The effect of gradually increased mandibular advancement on the efficacy of an oral appliance in the treatment of obstructive sleep apnea.

STUDY

objectivesTo analyze the effect of gradual increments of mandibular advancement on the treatment efficacy of mandibular advancement devices and identify determinants of effective and target protrusion for OSA.

methodsPatients were prospectively recruited. The mandible was titrated from 0 mm with a stepwise increment of 0.5 mm until the AHI was reduced to the lowest level. Rhinospirometry, rhinomanometry, and magnetic resonance imaging were used to observe the change of respiratory function and upper airway morphology.

resultsForty-two patients aged 41.5 ± 9.0 years participated. There was a dose-dependent relationship between mandibular protrusion and the AHI improvement rate, the success rate, and the normalization rate; the changing curves plateaued after approximately 70% of maximal mandibular protrusion was achieved. The correlation between AHI and mandibular protrusion became stronger as the severity of OSA increased. The target protrusion for patients with mild, moderate, and severe OSA was 3.5 ± 1.8 mm (38.6 ± 19.4% maximal mandibular protrusion), 5.8 ± 1.9 mm (62.9 ± 18.8% maximal mandibular protrusion), and 5.9 ± 2.2 mm (68.8 ± 15.6% maximal mandibular protrusion), respectively. Regression analysis revealed that the factors influencing effective and target protrusion included change of maximal lateral dimension of the total upper airway with mandibular advancement devices, mean lateral dimension of the oropharynx, and soft palate length. Further protrusion brought more lateral expansion of the velopharynx, whereas the change in nasal ventilation was not significant.

conclusionsThe dose-dependent effect of mandibular protrusion on reduction of AHI by mandibular advancement devices was nonlinear and became more pronounced with increased severity of OSA. The mandibular protrusion should be more personalized to each patient. CLINICAL

trial registrationRegistry: Chinese Clinical Trial Registry; Name: Study of the Onset Point of Oral Appliance Treatment in Obstructive Sleep Apnea and Hypopnea Syndrome; URL: http://www.chictr.org.cn/showproj.aspx?proj=22291; Identifier: ChiCTR-IND-17013232.