R E M O V A B L E RP ER M

O SOTVH A
OB L N
DO E T IPCRS O S T H O D O N T I C S

Dental Appliances for Snoring and

Obstructive Sleep Apnoea:
Construction Aspects for General
Dental Practitioners
SIMON G.S. ELLIS, NICHOLAS W. CRAIK, ROBERT F. DEANS AND CHRIS D. HANNING

to revisit the medical aspects or the

Abstract: The medical and dental aspects of management for patients diagnosed with
alternative treatment options for sleeping
snoring and obstructive sleep apnoea are well documented. However, guidance for
treatment by the general dental practitioner is lacking. This article reviews aspects of disorders.
appliance provision and presents the use of a silicone material in an attempt to improve
the longevity of a recognized prosthesis.
RATIONALE AND
Dent Update 2003; 30: 16–26 CONCEPTS OF APPLIANCE
DESIGN
Clinical Relevance: This paper informs the general dental practitioner of the
concepts, rationale and financial implications of the types of dental appliances Snoring is a sign of partial upper airway
available for sleep-related breathing disorders and presents a technique to construct a obstruction during sleep. Snoring and
one-piece flasked silicone prosthesis. OSA are caused by abnormal airway (base
of tongue and soft palate) anatomy and
altered respiratory control mechanisms.
Dental appliances may prevent snoring

T he management and treatment of

patients who suffer from snoring
and obstructive sleep apnoea (OSA) have
long since been addressed by medical1,2
and specialist dental publications3–5 and
were recently highlighted by a number of
mainstream dental articles.6–10 These
articles inform the general dental
practitioner (GDP) of the medical
implications of the problem and the
medical and dental treatment options
available, but provide little technical
information on constructing these
appliances in the general practice setting.
Traditionally, such appliances have been
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, FDS
RCS(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 in
Sleep Disorders Medicine, Leicester General
Hospital.
provided in a hospital setting.
The department of Orthodontics and
Restorative Dentistry at Glenfield
and OSA by modifying the position of the
upper airway structures so as to enlarge
and/or reduce collapsibility of the airway.
Hospital, part of the University Hospitals Both the superior airway space (between
of Leicester NHS Trust, has eight years the soft palate and posterior nasopharynx)
experience in producing appliances and and the posterior airway space (between
currently receives in the region of 200 the base of the tongue and posterior
referrals a year from a sleep disorders oropharynx) may be increased.13 Three-
clinic. During this time, various designs dimensional reconstructions of computed
and materials have been used. However,
as the awareness of treatment with dental
prostheses increases (for example with
newspaper reports11 and dental
advertising12), GDPs may wish to offer this
treatment to the claimed one in four
patients who snore. This paper is written
to give guidance to those dentists
providing appliances in general practice.
The article reviews the concepts,
rationale and technical aspects of
appliance design and discusses clinical
and financial issues for the GDP. We also
present the clinical and laboratory stages
in constructing a one-piece silicone
appliance that have been established
within the department. No attempt is made Figure 1. Change of mandibular position.

16 Dental Update – January/February 2003

 REMOVABLE PROSTHODONTICS

Appliance name Description Type Occlusal coverage

24
Adjustable Soft Palate Lifter Lifts the soft palate and prevents vibration during sleep One-piece Full

Equaliser24 Repositions the mandible anteriorly, equalizes intra- and extra-oral air One-piece Full
pressure (via tubes) and elevates soft palate

Herbst2,24 Repositions the mandible anteriorly, in open and closed position, with Two-piece Full
adjustable struts.

Jasper Jumper24 Repositions the mandible anteriorly Two-piece Full

Mandibular Repositioner2,24 Repositions the mandible anteriorly (3–7 mm) One-piece Full

Nocturnal Airway Patency Repositions the mandible anteriorly and inferiorly One-piece Full
Appliance24

Sleep and Nocturnal Obstructive Repositions the mandible anteriorly (6–9 mm) and inferiorly (17 mm) One-piece Excludes anterior maxilla
Apnoea Reducer (SNOAR)24

Snore Guard2,24 Repositions the mandible anteriorly (3 mm behind maximal protrusion) One-piece Excludes molars
and inferiorly (7 mm)

Snoring Treatment Appliance24 Repositions the mandible anteriorly One-piece Excludes molars

Tepper Oral Proprioceptive Modifies tongue position One-piece Not applicable

Stimulator24

Tongue Locking Device24 Preformed elastic appliance with a cavity that holds the tongue forward One-piece Full
by self-created vacuum

Tongue Positioner and Helps train the tongue to be in a more favourable position One-piece Full
Exerciser24

Tongue Retaining Device2,24 Holds the tongue anteriorly during sleep by negative pressure in a bulb One-piece Full

Klearway2 Keeps teeth together, holding mandible and tongue forward Two-piece Full
2
PM Positioner Advances mandible, vertical opening of 5 mm Two-piece Full

Therasnore2 Lower fin prevents tongue and mandible dropping back Two-piece Full

Table 1. A summary of dental appliances described for the treatment of snoring and obstructive sleep apnoea (adapted from Lowe2,24).

tomography and magnetic resonance
imaging scans demonstrate significant
increases in airway dimensions with the
appliances.14,15 Successful treatment has,
and continues to be, demonstrated – from
questionnaires of patients and their
partners and scientifically from sleep
study polysomnography.2,3,13,16,17
The effectiveness of appliance therapy,
however, depends on the severity of the
sleeping disorder, the airway anatomy18
and whether the patient can tolerate the
appliance. It is generally advocated for
mild OSA and simple snoring (i.e. snoring
in the absence of OSA) and moderate to
severe OSA as an alternative to nasal
continuous positive airway pressure
(nCPAP) or craniofacial surgery.19 The
use 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 construction
have been evolving since the early
1980s,20,21 although prostheses were first
considered in the early 1900s.22 Originally
there were three concepts for a dental
appliance to modify the airway, which
could be used alone or in combination
depending on where the airway
obstruction occurred:
l Soft palate lifting – the prosthesis
lifts and/or stabilizes the soft palate,
preventing vibration during sleep.5
l Tongue retention – tongue-retaining
devices (TRDs) incorporate an
anterior hollow bulb, which generates
a negative pressure vacuum when the
tongue is inserted. The tongue is held
forward, away from the posterior
pharyngeal wall, opening up the
airway. Owing to muscle anatomy,
this appliance simultaneously
modifies the position of the
mandible.13
l Mandibular repositioning – these
appliances (MRAs) hold the mandible
in an anteroinferior position, which,
as a consequence of muscle
attachment, indirectly brings the
tongue forward, opening up the
posterior airway (Figure 1). The
repositioning may also stretch and
reduce the collapsibility of the soft
palate via its connection to the base
of the tongue and increase the
superior airway space.13,17
A recent review of 129 papers
suggested that more than 35 appliances
are currently available,23 although Lowe
estimates the number to be in excess of 55.

Dental Update – January/February 2003 17

REMOVABLE PROSTHODONTICS
Figure 2. Conventional vinyl MRA (non-
adjustable).
Figure 3. Green polyvinyl MRA (non-adjustable).
He analysed the literature relating to 13
commercially available appliances24 but
focuses on seven designs in his recent
work (see Table 1), which is probably the
most authoritative text available.
The soft palate lifting design is not
often used because of patient tolerance
and the fact that tongue posture rather
than soft palate position is considered to
have a significant influence on the
patency of the upper airway.25 An example
of this type of appliance is clearly shown
in the paper by Clark and Nakono.5 Whilst
TRDs directly move the tongue to open
the airway, patient tolerance is not
satisfactory. When appliances are
indicated the consensus appears to be a
type of MRA, which Johal and Battagel
consider most suitable for obstructions at
the level of the tongue.7 However, there is
considerable variation with respect to the
vertical and horizontal planes of
mandibular repositioning and the material
used for construction.
Mandibular Repositioning
Considerations
Appliances for the treatment of snoring
and OSA have been described with
different degrees of horizontal and vertical
repositioning. The most common
18
mandibular repositioning dimension
quoted is 50–75% of maximal protrusion
(approximately 5–7 mm) with minimal
vertical opening.2,5,6,10 The rationale for
minimal opening is that, as the mandible
opens, it rotates in an inferior and
posterior direction. Concurrent posterior
movement of the tongue and soft palate
with wider opening may narrow the Figure 4. MRA at an increased vertical
pharyngeal airway.7 Other authors favour dimension.
a 75% anterior position with a vertical
dimension of 7 mm,2,17 whilst the SNOAR
appliance in Table 1 has significant
anteroinferior repositioning. This, in
contrast, is stated to work by moving the
mandible and tongue away from the
posterior pharyngeal wall and soft palate.2
Bonham et al. advocated a more pragmatic
approach in describing the most
comfortable protrusive position.3 An
extensive review led by Ivanhoe found a
variety of protrusive dimensions were
associated with successful outcomes.23
This, along with Lowe’s text,24 suggests
that most protrusive positions are
effective.
Material Considerations Figure 5. IST Appliance – an adjustable two-part
Herbst-type appliance.
To date either poly-vinyl vacuum-formed
thermoplastic materials (soft or stiff blanks
depending on the Shore-hardness) or hard sufferers has been described.26 If retention
acrylic (predominantly heat cured) can be is a problem then a TRD may be an
used. The choice of material often alternative option.20
depends on appliance design and operator
preference. To optimize retention for the
vinyl appliances it is recommended that SOME DESIGNS OF MRAS
the flanges extend at least 3 mm past the Appliances can be considered as either
gingival margin but, if softer vinyl is used, one- or two-piece designs. One-piece
this depth should be increased. designs are not adjustable whilst the two-
piece appliances can be adjusted in the
anteroposterior plane. They may also
Occlusal coverage permit, as with the Herbst-type appliance,
The designs in Table 1 have varying
occlusal coverage but ideally complete
occlusal coverage should be prescribed to
prevent the potential of localized tooth
over-eruption. Case reports of
complications occurring when full
coverage was not used are discussed
below.
Edentulous Patients
Most appliances are made for dentate Figure 6. The Silensor – an adjustable two-part
mouths but a technique for edentulous appliance.
Dental Update – January/February 2003
REMOVABLE PROSTHODONTICS
Figure 7. An orthodontic Twin-Block functional
appliance.
Figure 8. Twin-Block design with no coverage of
occlusal surfaces anteriorly.
limited lateral movements for parafunctional
patients.
One of the most accepted designs is the
one-piece non-adjustable soft vinyl
vacuum-formed MRA (Figure 2). This
involves fusing the thermoplastic material
covering the maxillary and mandibular
arches in the desired anteroinferior
position. The occlusal position is
established and recorded in vivo by a
variety of methods including a wax-bite,
silicone-bite or anterior jig with an
interocclusal registration.6,9,17 An optional
anterior breathing hole can be placed to
reassure those patients who mouth
breathe but is not essential. Figure 3
illustrates a variation of a one-piece non-
adjustable MRA using stiffer green vinyl
Figure 9. Modification of the Twin-Block to help
prevent disengagement at night.
20
of Shore hardness 80; Figure 4 shows an
appliance made at an increased vertical
dimension of approximately 8 mm.
In the two-part Herbst-based IST (Intra-
Oral Snoring Therapy; Figure 5) and
Silensor (Figure 6) appliances, the arches
are connected by pivoting bars that can
be altered in length to titrate the protrusive
mandibular position for effectiveness and
comfort. The occlusal registration for
these two-part appliances is not as
important because mandibular Figure 10. In vivo fitting of the Therasnore Zx
repositioning can be titrated from the appliance.
intercuspal position.
Although designed for orthodontic
treatment, the Twin-Block functional
appliance can be used as a MRA because
its (two-piece adjustable) design allows
adjustment of the mandibular position by
removing or adding acrylic (Figures 7 and
8). These adjustments will be difficult,
however, if modifications have been
included in an attempt to prevent
nocturnal mandibular opening (Figure 9).
It is crucial that full coverage of the
Figure 11. The Zx is an adjustable two-part
maxillary and mandibular occlusal surfaces appliance.
is provided to prevent over-eruption and
the technician knows that the appliance is
for sleep breathing disorders rather than
orthodontics.
The recently advertised Therasnore Zx
has a different approach, in that the
appliance engages only the maxillary
dentition and relies on a lingual fin to
induce protrusive mandibular
repositioning and/or prevent the tongue
and mandible from dropping backward
during sleep.2,27 It is two-part in design
Figure 12. The increments of the Zx.
and adjustable via five slots of 1.5 mm
increments (Figures 10–12).
It is believed that if a patient opens their fits the maxillary dentition and relies on the
mouth at night the appliance will not mandible being closed or vice versa, but
function. To counteract this locking, again clinical studies demonstrate
elastics are advocated for the two-part success:2 indeed, the ARPS design has
Herbst-type appliances and adequate been used successfully in our department
retention of the dental arches is needed (Figure 13). One patient did keep opening
for the one-piece prostheses. However, his mouth at night and disengaged the
one must question this theory as a rule. standard MRA despite attempts at
For example, the Therasnore Zx engages maximizing retention. Another variation
only the maxillary dentition and relies on was attempted, at the patient’s request, to
the mandible being closed for the lingual address this. In light of the SNOAR
fin to effect mandibular repositioning. The appliance described in Table 1, an
anterior repositioning splint (ARPS) appliance was made to a vertical opening
described for temporomandibular of 16 mm and has been successfully,
disorders is similar to the mandibular effectively and uneventfully worn for over
repositioners in Table 1.28 The ARPS either 3 years (Figure 14).
Dental Update – January/February 2003
 REMOVABLE PROSTHODONTICS

Figure 13. A one-piece heat-cured acrylic non-
adjustable MRA (an ARPS).
ARE MRAS ALWAYS
SUCCESSFUL ?
Lowe’s text comprehensively documents
outcome success rates for many different
MRA designs.2,24 Rates vary between 50
and 90% and depend on factors such as
diagnosis, severity of the disorder and
(more critically) on the scoring value for
success, as successful outcomes in one
study would not be considered a success
in another! In our recent audit using three
different MRA designs, a success rate of
67% was scored by patients for whom the
appliance was often first-line treatment.29
Identical success rates were found for the
Silensor and MRAs with 3 mm or 8 mm
interincisal opening (Figures 2, 4 and 6).
DURABILITY AND
LONGEVITY OF MRAS
The laboratory construction of the
common one-piece Erkoflex MRA is
relatively simple and economic but the
longevity varies as the appliance may split
where the blanks are ‘glued’ together
(Figure 15). Appliances may also become
loose with parafunctional forces, cleaning
procedures (especially with hot water) and
gradual deterioration of the thermoplastic
material.
The thermoplastic Silensor is also at risk
of breakage at the hinge site, which
protrudes and is a tempting point of
application for removal. The hinge may
also cause discomfort to the lips. Acrylic
prostheses do not suffer from splitting
and can be cleaned with chemical agents
and warm water. Further, they can be
relined at the chairside with cold-cure
acrylic if any looseness occurs. Flange
tears, broken and displaced repositioning
wires and fracture of the connector pins
were durability problems highlighted
recently by Tyler.30 He was concerned at
the parafunctional forces the appliances
had to withstand and advocated a regular
recall programme to inspect for defects.
Longevity of appliances is considered to
be around 2 years but will vary between
individuals.31
ODONTOSIL SILICONE
MATERIAL AND THE
GLENFIELD APPROACH
Our original MRA approach was the glued
Erkoflex 95 (Shore hardness 95) design.
This method of construction requires an
accurate record of a comfortable
protrusive mandibular position, which is
used to mount the working casts on an
articulator. Erkoflex blanks are vacuum
pressed over the opposing casts before a
glue gun heats vinyl sticks to fill the space
between the maxillary and mandibular
arches and produce a strong resilient seal.
However, this ‘gluing’ process
occasionally fails and the appliance splits
apart along the glue joint. As with other

Stage Description

Patient counselling Patient informed about what the appliance treatment involves and related to the medical diagnosis from the referring sleeping
disorder specialist. Written consent for treatment obtained. Price agreed and plans discussed on what to do if appliance does not
work.

Clinical records Maxillary and mandibular impressions recorded with the preferred material. The Glenfield registration protocol is the most
comfortable protrusion mandibular position with a tooth contact. This contact serves to stabilize the relationship whilst the
interocclusal registration material sets. Once patient has practised finding and maintaining the position the registration is made
with injectable interocclusal silicone material.

Preparation of Kaffir ‘D’ plaster vacuum mixed for master casts. Casts trimmed to an appropriate size for articulator, which must be at least
master models capable of hinge movements. Casts articulated to the recorded maxillo-mandibular relationship and marked so they can be
removed and replaced accurately. Articulator opened 2–3 mm to allow space for the material and (if required) a breathing hole.

Wax-up Any undercuts not blocked. Double sheet of wax laid over upper and lower casts in horseshoe style, extending into the sulci. Wax
cut away over the central incisor teeth to accommodate a breathing hole (if required for mouth-breathers) and wax bases sealed.
Articulator closed to the desired vertical dimension and wax added to seal the maxillary and mandibular units. Smooth finished
wax surface produced for the finished appliance as cured silicone is difficult to trim and polish.

Flasking To allow access to the labial section of the appliance when injecting the silicone a small amount of laboratory putty should fill the
breathing hole. Appliance flasked with the lower cast in one half and the upper cast in the other half of the flask. Casts modified so
they fit the flask without obstruction – the lingual plaster of the mandibular cast should be removed to aid this process. The rest
of the flasking procedure carried out as per acrylic. Unifol insulating film is used to coat the plaster surfaces. Odontosil (60 Shore)
is gunned from the double cartridge through a mixing tip and applied separately to both halves of the flask without trapping air.
Putty spacer positioned and the flask closed slowly to ensure a thin flash. Flask kept under pressure for 30 minutes.

Finishing Appliance de-flasked, flash cut off with scissors and finished with soft lining finishing wheels. The trimmed appliance can be sealed
and given a shine with Odontosil lacquer.

Fit Written instructions provided. Patients advised to acclimatize during evenings for 1–2 weeks before first wearing at night. Patient’s
sleeping disorder specialist advised that the appliance has been produced. Comfort and fit of the appliance reviewed after a month.
Patient should undergo regular dental checkups at which appliance is periodically checked.

Table 2. Clinical and laboratory stages for construction of a MRA at the Glenfield Hospital.

Dental Update – January/February 2003 21

REMOVABLE PROSTHODONTICS

thermoplastic designs, the appliance may
loosen. The ideal design is probably the
more rigid acrylic two-piece adjustable
Herbst-type appliance but this design was
not financially viable for the department.
Materials were sought to construct a
one-piece MRA that would resist splitting.
We experimented with heat-cured silicone
(Monoplast-B) but found this
unsuccessful because of difficulties in
flasking and finishing; however, Odontosil
60 (Dreve-Dentamid, GMBH) was more
promising. It is a soft silicone with a Shore
hardness of 60 and comes as a double
cartridge system, similar to the low-
viscosity silicone systems for crown and
bridge impressions, with a mixing tip that
enables flasking without introducing air
bubbles. The clinical and laboratory
stages are outlined in Table 2 and Figures
16–25.
FINANCIAL ASPECTS
In a recent personal communication, the
Dental Practice Board stated that they
consider MRAs to be ‘medical devices for
a medical condition rather than a dental
condition’ and as such ‘there is no
provision in the NHS fee structure to make
payments under the General Dental
Service’.32 They did advocate that
practitioners could approach their local
health authority to negotiate a specific
contract to treat patients. At present, and
for the foreseeable future, patients will
have to pay privately. Hospital-based
treatment has the luxury of cost being
secondary to patient care and as such
clinicians may not, therefore, fully
appreciate the financial implications of
advocating treatment in general practice.
To highlight this, various material
charges and other aspects are set out in
Table 3. Commercial laboratories in Trent
charge in the region of £79–85 for a
Silensor, £60–72 for a Twin-Block, £35–50
for an ARPS and £142.50 for an IST
appliance.33 In fact, all laboratory-made
appliances take approximately the same
amount of time to construct, apart from the
Twin-Block, and the cost therefore will
depend more on the materials used. A
Herbst-type appliance is more expensive
as a set of adjustable bite jumping hinges
costs £32.
The Therasnore Zx recently received
attention in the national and dental press
and its marketing campaign claims a
clinical (fitting) time of 20 minutes.11,12,27 It
has an in vivo construction approach
similar to the heat-and-mould (‘boil-in-the-
bag’) type sportsguard and thus an
advantage of no laboratory fees, although
the material for each appliance costs £74–
85 plus VAT.34 There is no standard
‘private fee’ advocated for the Zx,
although the recommended price is £225.
Whilst any dental appliance has a finite
lifespan, maximizing longevity is a crucial
factor as repairs will have financial
implications.
PATIENT PERCEPTIONS,
COMPLICATIONS AND
FOLLOW UP
Patients may recall, when questioned, the

Appliance Materials and Material cost Laboratory time GDP charge

bulk costs per appliance and quoted charges

Silicone snorestop 24 ml Odontosil 60 £9.50* 4 hours* No standard

(8 x 48 ml £132);

Odontosil lacquer
(50 ml £23)

Conventional polyvinyl 2 Erkoflex 95 blanks £8.00* 4 hours* No standard

appliance (6 x 4 mm square blanks £20.40);

1 Erkoflex 95 glue stick

(18 glue sticks £17.70)

Silensor 1 set of hinges (10 pack £83.60); £12–65* 3–4 hours*; £79 and £85 No standard

2 Erkoflex 95 blanks
(12 x 2.5 mm square blanks £25.90)

Anterior repositioning Acrylic and clasps Negligible 4 hours*; £36-£60 No standard

splint

Adjustable Herbst Bite jumping hinges (£32 per pair); £32* 3–5 hours*; £120–£125 No standard
(minimum)
Acrylic and clasps

IST – – Set charge £142–150 No standard

Therasnore Zx £85 + VAT for 1–3; £74–£85 – RRP £225

£74 + VAT for 8;
Starter pack £289 inc VAT for 3

Twin-Block Acrylic and clasps Negligible 4–6 hours*; £60–£72 No standard

*Approximately

Table 3. Details relating to construction of appliances.

22 Dental Update – January/February 2003

REMOVABLE PROSTHODONTICS

Figure 14. A non-adjustable vinyl MRA with

significant opening of the vertical dimension.
Figure 16. Casts are mounted using the bite
Figure 15. Splitting of ‘glued’ vinyl blanks. MRA registration.
remounted for repair.

Figure 19. Completed wax-up of MRA.

Figure 17. The vertical dimension is increased Figure 18. Profile view showing the desired
to provide about 3 mm inter-incisal space. repositioning.

Figure 20. Silicone insert for preserving

breathing hole. Figure 21. Flasking procedure. Figure 22. Wax boiled out. Silicone remains to
provide space for breathing hole.

Figure 25. The completed Odontosil MRA.

Figure 23. Injection of Odontosil with mixing
tip.
Figure 24. Deflasking the MRA.

24 Dental Update – January/February 2003

 REMOVABLE PROSTHODONTICS

Information about the Snorestop Appliance potential detrimental effects on the TMJ,
associated musculature and occlusion so
This handout attempts to inform you about your proposed appliance – the Snorestop. that patients can be accurately informed
l Your motivation and dedication to the Snorestop is essential for any chance of success.
l The Snorestop WILL feel very strange initially but you will adapt to it (it is similar to ‘gum about potential complications – especially
shields’ worn for contact sports). patients who may have to wear a MRA for
l Do not wear it at night UNTIL you can tolerate it – wear it a few hours a day/evening to life. However, the authors of a recent
acclimatize (watching TV, reading, etc.).
l Individuals often notice different tastes, increased saliva, nausea/retching sensation, soreness of review were keen to reinforce the view that
gums, facial discomfort – this is generally temporary. minor changes should be balanced against
l The material may stain with certain foods – do not worry. Clean gently with toothbrush and the efficacy of the appliances.36 Caution
toothpaste/soap (don’t use hot water) or, if there are no metal components, soak in a dilute
Milton solution during the day. has been advised when treating patients
l Do not make any judgements on its success for at least a month of proper use. with previous temporomandibular
l Phone ####–####–#### if you have any problems. disorders and severe bruxism.2,5 As
IF YOU CANNOT WEAR THE SNORESTOP PLEASE LET US KNOW AT THE REVIEW symptoms may worsen in some patients, it
APPOINTMENT AND WE WILL DISCUSS FURTHER OPTIONS is important for the diagnosis to be
Figure 26. Patient information leaflet.
ascertained before treatment is
commenced and the patient followed up
by a medical specialist when appropriate.
Potential direct or indirect detrimental
following problems associated with study:37 the mean, standard deviation and effects on oral health of the appliance
wearing an MRA:2,13,29,35–37 ranges were 0.4(±0.5) and 0.0–2.0 mm for should be monitored by regular dental
OJ and 0.1(±0.3) and 0.0–1.0 mm for OB recalls; at the same time the longevity can
l episodes of dry mouth; but no control group was used. Marklund be assessed and replacements made when
l increased salivation; et al. also reported changes in OJ and OB necessary.
l facial and/or temporomandibular in a study over 1.9–4.2 years:38 the
discomfort; changes in the test group were very small
l momentary change in occlusion on (OJ: 0.4(±0.8) mm, OB: 0.4(±0.7) mm) and DOCUMENTATION
waking; also occurred in the reference group (OJ: Clinical examination forms and written
l nausea; 0.2(±0.4) mm, OB: 0.4(±0.5) mm). Both of consent proformas have been published,
l choking; these studies used full occlusal coverage and it may be advisable for the GDP to use
l unpleasant taste; MRAs and measurements were taken to such forms if possible.23 As a minimum the
l worsened breathing problems. the nearest 0.5 mm. In a retrospective TMJ status and signs of parafunctional
telephone and postal survey Clark et al. habits should be documented. It is our
However, these symptoms are usually found that up to 44% of patients wearing policy to provide an information leaflet
transient and part of the adaptation full-coverage MRAs reported occlusal advising patients on what to expect when
process – and are insignificant compared changes that were not transient. However, wearing the appliance and how to maintain
with the potential complications of as there was no clinical follow-up it (Figure 26).
alternative treatments of surgery to the examination, the significance of this Appliance effectiveness and guarantees
maxilla, mandible, tongue or soft palate. In finding was not discussed, although they of treatment are at the discretion of the
a recent prospective audit within our did propose occlusal changes to be more clinician, although Healthtec do offer a
department, 74% adapted within 2 weeks prevalent than previously thought, partial refund if their Therasnore approach
and only 6 of the 45 patients could not despite the evidence from the study being does not work.34 It is advisable that a
tolerate the MRA.29 Compliance appears inadequate to make such a statement.35 financial agreement for treatment,
to be related to a patient’s ability of Clinically significant findings have been maintenance and effectiveness is
adaptation and tolerance in a similar reported for two patients in whom acrylic established with the patient before
manner to dentures. In addition, appliances were used that did not cover treatment commences.
perseverance, which could be dependent the anterior maxillary teeth39 (it was the The potential sequelae of untreated
on the morbidity of the sleeping disorder belief that this space was required for OSA (which include stroke, cardiovascular
and experience of unsuccessful treatments breathing). Amongst other findings a disease and nocturnal mortality) are such
such as nCPAP, could prove to be an decrease in excess of 2 mm in OJ and OB that a team approach to treatment, in
important factor. in just over 2 years was reported but no conjunction with medical specialists, is
Side-effects per se of appliance temporomandibular joint (TMJ) or muscle advocated.18,36,40 Indeed, Lowe considered
treatment are not conclusive.5,7,13,35,36 problems were encountered. The latter it mandatory that appliances are made
Bondemark reported small but statistically outcome data cannot, however, be applied only after a complete medical
significant radiographic changes in to appliances with complete occlusal assessment.2,24 Definitive diagnosis
mandibular position and incisal overjet coverage. requires a sleep study to evaluate sleep
(OJ) and overbite (OB) from a 2-year Long-term data is required to assess and breathing patterns and can determine

Dental Update – January/February 2003 25

 REMOVABLE PROSTHODONTICS
the presence, type (central, obstructive or
mixed) and severity of any sleep apnoea
and effect of appliance treatment. The
chairside-derived Epworth Sleepiness
Score is a subjective report that may allow
differentiation of simple snorers from
those with OSA but it is not diagnostic
and has limitations of potential bias,
falsification and patient literacy.23
The GDP should be aware that snoring
can occur with or without OSA and there
may be potential medicolegal implications
of treatment undertaken unless a
diagnosis has been made by a consultant
in sleep disorder medicine. Medical
defence organizations do recognize the
provision of appliances for sleeping
disorders and medicolegal cover is,
therefore, part of the indemnity.41
SUMMARY
Aspects relating to the provision of
appliances for snoring and OSA by the
GDP have been discussed and the clinical
and laboratory stages for construction of
an appliance with Odontosil-60 provided.
The clinician should decide on the most
suitable design for the patient depending
on factors such as diagnosis of sleep
disorder, cost, parafunctional activity and
occlusal registration. A formal medical
assessment of the sleeping disorder is
advocated before treating such patients.
ACKNOWLEDGEMENTS
Figure 5 is used with permission of Scheu-Dental,
Germany (www.scheu-dental.com) and Figure 7
courtesy of Pamela Ellis, FTTA in Orthodontics,
Charles Clifford Dental Hospital, Sheffield. The
appliances shown in Figures 8 and 9 were
constructed by Colin Gravenor, Chief Orthodontic
Technician, Morriston Hospital, Swansea. Data
adapted in construction of Table 1 is used with
permission of Professor Alan Lowe, Department of
Oral Health Sciences in the Faculty of Dentistry at
the University of British Columbia. Personal
communications with Rachel Swindells (Healthtec),
Rod Staines (Dental Practice Board) and Iain
Cuthbertson (Dental Defence Union) and the
Commercial Dental Laboratories in Trent are also
acknowledged.
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