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Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine logoLink to Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine
. 2024 Mar 1;20(3):353–361. doi: 10.5664/jcsm.10866

The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study

Christianne CAFM Veugen 1,2,3,✉, Ellen Kant 1, Johannes C Kelder 4, Anna Schipper 5, Robert J Stokroos 2, Marcel P Copper 1
PMCID: PMC11019213  PMID: 38426847

Abstract

Study Objectives:

To prospectively validate drug-induced sleep endoscopy with mandibular advancement maneuvers as a prediction tool for treatment success of oral appliance treatment (OAT).

Methods:

Seventy-seven patients diagnosed with moderate obstructive sleep apnea were included and underwent drug-induced sleep endoscopy. The upper airway collapse was assessed using the VOTE classification. Additionally, three mandibular advancement maneuvers were performed to predict treatment success of OAT. If the maneuver was negative, the level and degree and configuration of the persistent collapse was described according to the VOTE classification. All patients were treated with OAT and completed a follow-up sleep study with OAT in situ without regard to their anticipated response to treatment.

Results:

Sixty-four patients completed 6-month follow up. A positive jaw thrust maneuver proved to be significantly associated with favorable OAT response, whereas the chin lift maneuver and the vertical chin lift maneuver were not. Additionally, a persistent lateral oropharyngeal collapse when performing any mandibular advancement maneuver was significantly associated with unfavorable OAT response.

Conclusions:

The current findings suggest that a jaw thrust maneuver should be preferred over the chin lift maneuver for predicting OAT response. Patients with a positive jaw thrust maneuver should be counseled toward favorable OAT response, whereas those with persistent lateral oropharyngeal collapse should be advised about the likelihood of unfavorable OAT response. A negative jaw thrust maneuver did not prove to be a significant predictor for unfavorable response to OAT. Consequently, uncertainties arise regarding the justification of performing drug-induced sleep endoscopy solely for predicting the efficacy of OAT. However, the results of the current study could be influenced by heterogeneity in the assessment of respiratory parameters, variability in the performance of the mandibular advancement maneuvers, and the instability of bolus technique sedation.

Clinical Trial Registration: Registry: Netherlands Trial Register; Name: Drug-induced Sleep Endoscopy: a prediction tool for success rate of oral appliance treatment; Identifier: NL8425; URL: https://www.onderzoekmetmensen.nl/en/trial/20741.

Citation:

Veugen CCAFM, Kant E, Kelder JC, Schipper A, Stokroos RJ, Copper MP. The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study. J Clin Sleep Med. 2024;20(3): 353–361.

Keywords: obstructive sleep apnea, OSA, drug-induced sleep endoscopy, DISE, oral appliance treatment, OAT, mandibular advancement device, MAD

BRIEF SUMMARY

Current Knowledge/Study Rationale: Oral appliance treatment is a noninvasive therapy for obstructive sleep apnea with high patient preference and a high compliance rate. However, there is a large range in response rate; finding predictors to select suitable patients that may benefit from oral appliance treatment is therefore of great importance.

Study Impact: The current findings suggest that a jaw thrust maneuver should be preferred over the chin lift maneuver for predicting oral appliance treatment response. Patients with a positive jaw thrust maneuver should be counseled toward favorable oral appliance treatment response, whereas those with persistent lateral oropharyngeal collapse should be advised about the likelihood of an unfavorable oral appliance treatment response.

INTRODUCTION

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by repetitive partial or complete upper airway obstruction, which often results in decreased arterial oxygen saturation and arousal from sleep.1,2 The gold standard treatment for moderate to severe OSA is continuous positive airway pressure.3,4 In patients with mild to moderate OSA or in cases of continuous positive airway pressure (CPAP) and then after call it CPAP intolerance, other treatment options include oral appliance treatment (OAT). The most frequently prescribed oral appliances for OSA are mandibular advancement devices (MAD), which are used intraorally at night to protrude the mandible and open the upper airway.5,6 While CPAP has lower efficacy than continuous positive airway pressure in terms of reducing the apnea-hypopnea index (AHI), OAT has a higher compliance rate and higher patient preference with fewer side effects, resulting in a similar overall therapeutic effectiveness in patients with mild to moderate OSA.7–10 Response rate to OAT is patient dependent and depends on how treatment success is defined. Approximately one third of patients have a complete resolution of OSA defined as an AHI below 5 events/h, and another one third of patients have a partial resolution of OSA defined as a 50% reduction in AHI, although AHI remains above 5 events/h and one third will not achieve > 50% reduction in AHI.7,11–13 Currently there is no validated clinical method to reliably preselect patients that may benefit from OAT. Finding predictors to select patients who will receive sufficient treatment efficacy from OAT is therefore of great importance.

Previous studies have shown increased response for patients who are young and female, patients with a lower AHI, a lower body mass index (BMI), and supine-dependent OSA.14 Additionally, different polysomnographic endotypes have been associated with OAT efficacy; lower loop gain, higher arousal threshold, lower ventilatory response, and less severe airway collapsibility were all found to be independently associated with favorable OAT response.15–17 Drug-induced sleep endoscopy (DISE) with mandibular advancement maneuvers to mimic the effect of OAT has been proposed by several authors as a diagnostic prediction tool for OAT effectiveness.18–21 However, opinions concerning the performance of a mandibular advancement maneuver vary among studies, and evidence on the positive and negative predictive values are so far limited.20,22–25 Additionally, there is growing attention to the different patterns of upper airway collapse during DISE and their possible prognostic value to OAT (ie, DISE phenotypes). Three DISE phenotypes have been associated with OAT treatment outcome: one beneficial (tongue base collapse) and two adverse (compete concentric collapse at the level of the palate and complete laterolateral oropharyngeal collapse).26–28

In this prospective study, all patients underwent DISE with concomitant mandibular advancement maneuvers to predict the success of OAT. All patients were treated with OAT and completed follow-up sleep study with OAT in situ, without regard to their anticipated response to treatment. The aim of this study was to prospectively validate DISE with concomitant mandibular advancement maneuver as a prediction tool for treatment success of OAT. According to prior retrospective research, the hypothesis was that patients with a negative mandibular advancement maneuver would not respond to OAT treatment.22

METHODS

Study design

A prospective single-center cohort study of consecutive patients diagnosed with moderate OSA with an AHI between 15 and 30 was performed. Patients were included if they met the inclusion criteria: 18 years and older with OSA confirmed by respiratory polygraphy, polysomnography, or 7 channel home sleep test (WatchPat); an AHI between 15 and 30 events/h; and a BMI below 35 kg/m2. Exclusion criteria were patients with ≥ 25% central apneas, edentulism, insufficient retention for OAT use, functional restrictions of the temporomandibular joint, micrognathia, and previous invasive upper airway surgery. In the outpatient clinic, the following clinical parameters were collected for all patients: sex, age, height, weight, BMI, self-reported complaints (daytime sleepiness, arousals, and snoring or apneas), tonsil size, and Mallampati score. The Epworth Sleepiness Scale and the Functional Outcomes of Sleep Questionnaire were completed. Variables collected from the baseline sleep study were AHI, AHI in supine position, AHI in nonsupine position, supine time in percentage, the oxygen desaturation index below 3% (ODI ≥ 3%), the oxygen desaturation index below 4% (ODI ≥ 4%), the obstructive apnea index, the central apnea index, and the mixed apnea index, if available. Positional sleep apnea was defined as an AHI in nonsupine position less than 50% of the AHI in supine position, a nonsupine AHI of < 10 events/h, and a supine time between 10% and 90% of the total sleep time. All patients underwent DISE to evaluate the level and degree of collapse with three mandibular advancement maneuvers to predict the success of OAT and were referred to the department of Oral- and Maxillofacial Surgery for fitting of OAT. No difference was made between patients who were expected to benefit and patients who were expected not to benefit according to the response to the mandibular advancement maneuver. After six months of use, a respiratory polygraphy or home sleep test was carried out with OAT in situ to evaluate treatment efficacy. Primary outcome measures were the AHI and the ODI ≥ 3%. Secondary outcome measures were the posttreatment Epworth Sleepiness Scale and Functional Outcomes of Sleep Questionnaire and complications (temporomandibular dysfunction, dental pain, gingival irritation, dry mouth, hypersalivation, and dentofacial changes) (Figure 1).

Figure 1. Study design.

Figure 1

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DISE

DISE was carried out in a quiet operating room with dimmed lights. All procedures were carried out by the same experienced ear, nose, and throat surgeon and somnologist (M.C.) with an anesthesiologist to manage sedation. All procedures were captured on video and were available for later review. Sleep was induced by an initial bolus of 1 mg/kg propofol followed by manual titration of propofol. The optimal depth of sedation was reached when the patient began to snore and/or no awakening from vocal or tactile stimuli was achieved. Once a proper level of sedation was approached, the upper airway was thoroughly observed by flexible fiberoptic laryngoscopy. The upper airway was assessed in supine position using the VOTE classification earlier described by Kezirian et al.29,30 This classification system is commonly used to assess levels and structures that may contribute to upper airway obstruction, namely velum (V), oropharynx (O), tongue base (T), and epiglottis (E). The degree of obstruction is defined as 0: no obstruction (collapse less than 50%), 1: partial collapse (between 50% and 75%, typically with vibration), or 2: complete collapse (> 75%). The configuration of obstruction is classified as anterior-posterior, lateral, or concentric. After this first assessment, three mandibular advancement maneuvers were performed to mimic the effect of OAT. First, a chin lift maneuver was performed, tilting the head backward and lifting the chin vertically upwards without excessive strength. Second, a chin lift maneuver was combined with a small vertical opening of the mouth with an interdental distance of about 1 cm. Third, a jaw thrust maneuver was performed, placing the practitioner’s hands behind the angles of the mandible and thrust forward without extensive force, bringing the lower incisors past the upper incisors by a couple of millimeters, producing a mild anterior protrusion of the mandible of approximately 75% of the maximal protrural range. The maneuvers were called positive if the obstruction was discontinued on all levels. The maneuvers were called negative if the obstruction was still present on one (or more) levels. If the maneuver was negative, the level, degree, and configuration of persistent collapse was described according to the VOTE classification.

OAT

Prior to inclusion, the dental status was assessed by an oral- and maxillofacial surgeon; clinical screening and orthopantomography was performed. If a patient met the inclusion criteria, dental impressions were taken and a custom-made, two-piece titratable MAD (SomnoDent, SomnoMed, Australia) was fitted by a qualified dentist. The MAD consists of a maxillary and mandibular full coverage splint; the two splints are connected bilaterally with adjustable metal titration screws on the upper splint and triangular-shaped wings on the lower splint. A bite fork was used to measure and register each patient’s maximum mandibular protrusion capacity and to determine the appropriate antero-posterior and vertical mandibular positions needed for the construction of the MAD. The MAD was placed at 50%–60% of the individual patients’ maximal protrusion. Acclimatization occurred over a period of approximately 2 months. During this time, the degree of mandibular advancement was titrated until the maximum comfortable limit was achieved and self-reported complaints were reduced.

Definition of treatment response/deterioration

Treatment response was defined as a posttreatment AHI < 15 events/h and a reduction of > 50% in comparison to baseline AHI. Treatment deterioration was defined as an increase of > 10% in comparison to baseline AHI.

Statistical analysis

The statistical analysis and graphical presentation were performed by using Statistical Package for Social Studies (IBM SPSS Statistics version 24 for Windows, New York, NY, USA) and Prism GraphPad (version 9.3.1, San Diego, CA, USA). Normality of the distribution was visually assessed by means of a histogram and a Q-Q plot. Normally distributed continuous data are presented as means with standard deviations. Categorical data are presented as frequencies with percentages. Comparisons between groups were performed using Student’s independent t-test for continuous variables and the chi-squared test for categorical variables. The predictive value of DISE outcomes on treatment response of OAT was established by using univariable and multivariable linear regression modeling. A two-tailed P value < .05 was considered statistically significant.

Sample size

We had no a priori formally statistically testable hypothesis. This study seeks to find such a hypothesis. Pragmatically, with regard to the sample size, we could include 80 patients: on average 40 patients with a negative jaw thrust maneuver and 40 patients with a positive jaw thrust maneuver. With the smallest group of 40 patients and setting alpha = .05 and a treatment effect (before-after) of 0.5 (Cohen’s d; treatment effect in terms of absolute effect divided by the standard deviation), we have 85% power to detect such a difference when using a paired t-test.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all study participants. Data on study participants was collected and stored anonymously to protect personal information. Ethical approval for this study was obtained from the local medical ethical review board of St. Antonius Hospital (Z19.069).

RESULTS

Study inclusion

Eighty-seven patients with OSA met the inclusion criteria; six patients did not sign the informed consent, three patients canceled the DISE, and one patient moved to another city. Seventy-seven patients underwent DISE; eight patients did not complete the study due to OAT intolerance, one patient never had an OAT fitting, three patients did not show up at the follow-up respiratory polygraphy, and one patient was excluded due to complicated hip surgery needing opioids causing central apneas and the inability to sleep on the side leading to only supine sleep position; 64 patients finished follow-up. No significant differences were found in the baseline characteristics of the patients lost to follow-up (n = 13) and patients completing the follow-up (n = 64) (Figure 2).

Figure 2. Flow-chart inclusions.

Figure 2

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Baseline characteristics

In the entire cohort, 16 patients (25%) were female. The mean age was 49.7 ± 10.2 years, and the mean BMI was 28.6 ± 3.7 kg/m2. Eighteen (28%) patients previously underwent a tonsillectomy. The mean pretreatment AHI was 19.9 ± 4.2 events/h, and the mean pretreatment ODI ≥ 3% was 19.9 ± 6.4 events/h. Nineteen patients (30%) had positional OSA. The mean Epworth Sleepiness Scale was 9.8 ± 5.3, and the mean Functional Outcomes of Sleep Questionnaire was 95.3 ± 17.4. Twenty-six patients (41%) had a positive jaw thrust maneuver, 12 patients (19%) had a positive chin lift maneuver, and 30 patients (47%) had a positive vertical chin lift maneuver. Response to treatment was seen in 36 patients (56%); deterioration was seen in 7 patients (11%). No significant differences were found in the baseline characteristics between responders and nonresponders and between deteriorating and nondeteriorating patients (Table 1).

Table 1.

Baseline characteristics.

Baseline Characteristics Total Sample (n = 64) Responder Deterioration
Yes (n = 36; 56%) No (n = 28; 44%) P * Yes (n = 7; 11%) No (n = 57; 89%) P *
Female patients, n (%) 16 (25) 9 (25) 7 (25) 1.0 2 (29) 14 (25) .817
Age (years) mean ± SD 49.7 ± 10.2 49.3 ± 9.3 50.3 ± 11.4 .716 47.0 ± 11.5 50.1 ± 10.1 .459
BMI (kg/m2) mean ± SD 28.6 ± 3.7 28.8 ± 3.6 28.4 ± 3.8 .678 28.8 ± 3.1 28.6 ± 3.7 .918
Previous tonsillectomy, n (%) 18 (28%) 10 (28%) 8 (29%) .944 1 (14%) 17 (30%) .388
AHI (events/h) mean ± SD 19.9 ± 4.2 19.8 ± 4.2 20.0 ± 4.3 .870 18.6 ± 4.0 20.0 ± 4.2 .388
ODI ≥ 3% (events/h) mean ± SD 19.9 ± 6.4 19.2 ± 6.1 20.8 ± 6.9 .366 18.4 ± 4.1 20.1 ± 6.7 .520
Positional OSA, n (%) 19 (30) 11 (31) 8 (29) .863 3 (43) 16 (28) .419
ESS (range: 0–24) mean ± SD 9.8 ± 5.3 10.1 ± 5.4 9.4 ± 5.2 .592 8.7 ± 4.2 9.9 ± 5.4 .568
FOSQ (range: 0–120) mean ± SD 95.3 ± 17.4 92.7 ± 19.0 98.6 ± 14.8 .180 96.4 ± 16.0 95.1 ± 17.7 .851
Jaw thrust maneuver (positive) n (%) 26 (41) 18 (50) 8 (29) .083 2 (29) 24 (42) .491
Chin lift maneuver (positive) n (%) 12 (19) 8 (23) 4 (14) .389 1 (14) 11 (20) .734
Chin lift vertical maneuver (positive) n (%) 30 (47) 19 (54) 11 (42) .355 3 (50) 27 (49) .966
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*

Chi-square test for categorical variables; Student’s independent t-test for continuous variables. AHI = apnea-hypopnea index, BMI = body mass index, ESS = Epworth Sleepiness Scale, FOSQ-30 = Functional Outcomes of Sleep Questionnaire, n = number, ODI = oxygen desaturation index, SD = standard deviation.

Posttreatment sleep study

The sleep study results are shown in Table 2; patients are categorized according to the mandibular advancement maneuvers. The posttreatment AHI in the entire cohort was 10.6 ± 7.6 events/h; the delta AHI was −9.3 ± 8.0. The posttreatment ODI ≥ 3% was 11.2 ± 7.9; the delta ODI ≥ 3% was −8.7 ± 9.1. Patients with a positive mandibular advancement maneuver had a lower posttreatment AHI than patients with a negative mandibular advancement maneuver. However, only for the jaw thrust maneuver did this difference prove to be significant (P = .02). The posttreatment ODI ≥ 3% was also significantly lower in the positive jaw thrust maneuver group (P = .05) (Figure 3).

Table 2.

Mandibular advancement maneuvers.

Variable Total Sample (n = 64) Chin Lift (n = 63)a Chin Lift Vertical (n = 61)b Jaw Thrust (n = 64)
Positive (n = 12; 19%) Negative (n = 51; 81%) P* Positive (n = 30; 49%) Negative (n = 31; 51%) P* Positive (n = 26; 41%) Negative (n = 38; 59%) P*
Pretreatment AHI (events/h) 19.9 ± 4.2 18.1 ± 3.0 20.3 ± 4.4 .105 20.1 ± 4.6 19.6 ± 3.9 0.634 19.4 ± 4.3 20.2 ± 4.2 .470
Posttreatment AHI (events/h) 10.6 ± 7.6 8.4 ± 4.6 11.1 ± 8.2 .262 8.8 ± 6.0 11.7 ± 8.3 0.131 8.0 ± 5.3 12.4 ± 8.5 .023
Delta AHI (events/h) −9.3 ± 8.0 −9.7 ± 5.3 −9.1 ± 8.7 .827 −11.3 ± 7.8 −7.9 ± 7.9 0.099 −11.4 ± 6.7 −7.8 ± 8.6 .078
Pretreatment ODI ≥ 3% (events/h) 19.9 ± 6.4 16.9 ± 6.0 20.5 ± 6.4 .081 20.4 ± 7.7 19.1 ± 4.9 0.455 19.7 ± 8.2 20.0 ± 4.9 .865
Posttreatment ODI ≥ 3% (events/h) 11.2 ± 7.9 9.6 ± 5.3 11.6 ± 8.5 .433 10.0 ± 6.9 11.8 ± 8.2 0.367 8.9 ± 5.9 12.9 ± 8.8 .047
Delta ODI ≥ 3% (events/h) −8.7 ± 9.1 −7.3 ± 6.2 −8.9 ± 9.7 .592 −10.4 ± 9.3 −7.3 ± 8.7 0.196 −10.9 ± 8.7 −7.1 ± 9.2 .114
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Numbers are presented as mean (standard deviation).

a1 Missing patient; b3 missing patients. *Student’s independent t-test. Bold is statistically significant. AHI = apnea-hypopnea index, n = number, ODI = oxygen desaturation index.

Figure 3. Individual pre- and posttreatment apnea-hypopnea index.

Figure 3

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Patients are categorized according to the response to the mandibular advancement maneuvers. Amt = amount.

Posttreatment quality of life

The mean posttreatment Epworth Sleepiness Scale was 7.6 ± 4.6, and the mean posttreatment Functional Outcomes of Sleep Questionnaire was 98.7 ± 19.2; no significant differences were found between responders and nonresponders and deteriorating and nondeteriorating patients.

Complications

Forty-four patients (69%) had no complications. Thirteen patients (20%) had temporomandibular dysfunction, 11 patients (17%) had dental pain, 2 patients (3%) had gingival irritation, and 2 patients (3%) had dentofacial changes. No patients reported a dry mouth or hypersalivation. There were no differences in complications between responders and nonresponders and deteriorating and nondeteriorating patients (Table 3).

Table 3.

Complications.

Complications Total Sample, n = 64 (%)
None 44 (69)
TMD 13 (20)
Dental pain 11 (17)
Gingival irritation 2 (3)
Dry mouth 0 (0)
Hypersalivation 0 (0)
Dentofacial changes 2 (3)
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n = number; TMD= temporomandibular dysfunction.

Linear regression analyses

Linear regression analyses were performed to establish the predictive value of the three different mandibular advancement maneuvers on the posttreatment AHI. Corrections were made for sex, age, BMI, pretreatment AHI, and the presence of positional OSA. Patients with a positive mandibular advancement maneuver had a lower posttreatment AHI; however, only for the jaw thrust maneuver did this relationship prove to be statistically significant [chin lift: β = 1.98; 95% confidence interval (CI): −2.90, 6.86; P = .43; chin lift vertical: β = 3.49; 95% CI: −0.39, 7.37; P = .08; jaw thrust: β = 4.88; 95% CI: 1.04, 8.73; P = .01). Similar results were found for the predictive value of the mandibular advancement maneuvers on the posttreatment ODI ≥ 3% (chin lift: β = 0.72; 95% CI: −4.26, 5.70; P = .78; chin lift vertical: β = 2.34; 95% CI: 1.73, 6.41; P = .26; jaw thrust: β = 4.46; 95% CI: 0.48, 8.44; P = .03). Indicating that a positive jaw thrust maneuver is an independent predictor for favorable OAT response.

Linear regression analyses were performed to establish the predictive value of the level and degree of collapse according to the VOTE classification on the posttreatment sleep study parameters. Corrections were made for sex, age, BMI, pretreatment AHI, and the presence of positional OSA. No significant relationships were found between the level and degree of collapse according to the VOTE classification and posttreatment sleep study parameters.

Additionally, linear regression analyses were performed to establish the predictive value of the level and degree of persistent collapse in patients with a negative mandibular advancement maneuver. Corrections were made for sex, age, BMI, pretreatment AHI, and the presence of positional OSA. A significant relationship was found between a persistent lateral oropharyngeal collapse when performing a chin lift maneuver and the posttreatment AHI (β = −13.02; 95% CI: −19.25, −6.79; P < .001); indicating that a persistent lateral oropharyngeal collapse when performing a chin lift maneuver is a negative predictor for OAT. A similar significant relationship was found between persistent lateral oropharyngeal collapse when performing a vertical chin lift maneuver (β = −15.12; 95% CI: −23.16, −7.1; P < .001) and a persistent lateral oropharyngeal collapse when performing a jaw thrust maneuver (β = −17.03; 95% CI: −23.14, −10.92; P < .001). Similar results were found between a persistent lateral oropharyngeal collapse and the posttreatment ODI ≥ 3%. These relationships remained significant when correction was made for tonsil size. Additionally, a significant relationship was found between a persistent complete concentric collapse at the level of the velum when performing a vertical chin lift maneuver and the posttreatment AHI (β = −23.26; 95% CI: −32.46, −14.07; P < .001). Indicating that a complete concentric collapse at the level of the velum when performing a vertical chin lift maneuver is a negative predictor for OAT. A similar relationship was found between a persistent complete concentric collapse at the level of the velum and the posttreatment ODI ≥ 3%. However, only two patients had a persistent complete concentric collapse at the level of the velum when performing a vertical chin lift maneuver.

DISCUSSION

The key finding of this study is that a positive jaw thrust maneuver is significantly associated with favorable OAT response in patients with moderate OSA, whereas the chin lift maneuver and the vertical chin lift maneuver are not. The β-coefficient in the linear regression analysis indicates that in patients with a positive jaw thrust maneuver there is an average reduction of 4.88 events/h in posttreatment AHI in comparison to patients with a negative jaw thrust maneuver. However, unlike the hypothesis based on prior retrospective research, a negative jaw thrust maneuver did not prove to be a significant predictor for OAT failure. Nearly 50% of the responder patients was not correctly identified by the jaw thrust maneuver. A second finding is that a persistent lateral oropharyngeal collapse when performing any mandibular advancement maneuver is significantly associated with unfavorable OAT response in patients with OSA. Both were independently associated with OAT response, corrections were made for sex, age, BMI, pretreatment AHI, and the presence of positional OSA. The results of this prospective study are in concordance with what was previously described in literature. However, thus far no prospective study has been performed that included patients treated with OAT despite a negative response to the mandibular advancement maneuver, possibly indicating unfavorable OAT response.

Given the large range in response rate, it is important to establish criteria that reliably preselect patients that may benefit from OAT prior to the initiation of therapy. DISE has been suggested by several authors as a potential clinical method for patient selection. However, other authors advocate that DISE is expensive and patients have to undergo sedation. A recent study by Sutherland et al concluded that phenotypic awake assessments do not improve the prediction of OAT treatment outcome, beyond models only using clinical characteristics.31 A review by Cheong et al concluded that DISE is a low-risk procedure providing an increased understanding of a patient’s upper airway to make adequate treatment decisions that may increase the frequency of positive treatment outcome.32 Nevertheless, the primary objective of a diagnostic tool should be to exclude patients who are expected to be nonresponders. Due to the lack of prospective validation regarding the use of a negative jaw thrust maneuver in the current study, uncertainties arise regarding the justification of DISE with mandibular advancement maneuvers solely for predicting efficacy of OAT.

Previously, different authors have retrospectively shown that a mandibular advancement maneuver could be of prognostic value in determining effectiveness of OAT.18,19,22,33 Other authors have prospectively evaluated the treatment effect of OAT with and without prior DISE with mandibular advancement maneuver. They found a significant difference in terms of AHI reduction in favor of the DISE group.21,34 This is in correspondence with the current study, showing that a positive jaw thrust maneuver is significantly associated with favorable OAT response. Additionally, several authors have performed DISE with a custom-made simulation bite and found that patients with relief of obstruction on all levels had a higher response rate to OAT in comparison with patients with either partial or no relief of obstruction.23,24,35–37 Furthermore, additional value was found in the quantitative pharyngeal airway measurements during DISE with OAT in situ in evaluating treatment outcome.38 These authors advocate that a jaw thrust maneuver is nonreproducible and nontitratable and may overestimate the treatment effect of OAT.23,24,36 The current study aims to inform clinical practice; a jaw thrust maneuver is less expensive than a custom-made simulation bite and is easy to use in clinical practice. Additionally, a recent study performed DISE with the mandibular advancement maneuver and a custom-made simulation bite in situ and found that both modalities are close to mimicking the expected effect on upper-airway obstruction of OAT.39

Strengths and limitations

This is the first prospective study that treated patients with OAT despite a negative response to the mandibular advancement maneuver, possibly indicating unfavorable OAT response. This is an important strength, because this grants the opportunity to prospectively validate DISE with mandibular advancement maneuvers as a prediction tool for OAT. The linear regression analyses were performed with continuous variables; the posttreatment AHI and the posttreatment ODI ≥ 3%. In previous studies, conclusions were based on dichotomous variables (responder vs nonresponder). Three different mandibular advancement maneuvers were used to predict success of OAT; the chin lift maneuver and the jaw thrust maneuver are both established in literature as possible predictors for treatment response of OAT. The chin lift maneuver with vertical opening was previously introduced by other authors because the other two maneuvers might not account for the vertical mouth opening that is induced by OAT.23,24,40

Only patients with moderate OSA (AHI 15–30 events/h) were included in this study. This might have introduced a selection bias. This decision was made to avoid unnecessary sleep studies, as moderate OSA patients are typically recommended for follow-up assessments after OAT therapy. Additionally, it is known that in patients with a higher AHI, the likelihood of OAT failure is higher, resulting in a smaller study population while still maintaining reasonable power. Furthermore, the default sleep study was a respiratory polygraphy, but a small subset of patients underwent a polysomnography or home sleep test. Consequently, there is a heterogeneity in the assessment of respiratory parameters due to use of these three different sleep studies. This was the case in the minority of patients, and these patients were equally distributed among the responder groups, minimizing the potential bias in the results. However, AHI measurement might be underestimated in a polygraphy or home sleep test due to not considering the time that the patient is awake. Additionally, the assessment of the upper airway during DISE and the mandibular advancement maneuvers are based on self-reported findings and, therefore, are prone to experience bias; a mandibular advancement maneuver cannot be performed exactly the same in every patient. Previous studies have shown DISE to be reliable and its interobserver reliability to be moderate to substantial, especially in experienced ear, nose, and throat surgeons.41–43 In the present study, all DISE procedures and concomitant mandibular advancement maneuvers were executed by one surgeon (M.C.). All DISE procedures were recorded and available for later review. All DISE procedures were carried out with a bolus technique; previous literature has shown that this provides less stable and reliable sedation in comparison to the use of propofol with target-controlled infusion.44,45 This can possibly induce higher tolerability to the mandibular advancement maneuver, resulting in an overestimation of the OAT effect explaining the false-positive patients in the nonresponder group. Conversely, if patients were not sufficiently sedated, it is possible that the jaw thrust maneuver was not executed to an adequate extent. This could explain the false-negative patients in the responder group. Additionally, the degree of mandibular advancement of the OAT was titrated subjectively until the maximum comfortable limit was achieved and self-reported complaints were reduced. This approach has been a subject of debate due to its inherent imprecision and subjectivity, potentially accounting for the false-positive results observed in the nonresponder group, which could be attributed to insufficient titration. A recent study by Kazemeini et al has evaluated clinical effectiveness of subjective titration vs objectively guided titration during polysomnography and DISE in OAT for patients with OSA and found no differences in optimal mandibular positioning and corresponding efficacy.46 Additionally, Ma et al has shown that OAT reaches a plateau stage after reaching approximately 70% of protrusion, suggesting that more protrusion does not always yield a decrease in AHI.47

CONCLUSIONS

In this prospective study, the presence of a positive jaw thrust maneuver was significantly associated with favorable OAT response, leading to an average reduction of 4.88 events/h in posttreatment AHI in comparison to patients with a negative jaw thrust maneuver. Additionally, a significant association was found between a persistent lateral oropharyngeal collapse when performing any mandibular advancement maneuver and unfavorable OAT response. Contrary to our initial hypothesis, a negative jaw thrust maneuver did not prove to be a significant predictor for unfavorable response to OAT. Consequently, uncertainties arise regarding the justification of performing DISE solely for predicting OAT efficacy, since the primary objective of a diagnostic tool should be to exclude patients who are expected to be nonresponders. However, this study aimed to inform clinical practice and therefore is limited by heterogeneity in the assessment of the respiratory parameters due to the use of three different sleep studies, variability in the performance of the mandibular advancement maneuvers, and the instability of the sedation due to the usage of bolus technique during DISE instead of target-controlled infusion. Consequently, future prospective studies should be conducted while considering these constraints.

DISCLOSURE STATEMENT

All authors declare that they have seen and approved the final version of the manuscript. Institution where work was performed: St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands. The authors report no conflicts of interest.

ACKNOWLEDGMENTS

The authors thank all study participants. They are grateful for the administrational and organizational support of the secretarial staff of the department of sleep medicine at St. Antonius Hospital. Furthermore, the authors thank the co-workers of the Sleep Laboratory at St. Antonius Hospital for conducting the polysomnography and respiratory polygraphy examinations.

ABBREVIATIONS

AHI

apnea-hypopnea index

BMI

body mass index

CI

confidence interval

DISE

drug-induced sleep endoscopy

MAD

mandibular advancement device

OAT

oral appliance treatment

OSA

obstructive sleep apnea

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