An oral appliance is a small acrylic device that fits over the upper and lower teeth or tongue (similar to an orthodontic retainer or mouth guard). This device slightly advances the lower jaw or tongue, which moves the base of the tongue forward and opens the airway. This improves breathing and reduces snoring and apnea. The appliance is fabricated and customized for each patient by a dentist experienced in the treatment of snoring and sleep apnea. The appliances are comfortable and well tolerated by the patients. They are easy to place and remove, easy to clean and are convenient for travel.

Types of Oral Appliances

The two main categories of oral appliances currently in use are the mandibular advancement devices (MAD) and the tongue retaining devices (TRD).

The mandibular advancement devices are custom-made for each patient. The device is made of a special heat-sensitive acrylic material that will fit snugly, but comfortably over the upper and lower teeth and it will hold the lower jaw slightly forward. This will advance the tongue and soft tissues of the throat to open the airway and restore normal breathing during sleep. The MADs have an adjustment mechanism built into the device that allows the patient to gradually change the position of the bottom jaw under the dentist's supervision to improve the effectiveness of the device. Since the appropriate jaw position to achieve success with treatment is unique to each patient this is a very valuable feature.

The tongue retaining device is custom-made using a softer, pliable material with a compartment that fits around the tongue to hold it forward by means of suction. This device is used most for patients with dentures or patients who cannot adequately advance their lower jaw. The patient must be able to breathe well through their nose or they may have difficulty tolerating this appliance.

Appliances Used in Our Office

We use six different oral appliances in our office. The choice of which appliance will be used for each patient is based on many factors. These factors include severity of the apnea condition, patient's bite and jaw structure, size of the tongue and soft palate, presence of tooth clenching or grinding, jaw range of motion, health of teeth and gums, and many others. We will use our experience and expertise to help guide the patient to using the appliance that will be most comfortable and effective for that individual's situation. We have used many different appliances over the past several years, but currently we use:

Adjustable PM Positioner is a custom-made appliance constructed of a heat-sensitive acrylic that fits over the upper and lower teeth. The appliance is comfortable on the teeth and leaves added space for the tongue compared to other devices. It allows a small amount of jaw movement (4mm) so that the patient does not feel "locked into position". The adjustment mechanisms are on the cheek side of the appliance near the molars and allows for easy advancement of the jaw position to improve effectiveness of the device when it is indicated. This appliance is used most frequently in our office because of its ease of use, effectiveness and durability.

A rotating view of this appliance is available by clicking the image to the left. (Animation may take a few seconds to load - please be patient.)

TAP Plus is also a custom-made appliance that is made of a heat-sensitive acrylic that has a separate upper and lower portion that is connected in the front of the device by a hook and bar assembly. This device is comfortable on the teeth and allows good freedom of movement of the jaw. Therefore it is used frequently for patients who tend to grind their teeth heavily. Since the position of the jaw can be adjusted while the appliance is in place, it is also used for patients who have a certain jaw structure that would require that feature. As mentioned the front assembly is located near the tip of the tongue and it protrudes between the lips, so it may take a little bit more time to adapt to the device. However, most patients find it to be comfortable within the first 5-10 days.

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Tongue Retaining Device (TRD) is a custom-made appliance made of a soft, pliable material that has a compartment in which the tongue is held in place by means of suction. This appliance is most frequently used for patients who have very few or no teeth. The TRD may require some time for the patient to adapt to having their tongue held in place, so a tongue exercise and adaptation program is started a few weeks prior to the date of insertion of the device. This appliance may be difficult to tolerate if the patient has trouble breathing through their nose.

Silent Nite, SnoreAid and Therasnore are other appliances currently used in the office. The Silent Nite is a smaller appliance that is very comfortable to wear and can be effective for patients who are primarily snorers or have very mild apnea. However it is less durable and has much less adjustability. The SnoreAid and Therasnore appliances can be fitted the day of the appointment, which is a great option for patients who need the appliance immediately (if they are leaving on vacation the next day, etc.). However these devices are much less durable and the Therasnore is bulky compare to other appliances.

The Adjustable PM Positioner , TAP Plus and Tongue Retaining Device are all FDA accepted for snoring and sleep apnea. The Silent Nite, SnoreAid and the Therasnore are FDA accepted for snoring only.

Effectiveness of Oral Appliances

Research evidence shows that oral appliances are effective in treating snoring in 85-90% of the patients. The mandibular advancement devices are effective in normalizing the apnea levels in 75% of the patients with mild sleep apnea (5-20 events/hr.), 60% effective for patients with moderate sleep apnea (20-40- events/hr.) and 40% effective for patients with severe sleep apnea (more than 40 events/hr.). Patients with moderate or severe sleep apnea must have a follow-up sleep study, while using the oral appliance to confirm the effectiveness of the device and a consultation with the sleep medicine physician to discuss the results.

Indications for Oral Appliance Therapy

The American Academy of Sleep Medicine has stated that oral appliance is indicated as a first treatment of choice for patients with primary snoring and/or mild obstructive sleep apnea and as a second treatment option for patients with moderate or severe sleep apnea who cannot tolerate CPAP and/or are not good candidates for surgery.
Therefore, oral appliance therapy is indicated for:
" Primary/heavy snoring
" Mild or moderate sleep apnea
" Poor tolerance of nasal CPAP
" Failure of surgery
" Use during travel
" In combination with nasal CPAP

Possible Side Effects of Oral Appliance Therapy

There are a number of temporary side effects that may be noticeable during the first few weeks or may require minor adjustment of the appliance by the dentist. These include:

The potential side effects that can be more problematic include:

From the research evidence and our clinical experience, jaw muscle and joint pain occur in approximately 10% of the patients and the pain will disappear when the patient discontinues use of the appliance. However, the pain can recur for these patients when they start wearing the appliance again. Changes in the bite can occur for about 20% of the patients. Although the changes may be slight it may still be difficult for the patient to close their back teeth together and this may have an effect on their ability to chew effectively. The slight movement of teeth and loosening of dental restorations occurs very infrequently (1% of the patients) but is still worth noting.

(Some images courtesy of www.quietsleep.com)