(Kent Smith, Keith Thornton, Les Priemer, Tony Soileau, Francesca Milano, Patrick Tessier, Daniel Klauer, Steve Lamberg, Gina Pepitone-Mattiello, John Carollo, Dennis Marangos, Barry Glassman, Steve Carstensen, Christopher Kelly, Dan Tache, John Viviano)
The LinkedIn Discussion Group, “SleepDisordersDentistry” has just completed an open discussion on “Dealing with the 5-Minute Oral Appliance Fix”. Here is a consensus for all to ponder.
What was asked,
“We’ve all been there, you walk into the room, the patient is in the chair, and you have 5 minutes to do something… the patient hands you a broken appliance requiring lab work and informs you that he isn’t leaving without something to wear, because he simply can’t sleep without an appliance. What do you do?”
What was said,
Some clinicians discussed permanent in-house acrylic repairs, and that use of a pressure pot for these repairs is recommended. However, most solutions were temporary, intended to provide an immediate solution for the patient while a new appliance was being fabricated.
Dan Tache shared details on how to temporarily handle a broken acrylic appliance using Thermacryl. In this case, a TAP 3, that had experienced both fracture and delamination as a result of the fracture. The fracture was clean and the two pieces could be accurately positioned together.
What Dan did:
1. Roughened the edges of both and extended the "roughening" for about 1 cm beyond the fracture point
2. Cleared the delaminated liner and roughened that area as well. So far, 3-4 minutes
3. Conditioned the entire roughed areas, both inside and out, with acrylic monomer (methyl methacrylate)
4.Prepared some Thermacryl i.e. heated it to clear. See LINK:
5. Placed Thermacryl on the outside of, as well on the fracture, and held the pieces together letting the Thermacryl cool a bit
6. Ran it under cold water until it was cooled/firm, about 10 seconds
7. Added more acrylic monomer to the inside to re-condition the surface, heated some additional Thermacryl and placed it on the inside
8. Placed both trays of the TAP3 in patients mouth and had the patient close together with the still, soft Thermacryl in place, and swished with a little cool water for 10 seconds or so, moved the lower tray (fractured half) up and down 2 or 3 times to get the undercuts minimized so that it would not lock in place
9. Removed the appliance from the mouth and completed the job by chilling it under cool water
10. Placed the appliance back in her mouth and confirmed that it was a good fit; if it was a little off, one could gently warm the entire tray a little and place it back in the mouth
11. Appoint patient for impressions for a replacement appliance
Total time: 15-20 minutes. This repair should last a few weeks.
However, the most common 5-minute fix involved the use of a boil and bite temporary appliance. As an over the counter solution, Dan uses the NORAD boil-and-bite. They are inexpensive, quick and easy to insert, very retentive and can be fit in the patient’s mouth or on models. If fit indirectly, the thermoplastic material can be brought to a very high temperature (full boil), and adapted very accurately to the models, providing superb retention. The NORAD is also adjustable; advancement is accompanied with vertical increase so there is no impingement in the posterior. Information on the NORAD can be found at the following LINK:
Although several temporary appliances were mentioned, the most popular one was the MyTAP. Keith Thornton pointed out that the original MyTAP experienced a <2% breakage rate due to how it was molded. Since this was fixed, there have been no reports of breakage. He also pointed out that any trial appliance should be as effective as the permanent appliance otherwise the patient is being left under treated.
Daniel Klauer discussed his use of the 3rd Generation 3Shape Trios digital scanner, pointing out that no longer having patient models readily available posses some challenges for these repairs, but not often enough to warrant storing models. He has trialed the protocol of printing a second appliance for patients once the initial appliance proves effective and that has worked well for patients that have two homes, travel a lot for work and as a backup appliance.
Dennis Marangos discussed the non-custom appliances offered by Myofunctional Research. For sleep patients, he specifically mentioned the Myo-OSA appliance. It is low cost at $75-90 Canadian, inserts in 2 minutes, and also works as a functional appliance to train the tongue in repositioning. More information on the Myo-OSA can be found at the following Link:
Barry Glassman discussed the Snore Hook, developed by Jim Boyd several years ago. It is a Thermocryl filled appliance that is fabricated on a patient’s models in 15 minutes or less. FDA approved for snoring and mild to moderate OSA, it is fully titratable, complies with all insurance guidelines (Medicare Approved) and the kit costs $59 USD. You can watch a video of how to fit this device onto a model at the following LINK:
For those that still insist on making their tomato sauce from scratch, Keith Thornton explained another “quick, easy and cheap” (I love that term) way to deal with this problem. Take impressions and make 2mm thick trays. Measure protrusion of the broken appliance with a ProGauge without the bite fork. Lute the upper and lower trays together at that protrusion with Thermacryl. This makes a great Monoblock appliance that will be durable and effective, even for severe patients. Keith calls this an adjustable Monoblock and uses it when he wants to minimize opening and bulk. The protrusion can be reset as needed, by simply heating and resetting.
Steve Carstensen uses mostly the MyTAP for these situations, however, he also uses the Apnea Guard and shared with us an incident where the Apnea Guard helped him to provide a temporary solution to a patient that has a serious cardiac disorder and was very fearful of sleeping without his appliance. Of course, a very good case for a second, backup appliance could be made for this type of individual. When this patient’s appliance broke, his physician was little to no help advising that they could see him in a week. Steve was able to get him in the same day and quickly provide an Apnea Guard to manage his airway until his new appliance arrived.
Christopher Kelly commented that all appliance manufacturers should provide a “cousin” appliance to their main appliance to fulfill this temporary need. The TAP has the MyTAP, the EMA has the First Step. He feels that the temporary appliance should have all of the advantages of the custom version, but fit by the dentist in an “off the shelf” design. Christopher is currently working on a temporary design that matches his Freedom MRD.
(Kent Smith, Keith Thornton, Francesca Milano, Patrick Tessier, Daniel Klauer, Steve Lamberg, Gina Pepitone-Mattiello, John Carollo, Dennis Marangos, Barry Glassman, Steve Carstensen, Christopher Kelly, Dan Tache, John Viviano)
Responsibility for the cost of these repairs is handled in various manners. Some charge an office fee visit for in-office repairs if the patient is not an active patient in the recall system. If lab work is required and the patient is active, an office visit and lab fee is charged. If the dog eats it, they lose it, or destroy it, the fee established in the “informed Consent” is charged; presetting this fee for the patient helps this process go smoother.
Kent Smith discussed the notion of offering the patient a second appliance at a reduced fee (even as low as lab fee only) to use as a backup appliance in the case of loss or breakage. He also offers a third party warranty on breakage which is an option about half of his patients opt for. Information on this warranty can be found at the following LINK:
Kent offers the option of either a warranty or a second appliance at a reduced rate to all his patients. If they refuse both, he feels that they at least have processed the notion that things can happen, making it easier to deal with if they do. He also points out that for patients that have a CPAP sitting in their closet, they always have the option of temporarily using it while their appliance is repaired. Sometimes the appliance can be temporarily fixed in the office. If it's a broken arm on a Herbst, for example, the broken component can sometimes be switched out with a part scavenged from a sample appliance. If acrylic is broken, sometimes it can be smoothed off while a new appliance is fabricated. When all this fails, Kent offers his patient a MyTAP for $100, which is placed by one of his assistants, basically at cost. He points out that he does this to “not lose money”, not necessarily “to make money”.
(Kent Smith, Daniel Klauer)
Les Priemer pointed out that the greater durability associated with 3D printed Nylon appliances has eliminated his breakage issues. Tony Soileau discussed that introducing a physiotherapist into his regular protocol has resulted in a reduction in acrylic appliance breakage issues.
(Les Priemer, Tony Soileau)
Whatever the approach used, the general consensus was clear, the most important thing we should do is ensure that the patient does not go a night without any form of therapy for their medical condition. Steve Carstensen made a comment that I believe is representative of our dental training, “The key is to meet patients where their needs are and be a resource, not a barrier, to getting them into care.” It’s hard to take the dentist out of the Sleep Disorders Dentist; I think that’s a good thing!
Once again, I would like to express a heartfelt thanks to all that participated in this discussion. As always, these consensus articles should be considered working documents, meant to guide those clinicians beginning in this field and also present some valuable insights to those of us that have been at it a while. I look forward to future discussions on our SleepDisordersDentistry LinkedIn group!
John Viviano DDS D ABDSM