I
~
© 1992 American Sleep Disorders Association and Sleep Research Society
Treatment of Sleep Apnea with Prosthetic Mandibular Advancement (PMA) Yoichi Nakazawa, Tetsuro Sakamoto, Rika Yasutake, Ken Yamaga, Tatayu Kotorii, Yasushi Miyahara, Yuh Ariyoshi and Tadarilitsu Kameyama Departments of Neuropsychiatry and Oral Surgery, School of Medicine, Kurume University, Kurume, Japan
Summary: Nine males with sleep apnea DOES syndrome and three males with sleep apnea DIMS syndrome were treated with prosthetic mandibular advancement (PMA). The method uses a prosthesis, which is designed to advance the mandible 3-5 mm to prevent upper airway occlusion during sleep. The apnea index in the obstructive-type apnea and the percentage of time spent in obstructive apnea decreased significantly with PMA. Although the apnea index showed merely a tendency to decrease in central apnea (p < 0.1), the percentage of time spent in central apnea decreased significantly with PMA. A marked improvement in sleep structures was observed with PMA; a significant increase was seen in total sleep time, percent slow wave sleep (SWS) and percent rapid eye movement (REM) sleep, and the time spent in intra-sleep awakening decreased remarkably. PMA had excellent effects on snoring, and daytime hypersomnolence was reduced in almost all patients. Moreover, a survey on the therapeutic effects of PMA on sleep apnea syndrome and problems associated with wearing PMA was performed with a questionnaire for the sample of nine DOES patients and an additional 22 patients who were treated over a long time. The therapeutic effects could be maintained without any problems in about 213 of these patients. The therapeutic mechanisms of PMA in its reduction of both obstructive and central apnea are discussed. Key Words: Obstructive apnea-Central apnea-Prosthetic mandibular advancement-Sleep changes.
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r
I
I
Sleep, 15(6):499-504
Sleep apnea, particularly the obstructive type, fre- rence of obstructive sleep apnea by opening the oroquently results in many complications, including car- pharyngeal airway. They termed this therapy diovascular disorders, daytime drowsiness and noc- "prosthetic mandibular advancement (PMA)" (12-14). turnal insomnia (I). Although the first step in the Similar treatment modalities have been independently treatment of obstructive sleep apnea is the removal of developed for sleep apnea by some researchers (15any obvious causes of upper airway obstruction, such 19) and have been shown to reduce obstructive sleep causes are not detected in many cases. Accordingly, apnea. In this study, we tried to treat some patients surgical (2) [tracheostomy, uvulopalatopharyngoplasty with sleep apnea syndrome by PMA and found it to (UPPP)], mechanical [continuous positive airway pres- be therapeutically effective not only on obstructive apsure (CPAP) (3-5), diaphragm pacing (6), tongue-re- nea but also on central apnea. Although it has been taining device (TRD) (7)] and medical [respiratory reported that CPAP and TRD decreased both types of stimulants (8), central stimulants (9), progesterone (10), sleep apnea, the reduction of central apnea with PMA acetazolamide (11)] treatments have been employed in has not been reported so far. Accordingly, the fact that these cases. However, many of these treatment mo- PMA reduced not only obstructive apnea but also dalities are cumbersome and frequently have associ- central apnea in the present study may support the ated problems for patients, while they show therapeutic hypothesis of a developmental mechanism for central effects on sleep apnea. apnea proposed by Lowe et al. (18,20) and Issa and In 1984, Meier-Ewert et al. (12) reported that use of Sullivan (4). a prosthesis designed to nonsurgically pull the mandible 3-5 mm forward markedly reduced the occurSUBJECTS AND METHODS Accepted for publication July 1992. Address correspondence and reprint requests to Dr. Y oichi Nakazawa, Department of Neuropsychiatry, School of Medicine, Kurume University, 67 Asahi-machi, 830 Kurume, Japan.
The subjects included nine male outpatients with sleep apnea DOES syndrome (SASDOES) and three male outpatients with sleep apnea DIMS syndrome
499 Downloaded from https://academic.oup.com/sleep/article-abstract/15/6/499/2749289 by guest on 22 March 2018
Y. NAKAZA W A ET AL.
500
FIG. 1.
Side view of prosthesis.
(SASDIMS). The age of the patients ranged from 22 to 58 years (mean = 46.7 ± 13.0). No obvious cause for the sleep apnea could be detected by various examinations at the Department of Otorhinolaryngology, Kurume University Hospital, Japan, in the nose, throat or lower jaw of any of the patients, except for one patient in whom moderate hypertrophy of both the adenoid and palatine tonsils was identified. The prosthesis (Fig. I) was made at the Department
Table 1.
of Oral Surgery, Kurume University Hospital. The procedures for making the prosthesis are as follows. First, plaster figures of the maxilla and mandible are molded. Protective plates are then made by pressing 2-mm-thick plastic discs onto both plaster figures. After the protective plates are fitted to both the maxilla and mandible, the mandible is advanced 3-5 mm and is fixed in that position. Following fixation, the prosthesis is promptly made with acrylic dental resin in the patient's mouth. With the 3-5-mm anterior advancement, the mandible is positioned about 4 mm inferior to its position during normal closure. After the patient had become accustomed to the prosthesis, polysomnographic (PSG) recording was conducted using the prosthesis, and the data were compared to those obtained without the prosthesis for each patient. PSG and sleep record analysis were performed according to the manual by Rechtschaffen and Kales (21). The recordings of ventilation and respiratory movements were performed by thermistors attached under a nostril and by an abdominal wall strain gauge, respectively. Each episode of lapse of ventilation lasting longer than 10 seconds was regarded as an episode of sleep apnea. Hypopnea was differentiated from apnea and was not estimated in the study, although it was observed in some patients. Statistical analysis was performed using the Student's t test and Mann-Whitney U test.
Changes in sleep apnea parameters with prosthetic mandibular advancement (PAM) Pre-PMA Mean ± SO
Frequency of SA Apnea index Time spent in SA/TST(%) Mean duration of SA (seconds)
304.8 50.4 37.8 25.3
± ± ± ±
167.9 29.3 23.9 5.2
Post-PMA Mean ± SO
p
138.0± 117.8 19.0± 17.6 13.5 ± 14.1 23.1 ±4.4(n= II)
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© 1992 American Sleep Disorders Association and Sleep Research Society
Treatment of Sleep Apnea with Prosthetic Mandibular Advancement (PMA) Yoichi Nakazawa, Tetsuro Sakamoto, Rika Yasutake, Ken Yamaga, Tatayu Kotorii, Yasushi Miyahara, Yuh Ariyoshi and Tadarilitsu Kameyama Departments of Neuropsychiatry and Oral Surgery, School of Medicine, Kurume University, Kurume, Japan
Summary: Nine males with sleep apnea DOES syndrome and three males with sleep apnea DIMS syndrome were treated with prosthetic mandibular advancement (PMA). The method uses a prosthesis, which is designed to advance the mandible 3-5 mm to prevent upper airway occlusion during sleep. The apnea index in the obstructive-type apnea and the percentage of time spent in obstructive apnea decreased significantly with PMA. Although the apnea index showed merely a tendency to decrease in central apnea (p < 0.1), the percentage of time spent in central apnea decreased significantly with PMA. A marked improvement in sleep structures was observed with PMA; a significant increase was seen in total sleep time, percent slow wave sleep (SWS) and percent rapid eye movement (REM) sleep, and the time spent in intra-sleep awakening decreased remarkably. PMA had excellent effects on snoring, and daytime hypersomnolence was reduced in almost all patients. Moreover, a survey on the therapeutic effects of PMA on sleep apnea syndrome and problems associated with wearing PMA was performed with a questionnaire for the sample of nine DOES patients and an additional 22 patients who were treated over a long time. The therapeutic effects could be maintained without any problems in about 213 of these patients. The therapeutic mechanisms of PMA in its reduction of both obstructive and central apnea are discussed. Key Words: Obstructive apnea-Central apnea-Prosthetic mandibular advancement-Sleep changes.
r
r
I
I
Sleep, 15(6):499-504
Sleep apnea, particularly the obstructive type, fre- rence of obstructive sleep apnea by opening the oroquently results in many complications, including car- pharyngeal airway. They termed this therapy diovascular disorders, daytime drowsiness and noc- "prosthetic mandibular advancement (PMA)" (12-14). turnal insomnia (I). Although the first step in the Similar treatment modalities have been independently treatment of obstructive sleep apnea is the removal of developed for sleep apnea by some researchers (15any obvious causes of upper airway obstruction, such 19) and have been shown to reduce obstructive sleep causes are not detected in many cases. Accordingly, apnea. In this study, we tried to treat some patients surgical (2) [tracheostomy, uvulopalatopharyngoplasty with sleep apnea syndrome by PMA and found it to (UPPP)], mechanical [continuous positive airway pres- be therapeutically effective not only on obstructive apsure (CPAP) (3-5), diaphragm pacing (6), tongue-re- nea but also on central apnea. Although it has been taining device (TRD) (7)] and medical [respiratory reported that CPAP and TRD decreased both types of stimulants (8), central stimulants (9), progesterone (10), sleep apnea, the reduction of central apnea with PMA acetazolamide (11)] treatments have been employed in has not been reported so far. Accordingly, the fact that these cases. However, many of these treatment mo- PMA reduced not only obstructive apnea but also dalities are cumbersome and frequently have associ- central apnea in the present study may support the ated problems for patients, while they show therapeutic hypothesis of a developmental mechanism for central effects on sleep apnea. apnea proposed by Lowe et al. (18,20) and Issa and In 1984, Meier-Ewert et al. (12) reported that use of Sullivan (4). a prosthesis designed to nonsurgically pull the mandible 3-5 mm forward markedly reduced the occurSUBJECTS AND METHODS Accepted for publication July 1992. Address correspondence and reprint requests to Dr. Y oichi Nakazawa, Department of Neuropsychiatry, School of Medicine, Kurume University, 67 Asahi-machi, 830 Kurume, Japan.
The subjects included nine male outpatients with sleep apnea DOES syndrome (SASDOES) and three male outpatients with sleep apnea DIMS syndrome
499 Downloaded from https://academic.oup.com/sleep/article-abstract/15/6/499/2749289 by guest on 22 March 2018
Y. NAKAZA W A ET AL.
500
FIG. 1.
Side view of prosthesis.
(SASDIMS). The age of the patients ranged from 22 to 58 years (mean = 46.7 ± 13.0). No obvious cause for the sleep apnea could be detected by various examinations at the Department of Otorhinolaryngology, Kurume University Hospital, Japan, in the nose, throat or lower jaw of any of the patients, except for one patient in whom moderate hypertrophy of both the adenoid and palatine tonsils was identified. The prosthesis (Fig. I) was made at the Department
Table 1.
of Oral Surgery, Kurume University Hospital. The procedures for making the prosthesis are as follows. First, plaster figures of the maxilla and mandible are molded. Protective plates are then made by pressing 2-mm-thick plastic discs onto both plaster figures. After the protective plates are fitted to both the maxilla and mandible, the mandible is advanced 3-5 mm and is fixed in that position. Following fixation, the prosthesis is promptly made with acrylic dental resin in the patient's mouth. With the 3-5-mm anterior advancement, the mandible is positioned about 4 mm inferior to its position during normal closure. After the patient had become accustomed to the prosthesis, polysomnographic (PSG) recording was conducted using the prosthesis, and the data were compared to those obtained without the prosthesis for each patient. PSG and sleep record analysis were performed according to the manual by Rechtschaffen and Kales (21). The recordings of ventilation and respiratory movements were performed by thermistors attached under a nostril and by an abdominal wall strain gauge, respectively. Each episode of lapse of ventilation lasting longer than 10 seconds was regarded as an episode of sleep apnea. Hypopnea was differentiated from apnea and was not estimated in the study, although it was observed in some patients. Statistical analysis was performed using the Student's t test and Mann-Whitney U test.
Changes in sleep apnea parameters with prosthetic mandibular advancement (PAM) Pre-PMA Mean ± SO
Frequency of SA Apnea index Time spent in SA/TST(%) Mean duration of SA (seconds)
304.8 50.4 37.8 25.3
± ± ± ±
167.9 29.3 23.9 5.2
Post-PMA Mean ± SO
p
138.0± 117.8 19.0± 17.6 13.5 ± 14.1 23.1 ±4.4(n= II)
