Mandibular advancement

Iowa Dental Board guidelines

Dental sleep medicine is a relatively new field in dentistry and there is an unfortunate history of overzealous dentists getting in over their heads. In response to this, the Iowa Dental Board has produced guidance document for dentists who include sleep in their practice: 'The Role of Iowa Dentists in Managing Sleep‐Related Breathing Disorders' which is heavily based on the American Dental Association's published guidance: 'The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders'. We strive to follow these guidelines as closely as possible while taking a conservative and medically focused role in helping our patients with SRBDs.

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 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 insistent on a pantomograph from within the past 12 months to rule out any bony joint abnormalities that could increase risk with mandibular advancement. 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, undermanaged, or severe periodontal disease.
• Frank hard tissue disease needs.
• Fewer than 10 teeth/arch.
• Chronic or significant myofascial pain or temporomandibular dysfunction.

Patients with dental contraindications

Many patients with current contraindications can be made into good candidates with disease control. For patients with a dental home, we will send their dentist a letter of our findings and recommendations. Often, patients with significant needs 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. We always offer to help find a trusted colleague that maximizes their insurance benefit or proximity to home. Regardless of how the patient chooses 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 patients 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 patients prior to fabricating a device; this consent emphasizes the aforementioned side effects, risks, and success rate(s).

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.
  • As of the end of 2025, the only appliance fractures we have seen have involved pets turning them into chewtoys.
• They are highly cleansable (although do pick up stain over time).
• The sharkfin/plane advancement is our preferred advancement apparatus.
  • Patients are not physically kept from opening.
    • This increases patient comfort and acceptance.
    • For patient who need additional guidance keeping their mouths closed, we can use elastics, the most benign way to keep a mouth closed.
  • The upper and lower are separate segments
    • Two smaller segments are easier to insert and remove than one large apparatus.
    • Separate segments allow patients to communicate with them in, even if it is not truly natural speech.
• 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 is highly accurate. The impression is relayed to the laboratory completely electronically.

We always use a calculated starting position for therapy custom to the patient. To determine this, we measure the patient's functional protrusive range. The starting point is based on 30-70% 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, particularly with the temporomandibular joints, at this position.

In designing the device, we provide the laboratory with a list 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 patients who have difficulty keeping their mouth closed at night, we can provide them with rubber bands (the same ones used in kids' braces) to encourage keeping their mouth closed overnight. While very few patients end up needing this, we like having the option as these can be difficult patients to predict.