Hi, I'm Dr. Ari Wolfson, and today I'd like to demonstrate the delivery of a mandibular advancement device on a patient with obstructive sleep apnea. The device I am using today, when categorized by propulsion style, is an attached bilateral traction device, and it was fabricated using a completely digital pathway. I used a scanner to acquire a digital impression and a digital bite, which was then sent to a laboratory that milled the device trays from a solid block of controlled cured PMMA. It has a flexible liner to provide retention. The bite was taken at a protrusive position of 50% and a vertical dimension that allowed for a minimum thickness of 4 millimeters of device material. Now that the appliance has come back from the laboratory, we want to check it on the models to be sure that the laboratory has followed our prescription and that the midlines are where we intended them to be. At the same time, we also check that there has been no increase or decrease in the vertical dimension position of the bite that we sent to the laboratory. I've also tried the device on the models to evaluate the fit and retention. Taking it on and off the model a few times helps me get an idea of its best path of insertion. This is my patient, David. He has never worn a device of any kind, so before I start the delivery process, my staff has shown him the device and explained how it should be cleaned and cared for. They've also fabricated a morning occlusal guide and provided written instructions on device warranty, morning exercises, and office contact information. Generally, they will also demonstrate the propulsion mechanism of any device and help the patient practice advancements. This way, the patient has a chance to become very familiar with the device before we begin the fitting process and hopefully will feel more comfortable with the device in his mouth. Since the upper and lower trays of this device are attached with a single nylon propulsion strap, I separated them by removing the strap before I begin the fitting process. I have an expectation of how tight it will be and a sense of its path of draw since I have practiced insertion and removal on the models. I want to coach the patient on what he will be feeling so he is prepared for the snugness of a device like this that relies on flexible rebound of the laminate material for retention. Now, I will align the device with the midline and lay it gently on the occlusal table to be sure it is lined up and ready to be inserted along its path of draw. Using gentle, uniform, and bilateral pressure, I can slide the device into place. Since I have practiced on the model, I will know by feel when it is seated completely and by taking a closer look, I can verify that the cusp tips are completely embedded in the acrylic. I will generally apply a little firmer seating pressure at that point to make sure there is no more seating movement. David, I'm going to place the upper part of your appliance in, okay? It's going to feel a little snug and I'm going to place it in and out a few times to make sure it's comfortable. Okay? If you can open. Thank you. As I take it in and out, I am getting a sense of how much force is required to insert and remove the tray while becoming even more familiar with the path of draw. I want to be able to instruct the patient on how best to insert and remove their device. Next, I'll repeat this same process with the lower tray and once satisfied, I will put both in together. On the other hand, if I encountered an excessive amount of resistance to insertion or removal, I would return the device to the model and re-examine the retentive areas before making any adjustments. If it was a device that was retained with ball clasps, I would observe the position of those clasps interproximally on the models first. Since these trays are retained with a flexible liner, I would examine the interior to see how far past the crest of convexity or interproximally the liner extends. I want to be sure that the patient will be successful with insertion and removal before I ask him to try it for the first time. You'll notice that other than asking my patient if he's okay, I have not yet asked him for any feedback on how the device feels. I want him to get used to the feel of how the device is fitting snugly against his teeth before I ask for specific areas that might seem too snug. After we've tried in the upper and lower trays separately, we will also put them in together in order to evaluate how the occlusal surfaces fit against each other. They will still be unattached at this point. With a little coaching, I'm going to watch the patient slowly close together. Generally, I'll ask the patient to tap their teeth a few times, squeeze, then tap again to confirm that the device fit feels even side to side. At this point, I will check for equal bilateral occlusion with articulating paper in a holder, but you can also use horseshoe paper or a shim stock as an alternative. Okay, David, we're going to put the upper and lower arches in together to see how they're fitting together in your mouth, okay? Okay. I'm going to relax your cheeks a little bit. Great. That's my finger. And then here comes the lower. Feel that little snap? I'm going to practice taking that in and out a little bit. I'm going to show you how to do that in just a minute, okay? How is it feeling when you tap together? Does it feel pretty even on both sides? It does. Great. I'm going to check it with my paper. Give me a few taps and a little grind. Great. And then open. Same thing on the other side. Tap tap tap. Grind around. Great. And I'm going to have you now show me how to take this out. First, you want to kind of get your fingers underneath the appliance and then lift out like that, okay? I'm going to place it, and you can try that. First do the lower, and then do the upper the same way by getting your fingers up there, okay? Okay. Let's see. Great. Awesome. Awesome. Now I've attached the upper and lower trays with a propulsion strap. Before I put the trays together, I will remind the patient how the device looks on the model and how the upper and lower trays rest together to hold the jaw forward. This way, he will be more prepared for how it feels in his mouth. Since the maxilla is stationary, I have the patient attach the device to the upper teeth first. This helps stabilize the position and makes it easier to guide the lower teeth into place. Then with the upper in place, I will ask the patient to slowly close into the lower tray. Holding a mirror for the patient to see what he is doing may help him position his jaw while encouraging him to protrude as he closes. Once it appears the device is fully seated, I'll ask him to just give a little squeeze before I verify it is in its place. All right, David. I'm going to have you place this in. Do the top one first. And just so you know, the lower is going to feel a little more forward than usual, but that's okay. Okay. All right. Now hold this just in case you need it. And then bring that jaw forward. Great. Yep. A little more. Awesome. Look towards me and I'm just going to confirm that. Looks great. No matter what style device I'm using or its retention characteristics, I want to verify that I can easily insert and remove the device before I ask the patient to do it themselves. I also want to verify the balance of occlusal surfaces from side to side, just as I demonstrated. For attached devices, this is often easiest if you remove the propulsion strap or arms so that the two trays are separated. With these steps completed, now is a good time to ask the patient how they feel with the device in place. They should have acclimated to it as you've inserted and removed it several times and are less likely to react to the bulk and awkwardness of having trays attached to their teeth. I want to assure them that it is natural for their jaw to feel like it is being pulled forward and ask them if there are any certain teeth that feel more pressure compared to the others. If they describe an area of the discomfort that is limited to a few teeth, then it may warrant adjustment at this time. However, since I have already verified insertion and removal, it is better to send a patient home with a device that feels a little bit too snug than to over-adjust it during the visit. You can always see them at a follow-up visit after the patient has worn it overnight. At this point, it is often more obvious which tooth is experiencing too much pressure. Before the patient leaves the visit, they will need to sign a proof of delivery form plus express understanding of device calibration, home care instructions, use of a morning occlusal guide, and exercises in addition to common side effects. Patients are usually both a little bit excited and a little bit apprehensive as they leave your office with their device in hand. It is always a good idea to encourage them to watch for symptomatic improvement but to contact you when they have questions or concerns. Thank you for joining me for this presentation on device delivery. I hope you found this content helpful for your dental practice.

mandibular advancement device

obstructive sleep apnea

digitally fabricated bilateral traction device

cleaning and care instructions

device insertion and removal