Our Sleep Apnea dentists use a variety of sleep apnea oral appliances that are custom-fitted to help the patient sleep soundly and minimize the effects of sleep apnea, such as snoring. These FDA-approved devices essentially treat Obstructive Sleep Apnea by preventing airway obstruction and allowing the patient to breathe easily and continuously. Worn in the mouth like an orthodontic appliance during sleep, oral appliances keep the soft tissue from collapsing and interrupting normal breathing patterns.
The purpose of the oral appliance may be to reposition the lower jaw, tongue, soft palate, and hyoid bone into a certain position, to keep the airway open with stabilization of the tongue and jaw, or to provide artificial muscle tone to prevent collapse and resulting airway blockage. The doctors will fit your oral appliance for comfort by using a mold of your mouth to design your unique fit.After a complete diagnosis, they will recommend an oral appliance if needed, and let you know which brand will work best for you.
Oral appliances may be used in conjunction with other apnea treatments. Listed below are common FDA-approved oral appliances accepted for snoring and Obstructive Sleep Apnea: Thornton Adjustable Positioner (TAP)Most Effective for Severe ApneaThe TAP 1 diagnosis appliance is the only appliance that can be titrated in the sleep lab while the patient is asleep. The Thornton Adjustable Positioner uses the principle of cardiopulmonary resuscitation to keep the airway open in order to help patients maintain proper breathing techniques.
Oxygen is allowed to flow adequately into the airway with the help of a device that holds the lower jaw forward to prevent collapse of the airway and eliminate instances of breathing cessation. With improved breathing, patients are able to get a good night's rest and give their partners a chance to sleep with decreased snoring. The TAP device is comfortable and adjustable to fit patients' unique size and shape mouths.
MicrO2MicrO2 is an easy-to-use and comfortable device that safely alleviates snoring and symptoms of Obstructive Sleep Apnea. If a patient has been diagnosed with Obstructive Sleep Apnea or snores, the MicrO2 lower jaw advancement device will assist him/her in waking with a better sense of rest and provide the energy needed to enjoy the day. The MicrO2 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 MicrO2 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. Only a dentist can provide MicrO2. Specially trained dentists play a key role in screening for Obstructive Sleep Apnea.
Then, partnering with medical doctors, the MicrO2 is provided to treat those suffering from Obstructive Sleep Apnea as well as individuals needing an alternative therapy to CPAP. SomnoMed MAS - Dorsal Fin ApplianceThe SomnoMed MAS - Dorsal Fin Appliance is a custom-made device, consisting of upper and lower dental plates with a unique patented fin-coupling component, which allows normal mouth opening and closing.
If required, a part can be added to make the device adjustable. This feature provides incremental and adjustable levels of lower jaw advancement, which improves the effectiveness and comfort-level of treatment as the jaw is moved only as far as is required to alleviate snoring and reduce OSA. Key features and benefits of the device include: Permits normal mouth opening Allows speech and drinking Provides full lip-seal Easily adjustable Safe and effective Clinically proven Custom-fitted Additionally, the SomnoMed MAS - Dorsal Fin appliance is made from durable fade-proof acrylic that retains its shape and color for at least four-five years and is covered by a three year manufacturer's warranty.
Respire - Dorsal Fin ApplianceThe Respire Blue Series is a custom made oral sleep device. It is composed of an upper and a lower component, which are not connected in any way, allowing the jaw to open and close naturally. The dorsal fin holds the jaw in a forward position preventing it from falling back and the airway collapsing. The Respire also has an anterior opening which allows the patient to breathe through their mouth, in turn providing extra patient comfort.
The advancement screw enables the doctor or patient to protrude the jaw at ź mm increments at a time, with a total advancement of 5.5 mm from the starting position. This device can be made with an acrylic fitting surface or a soft dual-laminate material. The Respire oral sleep appliance comes standard with a 1 year manufacturers warranty. The SUAD™ Device:The SUAD™ Device is a premium dental sleep appliance for the effective treatment of snoring and all levels of obstructive sleep apnea.
It is safe, effective, and FDA cleared to market for both health issues. The SUAD™ Device functions by slightly moving the lower jaw (mandible) in a comfortable, forward position to maintain an open airway. It is the only dental sleep appliance specifically engineered to withstand the forces of bruxism and its patented casted framework substructure helps minimize the potential of actual tooth movement.
The SUAD™ Device is custom-made giving the patient an effortless, comfortable fit, without impinging on tongue space. It is also non-restrictive in movement allowing the patient to fully open and close their mouth, speak clearly, yawn, and take oral medication while wearing the appliance. The SUAD™ Device is unlimited in protrusive advancement and easily adjusted by adding additional nylon-type or metal advancement spacers.
The SUAD™ Device is truly setting the standard in choices by being the only appliance that gives practitioners numerous design choice options including base material selection and choice of occlusal contact. Each SUAD™ Device fabricated comes with a two-year limited warranty on its metal components, including the framework, not just for manufacturer’s defects but also for accidental breakage by the patient.
The Temporary SUAD™ Appliance (TSA):The Temporary SUAD™ Appliance (TSA) is a temporary dental sleep appliance designed to mimic the functionality and performance of the renowned SUAD™ Device. The TSA is safe, effective, and FDA cleared to market for snoring and sleep apnea. It functions in the same manner as a premium appliance by comfortably positioning the lower jaw forward to maintain an open airway.
Unlike many other temporary appliances on the market, the TSA is not a boil-and-bite nor is it a chair-side fit appliance. Rather, the TSA is custom fabricated in our state-of-the-art laboratory using impressions of the patient’s teeth. The TSA requires minimal time for fabrication, making it an ideal real-time treatment option. The TSA serves many purposes including being a trial appliance for first-time patients seeking an affordable way to assess their compliance to oral appliance therapy.
It also offers continuity of treatment for current appliance wearers should they happen to damage or lose their premium appliance. The compact size and convenience of the TSA makes it an ideal back-up appliance for CPAP users as they no longer have to carry excess baggage or search for electrical outlets while travelling. The TSA also acts as a means of obtaining a bite registration when the patient decides to pursue treatment with a premium appliance.
Herbst Telescopic ApplianceThe Herbst Appliance has been proven to be effective on chronic snoring and mild to moderate obstructive sleep apnea sufferers. This appliance allows patients to move laterally and vertically without disengaging the appliance. Also, if it is determined that the initial position does not provide the anticipated relief of the condition, the mandible can easily be moved forward by two options of adjustability.
The first option is traditional hardware with sets of 1,2 and 3 mm shims for advancing those increments only. The second being the Telescopic version allowing the clinician to advance in ¼ mm increments by making one full turn of the protrusion collar up to 6-8mm from the start position. The appliance can be fabricated from hard acrylic, thermoactive and soft materials and is tooth retained via friction grip or clasps.
Quali-Som's TheraSom CastThe TheraSom Cast is: A small mouth piece designed to treat sleep disordered breathing. It's comfortable, fits entirely in a pocket and requires no electricity. The TheraSom Cast works by bringing your lower jaw gently forward allowing more tongue space thus increasing the opening of the airway at the back of the throat. Tongue Retaining Device (TRD)The TRD is lab constructed of a flexible polyvinyl material adapted to the general contours of the teeth and dental arches.
It does not depend on teeth for retention. Rather, the tongue is held forward by the negative pressure created in the vacuum bulb on the front of the appliance. The TRD is made by Kelly Doyle at KDNIGHT Appliances. I worked with Kelly back in the early 1980's when I was doing research on jaw position and sleep apnea as a Visiting Assistant Professor at Rush Medical School in Chicago. Kelly worked with Dr.
Charles (Charlie) Samuelson and Dr. Rosalind Cartwright to develop an alternative to the boil and bite TRD. I am frequently asked for contact information for Kelly and he has given me permission to put it on this site. Phone (262) 638-8353. The TRD is the only custom fit Tounge Retaining Device Available. Narval CC The Narval CC is a new version of a mandibular repositioning device (MRD) created uniquely for the treatment of obstructive sleep apnea (OSA).
The patented Optimized Retention of the Mandible (ORM) articulation keeps the mandible in an forward position leading to an effective treatment solution. Computer-aided design (CAD) allows for a high degree of customization to fit the complex dental anatomy of each patient Computer-aided manufacturing (CAM) using selective laser sintering of a biocompatible polymer material guarantees consistent, industrial-strength manufacturing Use of polyamide for a slim, lightweight device that is highly resilient and durable SNOR-XThe SNOR-X is a mouth guard that gently holds the tongue forward during sleep, keeping the upper airway open and free from obstruction.
The prevention of this obstruction relieves snoring. SNOR-X is made of two pieces, a tongue sleeve and a plastic ring that goes around the device and is held in place by notches on each side of the sleeve. The patient places their tongue into the tongue sleeve and squeezes the front end of the device to create a gentle suction that holds the tongue in an extended position. The patient can adjust the extension of the tongue for comfort and effectiveness.
Air vents are sculpted onto the upper surface of the device to facilitate mouth breathing. aveoTSDUnlike oral dental devices , the aveoTSD does not attach to the teeth, and does not require specialist fitting by a dental professional. For maximum compliance this device is best suited for use with consultation by a medical doctor or dental professional.The aveoTSD is a non-adjustable universal device that is the most cost effective and simple to use.
Approved by the F.D.A in the U.S.A as a medical device. Nose Breathe ApplianceThe Nose Breathe for Heavy Snorer [NB/HS] is a NEW tongue-retaining oral appliance. The tongue is held at the roof of the mouth and retained by a naturally occurring lip seal and tongue suction due to the negative pressure of the oral cavity. It is an anatomical feature of the human oral cavity, only found during nasal breathing.
The breathing/swallowing/tongue placement mechanism must function synergistically for normal esophageal peristalsis activity, as well as for the normal cranio-facial development. If not, problems, such as, acid reflux, aspiration, COPD, crooked teeth, aerophagia, dysphagia, diabetes, asthma, bed wetting,. could result. The biggest culprit is the tongue activity during swallowing. Nasal breathing is the most effective way to control the aberrant tongue function.
Nasal breathing/swallowing/tongue placement must be looked at as a unit and not as separate functions. Clasp Retained Mandibular PositionerThis appliance uses multiple clasps to positively lock the mandible into the appliance and prevent it from retruding. Because it is a one-piece appliance you can control the vertical dimension by changing the height of the appliance. There is also a larger airway cut into the acrylic in this design.
Elastomeric Sleep ApplianceConstructed in a dental laboratory, it is made of a very pliable soft, custom-injected silicone and is tooth retained. There are no clasps or wires to adjust. The flexibility of the material lends itself to a high degree of patient comfort. The Elastomeric appliance is not protrusively adjustable. The vertical opening is 5 mm and the mandible is afforded some limited movement due to the high flexibility of the material.
OSAPThe OSAP is a full coverage mandibular advancement mouthpiece made of a soft and flexible material to ensure maximum comfort for the patient. The OSAP is custom made, with or without an oral air passage, for optimal effectiveness. The appliance is compatible with home/office based bleaching techniques. A ready-made semi-universal trial version is also available for patients who cannot endure having their impressions taken.
In addition, the trial version is an inexpensive way to test a particular patients' tolerance to oral therapy. Works well with upper edentulous and some full edentulous patients. Sleep Apnea Goldilocks Appliance (SAGA)The SAGA incorporates the same materials and technology used to make Accutech's Goldilocks splint, which consists of a hard acrylic shell laminated to a soft vinyl liner. The two arches are connected in the posterior to hold the mandible in a protrusive and open position Mandibular Inclined Repositioning Splint (MIRS)An open airway is maintained with this appliance by directly holding the mandible in a downward and toward position with an incline flange.
This flange is made out of a thermoplastic material that softens at body temperature keeping it comfortable for the patient. The body of the appliance is made out of hard acrylic and snap fits to the upper arch. The lower dentition is deeply indexed into the occlusal surface of the appliance to hold the mandible in the forward position. A breathing hole is placed in the anterior portion of the appliance to allow for easy breathing throughout the night.
Nocturnal Airway Patency Appliance (NAPA)The Nocturnal AIrway Patency Appliance (NAPA) is constructed in a dental laboratory of rigid acrylic and is tooth retained by Adam's clasps. An anterior positioned "breathing beak: allows for oral breathing when necessary. The mandible is held firmly in position to prevent any jaw movement during use and , thus, is non-adjustable. The vertical opening is 5 to 10mm.
SnoreFreeThe SnoreFreeTM is a one-piece thermoplastic mandibular repositioning appliance that is made chairside. It comes in a kit that contains everything from complete instructions, to all the forms necessary to screen your patients for snoring and apnea. When you need an appliance to bring the tongue forward and clear the airway in the hypopharyngeal region, this appliance is a good one to use first as it is inexpensive, and it's easy to use.
SnoreGuardSnore Guard®, an oral appliance easily assembled at chair side, comprises a structure shaped to conform to the upper dental arch of the user and to create a ramp behind the lower anteriors. This ramp prevents the user's jaw from receding; in addition, the tongue seeks an opening between the upper and lower portion of the Snore Guard, thus keeping the air passage of the throat open.
SomnoGuard 2.0One-part thermoplastic mandibular advancement device to treat snoring and mild to moderate obstructive sleep apnea. Appliance consists of a hypoallergenic thermoplastic body. After heating the appliance in water that has been boiled the thermoplastic co-polymer becomes soft and mouldable. While soft, the appliance is fitted to the upper and lower jaws and once cooled it is ready to be worn at night.
It differs from the preceding SomnoGuard by a 3.0 mm thicker molar biting zone. This thicker molar area means that fitting is faster and easier for those patients with a "deep bite". Adjustable PM PositionerThe Adjustable PM Positioner™ utilizes materials and a design that minimize office chair-time and provide the patient control of adjusting the jaw position under the dentist's supervision.
Research studies have shown that this appliance is successful in treating 77% of patients with moderate obstructive sleep apnea. The appliance fits over all maxillary and mandibular teeth and is made of a special acrylic material (BruxezeT) that softens in hot water to provide a combination of comfort, strength, and retention. This material has proven to be very durable. Expansion screws are located on the right and left buccal areas to allow maximum space for the tongue and easy anterior-posterior positioning of the mandible to achieve optimal effectiveness.
This design permits ample lateral and protrusive movement to maintain jaw comfort.The device uses a unique method of retention consisting of small projections of acrylic within the device that comfortably grip the undercut areas of two posterior teeth in each quadrant. Therefore, no metal clasps are necessary. Z-Quiet Pro-Plus Introducing the ZQuiet Pro-Plus, an innovative appliance that incorporates multiple features designed to create more airflow with less TMJ stress.
Appliance features include: Lingual Ramps: Bilateral ramps on the lingual surface provide support and activate involuntary reflexes that facilitate the upward and forward position of the tongue creating greater pharyngeal space. Lingual ramps are especially helpful for patient with narrow arch forms or large tongues. Omega Loop: A unique appliance feature designed to reduce headaches associated with oral appliance therapy.
Appliances that cross the palatal midline restrict cranial-sacral movement, a physiologic tenet of osteopathic medicine. The use of a midline anterior omega loop allows for the expression of this very subtle palatal expansion and contraction. Fin & Buttress Angle : The angle bias of the fin and buttress junction necessitates anterior movement of the condylar mechanism in the temporomandibular joint, therefore when the mouth opens the jaw must translate anteriority.
Anterior Space: The low profile design of the device components is minimally invasive allowing for maximum intraoral space. There are no bulky hinges, posts, or mechanical hardware to interfere with the mouth opening or impede reflexive travel of the tongue. Patient-Specific Vertical Opening: The occlusal aspects on the mandibular orthotic are fashioned to increase the vertical inter-incisal dimension to further assist in dilating the upper airway.
. APM UltraThe APM Ultra is the next generation Adjustable PM Positioner. The APM Ultra has incorporated many design features that will increase patient comfort and acceptance in addition to effectiveness. The design features include: Made of a comfortable heat-sensitive acrylic Retention by projections of acrylic (no clasps) Open in the anterior for easy breathing through the mouth (or nose) Excellent freedom of jaw movement (6 mm in lateral excursion) Smaller expansion screws on R and L buccal segments Smaller overall size with shorter periphery and increased tongue space Hilsen Adjustable Positioning ApplianceThe appliance is constructed of maxillary and mandibular full arch thermoplastic bases with Velcro-like attachments on the occlusal surfaces of both.
It is retained by friction grip to the teeth. These provide simple and easy adjustment antero-posterior and left and right over a wide range. Adjustments are easily accomplished by the doctor or patient. Klearway Oral ApplianceKlearwayT is a fully-adjustable oral appliance used for the treatment of snoring and mild to moderate Obstructive Sleep Apnea. Fabricated of thermoactive acrylic resin, Klearway becomes pliable for easy insertion and confirms securely to the dentition for an excellent fit while significantly decreasing soft tissue and tooth discomfort.
Small increments (0.25mm) of forward lower jaw advancement are initiated by the patient under the direction of a dentist and this helps avoid rapid jaw movements that can cause significant patient discomfort. The appliance does not encroach on tongue space. Once warmed under hot water and inserted, the acrylic resin hardens as it cools to body temperature and firmly affixes itself to both arches. Lateral and vertical jaw movement is permitted which enables the patient to yawn, swallow, and drink water without dislodging the appliance.
The Moses ApplianceThis new, innovative device adds another dimension to oral-appliance therapy. Stimulating protrusive tongue reflexes and an open anterior design advances the tongue and enlarges the cross-sectional area of the airway. Combined with mandibular advancement, it becomes the most effective appliance available. Two-part construction allows patients to talk, drink, open wide and close their lips, making this the most comfortable appliance available.
OASYSThe OASYS Oral/Nasal Airway SystemT is the first dental device to be reviewed by both the dental and ENT divisions of the FDA and to be approved as a dental device for treatment of snoring and sleep apnea through mandibular repositioning and also as a nasal dilator for reduction of nasal resistance and improved nasal breathing. Silencer SystemThe Silencer? Professional is a laboratory fabricated fully adjustable oral appliance for the treatment of sleep apnea and snoring.
The appliance features a titanium precision attachment, which controls the anatomical settings of the appliance. It is capable of anteroposterior adjustment as well as vertical adjustment through a range of 10mm, in both dimensions. The design of the precision attachment also allows lateral movement of the mandible which respects and protects the TMJ. The titanium Halstrom Hinge? is made of implant grade titanium and carries a five-year warranty.
Elastic Mandibular Advancement Appliance (EMA)The EM® - Custom appliance is a simple, patient-friendly oral appliance created for noninvasive treatment of snoring and OSA. The primary treatment mechanism of opening the bite and gently moving the mandible forward is achieved with the use of interchangeable elastic straps that offer varying degrees of mandibular advancement. The flexibility of these elastic straps provides unsurpassed lateral movement and overall TMJ comfort.
The 2 mm thick pressure formed bases offer orthodontic retention (resulting in no tooth movement) and maximum anterior tongue space because there are no projections in the palate. Medical Dental Sleep Appliance (MDSA)MDSA Appliance Medical Dental Sleep Appliance (MDSA) A safe and effective treatment for snoring and mild to moderate sleep apnea.The MDSA is Effective Comfortable Easy to keep clean Simple to use Australian designed and manufactured NORAD ApplianceNORAD is an auto titratable, immediate placement, mandibular repositioning device for the management and treatment of snoring and sleep apnea.
The appliance, which is fabricated chairside, works by repositioning the lower jaw downward and to a slightly more forward position. Silent NiteThe Silent Nite® appliance is prescribed by more dentists for the initial treatment of snoring. Persons with mild sleep apnea also may be treated when surgical and other medical treatments are ineffective or not desired. A soft/hard frame material is available for increased patient comfort.
Snore-AidSnore-Aid plus is an adjustable mandibular bite plate that advances the mandible and repositions the tongue anteriorly and superiorly. The single plate orthotic utilizes an external lip shield and occlusal coverage to minimize tooth pressures. It has no components that interfere with tongue posture and vertical dimension can be altered at chairside. This appliance is constructed from special thermoplastic resins and vinyl polymers which make it comfortable,easy to fit and very retentive.
The external lip shield is easily titrated and can be quickly re-adjusted. The single plate design enables the appliance to be compatible with the patient's natural articular pattern and condylar path and this renders it a suitable appliance for nocturnal bruxers and TMD sufferers. Description for Web sites (public): Snore-Aid plus is comfortable laboratory constructed oral appliance that is prescribed by the dentist for snoring and mild obstructive sleep apnea.
The appliance works by advancing the mandible and positioning the tongue to open the patient's airway, thus permitting easier breathing and preventing loud snoring. Snore-Aid plus allows the patient to have their natural jaw motions while they sleep so that their jaws do not become sore from wearing the appliance all night, every night. This is particularly helpful in patients who grind their teeth (bruxism).
Speaking, yawning, and swallowing are not impaired by Snore-Aid plus. Dentists value how easily the appliance can be fitted and adjusted. This durable appliance rarely needs repair. Z-applianceThe Z-appliance is a combination of a soft palate lifter and a mandibular advancement device[the herbst]. TheraSnore AdjustableThe TheraSnore is one of the few appliances that requires no laboratory construction and is easily fitted chairside from a boil and bite blank.
In the non-adjustable device the mandible is retained in a protrusive position with pliable thermoplastic material and is afforded limited movement. Protrusive adjustability is possible to a small degree. CPAP ProCPAP/PRO is a nasal pillow device that is held in place by custom or boil and bite appliance. It may also attach to a mandibular repositioning appliance. Oral Pressure Appliance (OPAP)Patients who are unable to be compliant with a nasal mask due to claustrophobia, head aches due to chinstraps or head gear and complaints of mask leaks leading to eye irritation, sinusitis may benefit by using oral mask ventilation with the OPA P.
Oral positive air pressure delivered by a newly conceived proprietary dental appliance (OPA P) is a treatment alternative to nasally applied positive air pressure (CPAP or BiPAP). Mandibular advancement and modification of the upper airway structures is thought to enlarge the airway or reduce its collapsibility. Sleep Apnea Management System (SAAMS)The Sleep Apnea Airway Management System (SAAMS ™) is a combination of the TAP ® oral appliance and standard CPAP technology.
SAAMS™ decreases the pressure of CPAP while holding the CPAP mask in a precise position without straps, thus eliminating many of the problems associated with CPAP. All images courtesy of QuietSleep.com Snoring Only Appliances SomnoGuard AP® Two-part mandibular adjustable positioner with thermoplastic body to treat snoring and mild to moderate sleep apnea. SomnoGuard® AP is a unique mandibular advancement device.
Lateral movement of the jaw and an infinitely adjustable protrusion are key features. SomnoGuard® AP consists of an upper and a lower tray each made of two materials. The outer tray shells consist of solid clear and transparent medical grade polycarbonate. The inner lining which accommodates the teeth impressions is made of a thermoplastic copolymer as it is similarly used with the SomnoGuard® monobloc appliances.
After the oral appliance is heated in a hot water bath its thermoplastic body moulds easily to the teeth and jaws allowing any medical doctor to fit the device chair side. SomnoGuard AP Pro® Dental lab made two-part mandibular adjustable positioner to treat snoring and mild to moderate sleep apnea. The SomnoGuard® AP Pro can easily be constructed from common acrylic/elastomeric thermoform dental materials in any dental lab after taking impressions of the lower and upper jaws and producing plaster models.
The components used to connect the upper and lower trays of the dental appliance and enable the infinite advancement of the lower jaw are made from stainless steel. The components' technology is based on the preceding development of the SomnoGuard® AP. The components are very durable, more or less indestructible, inexpensive and can most often be reused when the oral appliance has to re-made for some reason.
As well as the advantages of the SomnoGuard ®AP, the dental device SomnoGuard® AP Pro provides the additional benefit that even patients with missing teeth or dentures can wear it. SomnoGuard® AP Pro is considered for long term use between about three to five years or longer. Discover how an anti-snoring equipment can do wonders for your sleep apnea condition. Call or email ihatecpap.com today for your sleep apnea consultation.See Also: Buy Jenn Air Appliances
An equipment is one of the biggest investments you might at any time make. Appliances are normally hefty buys, and are one in the most important parts of your private home. You trust in appliances for almost everything from cooking to cleansing, and especially thinking about the level of dollars you will be putting forth for it, it only is smart that you d would like to make sure you make the most sensible get.
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Click here to download the PDF version of this article. Few things in dentistry are as rewarding as restoring someone’s smile back to optimum oral health. One that provides the patient with the esthetic result they were counting on, as well as a functional and biomechanical result that will serve the patient for years to come. While ceramics and restorative materials have been evolving at a very rapid rate, until recently the way we communicated critical contours to the laboratory has not.
The goal of this article is to review the functional contours that must be communicated and to outline a more reliable way to provide the dental lab with the critical information required. Occlusal Goals 1.) Equal intensity stops in centric relation – The first tenant of any stable occlusion is for all the teeth in one arch to hit the teeth in the opposing arch at approximately the same time. Additionally, it is ideal if this can happen when the joint is at the most anterior-superior position in the glenoid fossa (centric relation).
1 This will create a reproducible position, and one where the masticatory muscles will be the most harmonious.2,3,4 Equal intensity stops will balance whatever the force the patient can generate over the entire dentition, as well as create vertical stability of each tooth. 2.) Posterior teeth the patient can’t rub (non-interfering posterior teeth) – One of the most important goals of any healthy occlusal scheme is to create a situation that the patient cannot run into their back teeth as they move in any excursive movement.
It is important to note that if the condyle has the ability to move upward from the patient’s habitual occlusion, there will ALWAYS be an interference.5 Additionally if the lingual contours of the anterior teeth are not steeper than the patient’s posterior morphology, there will always be posterior teeth that bump and/or have the capacity to rub. This can be seen in working, balancing and/or protrusive movements.
The primary reason back teeth should not contact in excursive movements, is because it dramatically increases the muscle activity, increasing the load to the dentition.6,7,8 Therefore, to decrease damaging occlusal load to ceramic materials on the anterior teeth (as well as the natural dentition), always make sure there is immediate disclusion of the posterior teeth when the mandible moves in any direction.
9, 10 3.) Anterior guidance in harmony with the envelope of function – If one of the goals is to prevent the back teeth from rubbing, it is logical to assume that it is the job of the front teeth to provide the disclusion. While some are questioning the importance of the anterior guidance11, there is just too much scientific evidence already described in this article not to support its use. Simply stated, if the anterior guidance does not disclude the back teeth, then the capacity for back tooth contact in excursive movements and damaging muscle activity will be evident.
It is simply risky to leave posterior interferences behind. However it is possible to make the anterior guidance too steep. Since the natural functional pattern of the patient during speaking and chewing is outside in, and not inside out12, the contours need to be customized intraorally to make sure appropriate contours are tested to verify harmony with the envelope of function.13 An anterior guidance that is too steep will lead to fremitus, migration of the teeth, wear and/or fractured anterior teeth/restorations.
It is important to recognize that posterior disclusion and contours that are in harmony with the EOF, don’t have to be mutually exclusive of one another. The optimum occlusion has to have both. Dr. Peter Dawson first described a technique that establishes this in 1974.14 The optimum anterior guidance:1.) Is steep enough to disclude the posterior teeth in any excursive movement.2.) Is concave enough to be in harmony with the envelope of function.
It is critical for the restorative dentist to understand that when restoring anterior teeth, this precise concavity from the centric stop to the incisal edge position must be communicated to the dental laboratory. A digital protocol has now evolved to make this much more predictable than previous techniques. Case Report A 51 year old male was referred to the practice for occlusal evaluation and the fabrication of a sleep apnea appliance.
He had been diagnosed with mild sleep apnea by a qualified physician and had been unable to wear a CPAP device (Figures 1-7). His mouth was healthy biologically, with no active dental caries and no probing depths greater than 3 mm. He did have mild localized gingivitis and would need a couple of appointments with our dental hygienist. Functionally, his primary sign of occlusal instability was occlusal wear.
Teeth 6-11 and 22-27 exhibited through the enamel and into the underlying dentin. Tooth number 30 had a porcelain fused to metal crown with a fractured mesial lingual cusp. His first point was tooth number 2,3/30,31 (Figure 8) in centric relation (CR) with a large slide to his maximum intercuspation. He also had balancing interferences bilaterally and there was concern that his sleep apnea may be contributing to his occlusal wear.
Ben complained of temporal headaches in the late afternoon and was aware of daytime clenching. Benʼs goals were to stabilize his bite, optimize his smile, and to be compliant with a sleep apnea appliance. His treatment plan was created and placed into three phases. Phase One: Treatment of Biologic IssuesThe only biologic issue was the mild generalized gingivitis. The patient was scheduled with two visits with our hygienist.
Appointment 1: Gross scale/Oral hygiene instructions Appointment 2: Prophy Phase Two: Treatment of Functional IssuesPhase Two is about creating a functional stable base in which to build the definitive restorative dentistry. A combination of reductive equilibration to eliminate the interferences to centric relation, combined with additive equilibration utilizing composite resin to restore the incisal guidance, was the technique employed in this case (Figures 9-10).
15,16 The goal was to create equal intensity contacts in centric relation, non-interfering posterior teeth (back teeth that can’t rub), and an anterior guidance in harmony with the envelope of function. In this phase, an obstructive sleep apnea orthotic was fabricated (TAP 3 device) and fitted for the patient (Figure 11). The patient desired to wait for a new insurance year (to maximize benefits) before proceeding to Phase Three.
This worked out perfectly as it gave us time to test the new occlusion and to get the patient back to his sleep physician for a follow up sleep study. In the months that followed the occlusion remained comfortable, none of the resins fractured, and his headaches were eliminated. Additionally, we received a positive report from the sleep physician. Appointment 3: Equilibration, IFL resins 22-27,6-11, impressions OSA appliance Appointment 4: Deliver OSA appliance, fine tune equilibration Appointment 5: Adjust OSA appliance, complete equilibration-refer back to sleep physician for confirmation of improvement Phase Three: Restorative Dentistry (Placement of Permanent Crowns)With the mouth stable biologically and functionally, the restorative phase of treatment should be uneventful.
The teeth that will need to be restored are teeth 22-27, 6-11 and 30. Because the teeth are in an esthetic and functional optimum position, we can do these sextants in any order. The patient elected to begin with maxillary anterior teeth. Phase Three began with new diagnostic impressions, facebow, centric jaw relations records and photographs. Their purpose was to do one final study of the occlusion and the esthetic contours.
Slight alterations were made to the esthetic contours (diastemaʼs and line angles), while every effort was made to preserve the tested lingual contours. Teeth 6-11 were prepared with utilization of preparation reduction guides. A two cord technique was utilized and a final impression was taken, and a master model poured (Figure 12). Provisional restorations were created and cemented. Steps were taken to verify the functional goals previously described (Figures 13-15).
Digital Duplication With all of the effort that has been taken to customize the patient’s anterior guidance, and ultimately create an optimum occlusal scheme, how we communicate these contours to the dental laboratory is extremely important. Previously techniques have been described to cross mount the die model with a doctor and patient approved provisional model. The use of silicone putty to fabricate a labial matrix was utilized to precisely duplicate the incisal edge position.
17 Whereas acrylic resin or light cured composite can be used to create a custom incisal guide table to facilitate the precise duplication of the lingual contours of the maxillary anterior teeth.18,19 While the author, along with many others, have utilized these modalities successfully for many years, there are times where predictability can be an issue. If the maxillary master casts and the provisional models are not mounted in the exact position in space, the incisal edge position, and lingual contours will be wrong.
This can and will create problems with some patients. Problems can include prolonged occlusal adjustments, all the way to the replacement of some or all of the restorations. Today the use of digital technology can make this duplication much easier. The restorative dentist goes through the exact same process of making a final impression and creating properly contoured provisional restorations as well as making an impression of the provisional restoration.
The laboratory will then scan the master model as well as the approved provisional model. The lab will then “marry” the images so that they can see the exact three dimensional contours over the digital master cast (Figures 16-17). These restorations can then be virtually designed, ensuring from the centric stop to the incisal edge position that the critical contours are duplicated (Figure 18).
It should be noted that if doctors are using one of the digital impression scanning systems, the final impression and the approved provisional can be easily scanned. This will save a step in the dental laboratory. From this point the laboratory can either mill the copings, or use a 3D printer. In this case the copings were printed (Figure 19). This facilitated the utilization of a micro cutback technique on the facial to enhance the esthetic result.
The resin copings were then invested, and the crowns were pressed using the IPS e.max all ceramic system. Figures 20-24 illustrate the final result. The restorations were bonded to place using Mulitilink self-etching cement, and then were finished and polished. It should be noted that this technique resulted in almost no occlusal adjustments. Minor finishing and polishing in a few areas was all that was required.
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