1. IL RUOLO
DEI DISPOSITIVI INTRAORALI
NELLA TERAPIA DELL’OSAS
Dott. Luca Gioia

2. ODONTOIATRIA ed OSAS
1. Cenni storici sulla letteratura
2. Linee guide MAS
3. Panoramica e caratteristiche dispositivi MAS

3. Paskow H, Paskow S.
 New Jersey Medicine. 1991 Nov;88(11):815-7.
Dentistry's role in treating sleep apnea and snoring.
Dental appliances have a place in the treatment of loud
snoring and obstructive sleep apnea (OSA), and may be
indicated for those patients who cannot tolerate
continuous positive air pressure ventilation.
Physicians and dentists must work together for the health,
comfort, and well-being of patients.

4. Schmidt-Nowara W, Lowe A,
 Sleep. 1995 Jul;18(6):501-10.
Oral appliances for the treatment of snoring and obstructive sleep
apnea: a review.
1. The appliances modify the upper airway by changing the posture
of the mandible and tongue.
2. Snoring is improved and often eliminated in almost all patients
who use oral appliances
3. Obstructive sleep apnea improves in the majority of patients; the
mean apnea-hypopnea index (AHI) in this group of patients was
reduced from 47 to 19. Approximately half of treated patients
achieved an AHI of < 10; however, as many as 40% of those
treated were left with significantly elevated AHIs.
4. Improvement in sleep quality and sleepiness reflects the effect on
breathing

5. Schmidt-Nowara W, Lowe A.
Sleep. 1995 Jul;18(6):501-10.
Oral appliances for the treatment of snoring and obstructive sleep
apnea: a review.
1. Compliance varies from 50% to 100% of patients
2. Comparison of the risk and benefit of oral appliance
therapy with the other available treatments suggests
that oral appliances present a useful alternative to
continuous positive airway pressure (CPAP),
especially for patients with simple snoring and patients
with obstructive sleep apnea who cannot tolerate
CPAP therapy.

6. Barsh LI.
Sleep Disorders Dental Society Wexford, Pennsylvania, USA.
Compend Contin Educ Dent. 1996 May;17(5):490-4, 496 passim; quiz
502.
1. Responsibilities of the dental profession in recognizing
and treating sleep breathing disorders.
2. Oral appliance therapy has been accepted by the
American Sleep Disorders Association as an
appropriate treatment modality for some patient.
3. It is essential, however, that dentists work as part of
the treatment team and not assume responsibility for
diagnosis and treatment without the involvement of a
physician or sleep specialist.

7. Barsh LI.
Sleep Disorders Dental Society Wexford, Pennsylvania, USA.
Compend Contin Educ Dent. 1996 May;17(5):490-4, 496 passim; quiz
502.
Responsibilities of the dental profession in recognizing and treating
sleep breathing disorders.
 dentist can identify patients with sleep-breathing
disorders and participate in their treatment
 it is essential that dentists realize that snoring and
obstructive sleep apnea are medical and not dental
problems

8. Findely LJ
Automobile accident involving patients with osas
American Review of Respiratory Disease 138: 337-340, 1988
INCIDENTI AUTOMOBILISTICI
Rischio 7 volte superiore

9. Riley RW et al
Trends in OSA therapy
West J of Medicine 162: 143-148, 1995
PERDITA DI PRODUTTIVITA’
20 miliardi di dollari annui

10. ODONTOIATRIA ed OSAS
1. Cenni storici sulla letteratura
2. Linee guide MAS
3. Panoramica e caratteristiche dispositivi MAS

11. ODONTOIATRIA e OSAS
Fondata nel 1991 Fondata nel 2004

12. Hoffstein V.
Sleep Breath. 2007 Mar;11(1):1-22.
Review of oral appliances for treatment of sleep-
disordered breathing.
 89 publications dealing with oral appliance therapy involving a total
of 3,027 patients
Parameters:
1. reduction in the apnea/hypopnea index
2. ability of oral appliances to reduce snoring
3. comparison of oral appliances with other treatments
4. side effects
5. long-term compliance

13. Hoffstein V.
Sleep Breath. 2007 Mar;11(1):1-22.
Review of oral appliances for treatment of sleep-
disordered breathing.
 Epworth sleepiness score (ESS) dropped from 11.2 to
7.8 in 854 patients
 54 % riduzione AHI (<10) 50% negli studi random e
placebo-ctr
 45 % riduzione snoring
 MAD reduced initial AHI by 42%, CPAP reduced it by
75%, and UPPP by 30%
 compliance data shows that at 30 months, 56-68% of
patients continue to use oral appliance

14. Hoffstein V.
Sleep Breath. 2007 Mar;11(1):1-22.
Review of oral appliances for treatment
of sleep-disordered breathing.
 We conclude that oral appliances, although not as effective as
CPAP in reducing sleep apnea, snoring, have a definite role in the
treatment of snoring and sleep apnea.

15. A. Hoekema et al
J Dent Res. 2008 Sep;87(9):882-7
Obstructive sleep apnea therapy
 103 individuals
 N= 51 oral-appliance
 N= 52 CPAP therapy

16. Obstructive sleep apnea therapy.
A. Hoekema et al

17. Aarab G, Lobbezoo F, Hamburger HL, Naeije M .
Respiration. 2011;81(5):411-9. Epub 2010 Oct 20.
Oral appliance therapy versus nasal continuous positive
airway pressure in obstructive sleep apnea: a randomized,
placebo-controlled trial
 64 pz mild-moderate OSAS
 3 gruppi: MAD – nCPAP – placebo
 2 polysomnographic recordings: before and after 6
month
 CONCLUSIONS
 There is no clinically relevant difference between MAD
and nCPAP in the treatment of mild/moderate OSA

18. Aarab G. et al
Clin Oral Investig. 2011 May 3
Long-term oral appliance therapy in obstructive sleep apnea
syndrome: a controlled study on temporomandibular side
effects
 43 pz (52.2 ± 9.6 years) AHI of 20.8 ± 9.9
 2 groups: n=21 MAD n=22 nCPAP
 4 polysomnographic recordings
 no difference between the MAD and the nCPAP groups
with mild/moderate obstructive sleep apnea.

19. Holley AB
Chest. 2011 Jun 2.
Efficacy of An Adjustable Oral Appliance and Comparison to
Continuous Positive Airway Pressure For the Treatment of
Obstructive Sleep Apnea Syndrome
 Retrospective analysis 497 pz
 AHI < 5
 70,3% mild 47,6% moderate 41,4% severe
with MAS
 CPAP 70,1% MAS 51,6%
The AOA is comparable to CPAP for patients with mild
disease, while CPAP is superior for patients with
moderate to severe disease.

20. ODONTOIATRIA ed OSAS
L’odontoiatra può individuare i fattori predittivi :
 Circonferenza collo (> 43 cm maschi, > 41 cm femmine)
 Retrognazia
 Grading tonsillare
 Classificazione di Mallampati
 Epworth Sleepiness Scale

21. ODONTOIATRIA ed OSAS
PAS
Posterior Airway Space < 9 mm

22. ODONTOIATRIA ed OSAS

23. ODONTOIATRIA ed OSAS
Meccanismo
d’azione

24. ODONTOIATRIA ed OSAS
L’APERTURA
DELLE VIE AEREE POSTERIORI
ALLA LINGUA
AVVIENE IN PARTICOLARE NELLA ZONA LATERALE
Stiramento dei tessuti molli

25. ODONTOIATRIA ed OSAS

26. ODONTOIATRIA ed OSAS
1. Cenni storici letteratura
2. Linee guide MAS
3. Panoramica e caratteristiche dispositivi MAS

27. Dispositivi intraorali – Oral appliance
 Dispositivi di ritenzione linguali (TRD) =Tongue retaining devices
 Propulsori mandibolari (MAS) = Mandibular advamcement device

28. Dispositivi di ritenzione linguali (TRD)

29. Dispositivi di ritenzione linguali (TRD)

30. Propulsori mandibolari (MAS)

31. Propulsori mandibolari (MAS)

32. Propulsori mandibolari (MAS)

33. Propulsori mandibolari (MAS)
somnodent

34. Propulsori mandibolari (MAS)

35. Propulsori mandibolari (MAS)

36. Propulsori mandibolari (MAS)
Quanto avanzare la mandibola?

37. Propulsori mandibolari (MAS)
SCHMIDT-NOWARA W et al
SCHMIDT-NOWARA W et al
Oral appliance for the treatment of snoring and OSA: a review
Oral appliance for the treatment of snoring and OSA: a review
Sleep 1995; 18: 501-510
Sleep 1995; 18: 501-510
La mandibola deve essere al 75% della protrusione
massima per ottenere risultati.
MARKLUND M et al
The effect of a mandibular advancement device on apneas and sleep in
patients with OSA
Chest 1998; 113: 707-713
La mandibola deve essere dal 41% al 88% della
protrusione massima per ottenere risultati.

38. Propulsori mandibolari (MAS)
MASSIMA POSIZIONE DI CONFORTO DINAMICA DEL
PAZIENTE
Ginnastica miofasciale
Posizione testa a testa
Dalla massima intercuspidazione scivolarecon gli incisivi in posizione testa a
testa inspirando; tenere la posizione per 10 sec, tornare indietro espirando.
Carota
Rosicchiare e masticare una carota solo con gli incisivi.
Contro-resistenza
Con la bocca socchiusa, opporsi alla forza retrusiva esercitata sul mento dal
paziente o dall’operatore.

39. Propulsori mandibolari (MAS)
EFFETTI COLLATERALI COMUNI:
1)Salivazioneaumentata
2)Temporaneo disagio ATM
3)Gola secca
4)Temporaneo disagio all’occlusione

40. Propulsori mandibolari (MAS)
Collaborazione
de Almeida et al
Journal of Clinical Sleep Medicine 2005;1(2):143-49.
Long-term compliance and side effects of oral appliances used
from the treatment of snoring and obcstructive sleep apnea
syndrome
544 pazienti (di cui 251 dopo una media di 5,7 anni)
64% stava ancora usando l’apparecchio
94% lo portava per più di 4 ore a notte
95% era pienamente soddisfatto del trattamento

41. Propulsori mandibolari (MAS)
Collaborazione
al 75 % ai sette mesi
Smidt-Novara WW et al
Chest 1991; 99: 1378-1385
Treatment of snoring and OSA with a dental orthosis
al 52 % dopo 3 anni
Clark Gt et al
Am Rev Respir Ds 1993; 147: 624-629
Effect of anterior mandibular positioning on OSA
al 70 % dopo 5 anni
MarKlund M et al
Eur J Orthod 2001; 23: 135-144
Orthodontic side effects of mandibular advancement
devices during the treatment of snoring and sleep apnea