reduction of tongue volume and the correction of
its position; forward movement of the maxilla,
the mandible, and the hyoid bone using maxillary
osteotomy of type Lefort I; and bilateral
osteotomy of the mandible. Surgical removal of
the accumulated adipose tissues in the region of
chin and in other areas has also been applied
(Padma et al. 2007 ).
Continuous positive air pressure (CPAP) is
the most preferred conservative apnea treatment.
It provides a steady stream of pressurized air to
the airways using a soft plastic bulb connected
with a mask covering a patient’s nose or nose and
mouth. Additional pressure ensures a mechanical
stiffening of the upper airways protecting from
the collapse of their walls.
4 Mandibular Advancement
Appliance
Difficulties with adherence of patients to CPAP
therapy and as a growing interest of physicians in
the apnea phenomenon have encouraged further
research to develop new therapeutic approaches,
with the goal to expand the upper airway volume
through pulling the lingual epiphysis away or
mandibular advancement (Campbell et al. 2015 ;
Hoffstein 2007 ; Schmidt-Nawara et al. 1995 ).
A monoblock causing the mandible to protrude
was first used by Pierre Robin in children with
micrognation (Robin 1934 ). Two types of oral
appliances to treat OSA are currently in use:
tongue retaining device and mandibular advance-
ment appliance (MAA) (Standards of Practice
Committee of American Sleep Disorders Associ-
ation 1995 ). The tongue retaining device,
described by Cartwright ( 1985 ), protects against
the tongue retraction. This action is possible due
to hypotension retaining the tip of the tongue in
the anterior part of the device. The device is
constructed of a plastic bulb with a tongue-like
shape. The tongue placed and sucked into the
device is advanced forward so that the anterior-
posterior size of the throat is expanded. In
addition, tongue retaining device enhances the
tension of the tongue and chin muscles.
Nonetheless, it is used rather infrequently, due
to certain discomfort it produces, although the
device is very beneficial in edentulous patients.
The AASM has specified the indications for
using dental appliances in patients with primary
snoring without OSA; in mild OSA with reduced
sleep apnea risk factors; and in moderate-to-
severe OSA in patients who are intolerant of
CPAP, who refused this kind of therapy, or
in those not classified for surgery (Standards
of Practice Committee of American Sleep
Disorders Association 1995 ). Patients’ eligibility
for treatment with prosthetic devices should be
preceded by a thorough polysomnographic, and
intra- and extra-oral examinations, enabling the
assessment of a possible application of MAA.
The assessment takes into account such factors
as the number and quality of preserved teeth and
the condition of perodontium and temporoman-
dibular joints. An attempt to treat OSA with the
use of MAA should meet two major conditions,
namely the presence of at least eight stable teeth
in the maxilla and the mandible, and the possi-
bility of establishing a constructive occlusion
with the mandibular position in 50–75 % of max-
imum protrusion, leaving 3–5 mm of space
between incisors allowing the patient to breathe
freely through the mouth (Johal and Bottegal
2001 ). In edentulous patients, it is recommended
to place the implants in the mandible for MAA
fixing.5 Methodology of ReviewWe set out to assess treatment effectiveness of
MAA in patients with OSA as compared with
placebo, conservative treatment, and CPAP.
The assessment was based on the analysis of
changes in AHI and ESS, and other commonly
used indicators of the assessment of treatment
effectiveness. The English-language literature,
covering the period of 10 years, from 2004 to
2014, was retrieved in the Medline/PubMed
database, using the query “obstructive sleep
apnea/hypopnea” AND “mandibular advance-
ment appliance” AND “continuous positiveMandibular Advancement Appliance for Obstructive Sleep Apnea Treatment 65