Which Design is the ‘Best?’

by Sonnie Bocala

As a lab that is licensed to manufacture over a dozen of the top sleep devices, we spend most of our day coaching our clients to align their clinical findings, diagnosis, treatment plan, and insurance constraints with one of the 4 (A,B,C,D) mechanisms of mandibular advancements. Once we understand what the mouse needs, we can then select “the best” mouse trap. The following are “pearls of wisdom” that we have gathered from over 20 years of helping our clients to select “The Best” sleep device for their patient. I’ve also asked some of our clients for remarks about their clinical experiences.

Design A – “Push & Pull”

The TAP Sleep Care (Airway Management, Inc.) device has been the leader in this category. Medicare approved. Thin overall profile with various material options for fit and comfort. Uses the anterior teeth to “engage/lock” the mandibular in position without a cumbersome buccal profile often seen in sleep devices.

I find the TAP design very helpful for patients with ‘supine dependent’ OSA – the interlock won’t let the jaw fall back in any position. It has very low buccal profile, so no metal to interfere with the cheeks – great for wide upper arches. Unique to TAP is a lip shield (I call it a nasal breathing trainer) that can be attached to the front to help seal the lips. I don’t use it with weak or heavily restored upper anterior teeth or when the patient has a large maxillary incisal angle. – Steve Carstensen, DDS, DABDSM

Design B – “Bilateral Push”

Commonly referred to as “herbst/hinge” and available through most brands (Apex Dental Sleep Lab, Inc., Oasys, Kava, SomnoMed North America, OravanOSA, ProSomnus^® Sleep Technologies, Panthera Dental etc.) Often prescribed for compliance with Medicare guidelines/reimbursements. Available in many materials for comfort and durability with various technologies being utilized for manufacturing. Uses herbst hardware on the buccal to mechanically hinge and advance the mandible. The Oasys hinge is the most preferred mechanism in this category because of its simple adjustability, low profile, and least lateral restriction.

During the titration process, TMJ issues may occur. The fact that the appliance allows for lateral play and can be adjusted on both sides, gives it an advantage in redirecting the mandible to reduce or eliminate TMJ symptoms. – J. Todd Gray, DDS, D.ASBA

Design C – “Bilateral Interlocking/Fastened”

Commonly known as “Dorsal” and available through most brands (SomnoMed North America, ProSomnus Sleep Technologies, Panthera Dental, Apex Dental Sleep Lab, Inc.) Originally made famous in North America by SomnoMed Team, the dorsal design has evolved significantly and is now available in milled PMMA and SLS Nylon. The bilateral dorsal wings allow for simple and easy mandibular advancement while maintaining tongue space. The efficacy of this MAD has been well researched by industry leading companies such as Somno-Med Team, Panthera Dental, and ProSomnus Sleep Technologies.

The Dorsal Fin design for the oral appliance has served many patients who have a limited vestibular space between their cheeks and teeth. The key feature for me is to have a 90-degree angle of the maxillary block when it contacts the mandibular fin. This helps prevent the fin from disengaging while the patient is sleeping in a supine position and assures the mandible will not “fall back”. Two additional design features I favor are to place the Dorsal Fin mechanism in the first molar area, where the molar teeth are the most stabilizing to limit tooth movements and bite changes. The second feature is to be mindful of those patients who have nighttime Bruxism. If Bruxism is moderate to severe, perhaps another mechanism would be indicated. However, it is standard for me to request a vertical reinforcing metal support implanted within the Dorsal Fin to resist lateral forces and Fin Breakage. – Barry N. Chase, DDS, D.ABDSM

Design D – “Bilateral Pull”

Originally introduced and patented by Dr. Don Frantz as the EMA (Elastic Mandibular Advancement), using a simple vacuform base design. This design has since been adapted to various forms such as the Medicare approved SLS Nylon D-SAD by Panthera Dental and the Avant by SomnoMed North America. This design category is the fastest growing because of its sleek and TMJ-friendly design. It appears that EMA will continue to be the top contender as it evolves to add milling technology with a proprietary puck as well as the SLS nylon by Serena.

As it was stated in the opening of this article, there are many different dental sleep appliances on the market and they all will work to treat OSA. The key to success with treatment is a good examination of the patient to see the oral anatomy and what the needs of the patient are and then you can pick the appropriate appliance for that patient. Too many times we tend to buy into the newest, latest, and greatest appliance (as advertised by that company) and forget that all of them work and then put some of the best on the shelf while we try others. I have done this myself. Most of the time, I have gone back to one of the first appliances that I was introduced to, the EMA. With the different base materials available (milled and printed), one of the tried-and-true appliances is exceptional with minimal problems. This appliance is very easy for anyone to titrate themselves (even seniors), has a very low profile in the buccal area, has a very good lateral movement possible (for bruxers) and will withstand the forces exerted. I have used this appliance on hundreds of patients over the years and had very few failures with the treatment or problems with the appliance. One of the main drawbacks of the older versions, breakage of the plastic bases, is not an issue now. – Terry R. Bennett, DMD, DABCP, D.ABDSM

Undoubtedly, these 4 mechanical designs categories are here to stay and fortunately, Apex Dental Sleep Lab, Inc. has long-standing manufacturing licenses with the top brands in each category. Thanks to our licensing partners for pushing the envelope of bioengineering.