But many patients find sleeping with a mouth guard less awkward or unpleasant than using a CPAP machine. The technical term for these appliances is mandibular advancement devices, so named because they work by pushing the lower jaw forward, which in most people helps keep the airway open. There are many variations of these gadgets available in drugstores, but a dentist can design a more effective personalized appliance, and modify or adjust it when necessary. The patients in the Laryngoscope study were all re-examined after the first fitting, and most needed adjustments over a two- to four-week period.
“We recommend a custom device made by a dentist,” Dr. Benjamin said. “And you should be retested to see how well it’s working. There’s subjective and objective improvement that should be tracked.”
But there are people for whom neither CPAP nor dental appliances work, either because they cannot use them consistently or correctly, or because the devices themselves do not solve the problem even when used properly. For these patients, there are various effective surgical procedures.
The most common is soft tissue surgery, which involves modifying or excising tissue at the back of the mouth. Depending on the structures and musculature of the mouth, the surgeon can trim the soft palate and the uvula, remove the tonsils, shrink tissues with a heated instrument, straighten a deviated septum, or alter the position of the tongue muscles, all with the aim of improving air flow.
There are also bone surgeries that move the jaw forward to make the entire breathing space larger, a procedure that can involve a protracted recovery period.
In 2014, the Food and Drug Administration approved a device called Inspire Upper Airway Stimulation. This is a small appliance implanted under the skin like a heart pacemaker. Using two electrical leads, it senses the breathing pattern and stimulates the nerve that controls the tongue to move it out of the way and allow air to pass freely. Implanting it is a day surgery procedure that takes about two hours.
“It doesn’t change the anatomy, and recovery is easier than with other surgeries,” said Dr. Maria V. Suurna, an associate professor of otolaryngology at Weill Cornell Medicine who specializes in surgery for sleep apnea. “It’s effective. It has the lowest complication rate of all the surgeries.