Selection of the MAD Device
The number of appliances available to treat OSA has exploded in the past decade or so. There are numerous dental laboratories that have developed a product line to serve the dental professional’s needs when considering a MAD. The common denominator is that they all advance the mandible in some manner using the maxilla as a push off point. Most rely on some form of hard acrylic or a bilaminar hard/ soft acrylic combination.
The two basic type of MAD are the fixed and the adjustable. The fixed MAD implies that the MAD is a monobloc appliance fabricated at a pre-set protrusive record of 50-60% and cannot be changed. The fixed MAD is generally less expensive. It may help the patient’s OSA symptoms, or it may not. The down side of the fixed MAD is a patient may need a greater degree of advancement than this appliance allows. At the least, this may help reduce or eliminate snoring, a welcome change for the bed partner.
More commonly used now by far are the adjustable MAD. As mentioned earlier, the bite registration sent to the lab is most commonly done at the 50% protrusion level. However, if 50% is not quite enough to alleviate their OSA symptoms per the ESS or a sleep study, then the device allows for further protrusion. A 0.25mm advancement every other night and titrated to effect can usually achieve the desired outcome. Some adjustable MAD are adjusted via a keyhole at either the front or side of the appliance (SomnoDent, dreamTAP). Other models have several arches that interface differently allowing for several preset advancements (MicrO2) (Figure 11).
Example of an adjustable MAD by Respire Medical.