Mandibular Advancement Devices in

630 Men and Women With Obstructive

Sleep Apnea and Snoring*
Tolerability and Predictors of Treatment Success
Marie Marklund, DDS, PhD; Hans Stenlund, PhD; and
Karl A. Franklin, MD, PhD, FCCP

Study objective: To evaluate the tolerability and to find predictors of treatment success for an
individually adjusted, one-piece mandibular advancement device in patients with snoring and
obstructive sleep apnea.
Design: Prospective study.
Setting: Departments of Respiratory Medicine and Orthodontics, Umeå University.
Patients: Six hundred nineteen of 630 patients (98%), who consecutively received treatment for
sleep apnea and snoring from February 1989 to August 2000, were followed up. They had a mean
apnea-hypopnea index of 16 (range, 0.0 to 76) and a mean body mass index of 28 (range, 19 to 42).
Measurements: Interviews, questionnaires, and overnight sleep apnea recordings. Patients with
an apnea-hypopnea index of > 10 in the supine and/or lateral position were considered to have
obstructive sleep apnea. A lateral apnea-hypopnea index of < 10, together with a supine
apnea-hypopnea index of > 10, defined supine-dependent sleep apneas.
Results: One hundred forty-eight of the 619 patients (24%) discontinued treatment. Female
gender predicted treatment success, defined as an apnea-hypopnea index of < 10 in both the
supine and lateral positions, with an odds ratio of 2.4 (p ⴝ 0.01). In the women, the odds ratios
for treatment success were 12 for mild sleep apnea (p ⴝ 0.04), and 0.1 for complaints of nasal
obstruction (p ⴝ 0.03). In the men, the odds ratios for treatment success were 6.0 for supine-
dependent sleep apneas (p < 0.001), 2.5 for mild sleep apnea (p ⴝ 0.04), 1.3 for each millimeter
of mandibular advancement (p ⴝ 0.03), and 0.8 for each kilogram of weight increase (p ⴝ 0.001).
Conclusions: The mandibular advancement device is recommended for women with sleep apnea,
for men with supine-dependent sleep apneas defined by a lateral apnea-hypopnea index of < 10,
and for snorers without sleep apnea. Men who increase in weight during treatment reduce their
chance of treatment success and are advised to be followed up with a new sleep apnea recording
with the device. (CHEST 2004; 125:1270 –1278)

Key words: activator appliances; mandibular advancement; nasal obstruction; sex; sleep apnea syndromes; supine
position

T here is clear evidence to support the positive

effects of a mandibular advancement device in
the treatment obstructive sleep apnea.1– 4 In spite of
this, nasal continuous positive airway pressure is
more effective in reducing apneas and symptoms in
unselected patients with obstructive sleep apnea.4 – 8
Predictors of treatment success with the mandibular
*From the Department of Orthodontics (Dr. Marklund), Umeå
University; and the Departments of Public Health and Clinical
Medicine, Epidemiology (Dr. Stenlund), and Respiratory Medi-
cine (Dr. Franklin), University Hospital, Umeå, Sweden.
This study was conducted at the Department of Respiratory
Medicine, University Hospital, and the Department of Orth-
odontics, Umeå University, Sweden.
This study was supported by grants from the Swedish Association
for Heart and Lung Patients and the Swedish Dental Society.
advancement device are therefore important when it
comes to selecting the patients who will particularly
benefit from this treatment.
Large samples are needed to evaluate the predic-
tors of success in the treatment of obstructive sleep
apnea. The largest study so far comprised 256 pa-
tients with sleep apnea treated with mandibular
advancement devices.9 Fifty-four percent of these
Manuscript received May 2, 2003; revision accepted November
4, 2003.
Reproduction of this article is prohibited without written permis-
sion from the American College of Chest Physicians (e-mail:
permissions@chestnet.org).
Correspondence to: Marie Marklund, DDS, PhD, Department of
Orthodontics, Umeå University SE-901 87 Umeå, Sweden; e-mail:
Marie.Marklund@odont.umu.se

1270 Clinical Investigations

patients had a reduction in their total apnea-
hypopnea index from ⱖ 10 to below that level.9 This
can be compared with success rates between 14%
and 78% in patients reported in other studies.4 –
8,10 –16 The success rate, defined as a reduction in the
total apnea-hypopnea index, is influenced by the
percentage of specific subgroups of patients in the
studied sample. The inclusion of more patients with
milder disease will therefore increase the success
rate and vice versa.12,13,16 –19 In addition, patients
who do not tolerate the device are usually not
considered in these evaluations. No study has eval-
uated the predictors of treatment success controlled
for sleep position in a large cohort of patients treated
for snoring and sleep apnea with mandibular ad-
vancement devices by one and the same dentist
using the same methodology for all treatments. The
results from our first 26 evaluated patients have been
presented in a previous study.20 The aim of the
present study was to evaluate the tolerability of
treatment and to find predictors of treatment success
with a mandibular advancement device in all patients
who consecutively received treatment with mandib-
ular advancement devices for obstructive sleep ap-
nea or snoring at one sleep apnea clinic during a
10-year period.

Materials and Methods

Patients

Six hundred thirty patients who consecutively received treat-

ment with mandibular advancement devices for obstructive sleep
apnea and habitual snoring from February 1989 to August 2000
were included (Fig 1). All the patients underwent medical
examinations and sleep apnea recordings at the Department of
Respiratory Medicine, and they were then referred for treatment
by the same dentist. Patients with Cheyne-Stokes respiration,
arthralgia, or myofascial pain from the craniomandibular system,
edentulous jaws, class III malocclusion, or acute periodontal
disease were excluded from the treatment. The sample consisted
of patients who were recommended the mandibular advance-
ment device as the first treatment of choice because of snoring or
mild sleep apnea, and patients with more severe disease who did
not tolerate nasal continuous positive airway pressure. There
were 457 patients with an apnea-hypopnea index ⬍ 20, 130
patients with an apnea-hypopnea index between 20 and 40, while
the remaining 43 patients had an apnea-hypopnea index ⱖ 40
without the device. Before the start of treatment, the patients
were asked about their smoking habits, complaints of excessive
daytime sleepiness, headache, and nasal obstruction.
Six hundred nineteen of the 630 patients (98%) were followed
up after using the device for 1 year. Nine patients had moved and
two patients had died during this period (Fig 1). Four hundred
ninety-nine men and 120 women continued with the device. The
men had a mean age of 51 years (range, 25 to 74 years), while the
women were older, with a mean age of 55 years (range, 30 to 75
years) [p ⬍ 0.001]. The body mass index, apnea-hypopnea index,
and percentage of supine-dependent patients did not differ
between the men and the women. A check of the subjective
Figure 1. The evaluated sample.
effects of the device on symptoms and side effects was performed
every second year after the start. All the patients who were
re-evaluated with sleep apnea recordings with the device before
January 2002 were analyzed to determine predictors of treatment
success. Approval for the study was obtained from the Medical
Ethics Committee at Umeå University.
Mandibular Advancement Device
The mandibular advancement devices were fabricated by
dental technicians from plaster casts of the teeth and construction
bites obtained by the dentist. The devices were made of SR-
Ivocap or SR-Ivocap elastomer (Ivoclar; Schaan, Liechten-
stein).21 Similar designs for the device were used in all patients,
but before 1993 all patients received devices made of hard
acrylic, and from 1995 the patients were treated with soft
elastomeric devices.21
The advancement and opening of the mandible by the device
was designed to move the tongue and soft palate in an anterior
position with a subsequent increase in pharyngeal airway space

www.chestjournal.org CHEST / 125 / 4 / APRIL, 2004 1271

but also to allow mouth breathing and speech with the appliance
in place. The mandibular advancement was intended to be
between 4 mm and 6 mm, and the mandibular opening at least 5
mm between the incisors. Patients with a limited capacity to
move the mandible forward were asked to advance their mandi-
bles as much as they could without discomfort. After 1 to 2
months, the patients were asked about their tolerance of the
device and the subjective effects of the treatment. The advance-
ment was further increased in patients who reported an insuffi-
cient improvement on snoring or apneas, and the advancement
was reduced in patients who experienced pain from the cranio-
mandibular system. Adjustments were offered until the patients
were satisfied with the effects of the device or chose to discon-
tinue treatment. Patients who did not tolerate the device after 1
year were regarded as having discontinued treatment.
The degree of mandibular advancement was measured on
plaster casts in the premolar area and along an occlusal plane
from the upper right central incisor to the mesial cusp of the
upper first molar or premolar if the molar was missing. The
mandibular opening was measured as the distance between the
upper right and lower central incisor edge plus the overbite.
These measurements were performed on the initial plaster casts
using the most recent construction bite at the time of the sleep
apnea recording with the device
Sleep Apnea Recordings
The patients underwent sleep apnea recordings including nasal
and oronasal air flow using a three-way thermistor (Nihon
Kohden Ze-732A; Nihon Kohden; Tokyo, Japan), abdominal and
chest movements (Resp-EZ; EPM Systems; Midlothian, VA),
finger oximetry (Ohmeda Biox 3740; Ohmeda; Louisville, CO),
body position (Vitalog Monitoring; Redwood City, CA), and
ECGs (V5). An obstructive event was scored if respiratory efforts
continued during apnea. An apnea was defined as a cessation of
air flow lasting at least 10 s, and a hypopnea was defined as a
decrease of ⱖ 50% in the thermistor tracing compared with
baseline, combined with an oxygen desaturation of ⱖ 3%. The
estimated sleep time was evaluated from the respiratory sleep
recordings and body position sensors.22 The apnea-hypopnea
index was the average number of apneas and hypopneas per hour
of estimated sleep time. The supine apnea-hypopnea index was
defined using the average number of apneas and hypopneas per
hour of estimated sleep time in the supine position. The lateral
apnea-hypopnea index was the average number of apneas and
hypopneas per hour of estimated sleep time in the lateral and
prone positions.
Patients with an apnea-hypopnea index of ⱖ 10 in the supine
and/or lateral position were considered to have sleep apnea.
Supine-dependent sleep apneas were defined by a supine apnea-
hypopnea index of ⱖ 10, together with a lateral index of ⬍ 10.
Nonsupine-dependent sleep apneas were considered in patients
with a lateral apnea-hypopnea index of ⱖ 10. Mild sleep apnea
was defined by a total apnea-hypopnea index of ⬍ 20, severe
sleep apnea as an index of ⱖ 40, while moderate sleep apnea was
defined as the values between mild and moderate sleep apnea.
Treatment Success
A reduction in the apnea-hypopnea index from ⱖ 10 in the
lateral and/or supine sleep position to an index of ⬍ 10 in both
the supine and lateral positions during treatment defined treat-
ment success with the device. Patients with an apnea-hypopnea
index of ⱖ 10 in the supine and/or lateral position with the device
were regarded as having an insufficient apnea reduction.
1272
Tolerability
Patients who did not use the device after 1 year were regarded
as having poor tolerability of the treatment. These patients were
interviewed about the reason for discontinuing treatment.
Statistical Methods
The Wilcoxon signed rank test for paired observations was used
to analyze the effects of the device on respiratory variables.
Differences between subgroups of patients and factors related to
the poor tolerability of the treatment were analyzed using the
Mann-Whitney U test for independent samples or the ␹2 test.
Factors related to the changes in sleep positioning during
treatment were analyzed using multivariate linear regression
analysis. The associations between treatment success and age,
gender, nonobesity (body mass index ⬍ 30), weight increase, and
time between the evaluation without the device and with it,
supine-dependent sleep apneas, mild sleep apnea, nonsmoking,
nasal obstruction, mandibular displacement, and the year of
treatment start were estimated by odds ratios using the logistic
regression analysis. Missing values for predictor variables were
coded to the reference category in the logistic regression models.
The weight change variable was categorized into steps of 1 kg and
was compared with a reference category including patients with
a variability of between ⫾ 2 kg in the analysis of cutoff points for
the influence of weight changes on the treatment outcome. The
SPSS 11.0 Statistical Software Package (SPSS; Chicago, IL) was
used in all calculations; p ⬍ 0.05 was considered significant.
Results
Patients Who Did Not Tolerate the Device
One hundred forty-eight of the 619 patients (24%)
did not tolerate the device and discontinued the
treatment (Fig 1). Discomfort, including excessive
salivation or a feeling of awkwardness when wearing
the device, was the main cause of a poor tolerability
of the device (Table 1). Insufficient effects on snor-
ing or odontologic problems, ie, symptoms from the
craniomandibular system, periodontal disease, or
changes in occlusion during treatment, were other
explanations for a failure to accept the device. A few
patients stopped using the device, as they had had
unrealistic expectations of the treatment in terms of
cured tinnitus or dysphagia (Table 1). Poor tolera-
bility of the treatment was unrelated to the severity
of the disease, supine-dependent sleep apneas, age,
Table 1—Causes of the Discontinuation of Treatment
No. (%)
Causes (n ⫽ 148)
Discomfort 86 (58.1)
Poor effect on snoring 22 (14.9)
Odontologic problems 13 (8.7)
Another treatment demanded 10 (6.8)
Other causes 3 (2.0)
Unknown 14 (9.5)
Clinical Investigations
nonobesity, gender, treatment start before 1995 or
after, smoking or complaints of excessive daytime
sleepiness, nasal obstruction, or headache before the
start of treatment.
Re-evaluated Patients
Sleep apnea recordings with the device were
performed in 263 of 356 patients with sleep apnea
and in 14 of 115 snoring patients without sleep apnea
(Fig 1, Table 2). No re-evaluation with the device
was later performed in otherwise healthy patients
with supine-dependent sleep apnea and milder dis-
ease, who were subjectively satisfied with the treat-
ment,20 or in the snorers. The re-evaluated sleep
apnea patients were older (p ⫽ 0.024) and included
a higher percentage of women (p ⫽ 0.003), patients
with nonsupine-dependent apneas (p ⫽ 0.001), and
patients who started treatment before 1995
(p ⬍ 0.001) than the patients who were not re-
evaluated. There was a mean of 573 ⫾ 521 days
(⫾ SD) between the sleep apnea recording with the
device and that without it.
Two hundred thirty-seven of the 263 re-evaluated
patients with sleep apnea had sufficient data in the
supine and lateral positions to define treatment
success in the sleep apnea recording with the device
(Fig 1). One hundred eighty-eight of these 237
patients had sufficient data for all variables for the
logistic regression models (Fig 1).
Effects of the Device on Sleep Apnea
Treatment success with an apnea-hypopnea index
of ⬍ 10 in both the supine and lateral positions was
found in 129 of the 237 (54%) re-evaluated patients
with sleep apnea. Ninety-seven of 192 men (51%)
and 32 of 45 women (71%) were successfully treated
with the device. Forty-four of 112 (39%) re-evalu-
ated patients with moderate and severe disease were
successfully treated by the device. A total apnea-
hypopnea index of ⬍ 10 with the device was found in
158 of the 219 patients (72%) who had a total sleep
apnea-hypopnea index of ⱖ 10 without the device.
Predictors of Treatment Success With the Device
The univariate odds ratios for treatment success
were 4.9 for supine-dependent sleep apneas
(p ⬍ 0.001), 3.3 for mild sleep apnea (p ⬍ 0.001),
2.4 for female gender (p ⫽ 0.01), and 0.9 for each
kilogram of increase in weight (p ⫽ 0.001) between
the evaluations in the 237 re-evaluated patients with
sleep apnea (Table 3).
Predictors of Treatment Success in Men
Supine-dependent sleep apnea was the strongest
predictor of treatment success in men (odds ratio,
6.0; p ⬍ 0.001), according to a logistic regression
model including all predictor variables. Mild sleep
apnea (odds ratio, 2.5; p ⫽ 0.04) and the degree of
mandibular advancement (odds ratio, 1.3; p ⫽ 0.03)
for each millimeter were also related to treatment
success with the device. Weight increase among the
men related to an insufficient apnea reduction by the
device (odds ratio, 0.8; p ⫽ 0.001) for each kilogram
(Table 4). The reduced chance of treatment success
appeared at a weight increase of between 3 kg and 4
kg (odds ratio, 0.1; p ⫽ 0.021).
Predictors of Treatment Success in Women
Mild sleep apnea predicted treatment success in
the women, according to a logistic regression model
including all predictor variables (Table 5). Com-
plaints of nasal obstruction were related to an insuf-
ficient apnea reduction by the device.
Supine dependence did not relate to treatment
success among the present women. Among the
patients with nonsupine-dependent sleep apneas,
women were more often successful with the device
than men (odds ratio, 6.1; p ⫽ 0.039; n ⫽ 60).
Predictors of Treatment Success in Patients With
More Severe Disease
Supine dependence was the strongest predictor of
treatment success in patients with a total apnea-

Table 2—Effects of the Device on Respiratory Variables (n ⴝ 277)

Without the Device With the Device

Variables No. Mean Range Mean Range p Value

Apnea-hypopnea index 277 21 1.1–74 7.6 0.0–72 ⬍ 0.001

Supine apnea-hypopnea index 222 37 0.0–114 13 0.0–90 ⬍ 0.001
Nonsupine apnea-hypopnea index 211 10 0.0–74 3.5 0.0–60 ⬍ 0.001
Supine time, % 225 40 0.0–100 44 0.0–100 0.018
Total sleep time, minutes 256 400 240–760 385 98–660 0.010
Lowest oxygen saturation, % 238 83 48–98 86 56–95 0.001
Longest apnea, s 127 45 13–111 32 9.0–100 ⬍ 0.001

www.chestjournal.org CHEST / 125 / 4 / APRIL, 2004 1273

 Table 3—Univariate Logistic Regression Analysis of Predictors of Treatment Success With the Device

Odds 95% Confidence

Variables Ratio Interval p Value

Background predictors
Female gender* 2.41 1.19–4.87 0.014
Nonobesity, body mass index ⬍ 30 at start 1.45 0.81–2.59 0.21
Age 0.99 0.96–1.02 0.42
Treatment start 1995 or later 1.46 0.85–2.53 0.17
Predictors from the sleep apnea recording
Supine-dependent sleep apneas 4.86 2.57–9.18 ⬍ 0.001
Mild sleep apnea (total apnea-hypopnea index ⬍ 20) 3.28 1.93–5.60 ⬍ 0.001
Predictors from symptoms at start
Nonsmoker during the last year before treatment start 1.39 0.75–2.59 0.30
Complaints of nasal obstruction 0.71 0.42–1.20 0.21
Predictors from mandibular position
Mandibular advancement, mm 1.06 0.91–1.24 0.44
Mandibular opening, mm 1.04 0.91–1.18 0.56
Control predictor
Increase in weight, kg 0.86 0.79–0.94 0.001
*The odds ratio was 2.49 (p ⫽ 0.04) controlling for age, body mass index, supine and lateral apnea-hypopnea indices, and supine-dependent sleep
apneas.

hypopnea index of ⱖ 20 (odds ratio, 3.1; p ⫽ 0.024), Mandibular Displacement

according to a logistic regression model including all
predictor variables including gender (n ⫽ 81). A
reduced chance of treatment success was found
together with complaints of nasal congestion (odds
ratio, 0.3; p ⫽ 0.026) or increases in weight (odds
ratio, 0.8; p ⫽ 0.044) for each kilogram.
Estimated Treatment Outcome in the Whole
Sample
It was estimated that 50% of the 619 snorers and
sleep apnea patients had treatment success or sub-
jective beneficial effects from the treatment. This
calculation was based on the assumption that snoring
patients without sleep apnea experienced subjective
beneficial effects from the treatment, if they contin-
ued treatment after 1 year. It was estimated that 26%
of all 619 patients had an insufficient apnea reduc-
tion by the device and that 24% had discontinued
treatment.
Table 4 —Predictors of Treatment Success With the
Device in Men (n ⴝ 155)
The mean mandibular advancement by the device
was 5.3 mm (range, 0.0 to 10 mm), and the mean
mandibular opening was 11 mm (range, 4.0 to 17
mm), which corresponded to a mean of 8.2 mm
(range, 1.3 to 13 mm) between the incisor edges.
The mean mandibular advancement was 5.4 mm
(range, 0.0 to 10 mm) in patients with treatment
success, and 5.2 mm (range, 0.0 to 9 mm) in patients
with an insufficient apnea reduction by the device.
The mean mandibular opening was 11 mm (range,
6.0 to 17 mm) or a mean of 8.3 mm (range, 3.3 to 12
mm) between the incisors in patients with treatment
success, and 11 mm (range, 4.0 to 16 mm) or a mean
of 8.3 mm (range, 1.3 to 13 mm) between the
incisors in patients with an insufficient apnea reduc-
tion by the device.
Changes in Sleep Position During Treatment
The patients increased their percentage of sleep in
the supine position when they used their devices
(Table 2). A multivariate linear regression analysis
revealed a relationship between the reduction in the

Odds 95% Confidence

Variables Ratio Interval p Value Table 5—Predictors of Treatment Success With the
Supine-dependent sleep apneas 5.97 2.43–14.7 ⬍ 0.001
Device in Women (n ⴝ 33)
Mild sleep apnea 2.50 1.06–5.91 0.036 Odds 95% Confidence
Mandibular advancement, mm 1.31 1.02–1.68 0.034 Variables Ratio Interval p Value
Mandibular opening, mm 1.21 0.98–1.50 0.08
Age 0.96 0.92–1.00 0.08 Mild sleep apnea 12.1 1.51–97.8 0.019
Increase in weight, kg 0.81 0.71–0.92 0.001 Complaints of nasal obstruction 0.11 0.02–0.79 0.028

1274 Clinical Investigations

supine apnea-hypopnea index and an increase in the
supine sleeping time (p ⬍ 0.001), controlled for
changes in oxygen saturation levels and weight, time
between the evaluations, and mandibular displace-
ment by the device.
Obesity and Nonsupine-Dependent Sleep Apnea
Obesity defined as a body mass index of ⱖ 30
was found in 37% of the patients with nonsupine-
dependent sleep apneas and in 23% of the patients
with supine-dependent sleep apneas (p ⫽ 0.006).
Discussion
Women with sleep apnea were more likely than
men with sleep apnea to have treatment success
with the mandibular advancement device. Supine-
dependent sleep apneas, mild disease, and an in-
crease in mandibular advancement predicted treat-
ment success among the men, while mild sleep
apnea was associated with treatment success in the
women. An insufficient apnea reduction by the
device, however, related to an increase in weight
among the men and complaints of nasal obstruction
among the women. The discontinuation of treatment
during the first year was not related to the severity of
the disease.
The present results were based on prospective
investigations of 619 of 630 patients (98%) with
snoring and obstructive sleep apnea who were
treated consecutively by one dentist using the same
methodology for all patients. All the sleep apnea
recordings were performed at the Department of
Respiratory Medicine in Umeå, which is the center
for the treatment of snoring and sleep apnea in the
County of Västerbotten, which has 255,000 inhabit-
ants. This is the largest study of patients treated with
mandibular advancement devices for snoring and
obstructive sleep apnea so far.
Twenty-four percent of the patients in the present
sample stopped using their devices during the first
year, which is comparable to the discontinuation of
treatment of between 18% and 45% among the
patients in other reports.23,24 Neither disease sever-
ity, age, or sex, nor complaints of nasal obstruction or
smoking habits were related to poor tolerability in
the present sample. McGown et al23 report that
patients who are satisfied with the effect of the
device on symptoms of sleep apnea have a higher
tolerance than the remainder. Personal preferences,
such as a feeling of awkwardness when using the
device, side effects from the treatment, or the relief
of symptoms, are probably the main reasons for poor
or good tolerance of the mandibular advancement
device.
www.chestjournal.org
Seventy-two percent of the patients with sleep
apnea experienced a good effect with the device
using the definition for treatment success, including
a reduction in the total apnea-hypopnea index from
⬎ 10 to below that level.12 One problem with this
definition is that a poor effect with the device may be
undetected in patients who have a large positional
difference in apnea frequency, together with a short
sleeping time in the position with the most frequent
apneas. We therefore required an index of ⬍ 10 in
both the supine and lateral positions for treatment
success with the device. This definition reduced the
success rate to 54% of the present patients with sleep
apnea. If the snorers and the patients who discon-
tinued treatment were also considered, we estimated
that half the patients in the present sample had
improvements as a result of their mandibular ad-
vancement devices. This calculation was based on
the assumption that the sleep apnea patients who
were not re-evaluated had the same success rate as
the re-evaluated patients. In fact, the patients who
were not re-evaluated had milder disease than the
re-evaluated patients. Consequently, the treatment
outcome might have been slightly better in the
present sample of patients with predominantly mild
disease. Even so, these figures illustrate that there is
a need for the establishment of more precise indica-
tions for the mandibular advancement device in
order to increase the success rate.
In our male subjects, supine dependence was the
best predictor of treatment success with the device
(odds ratio, 6.0; p ⬍ 0.001), compared with an odds
ratio of 2.5 for mild sleep apnea defined by a total
apnea-hypopnea index of ⬍ 20. In contrast, men
who increased their weight substantially reduced
their chance of treatment success with the device, as
there was a 19% reduction in the odds ratio for each
additional kilogram between the sleep apnea record-
ing without the device and that with it. This reduced
efficacy of the device may be explained by the fact
that these men may have increased their apnea
frequency, particularly in the lateral position. Obe-
sity has been associated with nonsupine-dependent
sleep apneas in previous studies,25,26 as well as in the
present study. It is advisable to follow up men whose
weight increases by ⬎ 3 kg during treatment with a
renewed sleep apnea recording with the device, as
these men reduce their chance of treatment success
and may therefore require treatment with nasal
continuous positive airway pressure.
Mild sleep apnea with a total index of ⬍ 20 was
the best predictor of treatment success, while supine
dependence was unrelated to the efficacy of the
device among the women in the present sample. In
fact, the women with nonsupine-dependent sleep
apneas had a significantly higher success rate than
CHEST / 125 / 4 / APRIL, 2004 1275
the men with nonsupine-dependent sleep apneas
(odds ratio, 6.1). An insufficient apnea reduction by
the device, however, related to complaints of nasal
obstruction among the women.
The more than twofold increase in the success rate
in the women in the present study compared with
the men is a new finding. Battagel et al27 report that
women enlarge their pharynx more during mandib-
ular advancement than men. This mechanism may
explain the gender difference in terms of the efficacy
of the device, in spite of the fact that men have a
wider pharynx than women.28,29 Moreover, men tend
to accumulate more fat in the pharynx than women,
which will further impair the opportunity for men to
maintain airway patency.30 Consequently, a stiffer,
less collapsible airway among the women31 may
explain why the mandibular advancement device is
more effective among women.
The high predictive value of supine-dependent
sleep apneas for treatment success among the men,
including patients with more severe disease in the
present large sample, supports the results of a
previous study from our sleep apnea center compris-
ing 23 men and 3 women with mild-to-severe ob-
structive sleep apnea.20 In that study, the odds ratio
for treatment success was 30 in the patients with
supine-dependent sleep apneas and 7.5 in patients
with mild sleep apnea (apnea-hypopnea index
⬍ 20).20 Supine-dependent sleep apneas are there-
fore a better predictor of treatment success than
the disease severity measured by the total apnea-
hypopnea index. A diagnosis of supine dependence
probably reflects a normal pharyngeal morphology
with a wide airway in the lateral dimension, while
lateral sleep apneas indicate lateral narrowings.32
Problems maintaining airway patency in the lateral
sleep position indicate a high risk of sleep apneas, as
the airway is usually more stable in the lateral than in
the supine position.33 The simple forward movement
of the mandible by a device will be insufficient and
there is a need for nasal continuous positive airway
pressure to keep the airways open at night in men
with nonsupine-dependent sleep apneas.
The nasal airway patency increases during man-
dibular advancement in healthy subjects.34 Improved
nasal patency may also be part of the mechanism of
action of the device in the treatment of snoring and
sleep apnea. This probably explains the reduced
chance of treatment success with the device in the
women in the present sample and patients with more
severe disease with complaints of nasal obstruction.
More studies of the influence of nasal obstruction on
the efficacy of the device on sleep apnea are needed,
as the present results were based on regression
models, including subjective reports from the pa-
tients.
1276
An increased percentage of sleeping time in the
supine position and a reduced amount of total
sleeping time were found during treatment with the
mandibular advancement device in the present
study. The increase in the percentage of supine
sleeping time was directly associated with the reduc-
tion in the supine apnea-hypopnea index. Sleeping in
the lateral position is probably a protective mecha-
nism against sleep apnea, as the pharynx is more
collapsible in the supine than the lateral position,33
and supine sleep apneas are therefore more severe
and produce longer sleep arousals than lateral sleep
apneas.35 Sleeping position training has also been
advocated for the treatment of supine-dependent
sleep apneas.36,37 The results indicate short-term
positive effects on apneas and symptoms,36,37 but the
longer-term success rate is uncertain.36 A mandibu-
lar advancement device is a better treatment alter-
native, as it effectively reduces supine sleep apneas
in patients with supine-dependent sleep apnea. The
device also gives these patients the freedom to
choose their favorite sleep positions instead of being
forced to sleep in the lateral position.
Many different designs have been suggested for
mandibular advancement devices.1–21,38 – 40 Compar-
isons of different devices in terms of their effects on
sleep apnea have indicated that a one-piece, individ-
ually designed mandibular advancement device is
more effective than a two-piece adjustable device or
a prefabricated appliance.38,40 We used an individu-
ally designed, one-piece device of a similar type
throughout the entire 10.5-year period, even when
we changed the material from hard acrylic to soft
elastomer in 1993 to 1994. From 1995 on, the soft
elastomeric device became the predominant treat-
ment method. The present results do not indicate
any difference in treatment effect between these two
appliances.
A larger degree of mandibular advancement im-
proves the efficacy of a mandibular advancement
device,41 while the degree of mandibular opening
within a specific range is of less importance.42 Pételle
et al43 evaluated the optimal degree of mandibular
advancement by titration during sleep and found a
mean of 13 mm (range, 9 to 17 mm), together with
2 mm of incisor opening in seven patients with
severe sleep apnea. We used smaller mandibular
advancements with a mean of 5.3 mm (range, 0.0 to
10 mm) and larger openings with a mean of 8.2 mm
(range, 1.3 to 13 mm) between the incisors in our
patients with predominantly mild or moderate sleep
apnea. The mandibular displacements were similar
in patients with treatment success and in patients
with insufficient apnea reduction. In men, a larger
mandibular advancement was beneficial, as the odds
ratio was 1.3 for each millimeter of mandibular
Clinical Investigations
advancement (p ⫽ 0.03). This association may be
explained by the large variability in treatment re-
sponse among the men. The generally weak relation-
ships between the degree of mandibular advance-
ment and treatment success with the device indicate,
however, that patient selection is more important
than the exact amount of mandibular advancement.
One limitation of the present study was the selec-
tion of patients toward those with mild disease and
those with more severe disease who did not tolerate
nasal continuous positive airway pressure. In addi-
tion, the patients were no more than slightly over-
weight, with a mean body mass index of 28. Our
patients served as their own controls in the study. We
did not perform full polysomnographic sleep record-
ings including EEG. Instead, we estimated sleep
time from the respiratory sleep recordings and body
position sensors, according to the method presented
by Svanborg et al.22 Moreover, we had to rely on
patient reports for estimations of the tolerability of
the device, as objective measurements, ie, time
counters, were not available.
Treatment with mandibular advancement devices
is indicated in women with sleep apnea, in men with
supine-dependent sleep apneas, and in snorers with-
out sleep apnea. Follow-up sleep apnea recordings of
men with nonsupine-dependent apneas (ie, a lateral
apnea-hypopnea index of ⱖ 10) and women with
more severe disease (ie, a total apnea-hypopnea
index of ⱖ 20) are recommended. Men with sleep
apnea who increase their weight reduce their chance
of treatment success with the device. They are
therefore advised to be followed up with a new sleep
apnea recording with the device, and are offered
treatment with nasal continuous positive airway pres-
sure when needed.
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Clinical Investigations