ORAL APPLIANCES FOR SLEEP DISORDERED BREATHING
A SUMMARY REFERENCE GUIDE By Robert L. Horchover, DDS, PS
Appliance brands and designs have come and gone. Knowing their names is secondary to understanding their fundamental differences. This reference is intended to provide a general day-to-day guide.

LONG TERM APPLIANCES (LT)

Characteristics:

1. Requires 2-3 clinical appointments to complete and insert.
2. Requires accurate impression of upper and lower teeth.
3. Trained laboratory tech for custom shaping to mouth contours.
4. Made of internal elastomeric and external rigid, dense acrylic.
5. Can obtain accurately select desired starting jaw position.
6. Custom contours create less bulk and easy patient accommodation.
7. Incorporated metal components allow finer adjustment increments.
8. Dense material resistant to odors and stain.
9. Durability is 5-7 years.
10. Anterior, posterior, lateral and vertical adjustments.

Advantages:

1. Easier accommodation.
2. Multi-directional adjustments.
3. Smaller adjustment increments.
4. Tough and durable.
5. Snug fit.
6. Stain and odor resistant.
7. Covered by most insurance carriers.
8. High patient satisfaction.

* Silencer recently introduced the Silencer 2000 that allows lateral and vertical adjustments.

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Any device must be comfortable and easy to maintain to be effective. This includes artificial limbs, CPAP machines and oral appliances. I've yet to discover a pill or device that works for everyone. Qualifying the patient and selecting that which best meets their need provides the best assurance for success.

The historic "Gold Standard" is still the nCPAP (nasal Continuous Positive Air Pressure) machine. It is a sophisticated air pump with a hose that connects to a mask that is secured over the nose with elastic straps. The air is adjusted to your breathing frequency and the pressure required to displace the obstructing tissue so the air can pass into your lungs. It requires electricity. It is 100% effective for 60-70% of the population. 30-40% cannot tolerate CPAP for a number of valid reasons.

Oral appliances resemble an athletic guard, but have more sophisticated features that enable them to dilate your airway by supporting the lower jaw in a slightly forward position. I separate appliances into two broad types. The "passive" appliance provides no additional breathing assist. It allows you to breathe naturally either through your nose or mouth. There are now at least two oral appliances that connect to a CPAP when a nasal mask can't be tolerated, but the additional breathing assist is indicated. Adding the pressured air makes them "active" appliances. Oral appliances enjoy a much higher acceptance, but they also have limitations. There are trade-offs, but a detailed description is more useful when applied to a specific situation and need.

First generation oral appliances had limited success in treating OSA and earned a poor reputation in sleep disorder medicine. They were one-piece, held the jaws rigidly and were not adjustable. Technology, research and creative design have produced some two-piece adjustable appliances with high success rates. They allow a slight lateral jaw movement while holding the mandible in the prescribed forward and vertical position. This feature is critical for people who grind or clench their teeth at night or have histories of "TMJ" related problems.

With new materials and processing techniques they are smaller, stronger, and enable smaller adjustment increments. A single mm. can dilate the airway greater than that provided in a single nostril. Materials used to make long and short-term appliances are different. Long-term appliances are stronger, and more stain and odor resistant. They can last 5-7 years. They require impression accuracy more similar to that required for a crown or permanent bridge. They are a one-of-a-kind for each patient. A trained technician custom shapes them to be compact and harmonize with mouth contours. I schedule 2-3 appointments from start to first insertion plus adjustments. Short-term appliances are indicated when long term durability is secondary to obtaining a quick, cost effective appliance for short term wear or testing. These are often called "boil and bite" appliances. They consist of a "one-size-fits-all" rigid plastic u-shaped shell approximating the shape of the jaw. The material inside the shell becomes soft when placed in hot water. The heated material is pressed and adapted over the teeth before it reaches a firm, but slightly elastic state at mouth temperature. They are more bulky, less stable and retentive, and more difficult to accommodate to. They require about 70% less clinic time than a long-term appliance, and require no laboratory processing. They are more prone to stain and odor, and are more fragile. Their durability is measured in weeks or months rather than years. B&Bs are adjusted in "mega" increments. Long-term appliances have "mini" adjusted increments. This is important for long-term wear.