Mandibular advancement device therapy for obstructive sleep apnea: a prospective study on predictors of treatment success.

OBJECTIVE: To survey potential predictors of success of mandibular advancement device (MAD) therapy in patients with obstructive sleep apnea (OSA), and in particular, to examine anatomical narrowings and sleep-related collapse levels in the upper airway. METHODS: This was a prospective study of 62 OSA patients (median apnea-hypopnea index [AHI] of 34), who were treated with a custom-made, monobloc MAD. The upper airway was examined by inspection, nasopharyngoscopy, overnight acoustic reflectometry recording collapses, and cephalometry of soft tissue dimensions (in addition to skeletal parameters). MAD treatment was controlled by polysomnograpy before and after at least five weeks from the beginning of treatment. Independent predictors of actual reduction in AHI and treatment success (reduction in AHI ≥ 50% with residual AHI < 10) were determined, using multivariable linear and logistic regression. RESULTS: Positional OSA (POSA) and nonsupine AHI (adjusted for upper airway narrowness and collapses, together with gender, age, body mass index, neck circumference, and baseline AHI) were the only independent predictors: POSA indicative for success, and nonsupine AHI inversely related to success. Cephalometry was not predictive. Two predictive models were proposed, one based on POSA having a specificity of 70% and sensitivity of 69%, and the other based on nonsupine AHI, generating a receiver operating characteristic (ROC) curve (area under ROC = 0.78). Using the ROC model, specificity could be increased to 80% without lowering sensitivity. CONCLUSIONS: Only variables related to sleep position proved to be independent predictors of success with MAD therapy. The results could be explained by the MAD counteracting the mandible from moving backwards when sleeping supine.

Influence of craniofacial and upper spine morphology on mandibular advancement device treatment outcome in patients with obstructive sleep apnoea: a pilot study.

BACKGROUND/OBJECTIVES: The aim of the study was to assess cephalometric predictive markers in terms of craniofacial morphology including posterior cranial fossa and upper spine morphology for mandibular advancement device (MAD) treatment outcome in patients with obstructive sleep apnoea (OSA). MATERIAL/METHODS: Twenty-seven OSA patients were treated with MAD for 4 weeks. Apnoea-hypopnoea index (AHI) was recorded before and after MAD treatment. The criteria of treatment success were 75 per cent reduction of AHI. Accordingly, two groups occurred: the success treatment group of 8 patients and the no success treatment group of 19 patients. Before MAD treatment lateral cephalograms were taken and analyses of the craniofacial morphology including the posterior cranial fossa and upper spine morphology were performed. Differences between the groups were analysed by Fisher's exact test, t-test, and multiple regression analysis. RESULTS: Upper spine morphological deviations occurred non-significantly in 25 per cent in the success treatment group and in 42.1 per cent in the no success treatment group. Body mass index (BMI; P < 0.05), maxillary prognathism (S-N-Ss; P < 0.01), mandibular prognathism (S-N-Pg; P < 0.05 and S-N-Sm; P < 0.01), and the distance between sella turcica and the deepest point in posterior cranial fossa (S-D; P < 0.05) was significantly smaller in the success treatment group. The maxillary prognathism (P < 0.05) was the most important factor for the MAD treatment outcome (R (2) = 0.47). LIMITATIONS: Relatively small sample size. CONCLUSIONS: The results indicate that BMI, posterior cranial fossa morphology, and retrognathia of the jaws are factors related to MAD treatment outcome. Furthermore, OSA patients with upper spine morphological deviations may respond poorer to MAD treatment.

Associations between craniofacial morphology, head posture, and cervical vertebral body fusions in men with sleep apnea.

INTRODUCTION: The aim of this study was to analyze craniofacial profiles and head posture in patients with obstructive sleep apnea (OSA) subgrouped according to cervical column morphology. METHODS: Seventy-four white men aged 27 to 65 years (mean, 49.0 years) diagnosed with OSA in sleep studies by using overnight polysomnography were included. Only patients with apnea-hypopnea index scores between 5.1 and 92.7 (mean, 36.4) were included. Lateral profile radiographs in standardized head posture were taken, and cephalometric analyses of sagittal and vertical jaw relationships were made. The patients were divided into 4 groups according to fusion in the cervical vertebrae: group I, no fusions (42 subjects); group II, fusion of cervical vertebrae 2 and 3 (15 subjects); group III, occipitalization (10 subjects); and group IV, block fusion (11 subjects). Mean differences of craniofacial dimensions between the groups were assessed by unpaired t tests. RESULTS: No significant differences were seen between groups I and III. Between groups I and II, significant differences were seen in jaw relationship (P < 0.05). Between groups I and IV, anterior face height and mandibular length deviated significantly. No significant differences were seen in head posture. CONCLUSIONS: OSA patients with block fusions in the cervical vertebrae and fusion of 2 vertebrae differed significantly in craniofacial profile from other OSA patients.

Cervical column morphology in adult patients with obstructive sleep apnoea.

Cervical column morphology was examined in adult patients with obstructive sleep apnoea (OSA) and compared with the cervical morphology of an adult control group with neutral occlusion, normal craniofacial morphology, and no history of sleep apnoea. The sleep apnoea group consisted of 91 patients, 16 females aged 29-59 years (mean 49.4 years) and 75 males aged 27-65 years (mean 49.0 years). All patients were diagnosed with OSA by overnight polysomnography. The control group consisted of 21 subjects, 15 females aged 23-40 years (mean 29.2 years) and 6 males aged 25-44 years (mean 32.8 years). From each individual, a visual assessment of the cervical column was performed on the radiograph. Differences in the cervical column morphology, between the genders and the groups were assessed by Fisher's exact test and the effect of age by logistic regression analysis. In the OSA group, 46.2 per cent had fusion anomalies of the cervical column and 5.5 per cent a posterior arch deficiency. Fusion anomalies occurred in 26.4 per cent as fusions between two cervical vertebrae. Block fusions occurred in 12.1 per cent and occipitalization in 14.3 per cent. A posterior arch deficiency occurred in 2.2 per cent as a partial cleft of C1 and in 3.3 per cent as dehiscence of C3 and C4. No statistical gender differences were found in the occurrence of morphological characteristics of the cervical column. The fusion anomalies of the cervical column occurred significantly more often in the OSA group. The results indicate that the morphological deviations of the upper cervical vertebrae play a role in the phenotypical subdivision and diagnosis of OSA.

Mandibular advancement appliance for obstructive sleep apnoea: results of a randomised placebo controlled trial using parallel group design.

The aim of this trial was to evaluate the efficacy of a mandibular advancement appliance (MAA) for obstructive sleep apnoea (OSA). Ninety-three patients with OSA and a mean apnoea-hypopnoea index (AHI) of 34.7 were centrally randomised into three, parallel groups: (a) MAA; (b) mandibular non-advancement appliance (MNA); and (c) no intervention. The appliances were custom made, in one piece. The MAAs had a mean protrusion of the mandible of 74% (range 64-85%). Outcome measures, assessed after continuous use for 4 weeks, were AHI (polysomnography), daytime sleepiness (Epworth) and quality of life (SF-36). Eighty-one patients (87%) completed the trial. The MAA group achieved mean AHI and Epworth scores significantly lower (P < 0.001 and P < 0.05) than the MNA group and the no-intervention group. No significant differences were found between the MNA group and the no-intervention group. The MAA group had a mean AHI reduction of 14.1 (95% CI 7.4-20.8), and a mean Epworth score reduction of 3.3 (95% CI 1.8-4.8). Eight MAA patients (30%) achieved a reduction in AHI > or = 75% ending with an AHI < 5, half of them having baseline AHI > 30. Sensitivity analyses confirmed these results. MAA had a significant beneficial effect on the vitality domain of SF-36. Four MAA patients (14.8%) and two MNA patients (8%) discontinued interventions because of adverse effects. Our conclusion is that MAA has significant beneficial effects on OSA, including cure in some cases of severe OSA. Protrusion of the mandible is essential for the effect. MNA has no placebo effect. MAA may be a good alternative to CPAP in subsets of OSA patients.

[Primary oral manifestation of Crohn disease]. / Primaer oral manifestation af Crohns sygdom.

We present a case of primary and histologically verified oral manifestation of Crohn's disease in a 26-year-old man, with bilateral, non-healing granulomatous ulcerations in the inferior alveolobuccal sulcus, following the use of tooth protection during the practice of martial arts. Typical gastrointestinal symptoms followed approximately two months the onset debut of oral manifestations. The results of rectum biopsy, radiological bowel examinations, and blood sampling were typical of Crohn's disease. Oral manifestations and gastrointestinal symptoms responded well to standard treatment. We direct attention to this disease in patients with non-healing oral oedema, ulceration, or granulation.