Informationen aus Orthodontie & Kieferorthopädie 2019; 51(03): 169-173
DOI: 10.1055/a-0961-6186
Übersichtsartikel
© Georg Thieme Verlag KG Stuttgart · New York

Die Anwendung von Protrusionsschienen zur Behandlung des obstruktiven Schlafapnoe-Syndroms bei erwachsenen Patienten

The Use of Oral Appliances in the Treatment of Obstructive Sleep Apnea Syndrome in Adult Patients
Ambra Michelotti
1   Department of Neurosciences, Reproductive Sciences and Oral Sciences, Division of Orthodontics, University of Naples “Federico II”, Naples, Italy
,
Serena Incerti Parenti
2   Unit of Orthodontics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
,
Stefano Martina
3   Department of Medicine, Surgery and Orthodontics, “Scuola Medica Salernitana”/DIPMED, University of Salerno, Salerno, Italy
,
Giulio Alessandri Bonetti
2   Unit of Orthodontics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
› Author Affiliations
Further Information

Publication History

Publication Date:
17 September 2019 (online)

Zusammenfassung

Die obstruktive Schlafapnoe (OSA) ist gekennzeichnet durch wiederholte Episoden mit totalem oder partiellem Verschluss der oberen Atemwege während des Schlafs mit resultierender Schlaffragmentierung und Sauerstoffentsättigung. Diese schlafbezogene Atmungsstörung ist mit Müdigkeit während des Tages, verminderter Lebensqualität, eingeschränkter Arbeitsleistung, neurokognitiven Einschränkungen, einem erhöhten Risiko von Unfällen mit Kraftfahrzeugen und langfristig mit einem erhöhten Risiko kardiovaskulärer Morbidität und Mortalität verbunden.

Die nasale kontinuierliche Überdruckbeatmung (nasal Continuous Positive Airway Pressure, nCPAP) erhält über eine Nasenmaske, die während des Schlafs getragen wird, einen Überdruck in den oberen Atemwegen aufrecht und stellt aktuell die wirksamste Behandlungsoption für OSA-Patienten dar. Die Therapieadhärenz ist jedoch gering. Die Verfügbarkeit alternativer Behandlungsoptionen ist deshalb von größter Bedeutung. Unterkieferprotrusionsschienen (UPS), die den Unterkiefer in einer nach vorn verlagerten Position halten, um so einen Verschluss der oberen Atemwege während des Schlafs zu verhindern, stellen eine weniger invasive, angenehmere und kostengünstigere Behandlungsalternative für Patienten mit leichter bis mäßiger OSA dar, die die nCPAP-Therapie nicht tolerieren, nicht auf sie ansprechen oder für die sie nicht infrage kommt. Die Vorverlagerung des Unterkiefers führt zu einer Volumenvergrößerung der oberen Atemwege, einer Erweiterung der lateralen Ausdehnung des Velopharynx, einer Straffung der Zungenmuskulatur, die dem Zurückfallen der Zunge während des Schlafs entgegenwirkt, sowie zu einer Vorverlagerung des Zungenbeins und einer Stabilisierung der Epiglottis und des Gaumensegels, was einer posterioren Kieferrotation vorbeugt. Die Behandlung mit einer Unterkieferprotrusionsschiene (UPS) stellt eine therapeutische Möglichkeit dar, um eine solche Vorverlagerung des Kiefers zu erzielen.

In diesem Artikel untersuchen wir die Anwendungsgebiete, die Wirksamkeit, die Bedeutung in der klinischen Praxis und die unerwünschten Wirkungen von Protrusionsschienen zur Behandlung der OSA.

Abstract

Obstructive sleep apnea (OSA) is characterized by repetitive episodes of complete or partial closure of the upper airway during sleep leading to sleep fragmentation and oxygen desaturation. This sleep-related breathing disorder is associated with daytime sleepiness, impaired quality of life, poor work performance, neurocognitive decline, increased risk of motor vehicle accidents and, in the long term, an increased risk of cardio-vascular disease and mortality.

Nasal continuous positive airway pressure (nCPAP) maintains a positive pressure in the upper airway through a nose mask worn during sleep and is currently the most effective treatment option for OSA patients. Nevertheless, adherence to this therapy is low. The availability of alternative treatment options is therefore of the utmost importance. Mandibular advancement devices (MADs), which hold the mandible forward with the aim of preventing collapse of the upper airway during sleep provide a less invasive, more comfortable, and less costly treatment alternative for patients with mild to moderate OSA who do not tolerate, do not respond to, or are not appropriate candidates for treatment with nCPAP. Forward repositioning of the mandible increases the upper airway volume, widens the lateral dimension of the velopharynx, it stretches tongue muscles counteracting tongue’s retrolapse during sleep, and it moves the hyoid bone anteriorly and stabilizes epiglottis and soft palate preventing the posterior rotation of the jaw. The therapy with a mandibular advancement device (MAD) represents a treatment option to obtain this anterior jaw repositioning.

In this article, we will review the indications, the efficacy, the role in the clinical practice and the adverse effects of MADs for the management of OSA.

 
  • Literatur

  • 1 American Academy of Sleep Medicine . International Classification of Sleep Disorders. Diagnostic and Coding Manual. 2nd edn American Academy of Sleep Medicine; Westchester, IL: 2005
  • 2 American Academy of Sleep Medicine . International classification of Sleep Disorders. 3rd edn American Academy of Sleep Medicine; Darien, IL: 2014
  • 3 Sateia MJ. International classification of sleep disorders-third edition: highlights and modifications. Chest 2014; 146: 1387-1394
  • 4 Pedrosa RP, Drager LF, Gonzaga CC. et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension 2011; 58: 811-817
  • 5 Kasai T, Floras JS, Bradley TD. Sleep apnea and cardiovascular disease: a bidirectional relationship. Circulation 2012; 126: 1495-1510
  • 6 Marin JM, Agusti A, Villar I. et al. Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA 2012; 307: 2169-2176
  • 7 Floras JS. Hypertension and sleep apnea. Can J Cardiol 2015; 31: 889-897
  • 8 Kim YS, Kim SY, Park do Y. et al. Clinical implication of heart rate variability in obstructive sleep apnea syndrome patients. J Craniofac Surg 2015; 26: 1592-1595
  • 9 Al-Falahi Z, Williamson J, Dimitri H. Atrial fibrillation and sleep apnoea: guilt by association?. Heart Lung Circ 2017; 26: 902-910
  • 10 Mulgrew AT, Ryan CF, Fleetham JA. et al. The impact of obstructive sleep apnea and daytime sleepiness on work limitation. Sleep Med 2007; 9: 42-53
  • 11 Tregear S, Reston J, Schoelles K. et al. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med 2009; 5: 573-581
  • 12 Wellman A, Eckert DJ, Jordan AS. et al. A method for measuring and modeling the physiological traits causing obstructive sleep apnea. J Appl Physiol 1985; 2011: 1627-1637
  • 13 Edwards BA, Andara C, Landry S. et al. Upper-airway collapsibility and loop gain predict the response to oral appliance therapy in patients with obstructive sleep apnea. Am J Respir Crit Care Med 2016; 194: 1413-1422
  • 14 Bosi M, De Vito A, Kotecha B. et al. Phenotyping the pathophysiology of obstructive sleep apnea using polygraphy/polysomnography: a review of the literature. Sleep Breath 2018; 22: 579-592
  • 15 Dempsey J, Veasey S, Morgan B. et al. Pathophysiology of sleep apnea. Physiol Rev 2010; 90: 47-112
  • 16 Gupta MA, Simpson FC, Lyons DCA. The effect of treating obstructive sleep apnea with positive airway pressure on depression and other subjective symptoms: A systematic review and meta-analysis. Sleep Med Rev 2016; 28: 51-64
  • 17 Li W, Xiao L, Hu J. The comparison of CPAP and oral appliances in treatment of patients with OSA: a systematic review and meta-analysis. Respir Care 2013; 58: 1184-1195
  • 18 Schwartz M, Acosta L, Hung YL. et al. Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: A systematic review and meta-analysis. Sleep Breath 2018; 22: 555-568
  • 19 Quan SF, Schmidt-Nowara W. The Role of Dentists in the Diagnosis and Treatment of Obstructive Sleep Apnea: Consensus and Controversy. J Clin Sleep Med 2017; 13: 1117-1119
  • 20 Ramar K, Dort LC, Katz SG. et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015; 11: 773-827
  • 21 Ferguson KA, Cartwright R, Rogers R. et al. Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review. Sleep 2006; 29: 244-262
  • 22 Chan AS, Sutherland K, Schwab RJ. et al. The effect of mandibular advancement on upper airway structure in obstructive sleep apnoea. Thorax 2010; 65: 726-732
  • 23 Tsuiki S, Ono T, Kuroda T. Mandibular advancement modulates respiratory-related genioglossus electromyographic activity. Sleep Breath 2000; 4: 53-58
  • 24 Gao YN, Wu YC, Lin SY. et al. Short-term efficacy of minimally invasive treatments for adult obstructive sleep apnea: A systematic review and network meta-analysis of randomized controlled trials. J Formos Med Assoc 2018; DOI: 10.1016/j.jfma.2018.02.008. [Epub ahead of print]
  • 25 Bartolucci ML, Bortolotti F, Raffaelli E. et al. The effectiveness of different mandibular advancement amounts in OSA patients: A systematic review and meta-regression analysis. Sleep Breath 2016; 20: 911-919
  • 26 Alessandri-Bonetti G, Ippolito DR, Bartolucci ML. et al. Cephalometric predictors of treatment outcome with mandibular advancement devices in adult patients with obstructive sleep apnea: a systematic review. Korean J Orthod 2015; 45: 308-321
  • 27 Alessandri-Bonetti G, Bortolotti F, Bartolucci ML. et al. The Effects of Mandibular Advancement Device on Pressure Pain Threshold of Masticatory Muscles: A Prospective Controlled Cohort Study. J Oral Facial Pain Headache 2016; 30: 234-240
  • 28 Alessandri-Bonetti G, D'Antò V, Stipa C. et al. Dentoskeletal effects of oral appliance wear in obstructive sleep apnoea and snoring patients. Eur J Orthod 2017; 39: 482-488
  • 29 Bartolucci ML, Bortolotti F, Martina S. et al. Dental and skeletal long-term side effects of mandibular advancement devices in obstructive sleep apnea patients: a systematic review with meta-regression analysis. Eur J Orthod 2018; DOI: 10.1093/ejo/cjy036. [Epub ahead of print]