Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Look up keyword
Like this
16Activity
0 of .
Results for:
No results containing your search query
P. 1
Dental Appliances for Snoring and Obstructive Sleep Apnoea_Construction Aspects for General Dental Practitioners

Dental Appliances for Snoring and Obstructive Sleep Apnoea_Construction Aspects for General Dental Practitioners

Ratings: (0)|Views: 587 |Likes:
Published by docx1975

More info:

Published by: docx1975 on Oct 06, 2009
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

07/31/2011

pdf

text

original

 
16
Dental Update – January/February 2003
REMOVABLE PROSTHODONTICS
 Abstract:
 
The medical and dental aspects
 
of management for patients diagnosed withsnoring and obstructive sleep apnoea are well documented. However, guidance fortreatment by the general dental practitioner is lacking. This article reviews aspects of appliance provision and presents the use of a silicone material in an attempt to improvethe longevity of a recognized prosthesis.
Dent Update
2003; 30: 16–26
Clinical Relevance: 
This paper informs the general dental practitioner of theconcepts, rationale and financial implications of the types of dental appliancesavailable for sleep-related breathing disorders and presents a technique to construct aone-piece flasked silicone prosthesis.
REMOVABLE PROSTHODONTICS
he management and treatment of patients who suffer from snoringand obstructive sleep apnoea (OSA) havelong since been addressed by medical
1,2
and specialist dental publications
3–5
and were recently highlighted by a number of mainstream dental articles.
6–10
Thesearticles inform the general dental practitioner (GDP) of the medicalimplications of the problem and themedical and dental treatment optionsavailable, but provide little technicalinformation on constructing theseappliances in the general practice setting.Traditionally, such appliances have been provided in a hospital setting.The department of Orthodontics and Restorative Dentistry at Glenfield Hospital, part of the University Hospitalsof Leicester NHS Trust, has eight yearsexperience in producing appliances and currently receives in the region of 200referrals a year from a sleep disordersclinic. During this time, various designsand materials have been used. However,as the awareness of treatment with dental prostheses increases (for example withnewspaper reports
11
and dentaladvertising
12
), GDPs may wish to offer thistreatment to the claimed one in four  patients who snore. This paper is writtento give guidance to those dentists providing appliances in general practice.The article reviews the concepts,rationale and technical aspects of appliance design and discusses clinicaland financial issues for the GDP. We also present the clinical and laboratory stagesin constructing a one-piece siliconeappliance that have been established within the department. No attempt is madeto revisit the medical aspects or thealternative treatment options for sleepingdisorders.
RATIONALE ANDCONCEPTS OF APPLIANCEDESIGN
Snoring is a sign of partial upper airwayobstruction during sleep. Snoring and OSA are caused by abnormal airway (baseof tongue and soft palate) anatomy and altered respiratory control mechanisms.Dental appliances may prevent snoringand OSA by modifying the position of theupper airway structures so as to enlargeand/or reduce collapsibility of the airway.Both the superior airway space (betweenthe soft palate and posterior nasopharynx)and the posterior airway space (betweenthe base of the tongue and posterior oropharynx) may be increased.
13
Three-dimensional reconstructions of computed 
Dental Appliances for Snoring andObstructive Sleep Apnoea:Construction Aspects for GeneralDental Practitioners
S
IMON
G.S. E
LLIS
, N
ICHOLAS
W. C
RAIK
, R
OBERT
F. D
EANSAND
C
HRIS
D. H
ANNING
Simon G.S. Ellis
 , BDS, MSc, FDS RCS(Edin.),Specialist Registrar,
Nicholas W. Craik 
 , Adv Ortho& Pros, RDT, LOTA, Senior Chief Dental Technician, and 
Robert F. Deans
 , BDS, FDSRCS(Eng.), FDS RCPS(Glasg.), FFD RCSI (Ire.),DRD RCS(Edin.), Consultant, Department of Restorative Dentistry, Glenfield Hospital,University Hospitals of Leicester NHS Trust, and 
Chris D. Hanning 
 , MD, FRCA, Consultant inSleep Disorders Medicine, Leicester General Hospital.
T
Figure 1.
Change of mandibular position.
 
REMOVABLE PROSTHODONTICS
Dental Update – January/February 2003
17
tomography and magnetic resonanceimaging scans demonstrate significantincreases in airway dimensions with theappliances.
14,15
Successful treatment has,and continues to be, demonstrated – fromquestionnaires of patients and their  partners and scientifically from sleepstudy polysomnography.
2,3,13,16,17
The effectiveness of appliance therapy,however, depends on the severity of thesleeping disorder, the airway anatomy
18
and whether the patient can tolerate theappliance. It is generally advocated for mild OSA and simple snoring (i.e. snoringin the absence of OSA) and moderate tosevere OSA as an alternative to nasalcontinuous positive airway pressure(nCPAP) or craniofacial surgery.
19
Theuse of intra-oral appliances is simple,non-invasive, reversible and cost-effective and may be the basis of definitive lifelong treatment.The technical aspects of constructionhave been evolving since the early1980s,
20,21
although prostheses were firstconsidered in the early 1900s.
22
Originallythere were three concepts for a dentalappliance to modify the airway, whichcould be used alone or in combinationdepending on where the airwayobstruction occurred:
l
Soft palate lifting – the prosthesislifts and/or stabilizes the soft palate, preventing vibration during sleep.
5
l
Tongue retention – tongue-retainingdevices (TRDs) incorporate ananterior hollow bulb, which generatesa negative pressure vacuum when thetongue is inserted. The tongue is held forward, away from the posterior  pharyngeal wall, opening up theairway. Owing to muscle anatomy,this appliance simultaneouslymodifies the position of themandible.
13
l
Mandibular repositioning – theseappliances (MRAs) hold the mandiblein an anteroinferior position, which,as a consequence of muscleattachment, indirectly brings thetongue forward, opening up the posterior airway (Figure 1). Therepositioning may also stretch and reduce the collapsibility of the soft palate via its connection to the baseof the tongue and increase thesuperior airway space.
13,17
A recent review of 129 paperssuggested that more than 35 appliancesare currently available,
23
although Loweestimates the number to be in excess of 55.
Appliance nameDescriptionTypeOcclusal coverage
Adjustable Soft Palate Lifter
24
Lifts the soft palate and prevents vibration during sleepOne-pieceFullEqualiser
24
Repositions the mandible anteriorly, equalizes intra- and extra-oral airOne-pieceFullpressure (via tubes) and elevates soft palateHerbst
2,24
Repositions the mandible anteriorly, in open and closed position, withTwo-pieceFulladjustable struts. Jasper Jumper
24
Repositions the mandible anteriorlyTwo-pieceFullMandibular Repositioner
2,24
Repositions the mandible anteriorly (37 mm)One-pieceFullNocturnal Airway PatencyRepositions the mandible anteriorly and inferiorlyOne-pieceFullAppliance
24
Sleep and Nocturnal ObstructiveRepositions the mandible anteriorly (6–9 mm) and inferiorly (17 mm)One-pieceExcludes anterior maxillaApnoea Reducer (SNOAR)
24
Snore Guard
2,24
Repositions the mandible anteriorly (3 mm behind maximal protrusion)One-pieceExcludes molarsand inferiorly (7 mm)Snoring Treatment Appliance
24
Repositions the mandible anteriorlyOne-pieceExcludes molarsTepper Oral ProprioceptiveModifies tongue positionOne-pieceNot applicableStimulator
24
Tongue Locking Device
24
Preformed elastic appliance with a cavity that holds the tongue forwardOne-pieceFullby self-created vacuumTongue Positioner andHelps train the tongue to be in a more favourable positionOne-pieceFullExerciser
24
Tongue Retaining Device
2,24
Holds the tongue anteriorly during sleep by negative pressure in a bulbOne-pieceFullKlearway
2
Keeps teeth together, holding mandible and tongue forwardTwo-pieceFullPM Positioner
2
Advances mandible, vertical opening of 5 mmTwo-pieceFullTherasnore
2
Lower fin prevents tongue and mandible dropping backTwo-pieceFull
Table 1.
 A summary of dental appliances described for the treatment of snoring and obstructive sleep apnoea (adapted from Lowe
2,24
 ).
 
18
Dental Update – January/February 2003
REMOVABLE PROSTHODONTICS
He analysed the literature relating to 13commercially available appliances
24
butfocuses on seven designs in his recentwork (see Table 1), which is probably themost authoritative text available.The soft palate lifting design is notoften used because of patient toleranceand the fact that tongue posture rather than soft palate position is considered tohave a significant influence on the patency of the upper airway.
25
An exampleof this type of appliance is clearly shownin the paper by Clark and Nakono.
5
WhilstTRDs directly move the tongue to openthe airway, patient tolerance is notsatisfactory. When appliances areindicated the consensus appears to be atype of MRA, which Johal and Battagelconsider most suitable for obstructions atthe level of the tongue.
7
However, there isconsiderable variation with respect to thevertical and horizontal planes of mandibular repositioning and the materialused for construction.
Mandibular RepositioningConsiderations
Appliances for the treatment of snoringand OSA have been described withdifferent degrees of horizontal and verticalrepositioning. The most commonmandibular repositioning dimensionquoted is 50–75% of maximal protrusion(approximately 5–7 mm) with minimalvertical opening.
2,5,6,10
The rationale for minimal opening is that, as the mandibleopens, it rotates in an inferior and  posterior direction. Concurrent posterior movement of the tongue and soft palatewith wider opening may narrow the pharyngeal airway.
7
Other authors favour a 75% anterior position with a verticaldimension of 7 mm,
2,17
whilst the SNOAR appliance in Table 1 has significantanteroinferior repositioning. This, incontrast, is stated to work by moving themandible and tongue away from the posterior pharyngeal wall and soft palate.
2
Bonham
et al 
. advocated a more pragmaticapproach in describing the mostcomfortable protrusive position.
3
Anextensive review led by Ivanhoe found avariety of protrusive dimensions wereassociated with successful outcomes.
23
This, along with Lowe’s text,
24
suggeststhat most protrusive positions areeffective.
Material Considerations
To date either poly-vinyl vacuum-formed thermoplastic materials (soft or stiff blanksdepending on the Shore-hardness) or hard acrylic (predominantly heat cured) can beused. The choice of material oftendepends on appliance design and operator  preference. To optimize retention for thevinyl appliances it is recommended thatthe flanges extend at least 3 mm past thegingival margin but, if softer vinyl is used,this depth should be increased.
Occlusal coverage
The designs in Table 1 have varyingocclusal coverage but ideally completeocclusal coverage should be prescribed to prevent the potential of localized toothover-eruption. Case reports of complications occurring when fullcoverage was not used are discussed  below.
Edentulous Patients
Most appliances are made for dentatemouths but a technique for edentuloussufferers has been described.
26
If retentionis a problem then a TRD may be analternative option.
20
SOME DESIGNS OF MRAS
Appliances can be considered as either one- or two-piece designs. One-piecedesigns are not adjustable whilst the two- piece appliances can be adjusted in theanteroposterior plane. They may also permit, as with the Herbst-type appliance,
Figure 2.
Conventional vinyl MRA (non-adjustable).
Figure 3.
Green polyvinyl MRA (non-adjustable).
Figure 4.
 MRA at an increased vertical dimension.
Figure 5.
IST Appliance – an adjustable two-partHerbst-type appliance.
Figure 6.
The Silensor – an adjustable two-partappliance.

Activity (16)

You've already reviewed this. Edit your review.
1 thousand reads
1 hundred reads
hazeemmegahed liked this
puriu liked this
anand liked this
jaminem liked this
Fadzira Maarof liked this
Fadzira Maarof liked this
jvlunod liked this

You're Reading a Free Preview

Download
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->