and skeletal positions.
The correlation between obstructive sleep apnea and diabetic neuropathy: A meta-analysis
2018, Primary Care Diabetes
The aim of this study was to explore the correlation between obstructive sleep apnea (OSA) and diabetic neuropathy.
After working out searching strategy, literatures were screened from the electronic databases: PubMed, Embase, and the Cochrane library. R 3.12 was utilized to perform meta-analysis, and odds ratio (OR) and its 95% confidence interval (CI) were used to present effect size. Heterogeneity was assessed by χ²-based Q test and I² statistics. Publication bias was estimated by Egger’s test and sensitivity was evaluated by leave one out methods.
According to the criteria, a total of 11 studies with 1842 patients were enrolled in this study. With a significant heterogeneity (Q = 31.83, I² = 68.60%), the random effects model was utilized to assess the effect size of pooled data. A remarkable correlation was identified OSA and diabetic neuropathy (OR = 1.84, 95% CI: 1.18–2.87) without publication bias (t = 1.68, P = 0.13). Meanwhile, the result of leave one out performed a well sensitivity. Moreover, the subgroup analyses presented that OSA was significantly correlated with type 1 diabetic neuropathy (OR = 1.97, 95% CI: 1.19–3.25), but no remarkable correlation was identified between OSA and type 1 (OR = 1.84, 95% CI: 0.86–3.93) or 1 + 2 (OR = 1.30, 95% CI: 0.43–3.92) diabetic neuropathy.
OSA was significantly correlated with neuropathy in type 1 diabetes, but not in type 2 and type 1 + 2 diabetes.

View all citing articles on Scopus

: Supported by grants from the Swedish Dental Society.

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Original articlePredictors of long-term orthodontic side effects from mandibular advancement devices in patients with snoring and obstructive sleep apnea

Section snippets

Subjects and follow-up

Results

Discussion

Conclusions

Does 2 years’ nocturnal treatment with a mandibular advancement splint in adult patients with snoring and OSAS cause a change in the posture of the mandible?

Am J Orthod Dentofacial Orthop

Side effects of mandibular advancement devices for sleep apnea treatment

Am J Respir Crit Care Med

Orthodontic side-effects of mandibular advancement devices during treatment of snoring and sleep apnoea

Eur J Orthod

Occlusal and skeletal effects of an oral appliance in the treatment of obstructive sleep apnea

Chest

Craniomandibular status and function in patients with habitual snoring and obstructive sleep apnoea after nocturnal treatment with a mandibular advancement splinta 2-year follow-up

Eur J Orthod

Dental and skeletal changes associated with long-term mandibular advancement

Sleep

Occlusal side effects caused by a mandibular advancement appliance in patients with obstructive sleep apnea

Angle Orthod

Dental side effects of an oral device to treat snoring and obstructive sleep apnea

Sleep

Dental and skeletal changes after 4 years of obstructive sleep apnea treatment with a mandibular advancement devicea prospective, randomized study

Am J Orthod Dentofacial Orthop

Influence of mandibular protruding device on airway passages and dentofacial characteristics in obstructive sleep apnea and snoring

Am J Orthod Dentofacial Orthop

Dental and occlusal changes during mandibular advancement splint therapy in sleep disordered patients

Eur J Orthod

Original article
Predictors of long-term orthodontic side effects from mandibular advancement devices in patients with snoring and obstructive sleep apnea