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Mandibular Advancement Device

Mandibular Devices for Obstructive Sleep Apnea

The mandibular advancement device (MAD), also called mandibular repositioning device (MRD) or jaw retainer, is the most common and successful device for sleep apnea and snoring.

The device is sold under many the trade names such as:

Thornton Adjustable Positioner,
Herbst Appliance ,
Tomed SomnoGuard,
Somni Snore Guard,
Hilsen Oral Appliance,

Silent Sleep device,
The Silencer device,
OrthoApnea appliance,
VitalSleep Mouthpiece,
and many others.

How do Mandibular Devices Work?

The mandibular advancement device works under a simple principle:

it holds the jaw forward of the upper teeth while you wear it (during sleep).

Since the tongue is attached to the jaw at the chin, this has a way of holding the tongue out of the airway (airway will be more open), by as many as several millimeters.

How the jaw advancement device work?

Now, you will think that several millimeters are not enough to open your airway to breathe normally. However, according to math, the area of a circle (your airway is a circle) is pi R squared, meaning that 1 mm would turn into 3.14 mm in area.

This is why you or your doctor need to take the adjustment of the mandibular advancement device really slowly. And you will also need to do lots of jaw flexing exercises after you take it out every morning.

In other words, the mandibular device for sleep apnea push the chin, but also the tongue forward, to create space in your upper airway for breathing in sleep.

Why Pushing the Chin Moves the Tongue Forward

the tongue is moved forward with the jaw because it is connected to the inside of the lower jaw at the genial tubercle.

when the jaw is advanced so is the tongue.

the tongue is connected to the soft palate by the Genioglossus muscle so that is also tightened.
That is why somnoplasty, pillar procedure, Laser Assisted Uvula Palatoplasty (LAUP) and Uvulopalatopharyngoplasty (UPPP) are usually not needed with dental appliance therapy.

Efficiency of Mandibular Advancement Devices

Considering the anatomical factors, results that a mandibular advancement device will work only if you have an obstructive based apnea, where holding the tongue and jaw forward will do you some good.

Will MAD work for me?

If your apnea was caused by excess fat crushing your windpipe when you lay on your back, a dental device might not be effective.

But if you combine weight loss with a sleep apnea dental device and part of the cause was tongue or jaw involvement, then it is much more likely to work.

Other reasons why a dental device for sleep apnea would not work may be the persons's inability to tolerate the device at it's best setting, which might be an advancement length that causes pain and pressure in the jaw hinge.

Another reason may be that some people with sleep apnea do not have significant tongue involvement.

Testing the Efficiency of MAD

The only test that tells you if a mandibular advancement device works is polysomnography. Also, a repeat test with your appliance in your mouth is essential.

The easiest dental appliance to titrate is the TAP 1,2 or 3, which is the only mandibular advancement device that can be adjusted easily by the patient or practitioner while in the mouth. This makes it easier to find an ideal treatment position for your jaw and tongue. Once the position is found, you should hold that position.

You will know if your jaw or tongue has the right position, when you wake up refreshed in the morning and when the sleep test confirms that you don't have apnea episodes and snoring.

Side Effects of Jaw Advancement Device

MAD Side Effects
myofascial pain	face and TMJ discomfort are associated with mandibular repositioning. The pain may appear in the early stages of treatment, but it will decrease in time with jaw motion exercises.
excessive salivation	this is more prevalent at the beginning of the treatment and usually decreases with the continued use of the oral appliance. Mouth breathing patients will continue having salivation problems. A chin strip may be helpful to correct this issue.
occlusal changes	are associated with using the device more than 6 to 8 hours a day. These changes will return to normal in 30 minutes or longer after stopping the treatment. Using the therapeutic bite rim received from your dentist, and doing the jaw motion exercises can also be helpful.

Jaw and Tongue Exercises and other Tips Necessary after MAD use

place the therapeutic bite rim (received from your dentist with your dental device) between your teeth and slide the mandible in a backward and forward position up to 10 times after removing the dental appliance.

applying moist heat to facial muscles (lower jaw muscles) while doing the exercises can be helpful.

open the mouth as wide as possible, and place the tongue up and as far back as possible. Close the mouth with your tongue in this position.

with the consent of your doctor, you can use a muscle relaxation medication before sleep.

The Purpose of Daily Exercises after using dental devices

You need daily morning jaw exercises, if you sleep with a mandibular advancement device.

Along with the dental device, you will receive a set of instructions on how to do these daily jaw exercises. Here is an explanation on why you need to do these exercises every morning:

with your jaw pulled forward, the "lube" at the joint socket fills in behind there, and because it isn't moving around a lot, it tends to "congeal" a bit overnight.

so the idea is in the morning to get the fluid evenly distributed again and loosened up.

also, the TAP instructions mention that a bite change might be caused by the prolonged shortening of the muscles that provide us the ability to push our jaw forward.
In the morning, those muscles must be stretched to allow the back teeth to come together properly.

How to Adjust the Mandibular Advancement Device?

Lots of patients with sleep apnea complain about the efficiency of dental devices. More failures seem to be attributable to people rushing the adjustment than anything else.

The key seems to adjust the mandibular advancement device gradually:

start with a fairly neutral position with the teeth fairly even or just a few turns.

leave it there until it feels "normal", even though this may not be opening your throat enough to help your sleep apnea...and that is the tricky part where I will remind you to seek the doctor advice.

then give it a few more turns, see how your snoring and apnea responds (gasping, dreaming, waking up feeling better, and of course a pulse oximeter would be ideal).

wait until it feels pretty normal.

then repeat until it feels about optimum.

Unfortunately, without a titration sleep study from a sleep center that is willing to work with mandibular advancement devices, it's tricky getting it dialed in.

So, the most important advice from me would be to insist on a follow up sleep test and do your jaw exercises!

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