The purpose of this review is to provide guidelines for the use of oral appliances (OAs) for the treatment of snoring and obstructive sleep apnoea (OSA) in Australia. A review of the scientific literature up to June 2012 regarding the clinical use of OAs in the treatment of snoring and OSA was undertaken by a dental and medical sleep specialists team consisting of respiratory sleep physicians, an otolaryngologist, orthodontist, oral and maxillofacial surgeon and an oral medicine specialist. The recommendations are based on the most recent evidence from studies obtained from peer reviewed literature. Oral appliances can be an effective therapeutic option for the treatment of snoring and OSA across a broad range of disease severity. However, the response to therapy is variable. While a significant proportion of subjects have a near complete control of the apnoea and snoring when using an OA, a significant proportion do not respond, and others show a partial response. Measurements of baseline and treatment success should ideally be undertaken. A coordinated team approach between medical practitioner and dentist should be fostered to enhance treatment outcomes. Ongoing patient follow-up to monitor treatment efficacy, OA comfort and side effects are cardinal to long-term treatment success and OA compliance.Keywords: Mandibular advancement splint, obstructive sleep apnoea, oral appliance, review, snoring.Abbreviations and acronyms: AASM = American Academy of Sleep Medicine; ADA = Australian Dental Association; AHI = apnoeahypopnoea index; ASA = Australasian Sleep Association; BMI = body mass index; CBCT = cone beam computed tomography; CT = computed tomography; ESS = Epworth Sleepiness Scale; MAS = mandibular advancement splints; OA = oral appliances; OSA = obstructive sleep apnoea; PSG = polysomnogram; SDB = sleep disordered breathing; TMD = temporomandibular disorder; TMJ = temporomandibular joint; TRD = tongue retaining device; TSD = tongue stabilizing device; UARS = upper airway resistance syndrome; UPPP = uvulopalatopharyngoplasty.

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The RCMP device was well tolerated by patients and successfully used to perform mandibular protrusion sleep studies in our sleep laboratory. The RCMP sleep study showed good accuracy as a prediction technique for oral appliance treatment outcome, although there was a high rate of inconclusive tests.

Study Objectives: An oral appliance (OA) is a validated treatment for obstructive sleep apnea (OSA). However, therapeutic response is not certain in any individual and is a clinical barrier to implementing this form of therapy. Therefore, accurate and clinically applicable prediction methods are needed. The goal of this study was to derive prediction models based on multiple awake assessments capturing different aspects of the pharyngeal response to mandibular advancement. We hypothesized that a multimodal model would provide robust prediction. Methods: Patients with OSA (apnea-hypopnea index [AHI] > 10 events/h) were recruited for treatment with a customized OA (n = 142, 59% male). Participants underwent facial photography (craniofacial structure), spirometry (mid-inspiratory flow at 50% vital capacity [MIF50] and mid-expiratory flow at 50% vital capacity [MEF50] and the ratio MEF50/MIF50) and nasopharyngoscopy (velopharyngeal collapse with Mueller maneuver and mandibular advancement). Treatment response was defined by 3 criteria: (1) AHI < 5 events/h plus ≥ 50% reduction, (2) AHI < 10 events/h plus ≥ 50% reduction, (3) ≥ 50% AHI reduction. Multivariable regression models were used to assess predictive utility of phenotypic assessments compared to clinical characteristics alone (age, sex, obesity, baseline AHI). Results: Craniofacial structure and flow-volume loops predicted treatment response. Accuracy of the prediction models (area under the receiver operating characteristic curve) for each criterion were 0.90 (criterion 1), 0.79 (criterion 2), and 0.78 (criterion 3). However, these prediction models including phenotypic assessments did not provide a statistically significant improvement over clinical predictors only. Conclusions: Multimodal awake phenotyping does not enhance OA treatment outcome prediction. These office-based, awake assessments have limited utility for robust clinical prediction models. Future work should focus on sleep-related assessments. Citation: Sutherland K, Chan AS, Ngiam J, Dalci O, Darendeliler MA, Cistulli PA. Awake multimodal phenotyping for prediction of oral appliance treatment outcome.

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Qualitative assessment of awake nasopharyngoscopy appears useful for assessing the effect of mandibular advancement on upper airway collapsibility. However, it is not sensitive enough to predict oral appliance treatment outcome.

Study Objectives To characterise how mandibular advancement splint (MAS) alters inspiratory tongue movement in people with obstructive sleep apnoea (OSA) during wakefulness and whether this is associated with MAS treatment outcome. Methods 87 untreated OSA participants (20 women, apnoea hypopnoea index (AHI) 7-102events/hr, aged 19-76years) underwent a 3T MRI with a MAS in situ. Mid-sagittal tagged images quantified inspiratory tongue movement with the mandible in a neutral position and advanced to 70% of the maximum. Movement was quantified with harmonic phase methods. Treatment outcome was determined after at least 9 weeks of therapy. Results 72 participants completed the study: 34 were responders (AHI&lt;5 or AHI≤10events/hr with &gt;50% reduction in AHI), 9 were partial responders (&gt;50% reduction in AHI but AHI&gt;10events/h), and 29 non-responders (change in AHI &lt;50% and AHI ≥10events/rh). Sixty two percent (45/72) of participants had minimal inspiratory tongue movement (&lt;1mm) in the neutral position, and this increased to 72% (52/72) after advancing the mandible. Mandibular advancement altered inspiratory tongue movement pattern for 40% (29/72) of participants. When tongue dilatory patterns altered with advancement, 80% (4/5) of those who changed to a counterproductive movement pattern (posterior movement &gt;1mm) were non-responders, and 71% (5/7) of those who changed to beneficial (anterior movement &gt;1mm) were partial or complete responders. Conclusions The mandibular advancement action on upper airway dilator muscles differs between individuals. When mandibular advancement alters inspiratory tongue movement, therapeutic response to MAS therapy was more common among those who convert to a beneficial movement pattern.

Objective: To investigate the efficacy of orthodontic microimplant-based mandibular advancement therapies for the treatment of snoring and obstructive sleep apnea (OSA) in adult patients. Materials and Methods: Ten adult OSA patients (seven men, three women; mean age 60.00 6 9.25 years) were each treated with two mandibular orthodontic microimplants attached to a customized reverse face mask for mandibular advancement. Pretreatment and posttreatment outcome measures of microimplant mobility, apnea-hypopnea index, snoring, respiratory movement, and Epworth sleepiness scores were evaluated after 6 months. Results: Highly significant reductions in the apnea-hypopnea index, snoring, and sleep variables were observed. Sixteen of the 20 (80%) microimplants were stable and showed no mobility, and four (20%) demonstrated grade 1 or 2 mobility and required removal and reinsertion of a new microimplant. Conclusions: Favorable reductions in sleep variables highlight the potential of microimplantbased mandibular advancement therapy as an alternative treatment modality for OSA patients who cannot tolerate continuous positive airway pressure and oral appliance therapy. (Angle Orthod. 2012;82:978-984.)