GATE DENTAL CLINIC Dock Road

Galway Ireland

Do you or your partner suffer from snoring?

Below is an overview of the appliances of varying complexity to offer solutions to suit your needs.

We offer to see patients for an initial consultation free of charge to discuss your needs, your expectations, your options, any remedial work that that may be required prior to fitting and the costs of your appliance options. You must have a good level of oral hygiene and teeth and restorations that of sufficient quality before appliances can be fitted. If required, we will recommend periodontal therapy to improve your gums and discuss and provide any new fillings or crowns required prior to impressions for snoring devices. Remember, all these appliances are made to fit your teeth. It is difficult or impossible to make new fillings fit your appliance and therefore a good standard of dental care is required. We will ask you to complete a questionnaire about your sleep history and snoring habits, and where deemed necessary, we will refer you to the Respiratory Department at NUIG Hospital for full respiratory and sleep analysis. When patients have no teeth it may be possible to offer options involving dental implants for fixation of the appliance. There are a multitude of options available to help. Below we have given you a sample of alternatives and indication of cost and durability for you to consider.

Please see our website www.gateclinic.com (heading – “sleep disorders” on home page).

or ring 091 547 592 for more information.

We look forward to hearing from you!

Dr. Paul Moore

NON SPECIFIC / NON CUSTOMISED APPLIANCES

Available over internet for retail

Low cost mandibular advancement appliances (MAA) are available from a wide variety of retailers and in an equally wide range of designs. This is a good indicator of the effectiveness of MAAs as a treatment for problematic snoring and obstructive sleep apnea, and the huge demand for solutions to these problems.

Low cost MAA range in price from £50 to £100 and generally look much the same. They are typically made from a plastic type material called EVA polymer. With a low production cost and a one size fits all approach, these low cost MAA's have flooded the increasingly competitive market.

A variation on the low cost MAA is the boil-and-bite MAS. These use thermoplastics that enable the user to heat the plastic and then bite into it with the aim of making a set of impressions of the teeth.

The principle idea behind most low cost MAA’s is sound; no doubt this has been an important factor in their popularity. However the one size fits all approach and absence of a professional fitting means that there is often limited effectiveness, unwanted side effects, and low compliance.

Many low cost MAA’s are bulky and take up a considerable amount of tongue space. By forcing the tongue backwards the main purpose of the MAA is compromised. They low cost MAA’s often restrict jaw movement and sometimes lock the jaws shut. Some only allow breathing through the nose. Others only allow breathing through the nose.

Typically the low cost MAA will by design exert pressure against the teeth and gums. This can lead to unwanted to tooth movements and gum irritation. These plastic and polymer devices are not ideal for long term oral use. Over time they can become unsightly and unhygienic, potentially damaging the teeth and gums.

Unfortunately low cost MAA’s are very limited in what they can offer your unique jaw alignment, jaw size, and teeth arrangement. This can greatly reduce the level of comfort achieved and therefore the compliance. A badly managed jaw positioning will often lead to jaw discomfort and pain.

CUSTOMISED APPLIANCES

1 The Silensor

2. The Tap Appliance Hooked.

3. The Tap Appliance Tubed.

4. The Narval Appliance

5. The Somnowell Appliance

Specialist mandibular advancement appliances (MAA) are made from variations of acrylic plastic and need to be ordered and fitted by a dental professional or sleep specialist. Some dental professionals and sleep specialists will supply their own in-house MAA. While other dental professionals and sleep specialists will supply a branded MAA from a company specializing in these products. Prices range from £250 to £1000.

Some specialist MAA’s are becoming more sophisticated in design as the effectiveness of MAA's in the treatment of obstructive sleep apnea and problematic snoring becomes more widely appreciated by health institutions around the world.

The use of acrylic plastic as the main material means the design of these MAA‘s must rely on the teeth and gums as the primary restrainer of the lower jaw. This can cause some soreness of the teeth and gums, along with occasional movement of the teeth.

Specialist acrylic plastic MAA’s are designed to last typically for up to 36 months. As a long term solution for problematic snoring or sleep apnea this can make them very expensive. Furthermore each time the device needs replacing new appointments normally need to be scheduled.

It is an often over looked fact that acrylic plastic itself is not a recommended material for use in the mouth over an extended period of time. Acrylic plastic absorbs water and has a tendency to become unhygienic and brittle over time, making them more prone to breakages.

EG 1. THE SILENSOR

A HINGED VACUUM FORMED APPLIANCE. Expected lifespan 2 – 3 years - Cost 450 euro

The Silensor is one of the oral appliances which can be worn at night. Its biggest advantage being that it is relatively non-bulky.

The success of the treatment is largely dependent on the patient's acceptance of the appliance. Obviously, the depth of sleep and comfort of the patient will increase with the reduction in bulk of the appliance.

All these benefits are advantages of the SILENSOR.

The SILENSOR makes use of the fact that the pharyngeal space is enlarged when the lower jaw is displaced in an anterior direction.

The SILENSOR consists of two separate formings which fit over the upper and lower tooth arches. The formings are connected by two lateral rotating connectors which gently pull the lower jaw forward. Any further opening of the mouth increase the anterior displacement of the lower jaw. Despite wearing the SILENSOR, movement of the lower jaw is possible.

Because the SILENSOR is of minimum bulk it is comfortable and an effective anti-snoring aid. The SILENSOR has proven highly successful even when breathing through the nose is difficult or blocked, since in almost all cases the noise involved in snoring is caused by constriction of the airways. Similarly, when breathing through the nose is difficult or impossible, e.g. by polyps, use of the SILENSOR is in no way precluded.

The SILENSOR cannot be used in the edentulous mouth. Where removable partial dentures are worn and are firmly retained within the mouth the SILENSOR can be used. In other cases, it must be assessed individually whether the standing teeth will provide sufficient retention of the device.

The SILENSOR is contra-indicated in cases of myofacial disfunction, TMJ disorders, arthropathy of the tempromandibular joint, or advanced periodontal condition.

THE TAP 3

A HOOKED VACCUM FORMED APPLIANCE

Expected lifespan 3 4 years - Cost 650 euro

The TAP® (Thornton Adjustable Positioner) device provides a powerful prescription for snoring and Obstructive Sleep Apnea (OSA). Based on the same principle as cardiopulmonary resuscitation (CPR), the TAP was designed to keep the airway open to allow for air to pass. A constricted or collapsed airway causes snoring and OSA. Both the TAP and TAP 3 TL hold the lower jaw in a forward position, maintaining a clear airway to reduce snoring and improve breathing. The TAP and TAP 3 TL consist of an upper and lower tray that fit over the teeth. Fitting more comfortably in the mouth than the original TAP, the TAP 3 TL features smaller hardware that provides more room for the tongue and allows the lips to close. A hook mechanism attached to the upper tray fits into a socket attached to the lower tray and positions the lower jaw forward, preventing the soft tissue of the throat from collapsing and obstructing the airway. An adjustment key allows the patient to adjust the device until a comfortable and effective position is achieved.

THE TAP TUBED TAP APPLIANCE

Expected lifespan 3 – 5 years - COST 750 EURO

The same vacuum formed strengthened appliance as the hooked tap but with lateral arms for positioning the jaw forwards.

Has the advantage of more tongue space, better patient acceptance and therefore higher adaptation to the individual patient

THE NARVAL APPLIANCE

A MANDIBULAR ADVANCING DEVICE

Expected leifespan 10 – 15 years - Cost 1800 Euro

We believe that comfort and compliance are directly related. That is why the Narval CC® is designed to minimise patient discomfort, which is caused by bulk, invasion of tongue space and lack of freedom of mandibular movement. The Narval CC® features:

Features of the Narval CC®:

• Custom made splints to ensure retention and maximum comfort • Precise and easy mandibular protrusion adjustment (15mm range) • Physiological articulation to minimise stress on the TMJ articulation (jaw joint) • No direct impact on incisors to avoid tilting • No tongue space invasion and minimal bulk • Three to five years duration • Wide range of customisation options to improve tolerance and efficacy • Fully biocompatible, comfortable materials • Compliant to ISO 10933-10, 10933-11 and 10933-13 (International Biocompatibility Standards.)

High Compliance

• After six weeks of treatment, 80% of patients wear the Narval device seven nights a week • 81% of patients are still under efficacious treatment after one year

Proven Efficacy

• Significant AHI reduction even in severe OSAS patients • Rapid improvement in sleepiness and quality of life parameters

Improved Tolerance

• No pressure on incisors to limit the risk of incisor tilting • The results on mouth opening and TMJ contact strength tend to demonstrate a better clinical profile in terms

of compliance and side effects for Narval traction based MRD1

Benefits for Patients

Discrete, comfortable and effective

• Small, custom-design minimises bulk in the mouth • Lateral flexibility enables freedom to move the lower jaw • Absence of contact with incisors minimises dental sensitivity post-wear • Ability to electively open the mouth • Patented Optimised Retention of the Mandible (O.R.M.) articulation promotes mouth closing and

physiological breathing during sleep

Easy to titrate – highly adjustable (15mm protrusive range)

The Narval CC® uses technology that has been developed and refined for a decade, with the help of multi-disciplinary medical teams. The unique innovation is the jaw relationship, which minimises the physiological joint-stress and limits the risk of dental side-effects. Instead of pushing the mandible forward, it is retained in a forward position. This mechanism design allows the use of semi-rigid plastic materials, which enable greater flexibility and comfort for the patient. CADCAM In March 2009 Laboratoires Narval introduced the first custom device, made by Computer Aided Design (CAD) and Computer Aided Manufacture (CAM). Using selective laser sintering of a biocompatible polymer, CAM guarantees consistent, industrial-strength manufacturing. The unique CAD/CAM technology delivers a highly adjustable (15 mm) bi-bloc, custom-made design, which gives the patient more time to adapt to wearing the device in a passive non-protruded position. Once they have become used to wearing it, the device can then be gradually adjusted to increase the effect. This technology is protected by international patents.

The Narval CC is custom made for each patient using CADCAM technology

• Computer-aided design (CAD) enables precise customisation to suit the dental anatomy of each patient • Computer-aided manufacturing (CAM), through selective laser sintering, guarantees consistent industrial-

strength manufacturing

As a result the Narval CC is:

• Metal free, small and light • Highly resistant and made using a durable, biocompatible polymer material

The journal SLEEP February 2006 (1) recommendations of the

American Academy of Sleep Medicine validated the indications for mandibular

advancement splints in sleep disordered breathing.

Custom MRDs are recommended as 1st Line Treatment

• In mild to moderate OSA for patients who: o Prefer MRDs over CPAP o Do not respond to CPAP o Are inappropriate candidates for CPAP o Fail behavioural measures treatment

• In Primary Snoring for patients who do not respond or are not appropriate candidates for behavioural measures treatment Custom MRDs are recommended as 2nd Line Treatment

• Severe OSAS (AHI>30) in case of failure of an initial trial of CPAP

Definitive Contra-indications

• It is not possible to treat patients with: • Complete removable dentures • Missing lower posterior molars on one or both sides of the mandible • Maximum mandibular advancement of less than 5 mm • Biomechanics: number and arrangement of elements of the remaining dentition, denture. • Fully removable bottom (unless attached to implants) • Infectious : Infectious diseases and complications of local dentition and periodontium

• Functional : Some dental problems , musculo-articular skeletal neurological or psychiatric • Short teeth, insufficient teeth per arch and quadrant (i.e. ~4 minimum per quadrant), absent lower molars and

insufficient undercuts to retain the device • Temporo-mandibular joint pain: unadvised - to be discussed between patient and a TMJ / occlusion specialist • Patients with a record of TMJ osteoarthritis should not be treated with an MRD

Temporary Contra-indications

• Periodontal disease: must be treated by the patient’s dentist before MRD treatment • Cysts and mouth ulcers: should be treated by the patient’s dentist before MRD treatment • Teeth to be extracted, prosthesis to be fitted, temporary prosthesis to be replaced - ask the patient to be

treated by their usual dentist before they are fitted for an MRD • Undergoing dental restorations, requiring or having had recent dental extractions

This diagram shows a high-level view of the different appointments of the patient with the Dental practitioner. To view short videos on these different appointments, please visit www.narvalwebtv.com. Log in to the Healthcare Professional section by registering your email address and then we will send you a password.

For five years, the Narval MRD has been fitted to more than 10,000 patients in Europe and North America. It has also been extensively researched in clinical trials at leading institutions around the world.

Below is a list of scientific research that has been published recently:

• Vecchierini Multicentric clinical study for abstract click here o Showed excellent compliance and good efficacy in a real-life setting o 60% responded to treatment before titration o 94% of patients had high rates of compliance within six weeks of treatment o Rapid and significant improvement in sleepiness, quality of life (improved social interactions and

self-assessed mental health, decrease in daytime dysfunctions) and sleep quality • Geraads CPHG multicentric study abstract

o One-year follow up with titration on 129 patients o Treatment efficacious on respiratory parameters (average AHI from 25 before treatment to eight

after one year of treatment) even for severe OSA patients (average AHI from 40 to 9) o Significant efficacy on sleepiness (Epworth score) and fatigue (Visual Analog Scale) o Only 6% of patients dropped out of treatment for tolerance issues after 12 months

• Cheze, Navailles Biomechanics study abstract - scroll down for English version o Biomechanics model to compare impact of Narval device vs. Herbst device on TMJ and mouth

opening issues o Narval had a superior tolerance profile to Herbst based on TMJ contact force, and mouth-opening

parameters assessment

THE SOMNOWELL CHROME COBALT APPLIANCE

Expected lifespan 10 – 15 years fee 1800 euro See Video http://www.screencast.com/t/GA38g4REt of appliance on model. Made of Chrome Cobalt and linked precisely to your natural teeth or indeed to dental implants for the edentulous ( No teeth ) the Somnowell has the advantage of durability, of improved hygiene and of increased tolerance.. Using the techniques and materials of the best partial denture design it is well tolerated, effective and hygienic. Best of all you can wear this appliance and it doesn’t really show to your partner and allows you to speak and drink while wearing it with minimal interference

At a Glance

• The world's leading oral appliances for snoring, sleep apnoea, TMJ, teeth grinding and retention • Individually designed by a senior consultant and specialists • Made from resilient cast Chrome Cobalt alloy, outperforming acrylic plastic and thermoplastic

devices • Best for oral hygiene, suitable for long term wear in the mouth • Thin, small, and discreet, the Somnowell is amazingly comfortable • Minimal infringement on tongue space and free vertical and lateral jaw movement • Truly effective lifetime solution, with no recurring costs • Highest level of medical care and expertise • Tailor made comfort with minimal interference • Practical alternative to surgery and other uncomfortable options

The Somnowell is the world’s most advanced oral appliance for treating problematic snoring and Obstructive Sleep Apnoea. The Somnowell is also used to treat Bruxism and TMJ. It is the only oral appliance that offers a truly effective and comfortable lifetime solution. The Somnowell is made from cast Chrome Cobalt alloy, commonly used by dentists when creating the highest quality dentures, bridges, and crowns. It is impervious to the bacteria and fungi commonly found in acrylic plastic and thermoplastic Mandibular Advancement Appliances, and is suitable for long-term use in the mouth. While comparably priced appliances will last only a fraction of the time, the Somnowell will look and feel exactly the same after decades of use.

The Somnowell gently holds your lower jaw in the ‘recovery position’ while you sleep, an ideal method for ensuring a well maintained airway. While other MMAs infringe on tongue space, causing the user discomfort, the Somnowell’s unique lower jaw connecting section gives the tongue free space to move. The Somnowell is so comfortable you won’t even notice you are wearing it. The wearer can talk freely, drink and take medication.

The design of the Somnowell takes into account the individual features of each user’s jaw joints, so the appliance can be used as a highly effective treatment for jaw pain. An added benefit of the Somnowell is that it keeps the teeth in position, and the the Somnowell Retainers are currently recommended by specialists as a permanent retainer after orthodontic work. Each and every Somnowell appliance is designed and manufactured by specialists, and made to exacting standards, for a lifetime of good sleeps.