Gina Johnson
Taking impressions and bite registration is a crucial step in fabricating custom oral sleep appliances for treating snoring and sleep apnea. This process involves creating detailed dental impressions of both the maxillary and mandibular arches, capturing the dentition and periodontium. Alginate impressions, for instance, require immediate pouring to ensure optimal accuracy. Digital scanning is also an option, offering improved accuracy, patient comfort, and elimination of shipping records. Following this, bite registration is performed to relate the maxillary and mandibular arches, typically at a 50-60% protrusive level, using tools like acrylic jigs or bite forks. The patient's tolerance for the protruded position is assessed before proceeding with the MAD fabrication process.
| Characteristics | Values |
|---|---|
| Impression material | Alginate or other desired medium |
| Impression arches | Maxillary and mandibular full arches |
| Impression capture | Adequately capture dentition and periodontium both facially and lingually |
| Impression of upper vestibule | Important in setting the Labial Acrylic Shield and Nasal Dilator Buttons |
| Impression of lingual tissue and tori | Important if using Lingual Tongue Buttons |
| Impression pouring | Alginate impressions should be poured immediately for optimal accuracy |
| Bite registration | Taken with the patient's jaw in the 50% protruded position using an acrylic jig |
| Bite registration tolerance | Patient sits with the jig in place for 5-10 minutes to assess tolerance |
| Bite registration protrusion | 50-60% of maximum protrusive ability |
| Bite registration tools | George Gauge, Perfect Bite, Pro Gauge, Airway Metrics gauge |
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What You'll Learn
Digital Impressions vs. Alginate Impressions
Digital impressions and alginate impressions are two methods used to take impressions for sleep appliance bite registration. Both methods aim to capture the dentition and periodontium, but they offer different advantages and considerations.
Digital impressions involve digitally scanning the maxillary and mandibular dental arches. This process eliminates the need for traditional impression-taking with alginate and trays. After capturing the protrusive bite, the software builds a model that relates the mandibular arch to the maxillary one. Digital impressions offer benefits such as increased patient satisfaction and efficiency. However, intraoral scanners used for digital impressions can be costly, requiring significant upfront and annual expenses. Additionally, there may be a learning curve associated with adopting new technology, particularly for dentists who are less familiar with digital systems.
On the other hand, alginate impressions have been the most commonly used impression type in dental practices due to their cost-effectiveness. Alginate impressions are created by taking impressions of both the maxillary and mandibular full arches using alginate or other desired media. These impressions should be poured immediately to ensure optimal accuracy and prevent the alginate from pulling away from the tray. While alginate impressions are more affordable, they may not be as accurate as digital impressions in capturing certain details, such as peripheral soft tissues.
The choice between digital and alginate impressions depends on various factors, including cost, accuracy, patient preference, and the specific requirements of the dental practice. Some dentists opt for a combination of both methods, using digital impressions for most workflows but relying on alginate impressions for specific cases, such as creating whitening trays and mouthguards.
When taking impressions for sleep appliance bite registration, it is crucial to ensure that the impressions include a detailed recording of all teeth and tissue, especially the upper vestibule, to facilitate the placement of the Labial Acrylic Shield and Nasal Dilator Buttons. Additionally, the midline position should be considered to minimize patient discomfort and maximize the effectiveness of the appliance.
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Using a George Gauge or Perfect Bite tool
The George Gauge and Perfect Bite are tools used to take the Construction Bite for an O2 OASYS. The Midlines should be checked in Centric and Protrusive to minimize patient discomfort and maximize the effectiveness of the device. The patient can usually be guided to maintain the same midline position, but sometimes there will be a variance.
Using the George Gauge, if the patient can extend 10mm, a good starting position for the device would be a 6 or 7mm advancement. The George Gauge has an easy sliding feature that allows the clinician to increase or decrease protrusion. The patient can try to snore with the Bite Jig in their mouth at different protrusive positions to find a starting position where it appears they are not snoring and the airway is open.
The George Gauge is a horizontal-only method for setting the bite for oral sleep appliances. It is considered easier to use than systems that incorporate both horizontal and vertical advancement. The Optimal Air system, for example, uses a vertical gauge to determine optimal vertical displacement, which is then paired with one of four horizontal keys. This requires no flipping, calculations, or specialized training.
The bite registration should be taken with the patient's jaw in a 50% protruded position using an acrylic jig. If the patient can tolerate this position, the MAD fabrication process can continue. If not, MAD may not be the right treatment. The protrusive bite registration should be taken with an Incisal Opening of 5-7mm, at 60-70% of Maximum Protrusion.
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Capturing the upper vestibule
Firstly, it is important to understand the context of this procedure. This procedure is often carried out to treat sleep apnea and snoring issues. The upper vestibule is the area of the mouth that includes the upper teeth and the surrounding tissue. To capture an accurate impression of this area, it is recommended to use alginate impressions, which should be poured immediately after taking the impression to ensure optimal accuracy.
Before beginning the procedure, it is important to prepare the patient by explaining the process and ensuring their comfort. This may include providing them with a bite block or a tongue depressor to help them maintain a comfortable mouth opening during the procedure.
To capture the upper vestibule, the patient should be instructed to sit upright in a relaxed posture. The dentist should then use a tray filled with alginate or another desired medium to capture an impression of the upper teeth and the surrounding tissue. It is important to ensure that the alginate covers all the teeth and tissue adequately and that it is not pulling away from the tray in any area, as this can compromise the accuracy of the impression.
During the procedure, the dentist should carefully guide the patient to maintain the correct head and neck posture to ensure the impression is captured at the desired vertical dimension. The patient may be asked to sit still for a few minutes while the alginate sets, and they should be carefully monitored to ensure their comfort throughout the process.
After capturing the upper vestibule impression, the dentist should carefully remove the tray and check the impression for any defects or areas that may require retaking. If the impression is satisfactory, it should be sent for processing, which may involve pouring the alginate impression into a model or digitally scanning the impression to create a digital model.
By following these steps, dentists can effectively capture the upper vestibule, ensuring accurate and comfortable sleep appliance bite registration for their patients.
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Scanning the arches
Bite registration can be taken with the patient's jaw in the 50% protruded position by way of an acrylic jig. If the patient can tolerate this protruded position, continue with the MAD fabrication process. If the patient cannot tolerate this position at all, MAD may not be the right treatment for their OSA. However, it is important to note that some forms of MAD allow the dentist to decrease the degree of protrusion from the original 50% protrusive captured at the first appointment.
The advantages of digital scanning over traditional impression-taking include improvements in the doctor's workflow, increased patient comfort, and more accurately fitting appliances. Digital scans can also eliminate the initial shipping of records and impression materials.
When using an iTero scanner, the upper arch is scanned first, followed by the lower arch. Then, the construction bite must be recorded using the dentist's method of choice. With this in place, the right buccal and left buccal are scanned to record the bite. Once the upper arch, lower arch, and bite have been scanned, the iTero software will create a digital file in the bite position.
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The patient's tolerance of the protruded position
To assess the patient's tolerance, the bite registration is taken with the patient's jaw in the 50-60% protruded position using an acrylic jig or a bite fork registration. The patient is then instructed to sit in this position for 5-10 minutes. If the patient can tolerate this position, the MAD fabrication process can proceed. However, if the patient cannot tolerate the protruded position, alternative treatments may need to be considered, as the MAD treatment may not be suitable for them.
It is important to note that the degree of protrusion can be adjusted by the dentist. Some forms of MAD allow for a decrease in the degree of protrusion from the original 50% protrusion captured at the first appointment. This adjustment can be made to improve the patient's comfort and tolerance of the appliance.
Additionally, the patient's curve of Spee and vertical dimension must be considered by the qualified dentist when determining the construction bite. The initial starting position may also be the appropriate therapeutic position, and no further advancement may be necessary. The patient's signs and symptoms, as well as those reported by their bed partner, can be clinically useful in determining the appropriate therapeutic position.
Furthermore, the design of oral appliance therapy plays a significant role in patient tolerance. Anterior stabilization interarch registration devices, which are commonly used in dental sleep practices, have been associated with several biological issues. These devices can reduce posterior oral airway space and negatively impact the position of the temporomandibular joints, particularly in patients with TMD problems. As a result, they misdirect protrusive movement in up to 95% of cases. A posterior stabilization device, on the other hand, facilitates normal anatomic TMJ movement and helps achieve optimal stented positioning for an oral sleep appliance.
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Frequently asked questions
Dental impressions are taken of both the maxillary and mandibular arches. The impressions should capture the dentition and periodontium, both facially and lingually. Alginate impressions should be poured immediately, whereas digital scans can be sent directly to the dental lab.
The patient's jaw should be in the 50% protruded position using an acrylic jig. If the patient can tolerate this position for 5-10 minutes, the MAD fabrication process can continue. The bite registration is then taken to relate the maxillary arch to the mandibular arch.
The George Gauge and the Perfect Bite are good tools for taking the construction bite. The Midlines should be checked in Centric and in Protrusive to minimize patient discomfort and maximize effectiveness.
Digital scans improve the doctor's workflow by eliminating the shipping of records and impression materials. They also improve patient comfort by avoiding traditional impressions and allow for more accurate fitting appliances.
