Oral Appliances and Combination Therapy




COAT: Continuous Open Airway Therapy

https://www.youtube.com/watch?v=nxPN_VOENxM





According to the Practice Parameters of the American Academy of Sleep Medicine, oral appliances are indicated for use in patients who have mild to moderate obstructive sleep apnea and who prefer them to CPAP therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP. Oral appliances increase airway size by moving the lower jaw, tongue and posterior soft tissues forward, preventing them from collapsing in the back of the throat and obstructing the airway. 

A definitive diagnosis by a certified sleep physician, along with a physician recommendation for OAT, is needed to initiate oral appliance therapy. Oral appliances should be fitted by a qualified dentist who is trained in dental sleep medicine and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated oral structures.

A follow-up sleep test (PSG or HST) is required to ensure treatment efficacy and may also be needed if symptoms worsen or re-occur. Although oral appliances have been shown to be as effective as CPAP therapy in reducing cardiovascular comorbidity in OSA patients [Van Haesendonck] and many patients prefer them to CPAP because of the smaller size and ease of wear, in some cases oral appliance therapy does not result in a full therapeutic response (even when snoring is improved), therefore it is critical to complete a follow-up sleep study in order to confirm the effectiveness of the treatment, and if necessary discuss alternative or adjunctive approaches with the sleep physician (Van Haesendonck, G., et al. "Cardiovascular benefits of oral appliance therapy in obstructive sleep apnea: a systematic review." Journal of Dental Sleep Medicine 2.1 (2015): 9-14 )

Using an over-the-counter appliance is not recommended, since the only way to identify the presence, type and severity of sleep apnea is a diagnostic sleep test and a full evaluation by the sleep physician - while the elimination of snoring alone may continue to mask apneas and significant oxygen desaturations which only a follow up sleep study can detect.


There are over a hundred types of oral appliances used to reposition the mandible and achieve mechanical stabilization of the airway.  Although the principle of action is essentially the same, variations in patients' skeletal and dental anatomy, soft tissue size, range of motion, dexterity and aesthetic preferences, as well as considerations such as grinding patterns and material sensitivity make every case selection process unique. 




APPLIANCES AND ADJUNCTS WE USE IN OUR PRACTICE


Somnomed appliances


We use both Somnodent Fusion (a dorsal fin design) and Herbst Advance for an increased protrusive range and exceptional comfort. Somnomed appliances come with a 3 year warranty and are  made with proprietary soft SMH BFlex lining that does not attract odors or delaminate. 

                                                       


Herbst appliances provide increased  tongue space and significant lateral and vertical freedom of movement, with an 8 mm protrusive range. They occupy less space than dorsal fin designs so are more suitable for patients with tight facial musculature. As with dorsal fin appliances, they can incorporate intermaxillary elastics to keep the jaw closed for increased efficacy, metal reinforcements for increased strength, an anterior opening for occasional mouth breathers and other functional features. 






Somnodent Fusion is a dorsal fin design that allows both 1mm and fine (.1mm) incremental titrations, for a total of 8.5mm. 

SomnoDent Fusion™ Demonstration Video:

https://www.youtube.com/watch?v=flQBrfyboE8







ResMed Narval


is a metal-free, biocompatible CAD-CAM appliance designed to be light, low-profile and flexible. 




Keller Clear Dream:  like the Somnodent Fusion, it has a dorsal fin mechanism, but no acrylic over the facial of upper anterior teeth for patients concerned about pressure on anterior crowns and veneers; the lingual surfaces are scalloped/contoured for patient comfort and additional tongue space. The manufacturing technology allows the lower arch with fin to be fabricated in one piece, greatly reducing the likelihood of fin breakage



 


The Herbst and Oasys Hinge appliances by Dream Systems Dental Lab are two other designs that we use in cases where we anticipate the need for Combination Therapy - using a removable bracket to attach the CPAP connection directly to the oral appliance, bypassing the need for facial masks and straps. Combination therapy is an option for patients who do not fully respond to mandibular advancement but can benefit from this mechanical opening of the airway by being able to reduce the pressure on the CPAP to tolerable levels (for more details on various combination therapies and adjunctive devices please see this article). 



 
  
Another form of Combination Therapy can incorporate the FDA-approved
Night Shift positional device along with an oral appliance


TAP 3 Elite - one of the most researched and effective appliances; a good choice for more severe apnea, patients who clench or where OAT/CPAP combination therapy may be required. 


                                                            


EMA -  one of the smallest profile appliances; metal free, for patients who are more aesthetically conscious, have limited mouth opening or require more lateral freedom of movement


 
Herbst designs, the Oasys Hinge appliance and the TAP 3 Elite are Medicare-approved. 



  
         
 A DentiTrac chip can be incorporated into oral appliances for treatment compliance reports, storing data up to 6 months - useful for DOT cases




Along with TMJ exercises, we include the AM Aligner with every case in order to gently guide the jaw back in its normal position every morning and minimize the risk of long term bite changes.






In addition to these devices, we use several temporary trial and titration appliances as needed, depending on the circumstances:

 
               MyTAP                                                                                                         ApneaRx
                                                                                                                           

                                                                       Apnea Guard