One of the greatest advantages of digital impressions and oral appliances is how there is very little post op adjustments to be made when you capture the vertical dimension correctly. Here, we deliver a Panthera OSA device with just an exam kit.
When scanning for an oral appliance with an intra-oral scanner, you can capture the upper jaw and the lower jaw and the Verical Dimension in protrusive, but if you don’t transfer that information to the lab, there is a good chance they will not properly mount them
There are a lot of software available to you where you can mount and pin the models together so when they are printed, they can use male and female components to align them properly
This video shows how to capture the upper jaw. It is the easier arch to scan as there is no tongue, saliva or a dark oro-pharynx to manage
Every type of user should watch this carefully and appreciate where we recommend you start scanning the lower arch. In our courses we go in to great detail on why you should not start in the anterior or the second molars. you instantly set yourself up for trouble. here’s the easiest place to start and to build and accurate model with
Also, as new user, if you are working alone, you can use the optragate to retract the lip and the tip of the camera to displace the tongue. We recommend that you use a focal setting of 12 mm’s. This may slow advanced users down, but for new users, it helps hide distractions for the camera and software and speed you along. If you look in the bottom right corner, anything in purple is what the camera ignores. There are certain elements you want the camera not to see so it doesn’t slow you down
quick little pointer for a new user that shows how to protect areas so that you don’t introduce errors like the tongue getting in your way. the blue models areas that are protected so any future data that lands on it is automatically deleted
Capturing the bite in open and protrusive position
With every 3D software, there are times where the data sets are too large for the software to recognize and merge models to. Once in a while, you may have to help in manual mode. In this case, you can see how the open bite prohibited the models from being articulated properly and we had to use the manual mode to pin the left and right bites
A friendly reminder- this case was table top scanned with a desktop scanner so don’t get distracted, but be aware that for oral appliances, particularly for apnea treatment or bruxism, to be aware of your lab’s capabilities. Many labs will just take your upper and lower scans and print them and hand make the appliances. To combat that, we recommend that you mount your models with support pins and edit / shape data , fill holes, etc,.. before sending it to the lab.
If you are using exocad, don’t make watertight models in the medit software, but do fill in major holes. Exocad doesn’t like closed models when it puts a base and adds support pins. If your lab prints these, at least the pins will force them to mount it in proper orientation
There are many ways to capture the upper and lower jaw digitally and mount them correctly in a protrusive and open bite for obstructive sleep apnea devices. In this videos, we feature how to digitize conventional impressions with the Medit i500 and mount them with a model creator so that that you order printed models and/or oral appliances.
Desktop scanners accomplish this much more readily, but it is a snap with intra-oral scanners. The key is to know how to pick up hidden and deep areas, which you can often correct by trimming away excess flash of impression material with a scalpel
One of the greatest challenges in oral appliances for obstructive sleep apnea therapy is to capture the bite in the protrusive and open position in such a fashion so that you reduce or eliminate any adjustments after delivery
One of the greatest benefits to capturing the arches digitally and relating to each other before production is that you eliminate most of these adjustments. Proper scans and proper prints of model for appliance manufacturing make delivery appointments just a few minutes long. We hardly ever open the exam kit anymore
A very important principle to keep in mind with intra-oral scanners is how that data is printed. There are too many reasons to list what can constitute a mis-print. One method to verify accuracy of your printed models is to scan them and take that digital model and merge them with your intra-oral scan model. You pick some common data points and manually align them.
Once that is performed, you can do “best fit matching” and the more green and blue you see in the color profile, the more accurately your meshwork or data points match each other. Once you do that you can take your slice tool and look at the contours of the data and see how well they relate to each other. In this case, we scanned the upper printed model and then merged it with the intra-oral scan used to fabricate the device. There was not a single adjustment made to the appliance for occlusion or for fit
This recent publication in the Journal or the American Heart Association details the relationship between sleep apnea and cardiovascular disease. It is a comprehensive study evaluating the success rate of possible treatment modalities, including oral appliance therapy.JAHA.118.010440
This article documents how to capture upper and lower scans for an oral appliance to treat obstructive sleep apnea. The patient was recently diagnosed with mild sleep apnea with a Home Study Test which revealed quite a lot about his sleeping habits and patterns.
The patient decided to pursue treatment with an oral appliance in lieu of CPAP therapy. Upper and lower impressions were taken, and the occlusal relationship was captured in protrusive and with the vertical dimension set a a tolerable distance. Cotton rolls were used to block out the movement of the tongue which usually interferes with capturing the bite.
Once the bite is captured, we recommend that you move back to the maxilla and mandible catalog box and take additional images to complete and remaining voids in the model. At the end of the article, you can download in multiple formats to see the meshwork and the data that is rendered from the Medit i500 scanner.
Once the patient adapts to the appliance, a titration study will be conducted to measure the effectiveness of the oral appliance
Introducing the CAD-Ray Obstructive Sleep Apnea Device, manufactured by Burbank Dental Lab. This appliance is printed with an FDA approved material by an FDA certified lab. They also happen to print thousands of surgical stents and models with a variety of printers.
You can submit your case digitally and the whole process is done without pouring up any models or suck-down stents. Printing vs. milling also has a lot of advantages with faster turn around time and less cost. Instead of delivering a device that has to meet minimum thickness requirements that inadvertently increase the patients vertical dimension, this oral appliance is ultra thin and durable.
In this video, you can see the required thickness of some materials that increase the vertical dimension to the pointy that they may cause discomfort. Moreover, we can customize the design to include small hooks and knobs, in which patients can even use orthodontic rubber bands, reducing the bulk of the material significantly.
These cases can be submitted through the CAD-Ray portal for design, sent to Burbank Dental for manufacturing (printing), and returned to you in a short period of time.
My daughter has been on my case about getting her the new iphone. Apparently, she’s in grave danger because she has no more storage left because of her images and music libraries. So I went over to the apple website to see the new phone but caught the live streaming part of the launch. Only saw a few minutes of it, but a tremendous amount of energy and resources have been poured into cardiac screening with the new watch.
I’m going from memory here so this may not be accurate but the two things that caught my attention was how they will closely monitor resting hear rate and more importantly, they will look for spikes in heart rate when there should not be any. The only word that was not spoken was apnea. Clearly, the next step is going to be pulse ox, measuring blood sugar levels, and other health monitoring systems.
Here’s the video. Watch from minute 27:30
Another appliance company for apnea. I believe its over 150 of them now. This one promoted at invisalign summit. I have no issues with the appliances. 300 would be even better, but what drives me nuts is when companies and shills show this before and after on CT’s and how the airway opens after treatment. It is absolutely fraudulent to make such claims and to measure success in this manner. It is very misleading and can get a lot of people in a lot of trouble.
I’m a big fan of CT scans. I don’t even take fmx any more. It’s CT and bitewings most of the time. Periapical in posterior maxilla is useless to me. But this non-sense has to stop. It starts with donut face stuffing fatsos making up conditions that don’t exist and that it perpetuates through the industry as the rest try and catch up. next thing you know everyone is claiming success with their device by showing before and after CT scans as their measured form of success.
Patient positioning can have an impact on this airway measurement. Tongue positioning does too. Swallowing can. So many factors in a 15 second scan can contribute to it as well.
let me make it simple for every dentist here to understand this: NO ONE can claim that the airway improved with sleep appliance therapy based on the measurement of airway difference between pre and post op CT’s. It is absolute fraud, dangerous, and it falls under the federal false claims act.
It is incredible what you will learn as a clinician once you get involved with sleep apnea.
I just met a woman with co-morbidities of diabetes and hypertension. The conversation led to how miserable she was when waking up from a terrible night’s sleep. In this bar graph, you can see how she desaturated for over 30 minutes. You can also appreciate the spikes in her heart rate during that time span, while she struggles to breathe. Every time i see this, Pink Floyd’s “Breathe” pops into my head
DR TRACEY NGUYEN
“There are only 2 ways we can breathe. Through our nose or through our mouth. Dentists are the most qualified and have the most training in craniofacial and dental development. So you’re not just a Dentist.
I have personally helped a lot of sick children and helped families. I have sleep physicans asking me if we can improve the airway volume. I invite you to come to my area, and meet my team of specialists. You have to buy us dinner though 🙂 My team consist of perio/Ortho/oral surgery/ent/pediatric sleep physican/and myofunctional therapist.”
Dr. Tracey Nguyen maintains a private private 30 minutes outside of Washington, DC, in Northern Virginia. She is accredited by the American Academy of Cosmetic Dentistry and a fellow of the Academy of General Dentistry. On top of being trained by some of the best leaders in dentistry, she continued her training at at the Kois Center in Seattle, Washington. In 2016, she was honored with Top 25 Women in Dentistry. As a member of the Wellness Dentistry Network, her practice is heavily based on integrating overall health, bridging the gap with medicine and dentistry.
Recently she created the Northern Virginia Interdisciplinary Airway Group, focusing on screening, diagnosing and treating children and adults with Sleep Disorder Breathing.
- Understand why dentists are the key players in treating Sleep Disorder Breathing (SDB)
- Recognize the major medical red flags that are important in screening children with SDB
- Develop a through pediatric screening protocol
- Understand what to look for in a pediatric sleep study and understand other in office screening tools
- How to developing a local interdisciplinary team and market yourself as ta leader in airway management
Patient information regarding the presence of sleep disordered breathing (apnea), begins with thorough clinical evaluation. The patient/parent should be interviewed regarding snoring, mouth breathing, medications, and visits to the ENT. An important initial area of assessment includes facial profile (as Class II dolicofacial profiles tend to have more airway problems than other facial types). Resting lip posture, droopy eyes, and the presence of “shiners” (vascular congestion manifested as darkness under the eyes) should be noted. Intraoral findings, such as high palatal vault, narrowed transverse dimensions of the maxillary and/or mandibular dentition, anterior or posterior crossbites with associated functional shifts can be related to airway irregularities.
Once the above questions and clinical assessment are performed, and the findings suggest presence of breathing disorder, imaging is useful to identify possible anatomic and morphologic structures that contribute to risk for presence or development of obstructive sleep-disordered breathing. While sleep apnea is not diagnosed with imaging, cone beam computed tomography (CBCT) exams are valuable in providing three-dimensional or multiplanar views that enable clear definition of irregularities that may be creating obstruction or resistance to airflow through the nasal passages, the nasopharynx, the oropharynx, and the hypopharynx. Some of these irregularities include soft-tissue enlargements or aberrant morphology, bony structures, dental findings, cephalometric measurements, and pathology. Examples in these categories are depicted in images below.
Commonly seen irregularities that indicate risk for presence or development of obstructive sleep-disordered breathing
Airflow into the patient’s airway begins at the external, then the internal, nasal valves. These entrances are composed of cartilage, muscle, ligaments, and mucosal soft-tissue, all of which can display irregularities of various etiologies, creating narrowing or blockages. The image above depicts narrowed left internal nasal valve, and constricted right internal nasal valve.
Deviation of the nasal septum is a frequent finding. A large range of variability is seen. Some examples include minor deviation of the full septum, deviation of a small segment, enlarged septal tubercle, formation of a septal spur, and S-shaped contour that deviates both to the right and the left at different levels of the septum. The image above shows right deviation near the level of the right middle meatus, with a bulbous morphology of the septal tubercle contacting the right inferior concha. This can introduce alteration to airflow pattern through the nasal passage.
Note: an anatomic variant of paradoxical turbinate (arrow) is present at the left middle concha. This finding is often without clinical significance, but can create a blockage of the ipsilateral ostiomeatal complex. In this case, the left ostiomeatal complex is patent.
The above image shows septal tubercle/spur formation to the left, where it contacts the superior portion of the left inferior concha and the left middle concha. More superiorly, the nasal septum displays a gradual curvature toward the right. Accompanying these deviations is mild soft-tissue enlargement of the nasal septum as well as mucosal thickening in the superior portion of the left maxillary sinus. The combination of these features is forming obstruction to airflow through the nasal cavity and creating obstruction of the left ostiomeatal complex.
Concha bullosa is an air cell which is most commonly seen occupying the middle concha, either unilaterally or bilaterally. On occasion, smaller conchae bullosa are seen at the superior conchae. They are frequently clinically insignificant, but can influence deviation of the nasal septum and create narrowing or blockage of the ostiomeatal unit. The image above shows an obstructed left ostiomeatal complex (red arrow).
Enlargement of the pharyngeal tonsils (adenoids) is commonly seen, most often in children, which would be expected. If enlargement is seen in adults, more questions regarding etiology are raised, as these tissues typically begin gradual regression after the age of 12. This size enlargement creates significant blockage in the nasopharynx. Note parted lips, even though the condition of deep anterior vertical overlap is present.
Thickened soft palate and uvula soft-tissue can narrow, and at times, constrict the airway, even while the patient is in an upright position. The presence of obstructive sleep-disordered breathing would be suspected with these patients in supine position. Both sagittal and axial views show the significant narrowing that can be created by swollen or enlarged uvula/soft palate.
Elongated uvula/soft palate is sometimes implicated in creating narrowing in the oropharynx. Typical length of this soft-tissue complex is approximately 40 mm or less. The image above shows a length that approaches the superior aspect of the epiglottis, with associated airway narrowing.
Enlarged palatine tonsils are most commonly seen in children, and demonstrate significant variety in size. The above image depicts considerable enlargement of the palatine tonsils, which is creating blockage of the airway. Regression of the palatine tonsils occurs gradually after the age of 12.
Enlargement of the lingual tonsils is less frequently seen than the pharyngeal or palatine tonsils, but is nevertheless a common finding, and can create significant narrowing of the inferior oropharynx, as shown above. Lordotic curvature of the cervical spine in this instance it exacerbating the constriction.
Commonly seen, but less scrutinized findings relative to risk of sleep-disordered breathing
High palatal vault is suggestive of narrowed maxillary alveolar and dental arches, which can result in unilateral or bilateral posterior crossbites, functional shifts, and restriction in the freedom of anterior mandibular movement. It also creates a space for the tongue to be positioned superiorly, which can lead to airway restriction at the superior oropharynx.
Narrow dental arches often reduce the amount of available tongue space, and may transversely constrict the tongue. This can lead to aberrant tongue shape and position, and subsequent alteration of normal airway space. Rule of thumb: less than approximately 44mm may indicate risk for development of breathing disorder. (Dr. Sean Carlson)
An unusual finding of enlarged soft tissue in the hypopharynx, at the level of the larynx, warrants evaluation medical ENT. The small hyperdensity is likely calcification of arytenoid cartilage.
Narrowed airway dimensions are seen more frequently in cases of this facial growth type than other growth patterns.
Less-commonly seen irregularities that indicate risk for presence or development of obstructive sleep-disordered breathing
The left maxillary sinus in the image above is considerably smaller than the right, and its lumen is opacified with mucosal thickening. This finding does not necessarily create a condition of sleep-disordered breathing, but should raise suspicion and indicates the need for further assessment.
Image from University of Washington Image from Radiopaedia contributed by Dr. Roberto Schubert.
Pneumatized crista galli may communicate with the frontal recess and can potentially obstruct the frontal sinus ostium.
These tissue enlargements are non-neoplastic, inflammatory swellings of sinonasal mucosa that buckles to form “polyps”. Considerable resistance to airflow is created by lesions this size.
Ossifying fibroma is an expansile benign fibro-osseous neoplasm which can create significant airway blockage.
A schwannoma is a normally benign, neural sheet tumor, in this case creating blockage in the right nasal cavity.
The preceding images represent some findings identified on CBCT exams that suggest the possibility of presence or future development of obstructive sleep-disordered breathing. Numerous additional abnormalities not included in this article can create obstructions or disruptions of normal airflow. This flow of air from the environment into the lungs must negotiate a course from the external nasal valves, through the nasal fossa, the nasopharynx, oropharynx, and hypopharynx. Airflow dynamics through this pathway are subject to laws of Poiseuille and Ohm, which show resistance to airflow can create increases in the pressure gradient between the mouth/nose and the alveoli (Hatcher, 2010). Anatomical structures along this pathway involve cartilage, bone, muscles, and mucosa, which are dynamic and can change in dimension and shape in response to normal physiological (swelling and shrinkage of nasal conchae), allergies, infection, and abnormal tissue proliferation, such as polyps or neoplasm.
Click here to submit your scan for an airway assessment
This patient was finally relieved to find out what the source of his exhaustion was. Years of struggling with sleep, being tired and frustrated all day led him to search for solutions. A simple home study test confirmed that he suffered from sleep apnea. More importantly a simple therapy resolved his problems. Watch this testimonial about the life changing experience and find out how you can impact your patient’s lives
Patients usually drive all doctors to find solutions and therapies to address their problems. As dentists, we have the unique ability to offer a solution that no one else can. Most importantly, it’s good to know what the competition is offering. How do you like your odds against this device?