D O Volume Three
Featured Articles PAGE ONE
Dr. Gy Yatros discusses Dorsal Mandibular Advancement Device.
PAGE TWO
Direct of Dental Sleep Medicine, Gary Quaka goes over why bite registration is the blueprint to success
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In this newsletter we took an exciting step outside of the world of orthodontics to feature a couple of interesting articles on snoring and sleep apnea. Sleep dentistry is currently the fastest-growing dental specialty at a rate of 25% per year according to the AADSM. Anti-snoring and sleep apnea devices are in fact very similar to orthodontic devices in that they contain several of the similar metals, screws and acrylics used in manufacturing orthodontic devices. Almost all sleep devices contain a jaw-repositioning component very similar to functional orthodontics. DynaFlex offers several different FDA cleared devices including the Dorsal appliance, the TAP and the Adjustable Herbst Device. As 2013 comes to a close it’s a great time to reflect back on the many exciting accomplishments during the year and look forward to what 2014 might bring. I feel blessed that we had another record year at DynaFlex and I can’t tell you how thankful I am that you have allowed us to serve you and your patients in 2013. All the best,
PAGE THREE
Dr. William Harrel talks about Cross Sectional Changes using Oral Sleep Appliances
PAGE SIX
DynaFlex Senior Technical Laboratory Advisor, Randy Williams answers questions about Hanks Telescoping Herbst or “HTH” Design
DynaFlex®
10403 International Plaza Dr.
St. Ann, MO 63074 1-800-489-4020
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Darren Buddemeyer, CEO
Fins to left! Fins to the right! Dr. Gy Yatros, DMD
“Fins to the left! Fins to the right!” If you’re a Jimmy Buffett fan then you know that quote from his famous song “Fins”. And if you know me, then you know I am a big Buffett fan. What you may not know is that since I was a young boy I have had a fascination with sharks. Some of my fondest memories are of our annual family pilgrimages to Florida where I would spend hours sifting through the sand in hopes of finding an odontogenic remnant from these elusive sea creatures. Of all of my childhood possessions the shark’s tooth necklace that I proudly wore and the sand shark jaws that hung prominently above my bed were among the most cherished. Everyone remembers how Steven Spielberg immortalized the vision of the dorsal fin breaking the water as the of “du-du-DU-DU-DU!” was forever embedded in our minds watching Jaws. As a dentist exclusively practicing sleep dentistry, my fascination with the dorsal fin continues. For
countless patients the dorsal fin now represents quiet, comfortable sleep. Those new to dental sleep medicine may be at a loss -- what in the world do sharks have to do with dental sleep medicine? The answer is the DORSAL FIN. The shark’s distinctive dorsal fin makes it stand out among other sea creatures, and the Dorsal Mandibular Advancement Device (MAD) stands out among other dental sleep devices. At Dental Sleep Solutions®, the Dorsal MAD has delivered a comfortable solution to thousands of patients for treatment of Obstructive Sleep Apnea and snoring. Although sleep dentistry requires the knowledge and use of various appliances, the Dorsal MAD is often our appliance of choice. The design offers multiple positive attributes that are ideally suited for many cases. Of its many positive features, the ability for the patient to open their mouth without restriction is one of the most desirable. The two-piece design also continued on page 5
The Bite Registration For Anti-Snoring & Sleep Apnea your blueprint to success
with Director of Dental Sleep Medicine, Gary Quaka Where a dentist takes the bite registration can determine success or failure of the patient’s oral appliance. Many doctors refer to this as “the construction bite” since it determines how and what position the sleep appliance will be fabricated The bite registration and the forward position of the mandible determine the success of an oral appliance when treating patients with obstructive sleep apnea (OSA).
DETERMINING THE PROTRUSIVE POSITION
Exciting News! In 2014 DynaFlex will open a NEW state-of-the-art Anti-Snoring & Sleep Apnea Laboratory. This will solidify our commitment to builiding the highest quality device and an increase in production capability.
page 2
I often get asked the question, “how far forward should I bring the mandible in my bite registration?”. Unfortunately, there is no one correct answer to this question. Simply stated, different schools of thought on this topic lead to different opinions on the amount of anterior opening and the forward position of the mandible. That said, “as a general rule”, many sleep dentists will have their patients advanced 40-60% of maximum protrusion. For most patients this range is a valid formula. There are exceptions, however, for example, if there are TMJ problems it may be necessary to advance the mandible less and gradually titrate the mandible with the adjustment of the oral appliance.
TAKING AN ACCURATE BITE REGISTRATION
There are a number of good bite gauges available, most have a range of advancement of 4-6mm. Two of the more common used gauges we receive with sleep cases at DynaFlex are the George Gauge and Airway Metrics. There are other gauges, it is suggested to use the one that works best for you in achieving an accurate bite registration consistently. Like bite gauges, there are several types of materials that can be used to record the forward position of the mandible. The three main materials used to record are bite wax, blue mouse or PVC. Whatever the material, an accurate bite registration requires that the material is well based to the bite fork and is extended to include and impress both the anterior and posterior teeth. To ensure proper articulating of the models and the bite at the laboratory, the bite registration should include deep indexing of all the teeth.
DEVIATION IN THE BITE REGISTRATION
To ensure a comfortable and accurate fitting sleep appliance for the patient,, it is important that the patient’s lower arch does not shift or slide to one side when the advancement bite is recorded. To prevent this from occurring, the patient can practice bringing their lower jaw forward, making sure to maintain the same relationship of their upper and lower dental midlines in both the centric and advanced position. Once this is comfortably accomplished, the bite fork and bite material are used to record the starting forward position of the mandible. In some cases, however, the patient may have a true deflection or deviation of the mandible to one side in a forward position. Patients that have a deflection of this kind, it is important that their bite is not repositioned or corrected in the forward position to realign and match the centric dental midline relationship. The deviation or shifted position of the mandible in the forward location is correct.
Cross Sectional Area Changes using Oral Sleep Appliances William E. Harrell, Jr., DMD Orthodontist Alexander City, Alabama | www.drharrell.com
Oral sleep appliances have been studied over the years for their efficacy in helping with Obstructive Sleep Disorders (OSA) (ref 1-5). Oral appliances are a less invasive and more tolerable for many patients than CPAP/BIPAP or Maxillo-Mandibular Orthognathic Surgery for the treatment of OSA (ref 5). Oral appliances may be the treatment of choice for patients who have mild to moderate OSA symptoms. ConeBeam CT (CBCT) was introduced into the USA in 2001 (ref 6). The advantage of using CBCT for imaging a patient ,who may have or has been diagnosed by their sleep physician as having a sleep disorder, is the volume of the airway can be rendered in three-dimensions and also viewed in cross sections of the Axial, Coronal, and Sagittal planes. Also the Minimal Cross Sectional Area can be measured along with visualization of where the obstruction may be located along the volume of the airway. The radiation dose for CBCT varies but is much lower than traditional medical CT and compares to dental x-ray imaging (ref 7). There are many different manufactures of CBCT units, comparisons can be seen at the following web sites: www.conebeam.com, www.3dorthodontist.com. Some units image in a supine position (ex. NewTom) while most image in an upright seated position (ICat, Sirona, PlanMeca, Kodak, etc.). For studying OSA patients, it would be best for the patient to be in a supine position as this relates more to the position of sleeping. The Unit I use is the iCAT Next Generation and is a seated upright unit. I feel since it is giving me the patient’s “best” airway position (upright and seated), the data is still valid and valuable. Dr. Steve Schendel (Past Chair Dept of Plastic Surgery Stanford U) and Dr. David Hatcher (Oral Maxillofacial Radiologist Sacramento, CA) published an article (Ref 8) on the “Automated 3D airway analysis from CBCT data”. They correlated the minimal cross sectional area of the CBCT with Sleep Studies and found a correlation when the Minimal Cross Sectional Area was less than 100 - 110 mm2 it related with the diagnosis of Moderate OSA. When the Minimal Cross Sectional Area was less than 50 mm2 this correlated with Severe OSA.
The following case shows what effect moving the mandible anteriorly and vertically has on the Cross Sectional Area of the Airway using ConeBeam CT 3D imaging.
Fig. 4
Fig. 1
Figure 4 shows the 3D rendered airway volume in the Coronal view and the position of the Minimal Cross Sectional Area of 41.2 mm2 . Figure 1 shows the Multiplaner Views on the left side (Axial, Sagittal & Coronal). The right view is the 3D reconstructed View and the airway volume of the Initial Occlusion of the patient’s CBCT data. The Minimal Cross Sectional Area is 41.2 mm2 which suggests possibility of Severe OSA. Her sleep physician did document a severe OSA through sleep study with RDI over 50.
Fig. 2
Fig. 5
Figure 5 shows the 3D rendered airway volume in the Sagittal view and the position of the Minimal Cross Sectional Area of 92.9 mm2 .
Fig. 6
Figure 2 shows the Multiplaner Views on the left side (Axial, Sagittal & Coronal). The right view is the 3D reconstructed View and the airway volume of mandible positioned forward shown in the patient’s CBCT data. The Minimal Cross Sectional Area is 92.9 mm2 . This is a 125% increase in the Minimal Cross Sectional Area measurement.
Figure 6 shows the 3D rendered airway volume in the Coronal view and the position of the Minimal Cross Sectional Area of 92.9 mm2 .
Fig. 3 Use your Smart phone’s QR Reader
to view an animation of Airway changes initial-forward mandible position Figures 3 shows the 3D rendered airway volume in the Sagittal view and the position of the Minimal Cross Sectional Area of 41.2 mm2 .
References: 1. Cistulli P, Gotsopoulos H, Marklund M, Lowe AA. Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Med Rev 2004;8:443-57. 2. Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep 2006;29:244-62. 3. Almeida FA, Lowe AA. Principles of oral appliance therapy for the management of snoring and sleep disordered breathing. In: Boyd S, Huag R, editors. Oral and maxillofacial surgery clinics of North America—evaluation and management of obstructive sleep apnea. Evanston, Ill: Northwestern University; 2009. p. 413-20. 4. Cistulli P, Ferguson KF, Lowe AA. Oral appliances for sleep disordered breathing. In: Kryger M, Roth T, Dement W, editors. Principles and practice of sleep medicine. 5th ed. St. Louis, Mo: Quintessence; 2011. p. 1266-77. 5. Chen H, Lowe AA. Updates in oral appliance therapy for snoring and obstructive sleep apnea. Sleep Breath 2012 May 6 6. Hatcher, DC. Operational principles for cone-beam computed tomography. JADA 2010;141(10S):3S-6S 7. Carlson S, Graham J, Harrell W, et, al, The Truth About ConeBeam Radiation, Orthotown, pp 62-68, Sept 2011 8. Schendel SA, Hatcher D, Automated 3-dimensional airway analysis from cone-beam computed tomography data, J Oral Maxillofac Surg March 68(3): 696-701, 2010 page 3
Your Solution for Snoring & Sleep Apnea ALL Sleep Appliances Include: Digital Model Storage, AM Bite Aligner & Durable Acrylic Models Dorsal Appliance Available in Acrylic, Comfort Fit and Accu-Fit The Dorsal appliance has evolved into one of the most popular choices for snoring and obstructive sleep apnea. The two piece construction allows for maximum patient comfort and lateral jaw movement. The Dorsal fins on the mandibular appliance interface with inclines built into the facial of the upper appliance to dictate a specific mandibular position. The appliance is fabricated with adjustable screws in the maxillary appliance to allow for further mandibular advancement. This appliance can be fabricated in a variety of materials including acrylic, dual laminate (Comfort Fit) or Accu-Fit (thermal acrylic).
Adjustable Herbst® Appliance Medicare E0486 Verified The Adjustable Herbst® is a two piece construction held together with two inseparable hinged mechanisms on the facial of the upper and lower appliances. The hinged mechanisms are designed with advancement screws to allow for titration and advancement of the mandible. The Adjustable Herbst® is designed for incremental advancement of the mandible to the desired position. The advancement screws have a 5mm range with an adjustment ratio of 16:1 or 16 quarter turns to one millimeter.
TAP® 1, TAP® 3 & TAP® 3 Elite Thornton Adjustable Positioner Medicare E0486 Verified The two piece Tap® appliances are fully adjustable on a horizontal plane, providing dentists the ability to locate the ideal mandibular position for their patient. This custom appliance is fabricated with separate upper and lower trays. The maxillary component utilizes an adjustable screw and hook which interfaces with a lower socket or lower lingual bar to hold the mandible in the desired position.
For more information please call today to speak with one of our technical advisors. page 4
continued from page 1
allows for easier placement in the mouth, with the ability for the patient to place the device in one arch at a time. These features, along with the fact that it can be made at very minimal VDO, make it a great choice for patients with limited mouth openings. Other positive features of the dorsal device include its small increments of adjustability, generous tongue space, and good durability. Dynaflex offers the Dorsal MAD in three materials to fit most any need. The device comes in a traditional hard acrylic with hooks for adjustable retention. It is also available in a flexible material called “Comfort Fit”. This material is aptly named, because a dorsal design with the “Comfort Fit” material is in my opinion one of the most comfortable devices available. Lastly the Dorsal MAD is also available in a thermoplastic acrylic called “Accu-fit”. This is one of my favorite materials, aptly named because of its ability to adapt for most all situations. Through chair side heating and cooling, ‘Accu-fit” can easily be made more or less retentive and change shape to accommodate newly placed restoration. All of these features add up to one of the most comfortable devices available with great adaptability and adjustability. It’s even available in a variety of colors! Of course with any device there are also con’s to go with the pro’s. The ability to open is a desirable option in many patients, but sometimes it can add to a decrease in efficacy of treatment. This can be counteracted by adding elastics to the device, or by utilizing Dynaflex’s unique reverse wing design called the “Air Plus”. Although the dorsal design holds up quite well, it may be less than ideal for severe bruxers. The Dorsal MAD is indicated for most cases of sleep disordered breathing, and it is often my device-of-choice for the following patients: • Any patient where comfort is of paramount concern. • Patients who are mouth breathers and/or can’t breath through their noses. • Patients with inadequate dentition. You can even make this device on a totally edentulous upper arch! • Patients who have limited openings or deep bites (can be made a low VDO). • Many patients with TMD problems. It is adaptable to have posterior support or disclussion depending on the specific TMD need. Also TMD patients benefit from the small increments of adjustment (0.1mm). • Patients with large tongues. • As a first appliance for dentists who are just getting started, due to outstanding patient comfort and the superb fit. All in all, the Dorsal MAD is great device for most cases. It has the comfort, flexibility, and durability that I look for when treating my patients. I enjoyed penning this article to help you better treat your patients with sleep disordered breathing. I also enjoyed thinking of Buffett and reminiscing about my childhood dreams and fancies. Now that I live in Florida I see Dorsal Fins almost every day (but most not in the water)! I hope that when you now think of the Dorsal Fin the sounds of “du-du-DU-DU-DU!” are replaced with the sounds of the silence for the many patients you help quit snoring and to sleep better with the Dorsal MAD. Enjoy using it in your offices. If you need me, I’ll be at the beach looking for Jimmy or helping my son find those elusive prehistoric odontogenic souvenirs!
It’s not just software… it’s your complete solution for dental sleep medicine.
Created by Dentists, for Dentists
Software: DS3 is a complete dental sleep implementation system
Dr. Gy Yatros is a nationally known lecturer and has helped thousands of dentists to begin their journey into dental sleep medicine. He is a Diplomat of the ABDSM and has offices in Holmes Beach, Sarasota and Tampa where he exclusively practices sleep dentistry. He is the CoFounder of Dental Sleep Solutions Franchising, LLC and DS3-Dental Sleep Solutions Software. Dental Sleep Solutions and DS3 software help both the experienced dental sleep dentist and neophytes to easily implement dental sleep in their offices. Contact Dental Sleep Solutions for more information about education and the DS3 software: www.dentalsleepsolutions.com www.dentalslepsolutions.com/software
We help with patient management, team education, implementation systems & medical insurance Our software is HIPPA & EMR/EHR compliant Free trials are available
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page 5
Q&A Hanks Telescoping Herbst or “HTH” Design Questions & Answers
with DynaFlex Senior Technical Laboratory Advisor, Randy Williams
1. What do you see as the main advantages of the “HTH” over some of the more traditional designs?
One of the major improvements that stands out over the traditional rod and tube design is the HTH is the only true “one piece” design available for Herbst treatment. The telescoping design eliminates problems of disengagement, greatly reducing the number of emergency appointments. Secondly, it incorporates a ball and socket pivotal screw that is built into the telescoping mechanism. The ball and socket allows for tremendous lateral excursion and increased patient comfort.
2. What are some of the other benefits using the “HTH” ?
e one I hear the most from the specialist I deal with is how easy and efficient delivery of the “hth” is because the screws Th are integral to the telescoping mechanism. They don’t have to worry about fumbling with separate pieces or parts falling into a patient’s mouth. Another big advantage is the ability to gain further advancement by adding crimpable “shims” to the base of the rods. No need to spend extra time chair side disassembling the appliance to add shims.
3. Can you tell about some options for the “HTH” in regards to banding?
I normally suggest the use of a crown, vented crown or Rollo band. We do manufacture a banded herbst. But the trend has been more towards the use of a crown because of strength and stability. I like a Rollo band as well. It can be used where banding is indicated or extra strength is needed. Its material thickness is .007 and has occlusal rollover to provide increased strength. Acrylic designs are also available.
4. What type of impressions do doctors send in to the lab for appliance fabrication?
e majority of the offices I speak to send in good quality alginate impressions poured up in yellow stone. Over the last year Th to 18 months, a lot of our clients offices have been converting to the new iTero system. By using the new scanning technology, offices can use an intra-oral scanner to scan the patient and send that electronic file to dynaflex for appliance fabrication.
10F%F
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OHTH
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New Exciting Informational Articles Inside!
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What to look forward to in the next issue... The Twin Block Appliance Dr. William Clark, an Orthodontist, developed an uncomplicated technique that incorporates the use of upper and lower bite blocks to reposition the mandible forward for skeletal Class II correction. The Twin Block technique is easy to use and very patient friendly. The design utilizes two separate appliances that fit the maxilla and mandible. The unique design allows for more patient comfort and increased patient cooperation. The Twin Block design also allows for independent development of the upper and lower arches with the addition of transverse and/or sagittal screws.
How To Go Alginate Free Dr. Jeff Haskins, Village Orthodontics discusses the benefits of using an iTero unit to go Alginate Free. Haskins owns one of the most progressive practices in digital technology and currently owns (3) scanners and has recently gone impressionless.
With the significant increase in iTero units in the market place, DynaFlex® has formed an iTero Study Club. This group will meet periodically throughout the year via online webinars. If you are interested in participating, email iterostudyclub@dynaflex.com
100713 © 2013 DynaFlex® , St. Louis, MO 63074. Printed in U.S.A. All rights reserved.
Would you like you and your practice to be featured in the next issue of OrthoDynamics? Submit your relevant and current article(s) to britneyv@dynaflex.com with subject line “article submission”. We prefer that the submission be between 600 to 1,200 words, submitted as the body of an email rather than an attachment. It is important that articles be copy-edited carefully before submission. If your article is selected to be shown in the next issue, we will contact you as soon as possible.