Office Procedures
Diagnosis:
Snoring is frequently associated with apnea and there should be a differential diagnosis made prior to treatment. Apnea is a medical condition and it is required that the diagnosis be made by a physician. Start your evaluation with a health history and clinical exam, and make a referral to a sleep physician or a primary care physician who will be able to make the diagnosis. The physician will usually prescribe a PSG in a sleep lab, or an ambulatory PSG (Watch-PAT 100) to assist in the diagnosis. Never assume that a patient presenting to you with simple snoring does not have some apnea. Following a diagnosis, explain the options available to the patient and have them sign an informed consent document.
Models:
Impression both arches with a high quality alginate like Khromopan, or your favorite impression material. Pour models with a quality stone such as Fuji EP.
Bite Records:
(We recommend using a George Gauge, Method 1)
Method One (with a protrusive bite record) Use a George Gauge to calculate the AP range of motion and to help you record a bite record at 70% protruded (anterior to the most retruded position). Send this record along with models to the lab.
Method Two (without a protrusive bite record) Send models to the lab w/o a record and they will use average numbers and fabricate the appliance with the lower jaw 6 mm protruded from MIP.
Carefully wrap the models/bite records and ship them to our laboratory along with a prescription for the LSWD appliance. (see Laboratory Services for more information)
At the Laboratory:
Eclipse material will be horseshoe shaped on the palate, and wrap over the incisal edges of the upper incisors providing a place for the lower incisors to stop. The appliance will end at the distal of the first molars on the palate, and an Adams clasp will be placed to engage the upper first molars. The protrusive element "PE" is placed in a position consistent with your bite record OR will maintain the mandible 6mm forward of MIP. This PE will be up to 10 mm long but no longer than the lingual length of the lower incisors. A thin polycarbonate thermoplastic "suck down" retainer will be provided to keep the lower anterior teeth in place.
Delivering the Appliance:
Upon receiving the appliance back from the laboratory it should be properly washed and disinfected prior to try in. Check the fit of the appliance and the comfort, as well as the patients' ability to insert and remove it properly. The upper front teeth should feel comfortable with the appliance in place and an acrylic lab bur can be used to relieve any pressure spots. The appliance is designed to allow the mandible to have freedom of movement side to side, vertically, and protrusively.
Follow-up Visits:
The situation where the PE is too short, allowing the lower teeth to "fall off or disengage from" this member, is an infrequent occurrence, and the PE is easily lengthened by adding acrylic to it. Alternatively you can request that the lab place attachments on both appliances to accommodate an elastic to keep mouth closed. Acrylic can also be added to the front of the PE to increase the advancement of the mandible as necessary. I recommend curing the acrylic in a pressure pot for a minimum of 10 minutes. When adding to the front of the PE, hollow out the back so the tongue has more room to move forward. The dentist should schedule observation visits every four weeks, for the first six months, to check that the appliance is comfortable and effective, and that no dental problems have developed. Send the sleep physician a follow-up communication reviewing the treatment. Always finish the case with a final attended study to validate your success.
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