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MAD & RME(Mandibular Advancement Device & Rapid Maxillary Expansion)MAD (Mandibular Advancement Device) CPAP treatment has proven to be effective in improving the cardiovascular morbidity in OSA patient but, the compliance and long-term acceptance is relatively low, resulting in a limited clinical effectiveness.Oral appliance therapy has emerged as a conservative, noninvasive treatment option for patients with OSA.Mandibular repositioning appliances (MRA)Tongue retaining devices.MRA are far more commonly used, effective than tongue retaining devices. repositioning of the tongue and mandible in a way that reduces the tendency of the airway to narrow or collapse during sleep. mechanism of action of MRA in the treatment of snoring and OSA remain uncertaintongue, soft palate, lateral pharyngeal walls, and mandible interact to control airway size mandibular advancement induces complex changes in these structures, resulting in improved airway stability. Short term efficacyreducing the number of obstructive breathing events in patients with mild to severe OSAarterial oxygen saturation levelsarousal frequencysnoringLong term effectivenesssnoring and sleep apnea : high success rate, with follow-up periods of 2–5 yearsAdverse effectsShort termIncreased salivation or dryness,discomfort from the teeth or gums : about 20–50% of initially treated patients.perception of an abnormal bite from the applianceLong termorthodontic effects on the teeth and jawsslight backward movement of the mandibular position.the mandibular condyle relocates downwards, which in turn produces an increase in the lower face heightanterior movement of the mandibleextreme changes in their occlusion important to continuously monitor the bite among patients treated with MRAPatient selection criteriaGeneral indicationsadults with OSANonapneic snorerspatients with mild severitypatients who refuse or cannot tolerate CPAP.expansion of their use in more severe forms of OSAContra : temporomandibular dysfunction, expansion of their use in more severe forms of OSASupine-dependent OSAA higher success rate with MRA compared with patients who have OSA in the lateral position.Patient selection criteriaDental and anthropomorphic predictors of outcomea shorter soft palate and a decreased distance between the hyoid bone and the mandibular planethe combination of a narrower SNB angle, wider SNA angle, shorter soft palate and narrow oropharynx (PAS).a larger retropalatal airway space (RPAS) and larger angle between anterior cranial base and mandibular plane (SNMP) as determined by cephalometry, a smaller neck circumferenceDesign features and titration proceduresMRA designsthe need for good retention, sufficient protrusion and vertical dimension.permit jaw movement, laterally or verticallyTitration proceduresa matter of trial and errorTitratable MRAsMandibular repositioning appliances designed with an integrated titratable mechanism (tMRAs) allow gradual mandibular protrusion in order to achieve maximal therapeutic effect.Treatment compliancea lack of self perceived efficacy or MRA related side-effects55 to 82% of patients continuing with their MRA after 1 year48% of patients continuing with their MRA after 2 years.Comparison to CPAP for OSA have been found to vary.Comparison with other treatmentsthe lack of evidence on MRA adherence compared to objective data on CPAP usage, this remains an important and unresolved question.Clinical pathways and educationInterdisciplinary communication and treatment planning via a coordinated care pathwaythe development and implementation of evidence based clinical practice guidelines in conjunction with continuing education of the respective disciplines Summary- MAD(MRA)RME (Rapid Maxillary Expansion)Craniofacial abnormalitiesmandibula
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MAD & RME(Mandibular Advancement Device & Rapid Maxillary Expansion)
MAD (Mandibular Advancement Device)
• CPAP treatment has proven to be effective in improving the cardiovascular morbidity in OSA patient
but, the compliance and long-term acceptance is rela-tively low, resulting in a limited clinical effectiveness.
Current opinions and clinical practice in the titration of oral appliances in the treatment of sleep-disordered breathingSleep Medicine Reviews 16 (2012) 177-185
• Oral appliance therapy has emerged as a conservative, noninvasive treatment option for patients with OSA.– Mandibular repositioning appliances (MRA)– Tongue retaining devices.
– MRA are far more commonly used, effective than tongue retaining devices.
Current opinions and clinical practice in the titration of oral appliances in the treatment of sleep-disordered breathingSleep Medicine Reviews 16 (2012) 177-185
• repositioning of the tongue and mandible in a way that reduces the tendency of the airway to narrow or collapse during sleep.
Current opinions and clinical practice in the titration of oral appliances in the treatment of sleep-disordered breathingSleep Medicine Reviews 16 (2012) 177-185
• mechanism of action of MRA in the treatment of snoring and OSA remain uncertain
• tongue, soft palate, lateral pharyngeal walls, and mandible interact to control airway size
mandibular advancement induces complex changes in these structures, resulting in improved airway stability.
Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliancesSleep Medicine Reviews (2004) 8, 443–457
Short term efficacy
• reducing the number of obstructive breathing events in patients with mild to severe OSA
• arterial oxygen saturation levels• arousal frequency• snoring
Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliancesSleep Medicine Reviews (2004) 8, 443–457
Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliancesSleep Medicine Reviews (2004) 8, 443–457
Long term effectiveness
• snoring and sleep apnea : high success rate, with follow-up periods of 2–5 years
Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliancesSleep Medicine Reviews (2004) 8, 443–457
Adverse effects
• Short term– Increased salivation or dryness,– discomfort from the teeth or gums : about 20–50% of initially treated
patients.– perception of an abnormal bite from the appliance
• Long term– orthodontic effects on the teeth and jaws– slight backward movement of the mandibular position.– the mandibular condyle relocates downwards, which in turn produces
an increase in the lower face height– anterior movement of the mandible– extreme changes in their occlusion
important to continuously monitor the bite among patients treated with MRA
Patient selection criteria
• General indications– adults with OSA– Nonapneic snorers– patients with mild severity– patients who refuse or cannot tolerate CPAP.– expansion of their use in more severe forms of OSA– Contra : temporomandibular dysfunction, expansion of
their use in more severe forms of OSA
• Supine-dependent OSA– A higher success rate with MRA compared with patients
who have OSA in the lateral position.
Patient selection criteria
• Dental and anthropomorphic predictors of outcome– a shorter soft palate and a decreased distance
between the hyoid bone and the mandibular plane
– the combination of a narrower SNB angle, wider SNA angle, shorter soft palate and narrow oropharynx (PAS).
– a larger retropalatal airway space (RPAS) and larger angle between anterior cranial base and mandibular plane (SNMP) as determined by cephalometry, a smaller neck circumference
Design features and titration procedures
• MRA designs– the need for good retention, sufficient protrusion and
vertical dimension.– permit jaw movement, laterally or vertically
• Titration procedures– a matter of trial and error
Current opinions and clinical practice in the titration of oral appliances in the treatment of sleep-disordered breathingSleep Medicine Reviews 16 (2012) 177-185
Titratable MRAs
• Mandibular repositioning appliances designed with an in-tegrated titratable mechanism (tMRAs) allow gradual mandibular protrusion in order to achieve maximal ther-apeutic effect.
Current opinions and clinical practice in the titration of oral appliances in the treatment of sleep-disordered breathingSleep Medicine Reviews 16 (2012) 177-185
Treatment compliance
• a lack of self perceived efficacy or MRA related side-ef-fects
• 55 to 82% of patients continuing with their MRA after 1 year
• 48% of patients continuing with their MRA after 2 years.• Comparison to CPAP for OSA have been found to vary.
Comparison with other treatments
• the lack of evidence on MRA adherence compared to ob-jective data on CPAP usage, this remains an important and unresolved question.
Clinical pathways and education
• Interdisciplinary communication and treatment planning via a coordinated care pathway
• the development and implementation of evidence based clinical practice guidelines in conjunction with continuing education of the respective disciplines
Treatment outcomes of mandibular advancement devices in positional and nonpositional OSA patients Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:724-731
Mandibular advancement splints for the treatment of sleep apnoea syndrome Swiss Med Wkly. 2011;141:w13276
Mandibular advancement splints for the treatment of sleep apnoea syndrome Swiss Med Wkly. 2011;141:w13276
Summary- MAD(MRA)
RME (Rapid Maxillary Expansion)
• Craniofacial abnormalities– mandibular deficiency– greater flexion of the cranial base– an inferiorly placed hyoid bone– maxillary and mandibular transverse deficiencies
correct or improve craniofacial structures.
oral appliances and maxillofacial surgical procedures
• OSAS patients with maxillary constriction
: mostly due to skeletal adaptation rather than a narrow dental arch
upper airway narrowing and increased nasal resistance
airway closure during sleep
consequent mouth breathing
a low tongue posture, provoking a flattening of the retroglossal airway space.
• Subjects with greater degrees of nasal resistance tend to have greater improvement after maxillary expansion
• Patients with constricted maxilla have elevated nasal re-sistance, and nasal resistance can be improved by maxillary expansion
Long term effects of surgically assisted rapid maxillary expansion without performing osteotomy of the pterygoid plates Journal of Cranio-Maxillo-Facial Surgery (2010) 38, 175-178
• Rapid maxillary expansion without surgical assistance is impossible after the age of 18.
• Surgically assisted rapid maxillary expansions (SARME) are commonly used for corrective transverse maxillary deficits in adults
• Crossbite and crowded teeth are a typical characteristic of maxillary compression syndromes.
Long term effects of surgically assisted rapid maxillary expansion without performing osteotomy of the pterygoid plates Journal of Cranio-Maxillo-Facial Surgery (2010) 38, 175-178
• Surgery was easier, both for the surgeon and the patient; the orthodontic phase was longer, but this provided an occlusal correction.
• Minimal changes in the facial profile. • Presence of a transverse deficiency of the upper and
lower dental arches.
• This procedure clearly has limitations. – The distraction devices need to be left in place for 3 to
4 months, until the newly generated bone is suffi-ciently matured.
– The necessity of orthodontic treatment deters most adult patients for this treatment.
Children with OSAS
Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up Sleep Medicine 8 (2007) 128–134
Long term f/u
Surgically assisted rapid maxillary expansion: long-term stability European Journal of Orthodontics 31 (2009) 142–149
Long term f/u
Surgically assisted rapid maxillary expansion: long-term stability European Journal of Orthodontics 31 (2009) 142–149
• Treatment with SARME and orthodontic fixed ap-pliance normalizes the transverse discrepancy and is stable a mean of 6 years post-treatment.
• Pterygoid detachment does not entirely eliminate posterior resistance, and buccal tipping of the maxillary molars may still occur. Relapse is time related and is most pronounced during the first 3 years after treatment.
• Retention should be considered for this period.
Surgically assisted rapid maxillary expansion: long-term stability European Journal of Orthodontics 31 (2009) 142–149
A case report on the efficacy of transverse expansion in severe obstructive sleep apnea syndrome Sleep Breath (2009) 13:93–96
