It was with interest that we reviewed the December 15, 2014, Journal of Clinical Sleep Medicine article by Pliska et al. entitled “Obstructive Sleep Apnea and Mandibular Advancement Splints: Occlusal Effects and Progression of Changes Associated with a Decade of Treatment.”1 As noted in the accompanying commentary, mandibular advancement devices (MAD) are now utilized as one first-line option for mild to moderate obstructive sleep apnea (OSAS) and may be used in specific cases for severe OSAS.2 Consideration of potential long-term consequences of MADs assumes greater importance, and the authors have thus done a service via this addition to the sleep medicine literature.
In a more limited setting, we have also been aware of these occlusal changes. We would like to offer an alternative, but perhaps not mutually exclusive, explanation for the progressive declines in incisor overjet and overbite with resulting posterior open bites. We hypothesize that it may not be the teeth moving with time but rather a persistent posturing forward of the mandible. It is recognized that mornings after wearing an MAD that patients may have a difficult time posturing the mandible back to the normal occlusion. If not addressed by the patient or dental sleep specialist, this could eventuate in an irreversible anterior mandibular position with altered occlusion.
One limitation to the Pliska study is an absence of occlusal bite records, and accordingly no documentation of the condyle position in the glenoid fossae. If the dental casts were hand articulated during measurements, it could be difficult to ascertain whether teeth moved or if the mandible postured forward to a stable but inappropriate position. Furthermore, we would argue that an MAD itself (particularly a fixed device) should act to stabilize teeth position and thus reduce the likelihood of movement over time.
Regardless of the etiology, this paper brings to the forefront the necessity for careful and continued long-term management plans in patients using MADs. In fact, the first author of this letter (an oral maxillofacial surgeon with over a quarter century of experience in dental sleep medicine) has further strengthened his protocol for follow up care as a consequence of Pliska and co-authors' study. Finally, as the accompanying Journal of Clinical Sleep Medicine commentary stated, this is an area fertile for investigation.2 Computer imaging for dental and facial skeleton treatment planning is now available. Techniques such as this offer the prospect for further research studies, as well as improved documentation and follow-up in patient care.
The authors have indicated no financial conflicts of interest. This work was performed at Eastern Virginia Medical School, Department of Internal Medicine, Division of Sleep Medicine, Norfolk, VA. This manuscript involves no off label or investigational use of a product.
Ford ML, Vorona RD, Ware JC. An alternative cause for long term changes with mandibular advancement devices. J Clin Sleep Med 2015;11(4):501.
Pliska BT, Nam H, Chen H, Lowe AA, Almeida FR, authors. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med. 2014;10:1285–91. [PubMed]
Ngiam J, Cistulli PA, authors. Think before sinking your teeth into oral appliance therapy. J Clin Sleep Med. 2014;10:1293–4. [PubMed]