Treatment Options - Mandibular Advancement Splint (MAS)
Treatment options depend on the severity of OSA.
The level of evidence for treatment is based on GRADE ratings.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22
Treatment options should be considered, depending on the apnoea-hypopnoea index (AHI), body mass index (BMI), symptoms, comorbidities, possible pathophysiological background and preference of the patient.
A mandibular advancement splint (MAS), also known as a mandibular advancement device (MAD) or mandibular repositioning appliance (MRA), is an oral appliance worn by a patient during sleep and is designed to treat snoring and OSA by protruding the bottom jaw forwards to tighten up the muscles and soft tissues of the upper airway and stabilise the patient’s breathing.
MAS should be custom-made by a qualified, sleep-trained dentist who has specific expertise in MAS fitting and provision (Australian Dental Association). It is important to note that not all dentists are qualified to produce MAS for OSA. Patients need to be under long-term review by a dentist. In the long term, the splints may cause temporomandibular joint pain, changes to the bite, and excessive salivation. Simple mouth guards (or boil and bite devices) purchased without dental guidance may damage the teeth and often do not work.
Efficacy of MAS
Table. MAS vs. control
| Apnoea-hypopnoea index (AHI)
Moderate GRADE |
The meta-analyses of Sharples20, Zhu22, Okuno18, and Qaseem19 reported a significant improvement in AHI following treatment with MAS when compared to control. Baseline AHI differed between studies. Reported pooled reductions in AHI were between -7.05 events per hour (95% CI -12.07, -2.03; 3 studies 18) and -11.76 (95% CI -14.64, -8.87; 8 studies22), of MAS compared to control, with a slightly, non-significant, greater effect in patients with a baseline AHI of > 15 when compared to 5 – 15. De Britto Teixeira23 reported a non-significant effect following treatment with MAS when compared to control.
| Sleepiness (Epworth sleepiness scale (ESS))
Low GRADE | MAS, when compared to control, may reduce sleepiness 20,4,22,18,19 |
The meta analyses of Sharples 20, Bratton4, Zhu22, and Qaseem19 reported an improvement in sleepiness generally, as measured with the Epworth Sleepiness Scale (ESS), following treatment with MAS when compared to control. Reported pooled reductions in sleepiness were between -2.5 and -1.1 points ESS for MAS compared to control, outcomes which are not clearly greater than the agreed minimal clinically important difference of 2. Okuno18 reported a non-significant effect following treatment with MAS when compared to control on sleepiness with a pooled effect of -2.26 points ESS (95% CI -6.82, 2.31).
Oxygen saturation Low GRADE | MAS, when compared to control, may improve the minimum oxygen saturation 22,5,19 |
The meta analyses of Zhu22 and Qaseem19 reported a significant improvement in oxygen saturation following treatment with MAS when compared to control or no treatment. Reported pooled improvement in minimum oxygen saturation were between 3.08 (95% CI 1.97 to 4.19; 7 studies22) and 2.86 (95% CI 1.87 - 3.84; 4 studies19) of MAS compared to control or no treatment. De Britto Teixeira5 reported that treatment with MAS when compared to control on average oxyhemoglobin saturation was comparable.
Quality of life Very low GRADE | MAS, when compared to control, does not seem to affect quality of life 18,15 |
Okuno18 reported that treatment with MAS when compared to control on quality of life, as measured with the SF-36 was comparable. Johal15 reported an improvement on 1 out of 7 domains of the SF-36 (vitality) following treatment with MAS when compared to control.
Table. Monobloc vs. Bibloc MAS
Apnoea-hypopnoea index (AHI) Very low GRADE | Monobloc, when compared to Bibloc, MAS, may reduce AHI slightly more 12,21 |
| Sleepiness (Epworth sleepiness scale (ESS))
Very low GRADE | Monobloc, when compared to Bibloc, MAS, may reduce sleepiness to an equal extent 21 |
| Oxygen saturation
Very low GRADE | Monobloc, when compared to Bibloc, MAS, may improve oxygen saturation slightly more 21 |
Table. MAS vs. Continuous positive airway pressure (CPAP)
| Apnoea-hypopnoea index (AHI)
Moderate GRADE | MAS, when compared to CPAP, reduces AHI less 20,18,9,17 |
The meta analyses of Sharples 20, Okuno18 and Li17, reported a significantly greater improvement between 5.9 and 8.3 events per hour in AHI following treatment with CPAP when compared to MAS. The reported pooled decreases in AHI of CPAP vs. MAS included -7.7 (95% CI -10.1, -5.3; 9 studies19), -7.03 (95% CI -8.66, -5.41; 13 studies20), and -6.11 (95% CI -8.98, -3.24 18). Cross-over, when compared to parallel, studies reported a larger difference; Li17 reported, based on 6 crossover and 3 parallel included studies, pooled larger decreases of -8.25 (95% CI -10.61, -5.89) and -5.96 (95% CI -8.91, -3.40). One of the included studies in the meta-analysis of Qaseem19 reported that 30% of patients when using MAS achieved an AHI < 5, while another study which analysed this effect did not.
| Sleepiness (Epworth sleepiness scale (ESS))
Moderate GRADE | MAS, when compared to CPAP, reduces sleepiness less in OSA patients with an AHI ≥30 but both seem equally effective in reducing sleepiness in OSA patients with an AHI 5 – 30 20,3,8,17 |
The review of the Medical Advisory Secretary Ontario (2009) reported, based on 6 included studies, a pooled difference of -3.51 in points ESS (95% CI -5.36, -1.65) following treatment with CPAP when compared to MAS. The meta analyses of Sharples 20, Bratton3, Okuno18 and Li17 reported a non-significant improvement in sleepiness, between 0.7 and 1.3 points ESS, following treatment with CPAP when compared to MAS. The reported non- pooled decreases in sleepiness with CPAP vs. MAS included -1.33 (95% CI -2.85; 0.19; 3 parallel studies17, -1.28 (95% CI -2.74, -0.18; 3 studies 18, -0.9 (95% CI -1.8, 0.03, -0.74 (95% CI -2.17; 0.69; 2 crossover studies17, and -0.7 (95% CI -1.44, 0.11; 10 studies20).
Table. MAS vs. Positional therapy (PT)
| Apnoea-hypopnoea index (AHI)
Low GRADE | MAS is comparable to PT (position therapy or tennis ball therapy) and may improve AHI in patients with positional OSA and an AHI 5-301,6,16,10,2 |
| Oxygen saturation (Oxygenation desaturation index (ODI))
Low GRADE | MAS is comparable to PT (position therapy and tennis ball therapy) and seems to improve ODI in patients with positional OSA and an AHI 5-301,6,10,2 |
| Sleepiness (Epworth sleepiness scale (ESS))
Very low GRADE | It is unclear whether MAS, when compared with PT (position therapy), has a different effect on sleepiness in patients with positional OSA and an AHI 5-301,6,16,10 |
| Quality of life (Functional outcomes of sleep questionnaire (FOSQ))
Very low GRADE | MAS is comparable to PT (position therapy) and does not seem to affect quality of life in patients with positional OSA and an AHI 5-301,6 |
Table. Combination of MAS and CPAP
| Apnoea-hypopnoea index (AHI)
Very low GRADE | Combination of MAS and CPAP, when compared with either therapy alone, may be more effective at reducing AHI in selected OSA patients11 |
| Sleepiness (Epworth sleepiness scale (ESS))
Very low GRADE | Combination of MAS and CPAP, when compared with either therapy alone, may be more effective at reducing sleepiness in selected OSA patients11 |
Table. Combination of MAS and PT
| Apnoea-hypopnoea index (AHI)
Very low GRADE | Combination of MAS and PT (position therapy), when compared with either therapy alone, may be more effective at reducing AHI in selected OSA patients7 |
| Oxygen saturation (Oxygenation desaturation index (ODI))
Very low GRADE | Combination of MAS and PT (position therapy), when compared with either therapy alone, may be more effective at reducing ODI in selected OSA patients7 |
Efficacy of MAS on Co-morbidities
Table. Effect of MAS on blood pressure
| Blood pressure
Low GRADE | MAS treatment may lower systolic and diastolic blood pressure to a small extent in patients with OSA3,14 |
The GRADE system
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system
provides a transparent approach to grading quality (or certainty) of
evidence and strength of recommendations. Many international
organizations have provided input into the development of the GRADE
approach which is now considered the standard in guideline development.
The OSA resource’s treatment-options GRADE-evidence ratings are based on the recommendations of the Dutch Medical Specialists Federation ‘Federatie Medisch Specialisten (www.kennisinstituut.nl)’ published in ‘Obstructief slaapapneu (OSA) bij volwassenen’ on June 1st 2018 (https://richtlijnendatabase.nl). And the American Academy of Sleep Medicine’s most recent meta-analysis and GRADE assessment on the effectiveness of CPAP.
Further clinical practice guidelines for the management of OSA in adults reviewed include the American Academy of Sleep Medicine (AASM), the American Thoracic Society (ATS), the American Cllege of Physicians (ACP), the Canadian Thoracic Society and the International Geriatric Sleep Medicine Taskforce.
AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset