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 several 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:
The SomnoMed MAS™ is an oral appliance, which fits over the upper and lower teeth, much like a sports mouthguard. Unlike a sports mouthguard, however, it is a precision-made, clinically-tested medical device, which is highly effective (in most cases) in preventing snoring and mild to moderate obstructive sleep apnea.
The medical term for your lower jaw is 'mandible' and an oral appliance worn over the teeth is a 'splint', hence the name SomnoMed Mandibular Advancement Splint, or SomnoMed MAS™.
ResMed’s Narval™ CC is engineered to offer patients greater comfort than ever before to help them adhere to therapy. A mandibular repositioning device (MRD) that’s designed specifically for the treatment of adult obstructive sleep apnea (OSA), Narval CC uses an optimized articulation method that maintains the mandible in an advanced position, along the occlusal plane to providing superior patient comfort while enabling effective treatment. It is manufactured with a 3D printing process.
The MicrO 2 is designed to be the smallest and most comfortable custom-made jaw advancement device available. It is intended to offer the most tongue space, as well as the ability to open and close during wear. The MicrO 2 device holds the lower jaw in a slightly forward position, thus gently moving the throat tissues away from the back of the throat. This opens the way for airflow and helps reduce snoring and Obstructive Sleep Apnea. The MicrO 2 devices are very easy to use and to care for. They do not require any mechanical adjustments, like turning screws with keys or screwdrivers, or changing positions with elastics. And they don’t require any difficult handling or maintenance instructions.
MicrO 2 device is custom made to uniquely fit each individual that it is fabricated for. The device comes in two parts. One device fits over the upper teeth and one over the lower teeth. The device will also have a series of additional Upper or Lower devices; each one made to position the lower jaw to the most effective position. There are no confusing mechanisms to adjust on the actual device. Jaw advancements can be easily achieved by simply removing the current Upper or Lower device and inserting the next Upper or Lower device in the MicrO 2 advancing series
Herbst Advance hard/soft plastic appliance This is a hard plastic appliance with a soft liner which has the adjustment hardware set on the cheek side of the molar teeth. It prevents side-to-side motion, but since the bottom jaw is held closed with small orthodontic rubber bands, opening the jaws is fairly easy. The modified Herbst is smaller than most appliances and has a long life span. It allows jaw movement in all directions but backwards. The patient can take medications, use an asthma inhaler or talk with this appliance in place. This appliance can be fabricated out of material that has no methylmethacrylate and is thus safe for patients who are allergic to this material.The modified Herbst is one of the 'yardsticks' used by other appliances seeking FDA acceptance and is approved by Medicare and Blue Cross of Mass.. Patients who severely grind their teeth at night can crack this appliance.
E.M.A. appliance The E.M.A. is the thinnest and least bulky of all the appliances. It is similar to clear acrylic orthodontic retainers, and the 'hardware' (located to the cheek side of the molar teeth) consists of specially designed, patented elastic bands. This appliance moves the jaw forward in fairly significant steps, which may be difficult to tolerate. Some care must be taken to avoid breaking the lower portion when replacing the custom elastics. The EMA is well tolerated by patients who grind their teeth. It has no metal and can be used by patients with a nickel metal allergy.
The TAP 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.
Tongue Retaining Device
The Tongue Retaining Appliance 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 Somnomed, Herbst, Narval, MicrO2, TAPand 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:
- Tension in the jaw.
- Sore teeth or gums.
- Excessive salivation or a dry mouth.
- Temporary change in the bite (when appliance is removed in the morning).
- Noises in the jaw joint (TMJ).
- The potential side effects that can be more problematic include:
- Jaw muscle or joint pain.
- Permanent changes in the bite.
- Slight movement of teeth.
- Loosening of dental restorations (crowns, bridges, etc.).
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)