Hi, I'm Dr. Ari Wolfson, and I'm going to demonstrate the fabrication of a morning occlusal guide, sometimes abbreviated MOG. The term itself was first introduced in the ADSM 2017 consensus paper on management of side effects of oral appliance therapy for sleep disordered breathing. These guides of various designs are thought to function by using the bite force to reseat the condyles in the TMJ, reversing the changes that may have occurred in tooth position, and exercising or stretching the muscles of mastication. A morning occlusal guide is a simple and inexpensive way to reduce potentially significant occlusal changes while creating a pretreatment index of the habitual bite that allows the patient to share responsibility for monitoring bite changes. Both transient and permanent occlusal changes are reported side effects of oral appliance therapy. They may include posterior open bite, changes in incisor position, and a decrease in over bite and over jet. While transient bite changes resolve quickly after oral appliance removal in the morning, long-term occlusal changes often have gradual onset and are not recognized by the patient until they become fairly advanced and irreversible. It is beneficial for a dental sleep medicine practitioner to be proactive in educating the patient to monitor, recognize, and address occlusal changes as part of a daily home care routine. Today, I will be demonstrating chair-side fabrication of a morning occlusal guide utilizing a thermal resin wafer. The MOG provides an index of the interstitial relationship in pretreatment maximum intercuspation and can be used by the patient daily to help guide them back into their normal bite. There are many manufacturers of thermal resins for this purpose, but this one happens to be reinforced with Kevlar to give it a bit more resistance to deformity with use. These materials are characteristically very pliable at temperatures near 160 degrees Fahrenheit and hard at mouth temperature. We will use a thermal resin wafer, a glass beaker for hot water, a glass beaker for cold water, and articulating paper and a holder. Whether you are using a water bath, microwave, or tea kettle to heat the water, you'll discover that when the water is hot enough to soften the thermal material properly, it is too hot for your fingers. I'll be using a mirror to retrieve the wafer from the hot water. It is important to evaluate and record your patient's bite prior to the delivery of the oral appliance. This can be accomplished objectively with articulating paper or shim stock. If the patient upright in the chair, I'll insert articulating paper and instruct him to bite down lightly and tap on his back teeth several times. I'll also have him bite and hold gently on paper as I attempt to pull it out. This is a great opportunity to make the patient more aware of their bite and how their teeth fit together. If the patients have a little awareness of how their teeth occlude, they may not notice when their bite begins to change with the use of an oral appliance. Make sure to record your findings and alert the patient to any pre-existing problems such as light or open posterior occlusion. Okay, so give me a few taps with your back teeth. Get a sense for how they feel together, okay? And now I'm going to check it with my bite paper. And give me a couple of taps, tap, tap, tap. Great, and open. And again, tap, tap, tap. Great, and open. Let me just take a look. Very nice. And I'm going to have you bite down. And then I'm going to hold and pull. You stay still. Open. Same thing on this side, bite and hold. And open. Your occlusion is very even. That's awesome. There are many ways to fabricate a morning occlusal guide. As I mentioned earlier, I will be using a thermal resin wafer. You can see by its horseshoe shape that the wafer is intended to capture the entire occlusal surface. While you can use the entire wafer to fabricate an MOG, for today's demonstration, I've cut it into thirds and will only index the anterior tooth relationship. While this cuts down on material costs, the important reason for indexing only the anterior teeth is to provide tooth-to-tooth contact of the posterior teeth. This way, a patient can be instructed to use their morning occlusal guide until they can feel their upper and lower back teeth touching. I'll warm up the material in a very hot water until it's pliable, retrieve it from the beaker with the mirror, and warn the patient that it'll feel warm. When I place it onto the lower teeth, it will extend roughly from canine to canine, and I'll mold it around the facial and lingual extending into the gingival margins. Then, once in place, I'll instruct the patient to bite down on the back teeth and hold until the material hardens. I'll also want him to use his tongue to press the lingual material against the teeth, creating a comfortable tongue room and smooth surface. The facial of the upper incisors should not be covered, except for where the incisal edges have indexed slightly into the material. It will take a few minutes to harden. If removed too soon, the material will distort. Once the material has hardened, I'll remove it from the mouth and place it in cold water for final set. Okay, this is going to be a little warm, and you're going to feel me kind of press this on your teeth, okay? Let me know if it's too warm. Is that okay? Mm-hmm. Great. Okay, and then bite together on your back teeth like we had talked about. Great. And you stay biting nice and firm, and push with your tongue against the material while I press on the front. Keep pushing with that tongue. Awesome. It's almost done. So I'm going to check your bite to make sure your teeth are closed all the way in the back, okay? So open for me, and then bite together. Great. And then open again, and on the other side, close. Great. Okay, you can close. Once the MOG has hardened in the mouth, I would chill it in cool water and place it back on the teeth to verify there are no distortions. I want to be sure that the patient can still squeeze their molars together and feel them touching as they tap their teeth. You can see the guide is molded to the lower arch and has indentations for both upper and lower teeth. The patient should be familiar with the appearance of the side that fits against the upper and lower teeth and trained on insertion and removal. A hand mirror may be helpful to the patient at this time. Instructions to the patient include waiting 15 to 30 minutes after waking to place the guide in the mouth to allow the TMJs to begin to normalize without force. Daily use for 5 to 10 minutes or longer if the bite does not return to its usual position. Stay away from pets, avoid extreme temperatures, and most important, to immediately alert your office if the bite is not normalizing on a daily basis. Chair-side fabrication of a morning occlusal guide is an inexpensive and reliable way to record a patient's pretreatment habitual bite. If used daily, it may decrease unwanted tooth movement or occlusal changes. It also enlists the patient in monitoring, managing, and alerting the dental sleep medicine clinician of any perceived occlusal changes. Thank you for watching. I hope you found this demonstration useful.

Dr. Ari Wolfson

morning occlusal guide

occlusal changes

thermal resin wafer

dental sleep medicine clinician