Presently there are quite a variety of oral appliance designs that are available to address sleep apnea and snoring. There is no one best option and you must be comfortable using at least four to five different styles to fit the specific needs of your patient. With the knowledge that all of these devices bring the jaw forward, there are five specific options. They include:
- Anterior Point Contact (TAP)
- Push Appliance (Herbst/Suad)
- Pull Appliance (EMA, Silent Nite)
- Interlocking Appliance (Somnodent, Respire, Dorsal Fin)
- Adjustable Monoblock (Moses, Oasys)
All clinicians should keep in mind that when using oral appliances the goal is to maintain a good lip seal in patients that don’t habitually sleep with their mouths open. It would make no sense to use an appliance whose bulk prevents a good lip seal in this patient population. In a patient with open mouth breathing tendencies do not attempt to keep the lips closed with elastics connecting the upper and lower rims unless you know he or she has patent nasal passages. In all cases, side positioning should be encouraged with props; and efforts to increase the size of the nasal valve with Breathe Right strips or other devices is also potentially helpful.
Anything you can do, therefore, to minimize the amount of jaw positioning necessary to facilitate airflow with the chosen device should be considered (including weight loss options if practical).
The most significant co-morbid factor that must be kept in mind is sleep bruxism (lateral bruxer or clencher) and the following guidelines should be helpful. It is important to understand that sleep bruxism is only sometimes driven by compromised airways and OSA, so don’t assume that you will fix the bruxism as well.
If the patient has a history of lateral bruxing based upon tooth wear patterns or evidence on a bruxism guard, one option could be an EMA appliance that has posterior occlusal contacts built by the lab or in the office. I would start with a forward position of 60% of maximum and use lightweight straps. If the forward jaw positioning chosen helps reduce or eliminate the airway obstruction then you are probably all set for this patient. If airway compromise is still present based on pulse ox testing or HST (home sleep test) data, then advancement of the appliance position is clearly needed.
If the positioning sufficiently helps the airway but not the bruxism (which is common) frequent changing of the bands will be necessary as they lose their resiliency. The use of a TAP 3-Elite appliance, which allows for lateral shift is a reasonable option as well providing you build posterior contacts. Other devices are notorious for breaking in the lateral bruxing patient, as I have seen with Herbst and all the dorsal fin appliances.
For dead-set clenchers the dorsal fin designs work well, especially if you add a contact point anteriorly without closing the tongue space. Herbst and Suad appliances hold up well in this subset of patients as well. Also, EMA appliances are fine in the heavy clencher, but hold up better when made of processed acrylic and not the bilaminar construction.
Dorsal fin appliances are helpful in patients who sleep with their mouth open due to poor nasal airflow. At times, however, the wings may be too bulky for smaller females. Whenever there are short teeth with poor retention, I use dorsal fin designs as well (Somnodent/Respire) as the interlocking relationship of the separate rims prevents dislodgement of the device unless elastics are needed to keep the mouth from opening too much.
Appliances such as the Oasys have their appeal to assist nasal breathing, and the engagement of only one arch allows for lateral shift of the lower jaw. I would avoid this option if there are sensitive upper front teeth or periodontal concerns. The Lamberg appliance, which is a spin-off of a TMJ appliance used to stop morning jaw locking, also can be used in patients who clench, providing the lower shell which is worn allows for posterior contact points.
Clearly, there are other options and designs available. I would love to hear your suggestions because, as we all experience, on a daily basis there will be another problem to solve if you continue to look!