If PAP is the gold standard for the management of OSA, then mandibular advancement devices (MAD) can be considered the silver standard. MAD may be a first line option in those with mild to moderate OSA. MAD may even be considered in severe OSA in those who fail PAP therapy due to a compliance issue or to PAP intolerance.
The rationale behind the therapeutic effect of MAD is that the mandible is advanced (positioned anteriorly or protruded). This advancement brings the major muscles of the tongue forward, as these are attached to the mandible thereby relieving the mechanical obstruction posteriorly in the oropharynx. With improvements in airway shape, air can now flow more readily to the lungs. This mechanism alleviates OSA and snoring with concomitant decreases in the number of apneas and hypopneas.
While PAP can be used for all severities of OSA, MAD is typically used in mild to moderate cases. However, in severe OSA cases where the patient is intolerant of PAP, MAD is recommended as a back-up option.24-26