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Received date: May 11, 2017; Accepted date: June 19, 2017; Published date: June 21, 2017
Citation: Amoric M (2017) Treatment of Sleep Apnea with Herbst Mandibular Advancement Splints. J Sleep Disord Ther 6:272 doi: 10.4172/2167-0277.1000272
Copyright: © 2017 Amoric M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Sleep apnea and obstructive sleep disorders represent a danger for the cardiovascular system and metabolism. They also give rise to somnolence, which can cause accidents at work or road accidents. Along with positive pressure ventilation, oral mandibular advancement devices are today regarded as reliable forms of treatment. Unfortunately, not all patients adhere fully to the treatment, particularly over time. Some even abandon it entirely. The reasons generally put forward to explain this poor compliance are discomfort, pain, occlusal problems and poor psychological disposition (Figure 1). Orthesis over three years showing the high levels during the first months of treatment.
Obstructive sleep apnea; Mandibular advancement device; Compliance; Manufacture
Twenty-three referenced articles concerning the efficacy of the Herbst appliance for the treatment of obstructive sleep apnea have been studied: Table 1 lists a selection of articles on the Herbst appliance, presented methodologically [1-25]. Also listed are three doctoral theses presented in two French medical schools (Table 2) [26-28]. Table 3 lists 23 articles presented in terms of efficacy of treatment of respiratory disorders. A summary report on the subject of sleep presented to the French Ministry for Health and Solidarity in December 2006 (Appendix Ch. 2.2.3.), concluded in these terms: “Currently only made-to-measure orthesis have proved their efficacy in controlled trials. Herbst mandibular advancement splints, used in orthodontics since 1980, remain the most widely- studied systems.”
|SL No.||year||1st author||Orthotics||Comparators||Pop.||Study type||NP|
|1||1994||Eveloff||Herbst||PSG||14||12 m, Retro.||CIII|
|2||1994||Sjöholm||Herbst/Relax musc||PSG, n acriv||12||2 m, Prosp.||CIII|
|5||2000||Shadaba||Herbst||satisfaction||132||2 m, Retrospect||CIV|
|7||2000||Clark||Herbst||Ports Ef. parasites||65||Investigation|
|9||2001||Fritsch||Herbst/piece||Effetssecondaires||24||30 m, Prospect.||CIII|
|10||2002||Pételle||Herbst/prototype||PSG||7||12 m, Pilote||CIII|
|12||2004||Fleury||Herbst||PSG||40||17 m, Prosp.||CIII|
|13||2005||Johal||Herbst||endoscopie.||19||25 m, Cohort Prosp.||CIII|
|14||2005||Lawton||Herbst/block dick||PSG, subj.||16||15 m, Prosp, Non randomisé||CII|
|15||2005||Battagel||Herbst||Mvt. dent.||192/30||42 m,Retrospect.||CIII|
|17||2006||Johal||Herbst||Effet /Qual. de vie||120+95t||25 m, Non random||CIII|
|18||2007||Johal||Herbst||Electromyo.||107 (T)||25 m,Cohort||CIII|
|19||2007||Itzhaki||Herbst||oxymétrie||16+6t||12 m, Prospect.||CIII|
|21||2011||Barros||Herbst||association avec trait odf||16 de 840 de 9 à 14 ans||12 mois, Multic.||CIII|
|22||2011||Johal||Herbst||Psycho-social||75 (40+T)||3 m, Prosp.||CIII|
|23||2011||Vezina||Herbst/PPC/Narval||PSG, mvy dent, lg.||162/50||24 m,Retrospect.||CIII|
Table 1: T: control population; CO: Crossover; PPC: Continuous Positive Airway Pressure (CPAP); PSG: Polysomnographic Results (apnea-hypopnea index, oxygen saturation, etc.); Somn: Subjective Somnolence Test; NP: Level of Evidence; A1: Randomized, Null Hypothesis Rejected less than 0.05; BII: Randomized with Errors Deriving from Volume Studied; CIII: Competitor or Non-randomized Cohort; Historic or Non-randomized Cohort; CV: Case Series.
|1||2002||Pauron||ParisVI||Traitement du syndrome can be triggered by the type of drugs that are available in the following areas: 6 cas 7 témoins, 1 an.|
|2||2003||Roussel||Rouen||Search for cephalometric factors predictive of the effectiveness of a mandibular prosthetic orthosis (Herbst rods) in the treatment of obstructive sleep apnea syndrome in adults, 8 cases over 50 months,|
|3||2004||Lavis||Rouen||Cephalometric and polysomnographic analysis of 32 patients with moderate obstructive sleep apnea syndrome treated with Herbst's mandibular advancement orthosis. 32 cases, 15 paired, over 53 weeks.|
Table 2: French dissertations on the Herbst appliance.
|1||Eveloff||42%success. A mathematicalprocedurecanpredict the respiratorytherapeuticeffect|
|2||Sjöholm||The Herbst has amuch more effective action than the muscle relaxation devicefrom a 50% propulsion. Action on oxyhemoglobindesaturation, respiratorypermeability and body movements).|
|3||Johal||The nocturnal advancement of the mandiblewouldavoidglosoptosis, knowingthat the base of the tongue tilts the epiglottis and diminishes the entry orifice of the pharynx. This forcedmovementinitiated by the orthesiswould have amechanicalrole in the reduction of the pharyngeal collapse.|
|4||Bloch||The overallsuccess of Herbst's orthoses is 66%, no differencebetweenHerbst and monobloc|
|5||Shadaba||The most relevant argument in favor of endobuccalorthoticsremainsitsacceptance by patients, in particular in relation to PPC ventilation|
|6||David||The averageapnea-hypopnea index and snoringdecreasedsignificantly.|
|7||Clark||Efficiency of 50%, but lessthan the fan.|
|8||McGown||Long-termbehavior questionnaire showing discontinuation of treatment.|
|9||Fritsch||Pneumosomnographicresultssatisfactoryafter 30 months|
|10||Pételle||71.4% of patients are fastwith an index of lessthan and lessthan 20 per hour and 42.9%lessthan 10.|
|11||Millman||Postponedresultsthatreportedthat 45 randomized patients giving favorable results and sideeffects|
|12||Fleury||Symptomaticbenefits of progressive mandibular advancement.6 of 40 patients whorejected the use of ventilation showedimprovement. The activation of the propulsion was progressive. For 18.2%, a limitedresponsewasobserved (AHI, 21 ± 11 events per hour, snoring, 88 ± 15%, ESS drowsiness, 6 ± 3). 25% weremotivated (21 ± 10 events per hour) despiteresolution of symptoms, while 20%had persistent symptoms (despite a normal measurementat 6 ± 2 events per hour). After an average duration of 17 ±4 months, 34 patients reportedthattheyused OA 5 ± 2 days per week for 89 ± 19% of theirsleep time.|
|13||Johal||On 44 patients an increase in the lateralpharyngeal dimensions isobservedverysignificant. There was an improvement in airwayopening and snoring. In conjunctionwith a reduction in the apnea-hypopnea index from 28.1 to 6.1. Oxygen concentrations werehigher the orthesis in place. Theyfound a reduction in HAI of 28.1 to 6.1, P<0.001 and improvement in somnolence washighlysignificant.|
|14||Lawton||HERBST orthotics have proved to be more effective thanTwin-block devices in reducing somnolence (p=0.04). No significantdifference in orthoticsapnea index (p=0.71), snoringfrequency (p=0.49), oxygen saturation (p=0.97), arterial pressure|
|15||Battagel||Meansignificantdecrease in meanapnea-hypopnea index (from 28.1 to 6.1, p<0.001).|
|16||Battagel||Effect of propulsion on the oropharyngealairway, the soft palate and the position of the hyoidbone.|
|17||Johal||Significantdifferences in energyvitality (P=0.001) and physicaldomains of role limitation (P=0.025) following 4 months of treatmentwith an orthosis.|
|18||Johal||Role of the mandibularadvancement on the manducatory musculature initiated by the orthesis. Increasedmyoelectricactivitywouldplay a role in increasing the airwaydiameter (related to displacement of the hyoidbone.|
|19||Itzhaki||There is a correlationbetween the decrease in the apneic index and the oxygen concentration in the blood due to mandibular propulsion.|
|20||Martinez||Work on sideeffects|
|21||Barros||Study of changes in sleep patterns in retrognathic adolescents (free of adenopathies) duringtheirorthodontictreatment. Improvedbreathing and snoring. Significantincrease in nasopharyngeal, oropharynx and hypopharyngeal gauges|
|22||Johal||Psychosocial improvement (confidence intervals of 0.26 (0.09, 0.75) and 0.36 (0.14, 0.92) respectively for somnolence and energy of vitality, (significance of mean points of somnolence (10 [1 to 18] 1 to 14] P and energy/vitalitydomain (18 [7 to 20] to 19 [14 to 20] The meanapnea-hypopnea index increasedfrom 16 [5.2 to 30] to 4.6 To 17.2] SO2from 11 to 0.|
|23||Vezina||The objective and subjective effectiveness of Herbst's "compression" rodmechanicsis no differentfromthatobtainedwith "stretching" devices.|
|1||Pauron||Effectiveness in decreasing confirmed HAI; Side effects: dry mouth, dental and musculo-facial pain, dental displacements (10th of mm).|
|2||Roussel||Effectiveness in decreasing AHI c
Effectiveness in decreasing confirmed HAI; Side effects: dry mouth, dental and musculo-facial bread, dental displacements (10th of mm). onfirmée; Side effects: dry mouth, dental and musculo-facial pain, dental displacements (10th of mm).
|3||Lavis||Decreased IAH by -5.6 ± 10.2, (for 44% of the sample), advancement of the palate, increased pharyngeal space. No break was observed|
Table 3: Data similar to those of Table 2 presented according to respiratory efficacy.
This review of the literature is illustrated by the captions accompanying figures derived from these articles (Figures 2-12); adverse and parasitic effects: the discomfort caused by the Herbst advancement splints is no different from that described with other types of oral orthesis or with ventilators. But, unlike other models , they remain well positioned on the teeth.
Figure 2: This representation taken from the first study already showsindividual variations in response to therapeutic mandibular advancement. AHI: apneahypopnea index (events/hour), RHA with Herbst splint. Note here that patients starting with a high index finally achieve an index close to that of patients with low initial levels of apnea. Study by Eveloff et al. .
While TMJ pain is only temporary, tooth pain persists if it is linked to the initial state of the mouth or to movements caused by the orthesis. Pain in the facial muscles is more often the result of poor adjustment of the amplitude of propulsion. As for breakages, they are due to faulty manufacturing methods (Table 4).
|1||Eveloff||Discomfortat the ATM level and dental pain.|
|4||Bloch||Pain and discomfort of ATM, masticatory muscles and teeth|
|5||Shadaba||32% experienced occlusion disruption, 36% drought, 38% had ATM pain initially, 23% experienceddiscomfort in the atm, 35% facial discomfort, 35% Dental pain|
|6||David||Strongcorrelationbetween the change of the supraclusion index and ANB.|
|7||Clark||37% dental pain, 26% disturbance due to change in occlusion, 41% dryness, 30% feeldiscomfortat the atmafter, 23% ATM pain,|
|8||McGown||49 users out of 166 complained of sideeffects, 67 thattheysnoredless (p: 0.001), 97% were effective evenaftershutting down the device. The reasonswhy patients no longer bore the orthosiswere: pain (52%), perceivedefficacy (10%), social circumstances, dental treatment. 13% disruption of occlusion, 10% hypersialorea, 38% feeldiscomfortat the level of discomfort 36%, geneduringsleep 16%, bad port related to discomfort 23%.|
Mucosaldermatitis (86% of patients), dental discomfort 22%, dental pain (59%), hypersalorectal pain (22%), ATM pain 22%, muscle pain 22%
Dental displacements: upperincisors / occlusal plane: -1° ± 2°after 12 to 30 Months (0.05 of p). Incisive overlap and overhang: -1 mm identicalminoreffects for both types of appliances
|10||Pételle||Interest in regulating the mandibularadvancementduring the patient'sfallasleep for an optimization of the polysomnographicresponses.|
|14||Lawton||No significantdifferencebetween the twodevicesregardingquality of life or sideeffects. 5 preferred the Twin-block, 9 preferred the Herbst.|
|15||Battagel||Vertical and horizontal change of the incisors of 0.4 mm, correlatedwith an increase of the overlap, the twoeffectsbeingindependent of the amplitude of the propulsion.|
|17||Johal||A difference in energyvitality (p: O, O1) wasobservedfollowing the 4 monthsfollowingtreatment. Orthotics have asignificanteffect on a limitednumber of quality of life domains.|
|20||Martinez||Subjective, permanent, transient, permanent effects over 5 years: No effect on TMJ but permanent occlusal changes.|
|21||Barros||Good adhesion due to fusion withorthodontictreatments.|
|22||Johal||Significantimprovement in severalemotional, physical, quality of life, vital energy perception indicators.|
|23||Vezina||No differencewasfoundbetween MAA for subjective and objective sideeffects, except in an uncertainmanner, greaterearlymasticatory muscle pain (p=0.02) and residualtongue pain (p=0.04) In the compression group.|
Table 4: Presentation according to complaints expressed by patients.
The economic filter
Patient selection represents a radical approach to the reduction of failures of compliance. The difficulty is to find an infallible method to avoid excluding patients with a favourable profile. In France, the conditions for reimbursement of costs are laid down by law: patients can only benefit if the treatment by orthesis:
-is second-line treatment (after refusal of CPAP);
-is first-line treatment for an index of between 15 and 30,
-without excessive somnolence or severe cardiovascular comorbidity;
-and is prescribed by a sleep specialist. However, no provision is made for the reimbursement of dental and stomatological procedures and consultations!
The Initial Dental State
Today, too many ortheses are still prescribed despite the presence of periodontal disease, dislocation, desmodontitis, ankylosis of the temporal-maxillary joints, multiple missing teeth, broken or carious teeth, etc. According to Petit et al. , 50% of patients requiring an orthesis have periodontal abnormalities, 31% have more than 10 missing teeth and 20% have bridges that complicate the insertion of an orthesis. More than 50% of patients present with malocclusions that expose some of them to a risk of irreversible occlusal modification caused by the side effects of the orthesis: subjects in Class I, Class III and with overbite are more at risk than those in Class II without overbite.
Since more than 50% of the population suffers from occlusal asymmetry, and since some cases of hyperdivergence can easily be worsened, the widespread use of advancement devices is not without certain consequences. After being worn for some time, mandibular advancement ortheses modify occlusion, according to Almeida et al. Doff et al. , the most visible man-infestation of these changes is the advancement of the lower teeth. While these movements may be beneficial for some subjects who are initially in Class II, for the others (44.3%) they cause permanent discomfort. Over a period of 5 years this is alleged to be the main cause of abandonment of treatment by mandibular advancement splints. Pancherz and Hansen  sought to reduce these parasitic movements by changing the support, but without success. Weschler and Pancherz  noted that whether they were cast or banded, splints always induced this movement (11.8” W 3.7” for the former, 9.3” W 2.9” for the 107 latter).
The articles in this selection concern samples of patients who were previously treated with CPAP ventilation. It is not surprising that this category of patients, emerging from a situation of treatment failure, should be more inclined to abandon this new treatment too. And yet it is this population that is given priority by the law in France for access to refunding of medical costs (second-line treatment)! In the context of treatment for sleep apnea, Poulet et al.  identified two predictive variables that would make it possible to avoid 85.7% of cases of discontinuation of treatment. These are patients’ perception of their state of health, and their mental state (depression test) [36-40].
Prevention of Discomfort and Device Fragility
Surveys of apnea sufferers treated with splints highlight the following complaints:
-Transient complaints: TMJ pain, pain in masticatory muscles, poor stability of the device , discomfort caused by lower pivots, hypersialosis;
-Long-term complaints: dry mouth, tooth pain, occlusal problems, mobility of teeth.
- Dry mouth
- Occlusal genes
- Tooth mobility
The information obligation: Considered as “knowing”, the practitioner is legally obliged to inform the patient of the disadvantages and ways to address them. The marketing of any laboratory does not absolve the practitioner’s professional responsibility [41-43].
Patient comfort must be sought carefully at the first appointment. To eliminate the pains of ATM and musculature, nothing is more effective than activating the propulsion gradually. Thus, the masticatory muscles and the back-meniscal ligaments have time to become accustomed without painful reaction . Postherpetic expressed in many articles (Bloch, Evenoff, Clark) could be prevented by reducing the magnitude of the propulsion from the start of treatment. Also in those first moments, the practitioner should be concerned about the retention of the orthosis: too maintained, it will require grinding; too loose, it will require a reline. A special care should be given to the adaptation of the lower lip opposite the pivots. With some forms of arches and adjacent tissues, it will not hesitate to change the location of these pins:
The manufacturing process: Breakage, lack of retention or unexpected discomfort always originally a development error. The meta-analysis of 36 Ahrens 2010 (of 1475 references) joined our opinion, “The success and subjective input depend on a variety of factors including the type of material, technical or manufacturing model devices individualized to determine the propulsion.”
Also remember a manufacturing protocol bringing more unreliability:
• To secure the inclusion of son and pivots, the molding technique can be used using two plates: a first formed on the model is 0.5 mm thick and a second 1.5 mm thick.
• This way allows to include completely metal and resin filling between the two thermoformed sheets. In addition, it eliminates contact between the lining and metal for comfort.
• The titration is done by reducing the length of tube or by setting calettes crimped on the axis.
Note, finally, that all the authors propose to add vertical elastic rods on the gutters to force the patient to close the mouth.
Implementation and Monitoring Treatment
The Church of study 38 concludes by noting that one-day training for a general is sufficient to control it. (Success rate 48%). Any pain, any discomfort may result in discontinuation of treatment, especially in the absence of motivation by a practitioner. A decreased range of propulsion as the grinding sound associated with a few words of comfort can go a tour status to failure.
If Herbst updated on gutter device is a generic method for reliable and proven mandibular propulsion. Also, the main failure of treatment with orthoses Herbst is not medical but behavioural, by patient membership loss. It is on this crucial point that the expertise and knowledge provide the practitioner, came to the fore. Without controls, parasites tooth movement can occur and develop. How to eliminate injuries, pain and discomfort without careful control? How to avoid the abandonment, without encouragement and information from the practitioner? How to conduct suitable treatment with a faulty initial dental condition? How not to expose themselves to major failures without following a reliable and rigorous manufacturing process?