David B. Rosen, D.M.D.- Practice Limited to Periodontics & Dental Implants
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David B. Rosen, D.M.D.- Practice Limited to Periodontics & Dental Implants
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Mandibular Repositioning Devices [MRD] The Mandibular Repositioning Devices [MRD] is the largest family of appliances available for the treatment of snoring and sleep apnea. Of the more than 50 appliances available on the market today, fewer than 15 are accepted by the FDA for the treatment of obstructive sleep apnea. ALL of the accepted appliances are custom-made in a laboratory and cannot be fitted in a single appointment. Only a few of the available appliances will be discussed, but others will be listed at the end of the discussion. All MRD appliances work approximately the same way. They all fit extremely tightly over the patient's teeth and they all pull the bottom jaw forward into a "bulldog bite" and hold the teeth in the most closed position possible . The difference in appliances is the style of adjustment hardware, the position of the adjustment hardware, and the material used in the appliance itself. Some patients will find one appliance more comfortable than the others. There is no one appliance that will work for every patient. Any dentist supplying these appliances must be able to use more than just one to treat his patients. The older appliances are one-piece, nonadjustable appliances. If the patient finds the position of his jaw to be uncomfortable, the dentist will need to remake the appliance. Patients who grind their teeth at night (which is more than 30 percent of patients who have sleep apnea) may find it difficult to tolerate an appliance which locks them into one position for the entire night. Examples of this style of appliance are: NAPA®(Nocturnal
Airway Patency Appliance) More recently, adjustable appliances have become the most commonly used device. Some of these appliances can be adjusted by the patient and some must be adjusted by the dentist. Since the position of the bottom jaw, which will create an adequate airway to decrease or resolve snoring and sleep apnea, is unique to each patient, these appliances allow for alteration in the position of the bottom jaw without remaking the appliance. If a patient is having more trouble one night than others, many of the appliances can be changed to resolve the problem To use an MRD appliance, a patient must have 6-10 sound teeth in each jaw. The teeth must be restored with proper fillings and well fitting crowns (caps), and there must be no significant gum disease around the teeth. The appliances that are used, hold onto the teeth so tightly, that they will extract weak teeth or pull out ill-fitting fillings and caps.. Appliances are indicated for patients with mild to moderate sleep apnea, patients who are less than 50 percent above their ideal body weight, those with small bottom jaw (receding chin) and patients who cannot breathe through their noses. MRD appliances should be avoided by patients with gum disease, existing severe joint problems (the jaw joint is to the front and just below the ear), severe sleep apnea, patients who have heart rhythm problems related to their sleep apnea, patients with limited movement of their bottom jaw (opening the mouth or sticking out their chin), and children. The patients who are most successful with MRD therapy are those who have failed with surgical procedures aimed at correcting sleep apnea, have normal size tongues, and a normal length soft palate. Patients who have a long lower face (from the tip of their nose to the tip of their chin) will also be less successful. As of this time, researchers have not been able to determine strict guidelines for patient selection. Sometimes the most unlikely patient will be very successful when using an oral appliance. For this reason, patients who fail alternative forms of treatment, must be considered for oral appliance therapy. Patients with severe sleep apnea MUST have a follow-up sleep study to find out if the oral appliance is adequately treating their potentially fatal disease. Complications of MRD. use can include, but are not limited to, loosened teeth, joint pain, muscle aches, tissue sores, inability to touch the back teeth together when the appliance is first removed in the morning, and permanent tooth movement. Studies have shown that long-term use of appliances which moved the jaw forward result in permanent tooth repositioning in as many as 20 percent of patients. Developers of some appliances claim that their patients have experienced few or no side effects, but they have not routinely studied large number of patients, nor carried out studies over long periods of time. The patient can expect that the side effects will be fairly standard regardless of the appliance used. Patients must be aware that MRD therapy carries with it a 10 percent risk that the patient's disease we'll get worse. This appears to be unique to MRD therapy, and may require the patient to have a follow-up sleep study even if symptoms are relieved.
Klearway™: This is a thermoplastic appliance which must be
heated in hot tap water every night (to make flexible) before it is placed in
the
EMA in patient's mouth. Patient's mouth closed around EMA appliance T.A.P.™::
Unlike the previous appliances, this appliance can only be adjusted by the dentist. It is unusual in that it can be adjusted in both a horizontal (front to back) and vertical (open and close) direction which may be necessary to effectively treat the sleep apnea. The only metal in this appliance is titanium and the Silencer can be worn by patients who are allergic to nickel metal. Other FDA accepted appliances are the Equalizer, the SNOAR, and one that is made to snap on to dental implants.
(Nocturnal Airway Patency Appliance) |
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This is a hard plastic appliance which has the adjustment hardware set on the
cheek side of the molar teeth. It prevents side-to-side motion, but since the
bottom jaw is held closed with small orthodontic rubber bands, opening the jaws
is fairly easy. The modified Herbst is smaller than most appliances and has a
long life span. It allows jaw movement in all directions but backwards. The
patient can take medications, use an asthma inhaler or talk with this appliance
in place.
The
E.M.A. is the thinnest and least bulky of all the appliances. It is similar to
clear acrylic orthodontic retainers, and the 'hardware' (located to the cheek
side of the molar teeth) consists of specially designed, patented elastic bands.
This appliance moves the jaw forward in fairly significant steps, which may be
difficult to tolerate. Some care must be taken to avoid breaking the lower
portion when replacing the custom elastics.
This is an appliance which has a separate section for the top jaw and a bottom
jaw. Each portion of the appliance is placed the mouth separately and then the
patient sticks out his/her chin until the ' hook and bar' hardware can be
connected. The hardware is located at the tip of the tongue, and may take some
getting used to. The adjustment knob sticks out through the lips and is visible
when sleeping. This appliance is easily retained by tooth grinders, even those
who have worn away much of their tooth structure. There is also a TAP 2
This appliance is made of a thermoplastic material which must be
heated in hot tap water every night before it is placed in the mouth. The
adjustment hardware is rigidly bound on the cheek side of the molar teeth and
allows no movement of the bottom jaw while the appliance is worn.
This appliance has recently received FDA acceptance.
It is a "combination" therapy which combines a nonadjustable
MRD with continuous positive airway pressure (nCPAP). Instead of
using nasal nCPAP, which delivers air pressure through a mask over the
nose or the nose and mouth, the air pressure is delivered through a
small conduit that fits across the roof of the patients mouth. Thus,
the more effective nCPAP can be used by patient without the need to
wear a nasal mask, have elastic straps around the head, or sleep on
one's back.