A Combination Appliance for Obstructive Sleep Apnea: The Effectiveness of Mandibular Advancement and Tongue Retention

Study Objectives: The purpose of this study was to determine if subjects with moderate-to-severe obstructive sleep apnea would experience increasing treatment effect when a tongue retention component was added to a mandibular repositioning appliance. Design: Cohort study. Setting: Sleep clinic. Patients: Forty-four sequentially recruited patients with moderate-to-severe obstructive sleep apnea. Interventions: Subjects were sleep tested at 4 treatment stages of oral appliance therapy. The 4 stages were: 6-mm mandibular protrusion, 8-mm protrusion, 6-mm protrusion with a tongue retention bulb, and 8-mm protrusion with a tongue retention bulb. Measurements and Results: Forty-one of 44 subjects completed the protocol. There was a decrease in mean respiratory disturbance index from 33.5 events/h at baseline to 18.1 events/h at stage 4 (p = 0.001). Mean Epworth Sleepiness Scale (ESS) decreased from 12.3 at baseline to 9.0 at stage 4 (p = 0.0001. Conclusions: A combined approach utilizing both mandibular protrusion and tongue retention can provide effective treatment for moderate-to-severe obstructive sleep apnea. The addition of a tongue bulb may provide further treatment effect when mandibular protrusion is limited. Appliance designs that allow for convenient combination therapy need to be developed for this purpose.