Special article
Mandibular advancement devices in the treatment of obstructive sleep apnea. A necessary and effective option
Los dispositivos de avance mandibular en el tratamiento de la apnea obstructiva del sueño. Una opción necesaria y eficaz
Gabriel Sampol Rubioa,b,
, Emilio Macías Escaladac,d, Josep Maria Montserrat Canalb,e, Joaquín Terán Santosb,f
Corresponding author
a Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital Vall d’Hebron, Barcelona, Spain
b Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
c Unidad Multidisciplinar del Sueño, Hospital Universitario Marqués de Valdecilla, Santander, Spain
d Facultad de Odontología, Universidad de Oviedo, Oviedo, Asturias, Spain
e Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital Clínic, Barcelona, Spain
f Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital Universitario de Burgos, Burgos, Spain
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Una opción necesaria y eficaz" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3235 "Ancho" => 2376 "Tamanyo" => 318191 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Guidelines for the establishment of treatment with mandibular advancement devices.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">OSA: obstructive sleep apnoea; MAD: mandibular advancement device.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Modified by the Working Group of the Spanish Clinical Practice Guidelines.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a></p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Obstructive sleep apnoea (OSA) is characterized by the presence of recurrent episodes of total (apnoea) or partial (hypopnea) obstruction of the upper airway during sleep. These episodes determine the presence of intermittent hypoxia, awakening reactions that fragment sleep continuity and decrease intrapleural pressure. All this can condition the occurrence of somnolence, neurocognitive disorders, deterioration of the quality of life and an accident rate increase, and has been associated, among others, with cardiovascular disease and with an increase in mortality.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> In the adult population, 4% of adult men and 3% of adult women have OSA accompanied by subjective somnolence<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a>; however, we know that the asymptomatic form or the minor symptom presentation is much more common<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2,3</span></a> and, according to recent studies with current diagnostic methods, it may be present in more than 30% of the population.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> For these reasons, OSA is considered a public health problem, with challenges associated with its screening, its diagnostic evaluation and its treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Both patients with somnolence as well as those without it are referred to the sleep units for diagnosis. After this, the most significant aspect would be treatment individualization. To this end, there are priority open research lines that try to define phenotypes of the disease, either based on their physiopathological characteristics<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> or trying to identify subgroups of risk so as to report clinical consequences.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> While awaiting this improved treatment individualization, only a minority will be able to benefit from any potentially curative surgical alternative after the diagnosis of OSA, such as bariatric surgery or ENT or maxillofacial interventions. The vast majority of patients are faced with a chronic problem, in which algorithms of therapeutic action have been proposed based on the number of apnoeas-hypopnoeas per hour, known as apnoea-hypopnea index (AHI), and the presence or absence of symptoms and cardiovascular comorbidity.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Based on the AHI, 3 OSA categories have been defined: mild (AHI 5–14.9), moderate (AHI 15–29.9) and severe (AHI<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>30). In general, in asymptomatic mild and moderate cases without significant cardiovascular comorbidity, the treatment consists in general measures such as weight loss, maintaining good sleep habits, avoiding alcohol and sedative medication and sleeping in the lateral decubitus position. In the most serious cases or with greater symptomatic impact, the standard treatment nowadays is the use of <span class="elsevierStyleItalic">continuous positive airway pressure</span> (CPAP) during sleep.</p><p id="par0020" class="elsevierStylePara elsevierViewall">CPAP has shown full effectiveness in the control of OSA and its clinical consequences, and hundreds of thousands of patients have benefited from its use in Spain. Its use has been favoured over more than 3 decades by technological improvements in the devices, by organizational changes in the sleep units with the development of specialized nursing consultation, by the progressive involvement of primary medicine and coverage by the National Health System. An adequate prescription and standardization of its indications and the subsequent monitoring of the patient result in correct long-term adherence, in percentages similar to those of other chronic treatments. However, between the initial rejections and the medium-long term withdrawals, approximately 30% of the patients with OSA using CPAP remain without treatment, with the consequent persistence of its clinical impact. This fact leads to the need to have alternatives to CPAP in the treatment of OSA.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Quality evidence has been obtained in recent years which point to mandibular advancement devices (MAD) as the most significant alternative, although its use in our environment is infrequent. Clinical practice guidelines have been published based on randomized controlled trials on the use of MAD,<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,9</span></a> one of them adapted to our healthcare environment,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> which will certainly result in a more frequent use of this treatment. In this article, we review the current situation in terms of MAD use as a therapeutic alternative in OSA.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Mandibular advancement devices: mechanism of action and types</span><p id="par0030" class="elsevierStylePara elsevierViewall">The mandibular protrusion produced by a MAD increases the size of the upper airway, especially in the velopharyngeal area.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> This fact leads to a decrease in its collapsibility, making it difficult to close during sleep. There are multiple models of MAD in the market, these can be grouped in:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0035" class="elsevierStylePara elsevierViewall">Individualized models, made to measure by a qualified professional from a mould of the patient's dental arches, and prefabricated models, adjusted to the patient's dental anatomy, usually after applying heat.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0040" class="elsevierStylePara elsevierViewall">Adjustable models, which allow to adjust the degree of mandibular advancement progressively, and non-adjustable, with a fixed degree of advancement after their manufacture.</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">Systematic reviews of the medical literature have shown that the efficacy of MAD, as well as the presence of side effects, depend on the degree of mandibular advancement and show significant interindividual differences. For these reasons, as well as for the lower efficacy associated with the prefabricated models according to the randomized controlled studies analyzed, clinical practice guidelines recommend the use of custom-made and adjustable MAD.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Efficacy and effectiveness of mandibular advancement devices</span><p id="par0050" class="elsevierStylePara elsevierViewall">We have solid evidence to support the efficacy of MAD after comparing it with the absence of treatment (a placebo MAD), uvulopalatopharyngoplasty or CPAP.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,9</span></a> Studies differ in the success criteria of the treatment, with the presence of a final AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>5 or <10 or a decrease in the initial AHI greater than 50% being the most frequent. Although this fact makes it difficult to compare the results obtained, in most studies, the use of MAD was associated with a substantial decrease, over 50% of the initial AHI, resulting in AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10 in 30–83% of cases. A particularly relevant fact is that the efficacy of treatment with MAD is present throughout the spectrum of severity of OSA, as shown by studies focused on patients with severe OSA.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11–17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">These success rates are lower than those achieved with CPAP, which is also more effective in correcting other polysomnographic alterations such as sleep fragmentation or decreases in arterial oxygen saturation. However, this lower efficacy with respect to CPAP does not seem to lead to a worse result in terms of the clinical consequences of OSA. Systematic reviews and meta-analyses show a similar effect on somnolence<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,9</span></a> or only slightly better with CPAP in cases with more severe somnolence.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> Similarly, the use of MAD is associated with a similar improvement in the quality of life<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,9,19</span></a> and in the control of blood pressure.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,9,20</span></a> As a limitation of these findings, it should be noted that the randomized controlled studies comparing the effects of CPAP treatment with MAD are of short duration, between 4 and 26 weeks.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The remarkable effectiveness of MAD treatment, despite its lower AHI normalization efficacy compared with CPAP, has been attributed to a better adherence to treatment. It is therefore feasible to think that the success achieved with a 100% reduction of apnoeas and hypopneas with CPAP during 4<span class="elsevierStyleHsp" style=""></span>h/night, the minimum limit usually required to consider a patient is showing proper treatment compliance, could be matched with a smaller percentage reduction, but using MAD for more hours each night. However, the claim of a better treatment compliance with MAD compared to CPAP is mainly based on studies in which the hours using MAD are self-reported by the patient, probably leading to its overvaluation. On the other hand, the greater use of MAD over CPAP does not seem so clear in cases of severe OSA.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> We do not currently have studies that adequately compare the long-term adherence to treatment with CPAP and MAD. The recent introduction of objective assessment systems for the use of MADs though thermosensitive sensors<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> can help to better understand their use patterns and propose action guidelines aimed at improving them, as is the case with CPAP. In any case, the available evidence supports that in the long term, patients who initially respond to treatment with MAD maintain the efficacy of the device.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Also, the long-term treatment discontinuation rate with MAD, around 35%,<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> is quite similar in routine clinical practice to that observed among patients to whom CPAP is prescribed.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Indications of treatment with mandibular advancement devices</span><p id="par0065" class="elsevierStylePara elsevierViewall">The available studies allow to establish the following indications of MAD in an adult patient diagnosed with OSA:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1.</span><p id="par0070" class="elsevierStylePara elsevierViewall">Patients who are candidates for treatment with CPAP but do not adapt to it, show poor compliance or rejection.</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">In the opinion of the authors, this is the main indication of this treatment modality. Several aspects must be stressed in connection with it. First, contrary to previous indications, MAD has shown its effectiveness in cases of severe or moderate OSA accompanied by somnolence. Second, pending further studies, CPAP remains the first therapeutic option in this type of patient and, before considering its failure in a particular patient, the adaptation attempt must be made by a sleep unit with extensive experience in its use, with the possibility of conventional graduation of the effective pressure and with specialized nursing consultation in the resolution of problems associated with its use. The possibility of achieving a good control of the disease with the combined use of CPAP or MAD has also been described, allowing the patient to choose the device according to his/her personal circumstances. Third, an ENT and a maxillofacial assessment are also necessary to identify surgical treatment alternatives.<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2.</span><p id="par0080" class="elsevierStylePara elsevierViewall">In patients with mild or moderate OSA, without indication of treatment with nasal CPAP or other alternative treatment, the use of a MAD can be considered.</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">Unlike patients with indication for treatment with CPAP, the benefits of treating this group of OSA patients are scarce and most of them can be treated using the general measures already discussed. However, in clinical practice it is common to find patients with minor symptoms (socially unacceptable snoring, occasional bad night's rest, little relevant somnolence, isolated nocturnal asphyxial episodes, etc.), which do not improve with these general measures and could benefit from using a MAD; in this context, this decision must be individualized and it is advisable that it be carried out by a medical expert in the treatment of patients with OSA. In a similar way to the previous recommendation, it is necessary to perform an ENT and Maxillofacial Surgery assessment if necessary, in order to detect anatomical alterations compatible with surgery.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Establishment of treatment with mandibular advancement devices: practical aspects and protocol of action</span><p id="par0090" class="elsevierStylePara elsevierViewall">Several points are essential if we want to transfer the efficacy of MAD to clinical practice:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">a)</span><p id="par0095" class="elsevierStylePara elsevierViewall">Correct choice of candidates: before making a MAD, the dentist must ensure that the patient meets a series of minimum conditions: sufficient number of teeth, good periodontal health, without significant occlusal problems or involvement of the temporomandibular joint. Also, the presence of bruxism or an excessive gag reflex can make treatment with MAD difficult. It is noteworthy that poor dental health, often associated with a worse socioeconomic status, has been identified as one of the limiting factors in the implementation of treatment with MAD in countries with an adequate public coverage of it.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">As already mentioned, treatment with MAD is not effective in all cases of OSA and one of the main challenges of this treatment modality is the absence of reliable methods that predict its success. Multiple predictive factors have been proposed: obesity, positional OSA, AHI, effective CPAP pressure, ultrasound techniques, spirometry characteristics, rhinomanometry, measurement of pressures in the upper airway during sleep, the characteristics of pharyngeal soft tissues or several cephalometric parameters. None of them allows a candidate to be reliably discarded from MAD.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">24,25</span></a> Among the most easily obtained parameters, it should be noted that the absence of morbid obesity and pharyngeal soft tissue hypertrophy, as well as the presence of OSA with a significant positional component, show a better response to treatment with MAD.<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">b)</span><p id="par0105" class="elsevierStylePara elsevierViewall">Titration of the device: different degrees of mandibular advancement affect the efficacy of MAD in the same patient.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> The objective is to achieve a mandibular protrusion adjustment that is comfortable and involves the resolution of OSA symptoms in the opinion of the patient and his/her partner. This may require several successive visits to the dentist. This phase usually lasts between 4 and 12 weeks. In most cases the final advancements range between 50 and 75% of the patient's maximum mandibular protrusion. Since the treatment is not always effective, its effects should always be examined through a new sleep study. One of the areas under research has to do with incorporating titration technology for the devices in the sleep units.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">c)</span><p id="par0110" class="elsevierStylePara elsevierViewall">Treatment of side effects: MAD are usually well tolerated, although most patients report mild and transient side effects during the first months: hypersalivation, dry mouth, dental pain upon awakening, muscle discomfort in the area of the masseter muscles or the temporomandibular joint and difficulty, in some cases, to obtain the usual occlusion in the morning, once the device is removed, which reverts easily in a few minutes. The occurrence of stable occlusal changes has been described in the long term, which have been associated with the discontinuation of treatment. These changes are usually considered to be less relevant than the benefit obtained with the treatment; however, the patient should be warned of their possibility and it is recommended to obtain radiographic, photographic and/or baseline models for proper assessment. Avoiding side effects is associated with better long-term treatment adherence and requires regular monitoring of the patient by the dentist.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a></p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">Taking all these aspects into account, the action protocol collected in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> is recommended. It is important to highlight the close collaboration between the sleep unit and the dentist, as well as the need to evaluate the effects of MAD with a new sleep study in all patients.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Problems for its introduction in Spain</span><p id="par0120" class="elsevierStylePara elsevierViewall">The treatment of OSA with MAD is widely reported in the countries around us. In Spain, several aspects, all interrelated, hinder its implementation and have led to a much lower use.<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1.</span><p id="par0125" class="elsevierStylePara elsevierViewall">The main limiting factor is the lack of treatment coverage by the National Health System. Only Cantabria has this possibility, with satisfactory results. Recent cost-effectiveness studies<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> and the extensive experience of European countries with this coverage support, in the opinion of the authors, its inclusion in the catalogue of health benefits, especially its indication in cases of CPAP intolerance. This fact would entail, as it happened in the case of CPAP, the adoption of protocols of action supported by evidence for the correct use in our patients and the official approval of MAD models, suitably validated, and with the appropriate durability warranty.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2.</span><p id="par0130" class="elsevierStylePara elsevierViewall">Sleep units do not usually incorporate the use of MAD as an alternative to their portfolio of services. The document <span class="elsevierStyleItalic">Sleep unit: standards and recommendations for quality and safety</span><a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> document, prepared by the Ministry of Health, includes the MAD within the benefits of the multidisciplinary sleep units, although with an optional character and without providing details about this benefit. However, the sleep unit accreditation processes promoted by the Spanish Society of Pneumology and Thoracic Surgery and by the Spanish Sleep Society, despite considering this activity as an indicator of quality, have shown a very limited use of this alternative therapy. A collateral consequence of this situation is the fact that the alternative treatment with MAD is little known by patients diagnosed with OSA. In this sense, it is necessary to insist on the need for studies on the treatment of OSA centred on the patient and that reflect their expectations and treatment preferences, an aspect little analyzed until now.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3.</span><p id="par0135" class="elsevierStylePara elsevierViewall">The limited connection between sleep units and odonto-stomatology in our health system. We need to look for ways to incorporate into our Sleep Units, as a member of the multidisciplinary team, a dentist with training in OSA and an expert in DAM design. Sleep medicine is recognized in other countries as a specific area of knowledge among these professionals. The recent implementation in our country of the accreditation of professionals in this area by the Spanish Accreditation Committee of Sleep Medicine is an excellent opportunity to correct the current situation.</p></li></ul></p><p id="par0140" class="elsevierStylePara elsevierViewall">In summary, OSA is a frequent entity, susceptible of chronic treatment, in which general measures to promote sleep quality and adequate control of comorbidities must play a key complementary role; however, the current guidelines for its approach leave a significant percentage of patients without treatment in clinical practice. For this reason, it is necessary to expand our therapeutic options and ideally move towards a personalized treatment based on the phenotypes of the disease. MADs currently have enough evidence to support their use in a standardized manner and are a valid alternative to consider across the spectrum of severity of OSA, especially in cases of CPAP non-adaptation or even in the form of combination treatments. Available studies recommend the use of custom-made and adjustable DAMs, as well as, since they are not effective in all patients, verify their effects by means of a sleep study. The introduction of this treatment is only possible if there is a close collaboration between dentists and Sleep Units.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interests</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Mandibular advancement devices: mechanism of action and types" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Efficacy and effectiveness of mandibular advancement devices" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Indications of treatment with mandibular advancement devices" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Establishment of treatment with mandibular advancement devices: practical aspects and protocol of action" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Problems for its introduction in Spain" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-24" "fechaAceptado" => "2017-11-15" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sampol Rubio G, Macías Escalada E, Montserrat Canal JM, Terán Santos J. Los dispositivos de avance mandibular en el tratamiento de la apnea obstructiva del sueño. Una opción necesaria y eficaz. Med Clin (Barc). 2018;151:34–38.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3235 "Ancho" => 2376 "Tamanyo" => 318191 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Guidelines for the establishment of treatment with mandibular advancement devices.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">OSA: obstructive sleep apnoea; MAD: mandibular advancement device.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Modified by the Working Group of the Spanish Clinical Practice Guidelines.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sleep apnea: types, mechanisms, and clinical cardiovascular consequences" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. 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