What Is a Mandibular Advancement Device (MAD)?

A mandibular advancement device (MAD) is a mouthpiece worn during sleep that holds the lower jaw (the mandible) slightly forward. Moving the jaw forward pulls the tongue forward with it and stiffens the soft tissue of the throat, which keeps the airway more open and reduces the vibration that causes snoring. MADs are the most widely used type of oral appliance for snoring, and custom, dentist-fitted versions are a recognized treatment for obstructive sleep apnea when prescribed after a diagnosis.

You will see the same idea under other names: mandibular repositioning device (MRD), mandibular advancement splint (MAS), mandibular advancement appliance, “oral appliance therapy” (OAT), or simply an anti-snoring mouthpiece or snoring mouthpiece. This guide explains how MADs work, the main types, what the research actually shows, side effects, who should not use one, and what they cost.

Key Takeaways

• A MAD holds the lower jaw forward during sleep to keep the upper airway from narrowing. It is the most common anti-snoring mouthpiece design.
• There are three broad types: ready-to-wear over-the-counter devices, boil-and-bite over-the-counter devices (many adjustable), and custom devices made by a dentist from impressions or scans.
• For simple snoring, U.S. sleep and dental-sleep societies support oral appliances. For obstructive sleep apnea, their guideline suggests a custom, titratable appliance fitted by a qualified dentist, after diagnosis by a sleep physician — not an over-the-counter mouthpiece.
• CPAP lowers breathing pauses more reliably than a MAD, but many people wear a MAD more consistently, and several studies find similar effects on daytime sleepiness and blood pressure.
• Common side effects are temporary jaw and tooth soreness and extra saliva. The main long-term risk is gradual bite change, which is why regular users should see a dentist periodically.

How a Mandibular Advancement Device Works

When you fall asleep, the muscles that hold your jaw, tongue and soft palate in place relax. Especially on your back, the lower jaw drops slightly backward and the base of the tongue drifts toward the back of the throat. The airway behind the tongue and soft palate narrows, airflow speeds up through the gap, and the floppy tissue vibrates — that is snoring. If the airway narrows enough to partly or fully close, breathing becomes shallow or stops for a few seconds: those are the hypopneas and apneas of obstructive sleep apnea (OSA).

A MAD has a tray for the upper teeth and a tray for the lower teeth, connected so the lower tray sits forward of where your jaw would naturally rest. Because the tongue and several throat muscles attach to the mandible, advancing the jaw:

• pulls the tongue base forward, away from the back of the throat;
• increases tension in the muscles and soft tissue around the airway, so they are less likely to collapse or vibrate;
• enlarges the airway space behind the soft palate and tongue.

How far forward is enough varies from person to person. Clinical reviews suggest that advancement should be adjusted in small steps — about 1 mm or less at a time — to the smallest setting that controls symptoms, since more advancement means more strain on the jaw. That is why adjustability (“titration”) is one of the most important differences between devices. For a broader overview of mouthpieces, see how snoring mouthpieces work.

Types of Mandibular Advancement Devices

Two other design details matter:

• One-piece (monobloc) vs two-piece (bibloc). One-piece devices fix the jaw in a single position. Two-piece devices have separate upper and lower trays linked by screws, straps, rods or a hinge, which usually allows adjustment and some mouth opening or side-to-side movement.
• Prefabricated vs custom. Reviews of the research describe prefabricated devices as bulkier with weaker retention, while custom devices tend to be more comfortable, offer a wider adjustment range and work better. Over-the-counter boil-and-bite devices sit in between.

MAD vs tongue-stabilizing device (TSD)

The other main type of anti-snoring mouthpiece doesn’t move the jaw at all. A tongue-stabilizing device (also called a tongue-retaining device) is a soft bulb that holds the tip of the tongue forward by suction. TSDs don’t depend on your teeth, so they can work for people with dentures, few teeth or jaw-joint problems, but many people find the tongue pull and drooling hard to get used to. MADs are more widely used and better studied. See TSD vs MAD and the best tongue-stabilizing devices.

Do Mandibular Advancement Devices Work?

For snoring

Yes, for many people. The 2015 clinical practice guideline from the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) recommends that sleep physicians prescribe oral appliances, rather than no therapy, for adults who want treatment for primary snoring (snoring without sleep apnea). Results vary by person: MADs tend to work best when snoring comes from the tongue and throat rather than the nose. They are less likely to help if your snoring is mainly caused by nasal blockage.

For obstructive sleep apnea

The same guideline makes several points about OSA:

• Oral appliances should be considered for adults with OSA who can’t tolerate CPAP or prefer an alternative — rather than no treatment.
• When a sleep physician prescribes one, a qualified dentist should use a custom, titratable appliance rather than a non-custom device.
• Patients should have follow-up sleep testing to confirm the appliance is working, and periodic visits with both the dentist and the sleep physician.

Longer-term data are encouraging but not perfect. In the French ORCADES study of patients who had refused or not tolerated CPAP, about half still met the study’s definition of treatment success (at least a 50% drop in breathing events) after five years with a custom MAD, and most patients wanted to keep using it.

MAD vs CPAP

CPAP (continuous positive airway pressure) remains the first-line treatment for moderate and severe OSA because it reduces the apnea-hypopnea index (AHI) and improves oxygen levels more reliably than an oral appliance. But a treatment only works on the nights you use it. Many people wear a MAD for more of the night than they wear a CPAP mask, and several studies have found similar improvements in daytime sleepiness, quality of life and blood pressure. In the CRESCENT trial in Singapore (220 adults with moderate-to-severe OSA and high cardiovascular risk), the MAD group’s 24-hour blood pressure fell slightly more than the CPAP group’s and met the trial’s non-inferiority test; the MAD group also wore their device longer each night. The decision between them belongs with your sleep doctor. More: sleep apnea mouthpiece vs CPAP and can snoring mouthpieces treat sleep apnea?

What predicts success

Research reviews list a number of factors associated with a better response to a MAD: younger age, female sex, lower body weight and smaller neck, a recessed lower or upper jaw, milder OSA, OSA that is worse on the back (positional), and a lower CPAP pressure requirement. Nasal obstruction is associated with poorer results. Above all, success depends on wearing the device every night at an effective setting.

Important: snoring is a common symptom of OSA. If you or your partner notice pauses in breathing, gasping or choking, heavy daytime sleepiness, morning headaches, or you have high blood pressure, see a doctor before relying on an over-the-counter mouthpiece. A MAD can make snoring quieter while apnea continues. Untreated OSA is linked to high blood pressure, heart disease, stroke, atrial fibrillation and type 2 diabetes.

FDA Status: Do You Need a Prescription?

In the U.S., intraoral devices for snoring and obstructive sleep apnea — including mandibular repositioning devices and tongue-retaining devices — are regulated as Class II medical devices (21 CFR 872.5570) and generally need FDA 510(k) clearance. What a device is cleared for decides how it’s sold:

• Over-the-counter MADs such as ZQuiet, SnoreRx and VitalSleep are cleared to reduce snoring in adults. You don’t need a prescription to buy them, and they are not cleared to treat sleep apnea.
• Devices cleared to treat OSA are prescription devices, typically custom-made and supplied by a dentist after a physician’s diagnosis.

When buying online, check that the brand states FDA clearance and look it up in the FDA’s 510(k) database. Cheap look-alikes on marketplaces often have no clearance at all.

Side Effects and Risks

Short-term (usually mild and temporary)

• Jaw muscle or jaw-joint (TMJ) soreness, especially in the morning
• Tender teeth, particularly the front teeth
• Excess saliva or, less often, dry mouth
• Gum irritation
• A “bite feels off” sensation for a few minutes to an hour after removing the device

These usually ease within the first weeks. Starting at a low advancement and increasing gradually helps, as does gently moving the jaw back into its normal bite after waking (some dentists provide a small morning repositioning splint). See jaw pain from a snoring mouthpiece and how to adjust a snoring mouthpiece.

Long-term

The main long-term risk is gradual bite change: over years of nightly use, the front teeth can tip, the overbite and overjet can reduce, and the back teeth may not meet as before. These changes tend to grow with years of use, are often not noticed by the wearer, and may not reverse. Long-term studies have found the changes are mainly dental rather than skeletal. This is the main reason the AASM/AADSM guideline recommends dental follow-up for oral appliance users. More: are snoring mouthpieces bad for teeth? and are snoring mouthpieces safe?

Who Should Not Use a MAD (Without Seeing a Dentist First)

• People with full dentures or too few healthy teeth to anchor the device (a TSD may be an option)
• Anyone with loose teeth, untreated cavities or active gum disease — these should be treated first
• People with existing jaw-joint (TMJ/TMD) pain or clicking, which advancement can aggravate
• People with braces or ongoing orthodontic work
• Children and teenagers (over-the-counter MADs are for adults)
• Anyone with suspected or diagnosed sleep apnea, or with central sleep apnea, which a MAD does not address — get medical guidance first

Full checklist: who should not use a snoring mouthpiece.

Choosing the Right MAD

1. Rule out sleep apnea first if you have any warning signs. If you are diagnosed with OSA, the right device is the one your sleep doctor and dentist choose — usually custom and titratable.
2. For simple snoring, prefer an adjustable device. Being able to start low and move forward in 1 mm steps is the single biggest factor in balancing results and comfort.
3. Pick a fit method you’ll actually use. Boil-and-bite gives a better grip; ready-to-wear is easier and often less bulky.
4. Check the size of the device against your mouth. Bulky trays are a common reason people give up — see mouthpieces for small mouths and the most comfortable snoring mouthpieces.
5. Buy from the maker or an authorized seller with FDA clearance and a money-back trial, so you can return it if it doesn’t suit you. See where to buy an anti-snoring mouthpiece.

Cost, insurance and lifespan

• Over-the-counter MADs typically cost between $50 and $150. Most last somewhere between a few months and a year or more, depending on the material and whether you grind your teeth.
• Custom dentist-made appliances often cost around $1,800 to $2,000 including the device and the fitting and follow-up visits, though quotes vary widely by region and practice. The separate sleep study is extra. Custom appliances are made of harder, more durable materials and generally last several years with dental check-ups.
• Insurance: medical insurance (including Medicare, under specific rules) may cover a custom oral appliance for diagnosed OSA when it is ordered by a physician and supplied by an enrolled dentist; prior authorization is often required. Over-the-counter snoring mouthpieces are generally not covered.

More: how long snoring mouthpieces last and how to clean a snoring mouthpiece (daily brushing with mild soap and cool or lukewarm water, air-drying, and a ventilated case go a long way).

Getting Started and Adjusting to a MAD

With a custom device, the process usually runs: diagnosis by a physician (often a home or in-lab sleep test), a dental exam to confirm your teeth, gums and jaw joints are healthy enough, impressions or scans, a fitting appointment, then several weeks of gradual adjustment by the dentist, followed by a repeat sleep test to confirm the setting works.

With an over-the-counter boil-and-bite device, you mold it at home following the maker’s instructions (step-by-step fitting guide). Whichever route you take:

• Start at the lowest advancement that reduces snoring, and wait several nights between adjustments.
• Expect a one-to-two-week adjustment period with some morning soreness and extra saliva.
• Record your snoring with an app or ask your partner, so you can judge changes objectively.
• Stop and see a dentist if pain persists, teeth loosen, or your bite stays off after the first hour of the morning.

Lifestyle measures — losing excess weight, avoiding alcohol and sedatives close to bedtime, treating nasal congestion and sleeping on your side — work alongside a MAD and can reduce how much advancement you need. Compare other non-mouthpiece options in mouthpieces vs nasal strips and mouthpiece vs chin strap.

FAQ

What does a mandibular advancement device do?

It holds your lower jaw slightly forward while you sleep. That pulls the tongue forward and tightens the tissues around the throat, keeping the airway more open so air moves through with less vibration (snoring) and fewer collapses (apneas).

Do mandibular advancement devices work?

For snoring, they help many people, and U.S. sleep medicine guidelines support oral appliances for adults with primary snoring. For obstructive sleep apnea, custom, adjustable MADs fitted by a dentist are an established alternative for people who can’t tolerate CPAP or prefer another option; they reduce breathing events less reliably than CPAP, but people often use them more consistently. Results vary, so follow-up testing is recommended for apnea.

Do I need a prescription for a mandibular advancement device?

Not for an over-the-counter device cleared to reduce snoring — those are sold directly to adults. Devices cleared to treat obstructive sleep apnea are prescription devices, usually custom-made by a dentist after a physician diagnoses OSA.

What are the side effects of a MAD?

Early on: jaw and tooth soreness, extra saliva or dry mouth, and gum irritation, which usually settle within weeks. Long term, nightly use can slowly change how your teeth meet. Regular dental check-ups catch this early.

Is a MAD the same as a mouthguard or night guard?

No. A sports mouthguard or a night guard for grinding protects the teeth but doesn’t move the jaw forward. A MAD is specifically built to advance the lower jaw, and it should not be assumed to protect against grinding unless the maker says so.

How long does it take to get used to a MAD?

Most people need one to two weeks. Starting at a low setting and adjusting gradually makes the transition much easier.

References

• Ramar K, et al. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. Journal of Clinical Sleep Medicine, 2015 (AASM/AADSM). https://pmc.ncbi.nlm.nih.gov/articles/PMC4481062/
• Vecchierini MF, et al. Mandibular advancement device use in obstructive sleep apnea: ORCADES study 5-year follow-up data. Journal of Clinical Sleep Medicine, 2021. https://pmc.ncbi.nlm.nih.gov/articles/PMC8656912/
• Pattipati M, et al. Continuous Positive Airway Pressure vs Mandibular Advancement Devices in the Treatment of Obstructive Sleep Apnea: An Updated Systematic Review and Meta-Analysis. Cureus, 2022. https://pmc.ncbi.nlm.nih.gov/articles/PMC8890605/
• Mandibular advancement device versus CPAP in lowering 24-hour blood pressure in patients with obstructive sleep apnoea and hypertension: the CRESCENT trial protocol. BMJ Open, 2023. https://bmjopen.bmj.com/content/13/5/e072853 (results summary: American College of Cardiology, 2024)
• Manetta IP, et al. Mandibular advancement devices in obstructive sleep apnea: an updated review. Sleep Science, 2022. https://pmc.ncbi.nlm.nih.gov/articles/PMC8906377/
• U.S. Food and Drug Administration. 21 CFR 872.5570 — Intraoral devices for snoring and intraoral devices for snoring and obstructive sleep apnea. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=872.5570

Related: TSD vs MAD · SnoreRx Plus review · VitalSleep review · ZQuiet review

Comments

• Snoring Mouthpiece Review May 10th, 2024
  

  A mandibular advancement device should keep your mouth from falling open while you sleep. This is why you should use a fitted device, which fits to your teeth.

• Thomas May 8th, 2024
  

  Will this devise work if your mouth falls open while sleeping?

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