30 May 2022

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Effectiveness of mandibular advancement device in the management of moderate obstructive sleep apnea with concomitant temporomandibular disorder: a case report

Author: Aleksandra Komogortseva, Leopoldo P. Correa

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The comorbidity between obstructive sleep apnea (OSA) and temporomandibular disorder (TMD) is high. Approximately one in four patients with clinically diagnosed TMD has polysomnographic-diagnosed OSA. This comorbidity poses difficulty for management because neither appliance is considered effective in treating both conditions. Mixed results have been reported with some studies claiming mandibular advancement device (MAD) worsened TMD. In contrast, other studies found symptoms to be alleviated. In addition, MAD therapy is not efficacious for all, with approximately one-third of patients experiencing no therapeutic benefit. However, there is strong evidence demonstrating MAD improve OSA in the majority of patients.

Report of Case: 55-year-old female, diagnosed with moderate OSA (AHI=16.3 and 84% O2) with chronic history of TMD symptoms. A through clinical history and examination completed, BMI 31.6, neck circumference 12.5”, and cephalometric analysis depicted a low mandibular angle and reduced hyoid bone-to-mandible distance. Intolerant to CPAP due to air leakage and facial pain aggravated by the mask. MAD as an alternative therapy was suggested to the patient by the sleep physician. TMD symptoms included bilateral masticatory myofascial pain, TMJ sounds, and headaches. A bilateral traction oral appliance design was selected with 50% of mandibular protrusion, and 5 mm of vertical dimension of occlusion (VDO). The sleep oral device and morning repositioning aligner were fabricated, delivered, and fitted. A lower stabilization orthotic appliance for daytime use was fabricated to address TMD symptoms. The patient returned for a follow-up with and reported increased dreaming, decrease in snoring, headaches, bite changes, facial and jaw pain from moderate to mild based on a subjective report by the patient confirmed by visual analog scale (VAS). Additional titration and occlusal adjustments of the oral sleep device and daytime orthotic device were made to achieve further therapeutic jaw protrusion and management of TMD symptoms. After completing the MAD titration protocol, she was referred to the sleep physician for a follow-up sleep study to objectively assess the efficacy of the appliance, which revealed an AHI of 3.5 and 89% 02 (baseline AHI 16.3 and 84% 02). Long-term follow-up was implemented as standard of dental sleep medicine clinical care at six months for the first year and yearly after.

Discussion: In this case report, we describe the impact of OSA on chronic pain as a vicious cycle with mutual deleterious influences causing an increase in pain and disrupted sleep. MAD is a well-established alternative to the gold standard CPAP currently recommended for mild to moderated OSA management. This case report demonstrates successful management of concomitant moderate OSA with an existing TMD condition when evidence-based and clinical expertise help to customize a treatment plan based on the patient’s unique medical history and examination.

Support: Authors declared no conflict of interest and no financial support provided for this case report.

Source: https://www.aadsm.org/