Drug-induced sleep endoscopy completed with a simulation bite approach for the prediction of the outcome of treatment of obstructive sleep apnea with mandibular repositioning appliances

Mandibular repositioning appliances (MRA) are currently the most widespread and evaluated type of oral appliance used to treat obstructive sleep apnea (OSA). Although oral appliance therapy usually reduces snoring, it is not always as effective in treating OSA. The methods that have been described to predict treatment outcome with oral appliance therapy mostly have relied on retrospective analysis and there is a significant lack of uniformity concerning the predictive models. Therefore, the ability to predict treatment outcome of oral appliance therapy prospectively in the individual patient and, thereby, preselecting suitable OSA patients for oral appliance therapy, is still limited in clinical practice. The site of upper airway obstruction can be assessed by sleep nasendoscopy or ‘drug-induced sleep endoscopy’ (DISE). Generally, a decision is made after performing the so-called ‘chin-lift’ maneuver, whereby the mandible is brought forward maximally. Although allowing for a visual inspection of the effect of mandibular protrusion, the position itself is not reproducible and it remains to be determined to what extent it is physiologically tenable by the patient. Furthermore, the chin-lift maneuver requires a further opening of the mouth simply for allowing the dental sleep professional the possibility to grasp and protrude the mandible. At our multidisciplinary dental sleep clinic at the Antwerp University Hospital, we started using a bite simulation approach to investigate the patient’s protrusive characteristics prior to the modified multipart DISE procedure. This specific technique using a simulation bite, custom-made for each individual patient, during DISE is described in detail in this article.