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In the present study, we tested the hypotheses that oral appliance therapy (i) reduces pharyngeal collapsibility preferentially in patients with posteriorly\u2010located tongue and (ii) is most efficacious (reduction in apnoea\u2010hypopnea index; AHI) in patients with a posteriorly\u2010located tongue and less\u2010severe baseline pharyngeal collapsibility. Twenty\u2010five OSA patients underwent upper airway endoscopy during natural sleep to assess tongue position (type I: vallecula entirely visible; type II: vallecula obscured; type III: vallecula and glottis obscured), as well as obstruction as a result of other pharyngeal structures (e.g. epiglottis). Additional sleep studies with and without oral appliance were performed to measure collapsibility (critical closing pressure; Pcrit) and assess treatment efficacy. Overall, oral appliance therapy reduced Pcrit by 3.9\u00a0\u00b1\u00a02.4\u00a0cmH<jats:sub>2<\/jats:sub>O (mean\u00a0\u00b1\u00a0SD) and AHI by 69\u00a0\u00b1\u00a019%. Therapy lowered Pcrit by an additional 2.7\u00a0\u00b1\u00a00.9\u00a0cmH<jats:sub>2<\/jats:sub>O in patients with posteriorly\u2010located tongue (types II and III) compared to those without (type I) (<jats:italic>P<\/jats:italic>\u00a0&lt;\u00a00.008). Posteriorly\u2010located tongue (<jats:italic>p<\/jats:italic>\u00a0=\u00a00.03) and lower collapsibility (<jats:italic>p<\/jats:italic>\u00a0=\u00a00.04) at baseline were significant determinants of (greater\u2010than\u2010average) treatment efficacy. Predicted responders (type II and III and Pcrit\u00a0&lt;\u00a01\u00a0cmH<jats:sub>2<\/jats:sub>O) exhibited a greater reduction in the AHI (83\u00a0\u00b1\u00a09 <jats:italic>vs<\/jats:italic>. 48\u00a0\u00b1\u00a08% baseline, <jats:italic>P<\/jats:italic>\u00a0&lt;\u00a00.001) and a lower treatment AHI (9\u00a0\u00b1\u00a06 <jats:italic>vs<\/jats:italic>. 32\u00a0\u00b1\u00a015 events\u00a0h<jats:sup>\u20131<\/jats:sup>, <jats:italic>P<\/jats:italic>\u00a0&lt;\u00a00.001) than predicted non\u2010responders. The site and severity of pharyngeal collapse combine to determine oral appliance efficacy. Specifically, patients with a posteriorly\u2010located tongue plus less\u2010severe collapsibility are the strongest candidates for oral appliance therapy.<\/jats:p><\/jats:sec>","DOI":"10.1113\/jp278164","type":"journal-article","created":{"date-parts":[[2019,9,10]],"date-time":"2019-09-10T12:44:38Z","timestamp":1568119478000},"page":"5399-5410","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":52,"title":["Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea"],"prefix":"10.1113","volume":"597","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1477-5459","authenticated-orcid":false,"given":"Melania","family":"Marques","sequence":"first","affiliation":[{"name":"Division of Sleep and Circadian Disorders Departments of Medicine and Neurology Brigham and Women's Hospital and Harvard Medical School  Boston MA USA"},{"name":"Laboratorio do sono Instituto do Coracao (InCor) Hospital das Clinicas HCFMUSP Faculdade de Medicina Universidade de Sao Paulo  Sao Paulo SP Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pedro R.","family":"Genta","sequence":"additional","affiliation":[{"name":"Laboratorio do sono Instituto do Coracao (InCor) Hospital das Clinicas HCFMUSP Faculdade de Medicina Universidade de Sao Paulo  Sao Paulo SP Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ali","family":"Azarbarzin","sequence":"additional","affiliation":[{"name":"Division of Sleep and Circadian Disorders Departments of Medicine and Neurology Brigham and Women's Hospital and Harvard Medical School  Boston MA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luigi","family":"Taranto\u2010Montemurro","sequence":"additional","affiliation":[{"name":"Division of Sleep and Circadian Disorders Departments of Medicine and Neurology Brigham and Women's Hospital and Harvard Medical School  Boston MA 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