I’m often asked “What is the best oral appliance to treat snoring and obstructive sleep apnoea?”
Sometimes referred to as a snoring or sleep apnoea mouth guard, this article will discuss the basis for choosing an oral appliance and then review some of the commonly used appliances in Australia.
Custom made, titratable (adjustable) oral appliances are now recognised by researchers and experts in the field as the best available treatment for snoring, and along with the CPAP machine, one of the two main proven treatments for sleep apnoea.
There have been 10 studies comparing different combinations of custom made appliances and the results always demonstrate that each of the appliances are equivalent with regard to effectiveness. There is no “Gold Standard” appliance- despite the claims made by companies. The key to success is not the specific design of the appliance but the level of comfort, the ease of titration, and the minimisation of side effects.
Compliance is the key, and when it comes to the level of comfort with minimal side effects, not all appliances are the same. The fit, dimensions and type of material used in construction are becoming the main factors.
The type of material
Traditionally appliances have been made from the acrylic resin plastic material and while this material has served the profession well, it is not without problems. Acrylic is brittle, prone to fracture, and consequently needs to be relatively thick. There has been a revolution in the materials used for appliances with the advent of 3D printed nylon.
3D printed nylon
3D printed nylon brings in a new era which is rendering the traditional acrylic resin obsolete for the manufacture of sleep appliances.
Appliances made from nylon can be made down to a thickness of 0.5mm, yet still be unbreakable in the mouth. This is of the utmost importance given that comfort, compliance and longevity are regarded as the key factors for successful outcomes.
Selecting the right appliance for each individual patient
It is important that a dentist can choose from a range of snoring or sleep apnoea mouth guards or appliances in order to select the one most appropriate for the individual patient. The choice of appliance may depend on factors such as number and configuration of teeth, the relationship between the upper and lower teeth, the presence and degree of bruxism (clenching and grinding), the presence of jaw joint dysfunction and the amount of intra oral space.
9 Commonly Used Custom-Made Oral Appliance Reviews
The appliances reviewed here have a similar level of efficacy, however they vary in comfort, longevity and the potential to cause side effects.
Apart from the materials used, a significant point of difference between the appliances is whether there is a solid connection between the upper and lower components. When the upper and lower components are connected there is the potential to cause more side effects than if they are not connected, and can move independently.
The following factors were assessed for each appliance:
Appliances are subjected to the forces of clenching and grinding, and it is extremely important that they are sufficiently strong so they don’t break while in use. Traditional materials, such as acrylic resin, are prone to fracture. This can have extremely serious consequences with pieces of material floating around the mouth while the patient is asleep. There is a real danger of swallowing, or even inhaling a piece of acrylic, with extremely severe consequences.
One of the key advantages of 3D printed nylon is the far superior resistance to fracture than any other current material in use. They are considered unbreakable in the mouth.
As patients will use their appliance up to 8 hours per night over the mid to longer term, a focus on comfort is key for achieving successful outcomes. Comfort can vary considerably depending on the type of material, and the design of the appliance.
Adjusting the appliance is crucial in finding the optimal position of the jaw that eliminates the snoring and the symptoms of sleep apnoea. While it is critical that an appliance has inbuilt adjustability (not all do) the ease and ability to make fine adjustments can vary considerably.
The following table outlines and reviews the most common appliances that dentists are currently providing for their patients in Australia.
3DSleep Nylon Dorsal Panthera X3
Both these appliances from different companies are equivalent, being of the dorsal design and made from 3D printed nylon.
The dorsal design is the only type of appliance in which the upper and lower parts are not connected allowing jaw opening and closing, sipping water and speaking. The nylon construction allows for minimal dimensions yet optimal strength in thin sections.
3D Nylon Panthera D-SAD
Manufactured in Canada from 3D printed nylon, the upper and lower components are connected with exchangeable side connectors which allows for mandibular advancement.
Acrylic Somnodent – classic and flex
A dorsal design appliance, with the advantages of upper and lower parts not connected. Construction is from hard acrylic, or a soft-hard combination, making these appliances thicker than those made from nylon and also more prone to fracture.
MDSA (Medical & Dental Sleep Appliance)
An Australian designed appliance in which the upper and lower parts are connected by an anterior, adjustable hook attached to a plate on the lower. This appliance prevents the jaw from dropping during sleep which can increase the effectiveness for a subgroup of patients.
While the stainless steel of the anterior mechanism is strong, the acrylic construction of the body of the appliance is prone to fracture. Also the anterior mechanism can be an irritant to the tongue for many patients.
It is generally thought there is a greater potential for bite changes with this appliance due to the focus of forces on the anterior teeth.
Made from 3D printed nylon, this appliance has flexible side connectors identical to that of the EMA appliance. There is an anterior air vent which may be useful for patients with nasal obstruction. The addition of the air vent adds to the thickness and vertical height, making the appliance more obtrusive than others.
The Avant is a milled acrylic appliance with a soft liner. Mandibular advancement is achieved by interchanging connectors of differing lengths between the upper and lower.
The appliance is less obtrusive than the Somnodent dorsal range, however the ability to do fine titration has diminished. The strength of the acrylic has improved by the milling process however may still be prone to fracture.
Silensor EMA (Elastic Mandibular Advancement)
These appliances are very similar and are generally made from a hard/soft laminate material which while adding to the level of comfort, has limited longevity and is prone to fracture and staining. The upper and lower components are connected with exchangeable elastic or plastic side connectors for titration and bringing the jaw forward. The side connectors are prone to stretch or break, thereby not maintaining the mandibular position and requiring regular changing.
Custom made oral appliances are now regarded by medical experts in the field as one of the two proven treatments for snoring and sleep apnoea.
Patient comfort and compliance are the keys to successful outcomes with oral appliance therapy. It is important that the dentist uses appliances that are robust, fit well, are of minimal dimensions, and are associated with little side effects. For further advise on sleep apnoea treatment get in touch with our Sleep Clinic in Melbourne or Geelong for a consultation today.