Why Start There?

Finding the Starting Jaw Position

One challenge, and point of many discussions, is the starting position for oral appliance therapy in the management of obstructive sleep apnea (OSA). A question that often comes up is “where do I set the first jaw position?” If I had the answer to this question, I would look like a genius. We seem to forget that our bite position, whether it be a phonetic bite, George gauge, ProGauge, pharyngometry, or any other method, is a relative starting position. This bite position allows us to start at some point in space while considering a comfortable position for the patient.

The Oral Appliance – How it Works

Oral appliances (OA) are designed to improve upper airway configuration and prevent collapse through alteration of jaw and tongue position. These appliances are often termed “mandibular advancement devices (MAD),” “mandibular advancement splints (MAS),” or “mandibular repositioning appliances (MRA).”

The posterior airway is opened with an OA by advancing the mandible relative to the maxilla, and repositioning the many connected soft tissues in a forward position. While these devices are thought to increase upper airway caliber, activate upper airway dilator muscles, and decrease upper airway compliance, their precise mode and site of action are unknown.

The velopharynx was revealed to be a principal site of enlargement by the action of MAD by many authors using cephalometric analysis,1,2 or fiber-optic video-endoscopy.3  Choi et al showed that both the retropalatal (velo-pharynx) and the retroglossal areas of the oropharynx are significantly enlarged with mandibular advancement in most patients with obstructive sleep apnea.4

Imaging studies show that mandibular advancement with OA enlarges the upper airway space, most notably in the lateral dimension of the velopharynx.5 Lateral expansion of the airway space is likely mediated through tissue movement via direct connections between the lateral walls of the pharynx and the ramus of the mandible.6

The Treatment Outcome

Various patient factors have often been associated with the treatment outcome. Less severe disease and supine-predominant OSA (a higher AHI in supine compared to lateral sleeping position), have been considered favorable predictors for treatment success.7,8 Younger age, female gender, and less obesity (lower BMI and neck circumference) can even be positive predictors of treatment success.7,9

Craniofacial features assessed by lateral cephalometry, including shorter soft palate length, lower hyoid bone position, greater angle between the cranial base and mandibular plane, and a retrognathic mandible, are also associated with favorable treatment outcome.7,10,11 Although various patient phenotypes have been related to a higher likelihood of treatment success, these are not universal, meaning that patient response is not predictable using phenotype details. If we can’t predict where the jaw needs to be at the end, it means we have to randomly choose where to start, also.

OA Design Parameters

Even the most experienced clinician universally uses titratable appliances, because of this need to select among the many start position choices. Numerous prefabricated or custom-made MAD have been designed and developed for OSA patients that allow adjustment after delivery.12-14 While there are many different design parameters, we must determine the degree of mandibular protrusion and vertical opening. These crucial design parameters have been extensively investigated, but the ideal amount of therapy has not yet been defined.4,15,16 I’m sure we will get to a better definition, but for now it is left to our interpretation.

A dose-dependent effect of mandibular advancement was demonstrated using 4 randomized levels of advancement (0%, 25%, 50%, and 75% maximum), with the efficacy of 50% to 75% advancement greater than 25%, and 25% greater than 0%.3 However above 50% of patient’s  advancement range,, there was an associated increase in reported side effects. A titration approach to determine optimal level of advancement with gradual increments over time is thought to optimize treatment outcome.17

Titration can be guided by subjective symptomatic improvement, consumer-level devices and apps, and objective monitoring by overnight oximetry, all the while limited by patient comfort, to (unofficially) find the optimally effective advancement level. 17

Assessment of pharyngeal collapsibility during mandibular advancement has also shown a dose-dependent effect in improvement of upper airway closing pressures.18  Gao et al.19 reported an expansion of 7.5% in the upper airway for every 25% increase in mandibular protrusion after 50% mandibular protrusion.

Generally, the greater the level of advancement, the better the treatment effect. However, it is vital that this is balanced against a potential increase in side effects. We can’t say what the perfect starting jaw position is, but we can take proactive steps in helping us find an optimal solution for each individual patient.

Having a limited practice to Craniofacial Pain and Dental Sleep Medicine, Dr. Mayoor Patel, DDS, MS, RPSGT, D.ABDSM, DABCP, DABCDSM, DABOP, utilizes his experience and expertise to help dentists across the country excel in these areas within their dental practices. As Clinical Education Director with Nierman Practice Management, Dr. Patel develops up-to-date curriculum for their sleep apnea and craniofacial pain programs. Dr. Patel serves as a board member with the Georgia Association of Sleep Professionals, the American Board of Craniofacial Dental Sleep Medicine, American Board of Craniofacial Pain and American Academy of Craniofacial Pain. He also has taken the role as examination chair for the American Board of Craniofacial Dental Sleep Medicine and American Board of Craniofacial Pain.

  1. Tsuiki S, Almeida FR, Lowe AA, Su J, Fleetham JA. The interaction between changes in upright mandibular position and supine airway size in patients with obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics 2005;128(4):504-12.
  2. Tsuiki S, Hiyama S, Ono T, et al. Effects of a Titratable Oral Appliance on Supine Airway Size in Awake Non-Apneic Individuals. Sleep 2001;24(5):554-60.
  3. Lowe A, Sjöholm T, Ryan C, et al. Treatment, airway and compliance effects of a titratable oral appliance. Sleep 2000;23:S172-8.
  4. Choi J-K, Hur Y-K, Lee J-M, Clark GT. Effects of mandibular advancement on upper airway dimension and collapsibility in patients with obstructive sleep apnea using dynamic upper airway imaging during sleep. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 2010;109(5):712-19.
  5. Chan ASL, Sutherland K, Schwab RJ, et al. The effect of mandibular advancement on upper airway structure in obstructive sleep apnoea. Thorax 2010;65(8):726-32.
  6. Brown EC, Cheng S, McKenzie DK, et al. Tongue and Lateral Upper Airway Movement with Mandibular Advancement. sleep 2013.
  7. Hoekema A, Doff MHJ, de Bont LGM, et al. Predictors of Obstructive Sleep Apnea-Hypopnea Treatment Outcome. Journal of dental research 2007;86(12):1181-86.
  8. Chung JW, Enciso R, Levendowski DJ, et al. Treatment outcomes of mandibular advancement devices in positional and nonpositional OSA patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(5):724-31.
  9. Liu Y, Lowe AA, Orthodont D, Fleetham JA, Park Y-C. Cephalometric and physiologic predictors of the efficacy of an adjustable oral appliance for treating obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics 2001;120(6):639-47.
  10. Liu Y, Lowe AA. Factors related to the efficacy of an adjustable oral appliance for the treatment of obstructive sleep apnea. The Chinese journal of dental research: the official journal of the Scientific Section of the Chinese Stomatological Association (CSA) 2000;3(3):15-23.
  11. Lee CH, Kim J-W, Lee HJ, et al. Determinants of treatment outcome after use of the mandibular advancement device in patients with obstructive sleep apnea. Archives of Otolaryngology–Head & Neck Surgery 2010;136(7):677-81.
  12. Barthlen G M, Brown LK, Wiland MR, et al. Comparison of three oral appliances for treatment of severe obstructive sleep apnea syndrome. Sleep Medicine 2000:299-305.
  13. Rose E, Staats R, Virchow C, Jonas IE. A comparative study of two mandibular advancement appliances for the treatment of obstructive sleep apnoea. The European Journal of Orthodontics 2002;24(2):191.
  14. Warunek S. Oral appliance therapy in sleep apnea syndromes: a review. Seminars in Orthodontics 2004;10(1):73-89.
  15. Choi J-K, Kee W-C, Lee J-M, Ye M-K. Variable site of oropharyngeal narrowing and regional variations of oropharyngeal collapsibility among snoring patients during wakefulness and sleep. CRANIO® 2001;19(4):252-59.
  16. Almeida F, Bittencourt L, Lowe A, et al. Effects of Mandibular Posture on Obstructive Sleep Apnea Severity and the Temporomandibular Joint in Patients Fitted with an Oral Appliance. Sleep 2002;25(5):505-11.
  17. Ryan C, Love L, Peat D, Fleetham J, Lowe A. Mandibular advancement oral appliance therapy for obstructive sleep apnoea: effect on awake calibre of the velopharynx. Thorax 1999;54(11):972-77.
  18. Tsuiki S, Lowe AA, Almeida FR, Kawahata N, Fleetham JA. Effects of mandibular advancement on airway curvature and obstructive sleep apnoea severity. European Respiratory Journal 2004;23(2):263-68.
  19. Gao X, Otsuka R, Ono T, et al. Effect of titrated mandibular advancement and jaw opening on the upper airway in nonapneic men: a magnetic resonance imaging and cephalometric study. American journal of orthodontics and dentofacial orthopedics 2004;125(2):191-99.
  1. Tsuiki S, Almeida FR, Lowe AA, Su J, Fleetham JA. The interaction between changes in upright mandibular position and supine airway size in patients with obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics 2005;128(4):504-12.
  2. Tsuiki S, Hiyama S, Ono T, et al. Effects of a Titratable Oral Appliance on Supine Airway Size in Awake Non-Apneic Individuals. Sleep 2001;24(5):554-60.
  3. Lowe A, Sjöholm T, Ryan C, et al. Treatment, airway and compliance effects of a titratable oral appliance. Sleep 2000;23:S172-8.
  4. Choi J-K, Hur Y-K, Lee J-M, Clark GT. Effects of mandibular advancement on upper airway dimension and collapsibility in patients with obstructive sleep apnea using dynamic upper airway imaging during sleep. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 2010;109(5):712-19.
  5. Chan ASL, Sutherland K, Schwab RJ, et al. The effect of mandibular advancement on upper airway structure in obstructive sleep apnoea. Thorax 2010;65(8):726-32.
  6. Brown EC, Cheng S, McKenzie DK, et al. Tongue and Lateral Upper Airway Movement with Mandibular Advancement. sleep 2013.
  7. Hoekema A, Doff MHJ, de Bont LGM, et al. Predictors of Obstructive Sleep Apnea-Hypopnea Treatment Outcome. Journal of dental research 2007;86(12):1181-86.
  8. Chung JW, Enciso R, Levendowski DJ, et al. Treatment outcomes of mandibular advancement devices in positional and nonpositional OSA patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(5):724-31.
  9. Liu Y, Lowe AA, Orthodont D, Fleetham JA, Park Y-C. Cephalometric and physiologic predictors of the efficacy of an adjustable oral appliance for treating obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics 2001;120(6):639-47.
  10. Liu Y, Lowe AA. Factors related to the efficacy of an adjustable oral appliance for the treatment of obstructive sleep apnea. The Chinese journal of dental research: the official journal of the Scientific Section of the Chinese Stomatological Association (CSA) 2000;3(3):15-23.
  11. Lee CH, Kim J-W, Lee HJ, et al. Determinants of treatment outcome after use of the mandibular advancement device in patients with obstructive sleep apnea. Archives of Otolaryngology–Head & Neck Surgery 2010;136(7):677-81.
  12. Barthlen G M, Brown LK, Wiland MR, et al. Comparison of three oral appliances for treatment of severe obstructive sleep apnea syndrome. Sleep Medicine 2000:299-305.
  13. Rose E, Staats R, Virchow C, Jonas IE. A comparative study of two mandibular advancement appliances for the treatment of obstructive sleep apnoea. The European Journal of Orthodontics 2002;24(2):191.
  14. Warunek S. Oral appliance therapy in sleep apnea syndromes: a review. Seminars in Orthodontics 2004;10(1):73-89.
  15. Choi J-K, Kee W-C, Lee J-M, Ye M-K. Variable site of oropharyngeal narrowing and regional variations of oropharyngeal collapsibility among snoring patients during wakefulness and sleep. CRANIO® 2001;19(4):252-59.
  16. Almeida F, Bittencourt L, Lowe A, et al. Effects of Mandibular Posture on Obstructive Sleep Apnea Severity and the Temporomandibular Joint in Patients Fitted with an Oral Appliance. Sleep 2002;25(5):505-11.
  17. Ryan C, Love L, Peat D, Fleetham J, Lowe A. Mandibular advancement oral appliance therapy for obstructive sleep apnoea: effect on awake calibre of the velopharynx. Thorax 1999;54(11):972-77.
  18. Tsuiki S, Lowe AA, Almeida FR, Kawahata N, Fleetham JA. Effects of mandibular advancement on airway curvature and obstructive sleep apnoea severity. European Respiratory Journal 2004;23(2):263-68.
  19. Gao X, Otsuka R, Ono T, et al. Effect of titrated mandibular advancement and jaw opening on the upper airway in nonapneic men: a magnetic resonance imaging and cephalometric study. American journal of orthodontics and dentofacial orthopedics 2004;125(2):191-99.

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