Chapter 11 Oral appliance and craniofacial problems of obstructive sleep apnea syndrome
Pierre Robin (1934) used the monoblock mandible advancement appliance for the purpose of treating patients with obstructive sleep apnea for the first time.1 Following this, Boraz treated pediatric OSA patients.2 Cartwright and Samelson (1982)3 reported the effectiveness of the tongue retaining device (TRD) which retains the tongue in the bulb of the device. Meier-Ewert (1984)4 used Esmarch–Heiberg manipulation, which opens the airway of a general anesthetized patient, and developed the Esmarch appliance. The tongue retaining appliance represented by the TRD, and the mandible advancing type represented by the Esmarch, are the two main types of oral appliance. Thereafter, other oral appliances were developed such as the adjustable type, which can adjust the amount of mandible advancement. Currently, more than 55 oral appliances (OAs) are on the market.5
In 2006, the Standards of Practice Committee of the American Academy of Sleep Medicine published the reports Oral Appliance for Snoring and Obstructive Sleep Apnea: A Review6 and Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005.7 Oral appliances are indicated for use with patients with primary snoring and with mild to moderate OSA, who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who have failed treatment attempts with CPAP.
With so many different oral appliances available, selection of a specific appliance may appear somewhat difficult, but they are designed around a few major themes. Oral appliances can be classified by mode of action or design variation. Nearly all appliances fall into one of two categories: the tongue retaining type and the mandibular advancing type.
The TRD functions by holding the tongue in a forward position by means of a suction bulb. When the tongue is in this position, the device keeps the tongue from collapsing during sleep and obstructing the airway in the throat.
The mandibular advancing type functions by repositioning and maintaining the mandible in a protruded position during sleep. This serves to open the airway by indirectly pulling the tongue forward, keeping the soft palate attached to the tongue (oral seal) by the negative pressure occurring in the mouth and making it more rigid. It also holds the lower jaw and other structures in a stable position to prevent opening of the mouth.
The mandibular advancing and non-titratable type of oral appliance is a custom-made monoblock device connected by two separate arches (maxillary and mandibular) without an advancing mechanism. Several versions are listed below.
The mandibular advancing and titratable type of oral appliance is a custom-made two-piece appliance composed of two separate arches (maxillary and mandibular) containing an advancing mechanism. Examples are listed below.
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