The Science Behind the Appliance

Over the past 20 years, there has been a dramatic rise in awareness of and interest in dental sleep medicine. In response, there have been major advances in home sleep testing, pulse oximetry, 3D scanning, 3D printing, and an array of different and specialized appliances have been developed. Yet, there have been relatively few advances in one key step in the process: bite registration.

Bite registration is one of the most important elements in successful Oral Appliance Therapy. Accurate measurements are key to fabricating a comfortable and effective device for treating OSA. The ideal starting position for treatment is a perfect balance between comfort and effect. Getting this right can make a big difference with patient compliance and ultimately the success of treatment. If the device is set too far forward and is uncomfortable, the patient may abandon treatment. Too many return visits for titration can lead to patient frustration, and even abandoning treatment. Accurate bite registration can prevent both scenarios: patients can experience treatment benefits on the first night, with little discomfort adjusting to the device. Positive initial experiences increase patient buy-in, ultimately leading to better treatment outcomes.

Despite the crucial role bite registration plays in dental sleep medicine, there are still only a handful of alternatives on the market, each with their limitations.

There are several issues that in various ways can apply to all the currently available options:

Horizontal Only

As the science of dental sleep medicine has advanced, there is growing acceptance that many patients benefit from a combination of horizontal protrusion and vertical rotation of the mandible. Many bite registration systems are horizontal only, or with limited vertical positions.

Slow

Bite registration should not take very long. Some options select a random starting point, waiting until the patient returns for titration to fine-tune the mandibular position. This delay in finding an ideal point of efficacy can lead to patient frustration and even abandoning treatment.

Inaccurate

The variation in bite registration systems can lead to inaccurate measurements in several ways. Some devices require very specific positioning to get an accurate reading. Some are manufactured using inherently variable methods. We tested one popular system and found that some of the gauges can be off by as much as 300 microns, which seems small but can be a huge difference when titrating an oral appliance.

Complicated

Some bite registration systems are overly complicated, with pieces that need to be flipped or reversed to step through all the sizes. Some require calculations to determine the final measurement, or specialized training like phonetic bite set methods. Some methods are so complicated that dentists don’t trust their assistants to take the registration correctly, resulting in more chairside time for each case. Complicated methods result in longer time in the chair and measurement mistakes, leading to more titration visits.

Not Designed for 3D Scanning Workflows

Not all bite registration systems play nicely with 3D scanners, which are increasingly replacing impressions. 3D scans are more accurate, and for 3D printed appliances, allow an entirely digital workflow. But not all materials and shapes are ideal for taking 3D scans of a patient’s start position. Shiny, reflective surfaces can interfere with the sensors, producing inaccurate scans. Bulky or obstructive devices can prevent the scanner from “seeing” enough teeth.

A New Way

Meet Stan Jones, a 26-year veteran of dental sleep medicine and inventor of Optimal Air, a patent-pending system for bite registration developed specifically for dental sleep medicine from Nexus Dental Systems. Stan got his start as a dental assistant back in the 90s just as dental sleep medicine was starting to gain wider acceptance. “I went to a day seminar on the topic with [his dentist], and that was the first time that I heard the words ‘dental sleep medicine’ used together,” Stan recalls. The following week Stan got a sleep test and was diagnosed with Obstructive Sleep Apnea. His physician offered a CPAP, but after attending the seminar, he decided to try oral appliance therapy first.

At the time, only a few appliances were available. Stan studied the different types carefully and being a lab technician, took his own impressions and fabricated his first device out of wire and acrylic. Within 3 months, his blood pressure was down, he had lost weight, and his AHI went from 28 to 7. This began a decades-long journey into the world of dental sleep medicine. Over the years since, Stan has worked with dentists of all experience levels to integrate Sleep Medicine into their practices as a coach. He has developed and refined protocols for each stage of sleep medicine in the dental practice – laser focused on making the process seamless for the team and reducing opportunities for errors.

“For many years, I used horizontal bite systems to set the bite for oral sleep appliances, but after studying the upper and lower airway and TMJ, I began to consider the possibility that horizontal and vertical offset might be the secret to optimal jaw position.” At the time, there were several systems on the market that incorporated horizontal and vertical advancement, and Stan tried them all. He received positive feedback from patients, and dentists were getting good therapeutic results, but he felt the available systems were complicated and difficult to use compared to a horizontal-only method like a George Gauge™.

Over the years, Stan had used all the various techniques to set a bite, searching for each patient’s optimal starting position. No method was exact, and devices always had to be titrated for optimal performance. Some patients quit therapy because oral appliance therapy was not comfortable at the starting position of the device. Each method of measurement came with its own learning curve. There could be significant differences in measurements based on how the device was held and read. Some systems involved flipping measurement blocks and doing calculations to determine jaw position. It was easy to write down the wrong number. That just didn’t fit with Stan’s philosophy of keeping things seamless, simple, and reducing the opportunity for error.

Stan knew there could be a better way. It needed to measure vertical and horizontal displacement. It needed to get the measurement right, before the appliance was made. It needed to be simple enough that the results would be the same no matter who took the measurements. After years of development and field testing, he partnered with Nexus Dental Systems to bring Optimal Air to practices across the country in 2023. “We’re always looking for smart solutions that improve everyday processes in dental practices. Optimal Air is exactly that. It’s a big upgrade to a process used on every patient – at the end of the year it’s a big difference for the practice,” says Brett Brocki, one of the founders of Nexus Dental Systems.

Every element of Optimal Air is designed to make the system easier to use, provide an accurate measurement and reduce possibilities for error.

Optimal Air has integrated well into my dental sleep workflow. There’s honestly so much to love about this product, especially for those familiar with Airway Metrics. The vertical gauge is much easier to use, more precise, and allows for patient buy-in as they can feel and hear their snoring soften chairside. The Horizontal keys have notches that sit better on patients’ incisors, which seems to improve the stabilization of the mandible in protrusion. The abundance of keys really helps us to dial in an accurate starting position and feel more confident about it. The large handle on the Horizontal keys, easy to read labeling, and very organized arrangement are advantages that make this system easy on myself and the team.
– Dr. Marc Newman, Newman Dental Sleep Medicine, Carmel, IN

The Vertical Gauge

Optimal Air comes with a 7-level vertical gauge, in 1mm increments. This allows accurate vertical measurements within 1mm to be taken prior to the fabrication of the appliance.

Horizontal Keys

Stan paid special attention to the shape of the horizontal keys. Other systems use double-sided keys, with different measurements on each side. This makes it hard to know what size was in the patient’s mouth and makes it hard to hold the key. Optimal Air keys are one sided, with the measurements written on each side, and with a large key shape on the other side. This makes the keys easy to hold, and easy to see what size is in the patient’s mouth, no matter where you are. Optimal air also features a safety system: a small hole in each key, allowing dental floss or wire to be threaded through, which prevents keys from falling on the ground or worse, into the patient’s mouth.

Accuracy

Optimal Air is proudly made the USA, 3D printed in house to an accuracy of under 50 microns of the indicated size. The bite notches on the horizontal keys are deep and oval shaped, making for a more secure fit on the tooth compared to systems with shallower or more rounded notches. Less wobble and play in the notch makes for a more accurate and reproducible bite registration.

Simple and Fast

The Optimal Air process is designed top to bottom to be easy to understand and fast to administer. First the clinician uses the vertical gauge to determine optimal vertical displacement, then tests each of the 4 horizontal keys for the corresponding vertical size. The keys are tested in order from left to right, with no flipping, no calculations, and only one set of numbers visible on all sides. This makes it easy for the clinician to record the correct measurements every time – spending as little as 2 minutes taking the bite.

Built for Scanning

Optimal Air is an ideal system for 3Dscanning. The selected horizontal key is compact and does not interfere or block any teeth. The keys are printed with a non-reflective surface, so the light from the scanner or ambient light from the room does not cause errors due to reflections.

I have been using Optimal Air for the better part of a year now. What I most value is that I am able to find a very therapeutic bite right out of the gate. I have had multiple experiences where my mandibular advancement appliances required zero titrations, which saves on chair time but also helps the patients feel confident in their treatment and my clinical skills. I love that I have the ability to control both vertical and horizontal possession independently with great precision and to demonstrate a desired outcome to my patients. The key system is easy to use. As part of the process of using Optimal Air, it also allows you to control for and evaluate upper/nasal airway restrictions that may affect treatment while assuring that you have the conversation with a patient who may benefit from nasal expanders or additional upper airway interventions. Optimal Air has helped make me a better clinician for my patients.
– Adam Milmont, DDS, Hilltop Family Dental, Casper, WY

Results

While there have been no definitive studies on Optimal Air yet, field testing has shown incredible potential. Dentists are reporting fewer titration visits are required to get optimal results, reducing the cost of treating each case. Some patients require no titration at all. Most patients are experiencing positive results the first night of treatment with appliances made using Optimal Air: their snoring stops, their AHI drops, and they feel better.

For more information on Optimal Air, visit optimalairsleep.com or nexusdentalsystems.com.