Maxillofacial prosthetics: theory and practice Airway sleep disorders9

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Removable prostheses for airway sleeping disorders
Introduction:
Upper airway sleep disorders (UASD) are becoming commonly recognized by the
medical and dental communities, and patients are now being referred to dentists for
treatment of these conditions using removable oral devices.
Snoring is the mild form of these disorders, obstructive sleep apnea (OSA) is the
severe form, and upper airway resistance syndrome (UARS) falls some where
between the two.
Anatomy:
In the normal anatomy, the upper airway is a soft tissue tube,
maintained by muscle activity extending from the oral and nasal cavities to
the bronchial tubes.
The activity and timing of the tensor veli, elevator veli palatine,
genioglossus, and geniohyoid muscles maintain the position of the soft
palate, uvula, tongue, and hyoid bone in a position away fromthe posterior
wall of the pharynx.
The airway patent of snoring patients is partially obstructed. This
obstruction is very often caused by the tongue and /or hyoid bone and
overlying soft tissues dropping back toward the posterior wall of the pharynx. In attempting to
get sufficient oxygen to the lungs, there is an increase in velocity of air passing through the
reduced airway space. This increase in velocity may cause flabby tissue, often the soft palate and
/or uvula, to vibrate. This vibration is the sound of snoring.
Treatment Options
Once diagnosed with a UASD, the physician has five basic treatment options:
behavioral modification,
surgery,
continuous positive air pressure (CPAP),
oral devices,
Medication.
Maxillofacial prosthetics: theory and practice Airway sleep disorders9
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upper airway muscle tone: mild OSA avoid alcohol and sedatives
upper airway lumen size:
o Mild to moderate OSA weight reduction, avoid supine position and use
oral prosthesis to keep airway patent
o Severe OSA: Uvulopalatopharyngoplasty
upper airway subathmospheric pressure:
o 1.mild to moderate OSA improve nasal patency;
o 2.severe OSA nasal CPAP
Bypass occlusion: severe OSA - tracheotomy
Maxillofacial prosthetics: theory and practice Airway sleep disorders9
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Oral Devices
Types:
Oral devices are of two basic configurations,
Mandibular advancement device (MAD).
Tongue retaining device (TRD)
The TRD is laboratory fabricated; MADs may be stock devices or laboratory fabricated.
Mode of action:
Oral devices generally work by directly or indirectly preventing the tongue form
approaching the posterior wall of the pharynx.
The TRDs work through the use of a hollow bulb and sufficient vacuum to hold the
tongue forward.
The MADs work indirectly by holding the mandible and hence the tongue forward. These
devices also aid in preventing the hyoid bone form dropping posteriorly and its overlying
tissues from impinging on the upper airway.
All dental devices are obviously intraoral and therefore require a certain amount of space and
movement of the mandible or tongue.
Tongue size and theamount of space between the soft plate and tongue are objective evaluations
that may help identify a compromised upper airway or be useful in determining the type of
device most suitable for a patient.
Maxillofacial prosthetics: theory and practice Airway sleep disorders9
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Maxillofacial prosthetics: theory and practice Airway sleep disorders9
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A] Mandibular advancement devices
MADs are either adjustable or single position devices.
Single-position MADs depend upon the clinician properly determining the desired protrusive
position that will eliminate the snoring and/or OSA.
Single-Position Stock Devices [single-piece single-position stock device].
These devices are generally fabricated from two rigid-plastic sheets in the shape
of impression trays joined into a single unit.
The trays fit over both the maxillary and mandibular teeth
simultaneously and receive retention from a thermoplastic
fill material.
The mandibular side of the device has a vertical arm
extending lingually below the plane of occlusion and behind the mandibular
anterior teeth.
Retention is not required on the mandibular arch because the lingual surfaces of
the mandibular anterior teeth are in direct contact with this lingual projection.
This flange will prevent the mandibular arch form moving posterior during sleep.
An interocclusal record is often made at approximately 70% to 75% of the
maximum protrusive movement.
A tongue blade is placed between the maxillary and mandibular incisors
with the patient in the normal retruded occlusal position.
A small mark is made on both the top and bottom of the tongue blade in
the midline and against the maxillary and mandibular incisors. The patient
is than asked to thrust the mandible as far forward as possible in a
protrusive movement with minimal lateral deviation, and a second mark is
made.
The distance between the two marks, multiplied by 0.7 is approximately
70% of the patients maximum protrusive movement.
An interocclusal record is made at this point. The tongue blade is also used
to determine the maximum vertical opening of the mandible.
Maxillofacial prosthetics: theory and practice Airway sleep disorders9
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Adjustable Stock MADs
These devices are generally shaped like plastic impression
trays. The trays are filled with thermoplastic material for fitting
to the patient with some mechanism for adjusting the mandible
in a protrusive and retrusive direction. e.g Stock two piece
adjustable device with a screw mechanism.

A screw mechanism for positioning the mandible is commonly used. A potential

disadvantage of this device is that the patient must be very careful when adjusting the
screws.
The two-piece adjustable devices do not require as much interocclusal space as one piece
devices. The thermoplastic material allows multiple adjustments as necessary, and the
adjustability allows the mandible to be protruded the minimum distance necessary to
achieve satisfactory results.
Adjusting the screw mechanism either moves the mandible in an anterior direction and
indirectly moves the tongue away form the posterior wall of the pharynx or the mandible
is allowed to drop more posteriorly, reducing stresses on the TMJ .
The interocclusal records are made at approximately 50% of maximum protrusion and
with at least 5 mm of clearance between the anterior teeth.
If the device reduces snoring to an acceptable level or eliminates it following insertion and no
TMJ or tooth discomfort is reported, adjustment is not necessary and the device can be worn
with the mandible in its initial position. However, if the snoring level is not acceptable, then the
mandible is slowly protruded 0.25 mm per night for no longer than 2 weeks, at which time the
patient is re-evaluated. This protrusion is resumed and continueduntil the desired snoring results
are achieved or TMJ discomfort begins.
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Tongue Retaining Device (TRD)
The TRD (e,g. Flexible tongue retaining device) is an
excellent device for edentulous patients or those who suffer
form TMJ sensitivity.
This is a one-piece device made of a non rigid vinyl material
without thermoplastic material to adapt to the teeth.
The effectiveness of these devices depends upon holding the tongue forward in a hollow
bulb away from the posterior wall of the pharynx.
Fabrication of this device requires a kit containing two hollow bulb templates. The
templates are basically hollow bulb devices on top of the tray of the device.
The templates is used to select the proper bulb size necessary to create a vacuum to
hold the tongue, to position the bulb to achieve the desired tongue protrusion, and as
tray to hold interocclusal recording material.
Once the proper bulb size is selected and the tongue is well retained in the hollow
bulb by the vacuum, the patient is asked to protrude the tongue the maximum
comfortable distance possible, and the incisors are closed onto the anterior part of the
template.
Air is squeezed out other bulb to achieve the vacuum, necessary to retain the tongue
in the hollow bulb.
Poly vinyl silaxance bite-recording material is placed on the sides of the template.
The template with recording material and diagnostic casts is used to fabricate the
actual TRD for the patient.
Patient instructions:
When initially inserting the device, the patient should be instructed to place the
device over both arches and push the tongue into the hollow bulb.
The patient is instructed to create a vacuum in the oral cavity, the bulb is squeezed
until as much air as possible is removed from the bulb and a significant vacuum is
created, especially around the tongue.

The patient is should be instructed to relax the lips and relapse the vacuum around
the maxillary and mandibular arches. The tongue must be well retained within the
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hollow bulb by the vacuum at this point and should be difficult to pull the device
off the tongue.

The patient is instructed to protrude the tongue into the hollow bulb and the
vacuum should hold it there for several hours per night a minimum of 6 hours of
sleep with the device inserted should be the goal for the patient.