title: Mandibular advancement titration for obstructive sleep apnea: optimization of the procedure by combining clinical and oximetric parameters.
abstract: BACKGROUND
  Oral appliances (OAs) have been used for the treatment of obstructive sleep apnea syndrome (OSAS), with different degrees of effectiveness having been shown in previous studies. But, in the absence of a consensual recommendation, the method of the determination of effective mandibular advancement varies from one study to another.
  
  
  OBJECTIVE
  We prospectively evaluated an OA titration protocol based on a combined analysis of symptomatic benefit and oximetric recording to guide the progressive mandibular advancement.
  
  
  METHODS
  University hospital sleep disorders center.
  
  
  METHODS
  Forty patients with OSAS (mean [+/-SD] apnea-hypopnea index [AHI], 46 +/- 21 events per hour) found on baseline polysomnography, who were intolerant of nasal continuous positive airway pressure, completed all aspects of the study.
  
  
  METHODS
  Two acrylic appliances connected by Herbst attachments were constructed. The mandible was advanced 1 mm every week until there was a resolution of the symptoms and a reduction in the oxygen desaturation index (ie, the number of desaturations yielding a > 3% fall in pulse oximetric saturation per hour of recording) [ODI] of <10 events per hour of recording or a maximum comfortable limit of advancement was obtained. The final response to OA was evaluated by full polysomnography recording.
  
  
  RESULTS
  A complete response (ie, mean AHI, 5 +/- 3 events per hour; mean snoring reduction [SR], 91 +/- 13%; mean Epworth sleepiness scale [ESS] score, 5 +/- 3) was obtained in 63.6% of patients, and a limited response (ie, mean AHI, 21 +/- 11 events per hour; mean SR, 88 +/- 15%; mean ESS, 6 +/- 3) was obtained in 18.2% of patients. Twenty-five percent of mandibular advancements were motivated by an abnormal ODI (ie, 21 +/- 10 events per hour) despite resolution of the symptoms, while 20% were motivated by persistent symptoms with a normal ODI (ie, 6 +/- 2 events per hour). After a mean duration of 17 +/- 4 months, 34 patients declared that they had used the OA 5 +/- 2 days a week for 89 +/- 19% of their sleep time.
  
  
  CONCLUSIONS
  A combination of the patient's subjective evaluation and oximetric score improves the effectiveness of the OA titration procedure.
authors.affiliation: Department of Respiratory Medicine, Hôpital Saint Antoine (Assistance Publique Hôpitaux de Paris-Université Paris VI), Paris, France. bernard.fleury@sat.ap-hop-paris.fr
authors.forename: Bernard
authors.initials: B
authors.lastname: Fleury
authors.forename: Dominique
authors.initials: D
authors.lastname: Rakotonanahary
authors.forename: Boris
authors.initials: B
authors.lastname: Petelle
authors.forename: Gérard
authors.initials: G
authors.lastname: Vincent
authors.forename: Nathalie
authors.initials: N
authors.lastname: Pelletier Fleury
authors.forename: Bernard
authors.initials: B
authors.lastname: Meyer
authors.forename: Bernard
authors.initials: B
authors.lastname: Lebeau
mesh_terms: D005260:Female; D006801:Humans; D008297:Male; D019186:Mandibular Advancement; D008875:Middle Aged; D010092:Oximetry; D011446:Prospective Studies; D020181:Sleep Apnea, Obstructive / Q000097:blood / Q000628:therapy*; D016896:Treatment Outcome