Oral Appliances

for
Obstructive Sleep Apnea
Mariona Mulet, DDS, MS
Diplomate, American Board Orofacial Pain
Associate Program Director, TMD / Orofacial Pain Graduate Studies, UofM
Orofacial Pain Dentist, HealthPartners Dental Group
[email protected]
 SHOULD I MAKE
AN ORAL APPLIANCE
FOR Mr. Jones?
TREATMENT OPTIONS
The gold standard is…

Continuous
Positive
Airway
Pressure
CPAP is more effective than oral
appliances in improving
objective parameters of obstructive
sleep apnea
ARE ORAL APPLIANCES (OA)
BETTER THAN
NO TREATMENT?
 …do no harm…
Full patient evaluation

Understanding of anatomy and physiology of

the masticatory system

Explain risks and benefits

 Outline
1. Sleep apnea definitions
2. Pathophysiology of Obstructive Sleep
Apnea (OSA)
3. Diagnosis of OSA
4. Treatment with Oral Appliances (OA)
a. Mechanisms of action of OA
b. Types of appliances
c. Side effects
d. Treatment protocol
 Outline
1. Sleep apnea definitions
2. Pathophysiology of Obstructive Sleep
Apnea (OSA)
3. Diagnosis of OSA
4. Treatment with Oral Appliances (OA)
a. Mechanisms of action of OA
b. Types of appliances
c. Side effects
d. Treatment protocol
 Sleep Disorders
Sleep Apnea

• Presence of 5 or more episodes of respiratory

interruption per hour of sleep lasting more than
10 seconds each and associated with loud snoring
and blood oxygen desaturation.
American Academy of Sleep Medicine

• 5% of all adults in western countries (Young 2003)

• Men > women
• In 20% of snorers.
 Types of Sleep Apnea

– Obstructive: absence of airflow despite breathing efforts

– Central: absence of airflow due to lack of breathing efforts

– Combination of both
 Severity of Sleep apnea
– Apnea: cessation of ventilation for 10 seconds or longer.
– Hypopnea: decreased airflow and oxygen desaturation of greater
than 4%.

– Apnea-Hypopnea Index (AHI): average number of apneas plus

hypopneas per hour of sleep.
– 5-15: mild
– 15-30: moderate
– >30: severe

– Saturation of Oxygen:
• >80%: mild
• 70-80%: moderate
• <70%: severe
Upper Airway Resistance Syndrome
(UARS)
• No actual cessation of airflow (apnea), nor
decrease in airflow (hypopnea), nor oxygen
desaturation.

• Increased effort to breath from upper airway

resistance causes arousals resulting in sleep
fragmentation, abnormal sleep architecture
and daytime somnolence and fatigue.
 Snoring

– Loud upper airway breathing sounds during

sleep without episodes of apnea or
hypoventilation.
International classification of sleep disorders

– Uvula drops back, causing narrowing of the

upper airway. Vibration of soft tissues causes
noise.
 Outline
1. Sleep apnea definitions
2. Pathophysiology of OSA
3. Diagnosis of OSA
4. Treatment with Oral Appliances (OA)
a. Mechanisms of action of OA
b. Types of appliances
c. Side effects
d. Treatment protocol
 Pathophysiology of OSA

• Anatomical dimensions upper airway

• Decreased upper airway dilator muscle

activity

Hudgel DH. The role of upper airway anatomy and physiology in

obstructive sleep apnea. Clinics in Chest Medicine 1992;13(3):
383-98
Anatomy of the Airway
 Mallampati Classification

Class I Class II Class III Class IV

One point increase OSA risk doubles

Nuckton TJ, et al. Sleep 2006
 Orofacial Anatomy - OSA
• Anatomical imbalances
• Retrognathic jaw
• Small maxilla
• Large tongue
• Long uvula and soft palate
• Large tonsilar tissues
Excessive soft tissue
expands to the
submandibular area

Cricomental space <1.5cm

Mallampati III or IV PPV 95%
Presence of overbite
Tsai WH et al, 2003. Am Respir Crit Care Med.
– Genioglossus – muscle activity
• largest upper airway dilator muscle

• Function is tongue protrusion

• Decreased activity causes narrowing and collapsibility

of the pharynx
 Consequences of OSA
• Hypertension (AHI >5)
• Increased risk of heart attack and stroke
• Diabetes
• Neuro-cognitive
– Sleepiness, altered memory and concentration, MVA
• Mortality (AHI >30 events/hr)
 Outline
1. Sleep apnea definitions
2. Pathophysiology of OSA
3. Diagnosis of OSA
4. Treatment with Oral Appliances (OA)
a. Mechanisms of action of OA
b. Types of appliances
c. Side effects
d. Treatment protocol
 Diagnosis

1. In-lab sleep study – Polysomnography

(PSG)

2. Portable monitors
 AASM Practice Parameters

Diagnosis of OSA
The presence of OSA must be determined by
polysomnography before initiating treatment with
OA ………..The severity must be established in
order to make an appropriate treatment decision.

American Academy of Sleep Medicine. Practice

parameters for the treatment of snoring and OSA with
oral appliance. Sleep 2006;29(2):240-3
ü Electro-encephalogram
ü Electro-cardiogram
ü Electro-oculogram
ü Chin electro-myogram
ü Airflow
ü Respiratory effort
ü Pulse oxymetry
ü Body position
ü Leg movement
Home sleep studies with
portable devices
• Cheaper
• “Real” sleep environment
• More limited data
• Unattended sleep
• Accuracy of data
• To test for OA efficacy
• Does not allow for titration of
CPAP or appliance
 Outline
1. Sleep apnea definitions
2. Pathophysiology of OSA
3. Diagnosis of OSA
4. Treatment with Oral Appliances (OA)
a. Mechanisms of action of OA
b. Types of appliances
c. Side effects
d. Treatment protocol
AASM Practice Parameters

OSA: Treatment objectives

Resolution of the clinical signs and symptoms
and normalization of the apnea-hypopnea index
and oxy-hemoglobin saturation

American Academy of Sleep Medicine. Practice

parameters for the treatment of snoring and OSA with oral
appliance. Sleep 2006;29(2):240-3
Treatment options
for
OSA
• Non-surgical
– Avoidance of risk factors / behavior modification
– Continuous Positive Airway Pressure (CPAP)
– Oral appliances

• Surgical
– Tracheostomy
– Uvuloplasty
– Uvulopalatopharyngoplasty (UPPP)
– Mandibular osteotomy with genioglossus advancement
– Maxillary/mandibular advancement
– Nasal reconstruction

• Genioglossus stimulation
ORAL APPLIANCES
The perfect should not get in
the way of the good

Oral Appliances are a good alternative:

– Snoring
– Mild-moderate OSA
– Upper airway resistance syndrome (UARS)
– Severe OSA

American Academy of Sleep Medicine. Practice parameters for the treatment of

snoring and OSA with oral appliance. Sleep 2006;29(2):240-3.
 How do
Oral Appliances
work?
Types of Appliances
How to choose?
Adjustable vs non-adjustable
– Adjustable superior to non-
adjustable
Verin et al 2006

– Custom-made OA superior
to “boil & bite” lowering AHI
Vanderveken et al, 2008
Non-adjustable appliances
“Monoblock”

• No Rx needed
• “Boil and bite”
• Lack of retention
Apnea Rx
• “Boil & bite”
• Needs Rx
• Non-custom design
• Adjustable
• Low cost
 EMA

• Thin acrylic (2 mm)

• Elastic connectors
• Good tongue space
APM positioner
• Thermoplastic acrylic
• Fixed position
• Vertical dimension is
not easily adjusted
• Moderate cost
Thornton Adjustable Positioner
(TAP III)
• Thermoplastic or
dual laminate
• One connector –
tongue space
• Inability to adjust for
lateral deviation
Herbst telescopic

• Allows vertical and

lateral movements
• Bruxism
• Medicare
SUAD
• Metallic frame
• Jaw movement - bruxism
• Unlimited mandibular
advancement
• Adjustment of VD
• Expensive
• Meticulous patient
SomnoMed
• Flex or hard acrylic
• Not thermoplastic
• Mouth opening
• Elastics
• Metallic frame
• Adjustment VD
• Expensive
Dynaflex Dorsal
• Comfort fit or hard
• Accu-Fit
• Cheaper
Dynaflex Dorsal

• Reverse fin
• Mouth stays closed
Narval
• Minimal bulk
• Light weight
• Expensive
• No pressure on
incisors
• Jaw movement
Know the functional characteristics
as well as the design of different
types of oral appliances
How to choose an appliance
• Patient comfort
• Retention on dental arches
• Easiness to manipulate
• Thickness/bulkiness of materials
• Allergies to materials
• Position of connectors
• State of dentition
How to choose an appliance

• Mandibular freedom of movement

• Amount of mandibular advancement
• Ability to alter vertical dimension
• Resistance to forces of bruxism
• Durability
• Easiness to repair, chairside or lab, timing
• FDA approval
• Cost
 Side Effects
of
Oral Appliances
 Side Effects
1. Excessive saliva
2. Dry mouth
3. Pain
– New onset of jaw pain
– Worsening of existing TMD
– Pressure on teeth or gingiva
– Mechanical irritation of the soft tissues
4. Bite changes
 Side Effects
1. Excessive saliva
2. Dry mouth
3. Pain
– New onset of jaw pain
– Worsening of existing TMD
– Pressure on teeth or gingiva
– Mechanical irritation of the soft tissues
4. Bite changes
Micro-trauma to the masticatory system:

repetitive low threshold input to the

system
 Pathophysiology
• Muscle and soft tissue length is changed

• Mandibular condyle is anteriorly displaced

• Changes in TMJ intraarticular pressure

 Common TMD symptoms

• Jaw muscle tenderness or pain

• Joint pain (capsulitis/arthralgia)
• Joint noise (clicking, grinding)
• Temporal headache
• Incidence: 10-20%
• Transitory
• Can interfere with use of OA
• Most frequent at beginning of treatment
• Mandibular exercises help decrease TMD side
effects
Perez et al 2013, Stetenga 2011,
Martinez 2010, Oliveira 2009, Cunali 2011
 Side Effects
1. Excessive saliva
2. Dry mouth
3. Pain
4. Bite changes
– Neuromuscular adaptation
– Dental movement
– Skeletal changes
 Neuromuscular adaptation
• Anterior mandibular (condylar) shifting
• Contracture of lateral pterygoid muscles

• Perceived as difficulty to bite normally

• Can occur in early stages of tx
• Can be permanent
 Dental Movement
• Anterior teeth:
– Lingual tipping of upper incisors
– Buccal tipping of lower incisors
• Posterior teeth:
– Mesial tipping of lower teeth
– Distal tipping of upper teeth

Decreased overjet and overbite

Posterior open bite
Almeida 2006
 Skeletal Changes

• Increase in lower facial height

• Downward rotation of the mandible without
forward displacement
 Bite changes

• Mild to severe
• Irreversible
• May require specific txs
• Incidence progressively increases with
time OA is used
 James 51 y.o.
• Initial evaluation 9/2011, interested in new OA
• Dx of OSA 2006 – AHI 13, lowest O2 sat 86%
• Failed CPAP
• Used Tap III for 3-4 years. It broke. Kept using
it.
• All sx resolved right away. No retest.
• Tried OTC appliance after that
• Exam in 2011
– Malocclusion – only contacts on CI.
• OJ = 0 mm
• OB = 0 mm.
• Vertical post open bite of 3 mm.

• New oral appliance 2011, 2 follow up

apps in 2011, didn’t return until fall
2014.
 Gregory 65 y.o.
• Initial evaluation only – Fall 2014
• Referred by DDS – bite change
• Progressive, 1-2 years
• OA for 10 years, for severe OSA
• No re-test, perceives benefit
• “Wife hated CPAP”
Assessment and Tx recommendations
• Malocclusion
• Severe OSA per pt’s report

• Restorative tx
• Possibility of relapse if OA use again
• CPAP
• Jaw exercises
• New adjustable OA
• Need to follow up with sleep MD to re-test
 Lynn 45 y.o.
• Initial visit 10/1/2013
• Mild OSA dx 6/2013. AHI = 5.9
• Unable to use CPAP
• Dental Exam:
– 11 congenitally missing teeth
– Crossbite 1M bilaterally. OJ and OB 1 mm.
– Solid contacts on shimstock on ALL teeth
• OA delivered 11/5/2013
• 1st follow up – 11/26/2013
– Improved sleep, some snoring
– No complications
– Jaw further advanced
• 2nd follow up – 12/18/2013
– Snoring controlled
– No complications
– Exam: no changes in occlusion
– Contacted sleep MD – no re-test needed
• 3rd follow up 12/2/2014
– Daily use of OA, effective controlling sx.
– Reports no bite changes, no side effects

– Exam: only contacts C to C. 2 blue papers

between posterior teeth
Lynne
Monica
 Todd 38 yo
• Initial evaluation 5/2013
• PSG 2013; 221 lb; 5’8”; AHI 9
• Epworth score: 17/24
• Exam:
– Occlusion on CI only. 0 mm OJ & OB
Bite before
treatment
 Tammy 44 y.o.
• Initial evaluation: 09/03/2014
• CC: Bite changes – increased overbite
Jaw pain
Jaw clicking
Limited mouth opening
• Medical history
– Chronic pain – neck, low back, leg
– Diabetes type 2
– Moderate sleep apnea (AHI 22), not using CPAP
– Psychosis, depression, general anxiety
– Hx of TMJ surgery: 2001, bilateral open joint sg,
disquectomy
• Exam:
– 35 mm max opening
– Tenderness to palpation – all jaw and neck
muscles and B-TMJs
– Occlusion:
• Class II OJ = 9 mm; OB = 5 mm
• TMD Diagnoses:
– Myofascial pain syndrome
– TMJ arthralgia
– B-TMJ degenerative joint disease
– limited mouth opening

• Tx plan:
– Education and self care for TMD
– Physical Therapy
– Possible OA for OSA
• Follow up 11/12/2014:
• Tx outcome:
– Improved mouth opening: 39 mm
– Decreased jaw and neck pain
– Confirmed by PE
– Referral from sleep MD to proceed with OA

– Dental impressions and bite registration taken

• OA insertion 11/7/2014
• Follow up 12/10/2014
– Used OA for 3 days, improved sleep but
developed headaches that lasted 1.5 weeks.
Continued PT and HEP – with significant benefit.
– Total days used OA – 8
• Follow up 1/6/2015
– Used OA consistently, improved sleep but still
snoring, gasping for air
– No jaw pain, no headaches
– “Ready to advance lower jaw forward”
9/11 mm of total range
 Sara 52 y.o.
• PSG 2/2014 – AHI 8.1
• Small arches
• Large tongue
• Somnomed flex – would choke on her
tongue as soon as she fell asleep
• Modification to lingual-less OA
lingual-less
Clinical Protocol
 Clinical Protocol
1. Initial appointment
• Diagnosis of OSA
• TMD assessment
• Occlusion
• Protrusion capacity
• Occlusal stability
• Potential for bite changes
• Dental state
• Oral hygiene, dental pathology
• Periodontal disease
• Edentulism
• Informed consent
 Clinical Protocol
2. Appliance fitting
1. Monitor occlusion
2. Adjustments
3. Use and care
4. Explanation of side effects
5. Jaw exercises / reset bite
6. Self care measures for TMD
 Clinical Protocol
3. Follow up with Dentist
1. Periodically until optimal fit is obtained and
efficacy shown subjectively.
2. Then, every 6 months for the 1st year.
3. Annually thereafter.

American Academy of Sleep Medicine. Practice

parameters for the treatment of snoring and OSA with oral
appliance. Sleep 2006;29(2):240-3.
Follow up with Dentist – what to control for:
1. Patient satisfaction
2. Adherence to treatment
3. Weight changes
4. Sleep changes – time, patterns
5. General health, other diagnoses
6. Appliance fit
7. Integrity of the appliance
8. Occlusion – bite changes
9. Muscles and joints
10. Oral health
 Clinical Protocol

4. Follow up with Physician

1. Sleep study with OA in place after final
adjustments performed
2. OA titration in PSG study
3. Home monitoring sleep study (HST)
In Conclusion…
 The dentist’s role…
• Recognize that sleep apnea is a medical
condition and life threatening disorder

• Work in coordination with sleep physician

• To monitor the benefit of OAs and to

manage potential adverse effects
 Benefits of OA
• Simplicity of treatment
• Convenient, portable, quiet
• Minimally invasive
• Much better tolerated than CPAP
• Good alternate tx for those unable to
tolerate CPAP
 Limitations of OA
• CPAP is better at reducing AHI
• Frequent occlusal changes
• Can take weeks/months to be effective
• Depends on dental state and ability to
protrude the jaw
 OA or CPAP
• No strong data as to which patients
would benefit most from each treatment

• Limited number of tx options

• Remember OA and CPAP can be used

together!
THANK YOU