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Oral appliances, of the mandibular advancement device (MAD) variety, are an effective treatment for obstructive sleep apnoea (OSA). In recent years, non-inferiority of MAD compared with continuous positive airway pressure (CPAP) in controlling important short-term health outcomes, like blood pressure, has been demonstrated, despite residual mild OSA on MAD treatment.1 2 This equivalent effectiveness is potentially attributable to greater usage and treatment preference for MAD over CPAP which counteracts any inferior efficacy.2
It is well recognised that Apnoea Hypopnea Index (AHI) changes with MAD vary from individual to individual, with some patients achieving major improvement or resolution of OSA, and others left with varying degrees of residual OSA.3 This uncertainty around therapeutic efficacy remains a clinical barrier. Therefore, MADs are generally reserved for second-line therapy in the event of CPAP failure, or preferentially for less severe and/or less obese patients who respond better on average, although these characteristics are of low accuracy in predicting MAD therapeutic response.3 Despite years of interest in clinical prediction tools for MAD treatment outcomes, current methods either lack verifiable utility or feasibility for routine clinical use.4
The success of MAD therapy also depends on clinical expertise and follow-up and quality of the oral device itself. There are numerous device options which vary in sophistication and customisation. The current guideline for MAD therapy recommend a customised, titratable (allowing adjustment to level of mandibular protrusion) device, over a non-custom device.5 However, this is a guideline only, due to limited device comparison trials. For customised MADs, titratable devices have been shown to have better efficacy than fixed, non-adjustable devices.6 Several studies report clear benefits of customised devices over non-customised options.7–9 However, the drawback of customisation is greater financial outlay and optimisation time, which ultimately may not …
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