Mandibular advancement

Iowa Dental Board guidelines

Dental sleep medicine is a relatively new field in dentistry and there is an unfortunate history of overzealous denists getting in over their heads, particualy in diagnosing sleep disorders that are outside the bounds of dentistry. In response to this, the Iowa Dental Board has produced a guidance document for dentists who include sleep in their practice. We strive to follow these as closely as possible.

At a more granular level, our protocols and criteria are based and built upon those of Dr. Reed Parker, who was the primary dental sleep provider at the University of Iowa College of Dentistry until his retirement.

Dental examination

We require all potential mandibular advancement patients to have a dental examination completed at our office. We typically vary the depth of this examination based on clinical presentation, taking into consideration whether or not the patient has a dental home where they receive regular care. We will take radiographs as necessary to rule out obvious dental disease. We are particularly insistant on a pantomograph from within the past 12 months to rule out any bony joint abnormalities that could increase risk. The end goal of this examination is to 1) give the patient a high level summary of their current oral status, 2) identify any dental needs that may cause an appliance to become obsolete sooner than expected, and 3) rule out the following contraindications:

Dental contraindications to mandibular advancement

• Active or severe periodontal disease.
• Frank hard tissue disease needs.
• Fewer than 10 teeth/arch.
• Chronic or historic myofascial pain concerns.

Patient's with dental contraindications

Many patient's with current contraindications can be made into good candidates with disease control. For patient's with a dental home, we will send their dentist a letter of our findings and recommendations. Moreoften, these patient's do not have a dental home. In these situations, we always offer the patient a cost estimate if the work was completed at our office as well as provide them information on how to transfer their records to a provider of their choosing; for patient's who travel to see us we will provide them with any trusted providers close to home. Regardless of how they choose to proceed, we instruct them to return once their dental needs are addressed.

Side effects

We discuss the following side effects and risks with each patient:

• Tooth movement.
• Changes in occlusion.
• Increase in or development of myofascial pain.
• Increase in or development of joint sounds.
• Non-retention of restorations.
• Loss of heavily restored teeth.
• Appliance fit & new restorations.

Success rates

Mandibular advancement does not have a high success rate, especially for individuals with more advanced diagnoses. While the prognosis is not as high as we would like, studies have found that patient's are generally 20% more likely to stick with mandibular advancement over PAP because of the increased comfort and portability.

Source: Holley, Lettieri, & Shah. Efficacy of an Adjustable Oral Appliance and Comparison With Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome. Chest. 2011;140(6):1511-1516.

Informed consent

We always obtain a written informed consent from patient's prior to fabricationg a devince, this consent emphasized the side effects, risks, and prognosis.

Device selection

The Panthera X3 is our preferred device, we switched to it almost exclusively starting in early 2023. We prefer it for the following advantages:

• The medical grade nylon is strong and robust while having less intraoral mass than other brands.
• They are highly cleansible.
• Separate maxillary and mandibular segments are easier for patients to get used to than appliance that are permantly attached.
• The sharkfin/plane advancement is, anecdotaly, our preferred advancement apparatus.
• They are easily adjustable with titration possible from 1.0 mm of retrusion to 5.0 mm of protrusion from the starting point, all in 0.5mm increments.

If you, as a medical sleep provider, have a preference for another appliance, please let us know.

Device impression & design

We utilize a digital impression technique which has been shown to be highly accurate. The impression is relayed to the laboratory completely electronically.

We use a calculuated starting position for therapy. In order to determine this, we determine the patient's functional protrusive range. The starting point is based on 30-60% of this functional range, depending on patient's diagnosis and risk of side effects. Before finalizing this position, we have the patient sit at this position for 5 minutes to ensure there are no obvious problems at this position.

In designing the we provide the laboratory with any teeth that are heavily restored or weakened, ideally decreasing the pressure on these specific teeth.

We design all of our Panthera devices with loops for rubberbands. These exist for patient's who have difficulty keeping their mouth closed at night, we can provide them with rubberbands (the same ones used in kids braces) to encourage keeping their mouth closed overnight. While very few patient's end up needing this, we like having the option as these can be difficult patients to predict.