PM Postioner 1

Published by Dental Services Group - Minneapolis, MN

The Adjustable PM Positioner™is an innovative new solution to snoring and sleep apnea.The PM Positioner®, an intraoral appliance worn during sleep, has proven 70% effective for patients with mild to moderate obstructive sleep apneas and 90% effective for managing patients' snoring. And now it is available as an adjustable appliance.

The Adjustable PM Positioner™ is an effective alternative to surgery or the use of an air pressure mask (CPAP) while sleeping. This appliance keeps the airway open by holding the jaw comfortably in a forward position, minimizing or eliminating snoring and obstructive sleep apneas. The patient continues to breathe naturally through the nose or mouth.

Comfort, High Patient Compliance

The Adjustable PM Positioner is a unique intraoral appliance that offers dentists a distinct advantage over many other oral appliances: ease of fitting and ease of altering mandibular position to maximize effectiveness and jaw comfort. Formed from a thermoplastic material, the Adjustable PM Positioner softens in warm water and in the mouth, ensuring outstanding comfort and patient compliance, trouble-free fabrication and simplified fitting. The mandibular position can be changed and customized by using a wire instrument to turn the screw mechanism on each side of the appliance. The screw mechanisms are attached on the buccal aspect of the appliance to offer ample space for the tongue and freedom of jaw movement in a lateral or protrusive direction to increase jaw comfort.

Turning the screw will advance or retrude the mandible to improve the effect of the appliance in resolving the snoring and the number of apneas.

Office Procedures

Just follow this step-by-step procedure for a simple solution to your patient's sleep apnea and snoring problem.

Note: You may prefer to place a trial appliance to confirm comfort, effectiveness and therapeutic jaw position prior to placing the final Adjustable PM Positioner.

First Visit Evaluation, Exam, Impressions

Important: Prior to any oral appliance therapy the patient should be referred to their primary physician or a physician who specializes in sleep medicine.

Exam

2. Perform examination.

Examine tongue size, size of so palate, size of uvula.
Examine overbite and overjet
Determine maximum vertical
opening, lateral excursive jaw
movements and protrusive jaw movement.
Evaluate soft tissues.
Evaluate periodontal condition.
Perform TMJ evaluation (including muscles of mastication).

3. Discuss treatment plan with patient

Once patient has decided on treatment plan, impressions are taken.

Impressions

Take impressions and bite registration

Take upper and lower alginate impressions. They should exhibit good, clear detail of teeth and gingival tissues. Each impression should extend at least 2 to 3 mm. beyond the second molar area or most posterior tooth.
The upper impression should include the entire hard palate with extension to the soft palate. The mandibular impression should include extension to the mylohyoid bone.
Pour models immediately to avoid distortion of the impression material.
Pour models immediately to avoid distortion of the impression material.
Take a bite registration of the mandible positioned at 5096 of maximum protrusion. The anterior teeth should be separated by 5 to 7 mm(edge to edge) in the treatment position.

Important: Move the mandible forward symmetrically, without deviating to the right-or left during registration. For accurate bite registration, use a George Gauge. The George Gauge can be obtained through your laboratory.

Trim upper and lower models and mark any existing crowns with "C" on appropriate stone teeth. Send models and bite to lab.

Second Office Visit Inserting the final Appliance

1. Place the appliance under warm/hot water to soften the Brux-eze material. Place over upper teeth and ask the patient to move the mandible forward and close slowly into the mandibular portion. The patient should not have to use excessive force to place the mandible firmly into the lower portion of the appliance.

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Page 2

2. If the mandibular or maxillary teeth are inhibited or prevented from closing into the appliance completely, the appliance can be placed back on the casts while running them under warm water in order to stretch the appliance slightly. Then remove the appliance from the casts carefully, while running under warm/hot water. If necessary, a manor adjustment can be made to the internal portion or periphery of the appliance to allow for proper seating.

3. To remove the appliance, instruct the patient to place the finger tips or thumbs on the lower edge of the lower portion of the appliance and push up while gently bracing the jaw. When the lower teeth have been freed from the appliance, the patient can place the finger tips on the upper edge (back part) of the upper portion and pull straight down to remove the appliance from the mouth. Do not remove the appliance by simply opening the mouth. The patient must remove the device using the fingers/thumbs because the wires attached to the screw mechanism will bend if the appliance is removed by simply opening out of it This can distort the appliance and may require replacement.

4. Provide the patient with care instructions and schedule a follow up visit for 10 to 14 days. Instruct the patient to call your office and discontinue appliance use if soreness or pain is experienced.

5. The patient should understand that the first two weeks with the appliance will allow the patient to adapt to it Tell the patient that adjustments may be made to the appliance and they will be given a special key (wire instrument), along with instructions on how to use it at their next appointment.

Third Office Visit: Evaluate Progress and Make Adjustments

1. Review patient's progress with Adjustable PM Positioner. Discuss comfort and effectiveness.

2. Examine/Evaluate:

Fit of appliance

Screw mechanism to verify that right and left sides still set equally

Patient's occlusion and OB/OJ

Evaluate TMJs and range of motion (ROM)

3. Make any needed adjustments to improve comfort or fit.

4. Adjust screw mechanism to improve effect of appliance by advancing the mandible or retrude mandible if there is jaw discomfort.

Give the patient the wire instrument key and instructions for altering the jaw treatment position by turning the screw mechanism. Show the patient the arrow on the side of the screw. Have the patient place the key into the hole in the center of the screw mechanism and push or turn the key in the direction of the arrow. One turn in the direction of the arrow will advance the mandible 0.25 mm. As you would expect, placing the key in the hole and pushing the key in the opposite direction of the arrow will retrude the mandible 0.25 mm. The patient needs to contact the doctor prior to making any change in the mandibular position. Advise the patient No change in mandibular position (turning the screws) should be made without instructions by the doctor.

6. Instruct the patient to contact the doctor if the snoring continues or if jaw pain/TMJ symptoms occur. The doctor will instruct the patient to change the appliance/screw mechanism and make a notation in the patient's chart This interaction can be completed by phone. Schedule the patent for a follow up evaluation in 3 to 4 weeks.

Note: Additional visits may be needed if the patient is experiencing discomfort.

Fourth Office Visit: Continue Evaluation of Progress, Examination, Adjustment of Appliance

1. Same as third office visit, #1.

2. Same as third office visit, #2.

3. Same as third office visit, #4.

4. If the appliance is effective and comfortable for the patient then the screw mechanism can be tied off with wire to avoid any changes in screw position during use that would alter jaw position (see Tying-off Screw section).

5. If the appliance is effective and comfortable the patient can be placed on a 6 month follow up (recall) after the screw mechanism has been anchored.

Tying-off Screw Mechanism

1. To prevent changes in the screw mechanism during the use of the appliance over time, a wire can be placed to "tie-off" the screw.

2. A .012" gauge wire can be threaded through the holes in the screw. Grasp both ends of the wire with a hemostat and twist the wire until it is snug. Cut off the excess twisted wire and tuck the loose end of the wire into the screw mechanism.

3. In the future, if it is necessary to change the mandibular position, the wire can be cut and the screw turned to advance or retrude the jaw.

Note: Patients currently using the PM Positioner can have screws added to their appliance to make it adjustable.

Copyrights 1996 Dental Services Group

The Adjustable PM Positioner™is an innovative new solution to snoring and sleep apnea.The PM Positioner®, an intraoral appliance worn during sleep, has proven 70% effective for patients with mild to moderate obstructive sleep apneas and 90% effective for managing patients' snoring. And now it is available as an adjustable appliance. The Adjustable PM Positioner™ is an effective alternative to surgery or the use of an air pressure mask (CPAP) while sleeping. This appliance keeps the airway open by holding the jaw comfortably in a forward position, minimizing or eliminating snoring and obstructive sleep apneas. The patient continues to breathe naturally through the nose or mouth. Comfort, High Patient Compliance The Adjustable PM Positioner is a unique intraoral appliance that offers dentists a distinct advantage over many other oral appliances: ease of fitting and ease of altering mandibular position to maximize effectiveness and jaw comfort. Formed from a thermoplastic material, the Adjustable PM Positioner softens in warm water and in the mouth, ensuring outstanding comfort and patient compliance, trouble-free fabrication and simplified fitting. The mandibular position can be changed and customized by using a wire instrument to turn the screw mechanism on each side of the appliance. The screw mechanisms are attached on the buccal aspect of the appliance to offer ample space for the tongue and freedom of jaw movement in a lateral or protrusive direction to increase jaw comfort. Turning the screw will advance or retrude the mandible to improve the effect of the appliance in resolving the snoring and the number of apneas.	Office Procedures Just follow this step-by-step procedure for a simple solution to your patient's sleep apnea and snoring problem. Note: You may prefer to place a trial appliance to confirm comfort, effectiveness and therapeutic jaw position prior to placing the final Adjustable PM Positioner. First Visit Evaluation, Exam, Impressions Important: Prior to any oral appliance therapy the patient should be referred to their primary physician or a physician who specializes in sleep medicine. Exam 2. Perform examination. Examine tongue size, size of so palate, size of uvula. Examine overbite and overjet Determine maximum vertical opening, lateral excursive jaw movements and protrusive jaw movement. Evaluate soft tissues. Evaluate periodontal condition. Perform TMJ evaluation (including muscles of mastication). 3. Discuss treatment plan with patient Once patient has decided on treatment plan, impressions are taken. Impressions Take impressions and bite registration	Take upper and lower alginate impressions. They should exhibit good, clear detail of teeth and gingival tissues. Each impression should extend at least 2 to 3 mm. beyond the second molar area or most posterior tooth. The upper impression should include the entire hard palate with extension to the soft palate. The mandibular impression should include extension to the mylohyoid bone. Pour models immediately to avoid distortion of the impression material. Pour models immediately to avoid distortion of the impression material. Take a bite registration of the mandible positioned at 5096 of maximum protrusion. The anterior teeth should be separated by 5 to 7 mm(edge to edge) in the treatment position. Important: Move the mandible forward symmetrically, without deviating to the right-or left during registration. For accurate bite registration, use a George Gauge. The George Gauge can be obtained through your laboratory. Trim upper and lower models and mark any existing crowns with "C" on appropriate stone teeth. Send models and bite to lab. Second Office Visit Inserting the final Appliance 1. Place the appliance under warm/hot water to soften the Brux-eze material. Place over upper teeth and ask the patient to move the mandible forward and close slowly into the mandibular portion. The patient should not have to use excessive force to place the mandible firmly into the lower portion of the appliance. { Continued Next Page }
	Page 2

2. If the mandibular or maxillary teeth are inhibited or prevented from closing into the appliance completely, the appliance can be placed back on the casts while running them under warm water in order to stretch the appliance slightly. Then remove the appliance from the casts carefully, while running under warm/hot water. If necessary, a manor adjustment can be made to the internal portion or periphery of the appliance to allow for proper seating. 3. To remove the appliance, instruct the patient to place the finger tips or thumbs on the lower edge of the lower portion of the appliance and push up while gently bracing the jaw. When the lower teeth have been freed from the appliance, the patient can place the finger tips on the upper edge (back part) of the upper portion and pull straight down to remove the appliance from the mouth. Do not remove the appliance by simply opening the mouth. The patient must remove the device using the fingers/thumbs because the wires attached to the screw mechanism will bend if the appliance is removed by simply opening out of it This can distort the appliance and may require replacement. 4. Provide the patient with care instructions and schedule a follow up visit for 10 to 14 days. Instruct the patient to call your office and discontinue appliance use if soreness or pain is experienced. 5. The patient should understand that the first two weeks with the appliance will allow the patient to adapt to it Tell the patient that adjustments may be made to the appliance and they will be given a special key (wire instrument), along with instructions on how to use it at their next appointment.	Third Office Visit: Evaluate Progress and Make Adjustments 1. Review patient's progress with Adjustable PM Positioner. Discuss comfort and effectiveness. 2. Examine/Evaluate: Fit of appliance Screw mechanism to verify that right and left sides still set equally Patient's occlusion and OB/OJ Evaluate TMJs and range of motion (ROM) 3. Make any needed adjustments to improve comfort or fit. 4. Adjust screw mechanism to improve effect of appliance by advancing the mandible or retrude mandible if there is jaw discomfort. Give the patient the wire instrument key and instructions for altering the jaw treatment position by turning the screw mechanism. Show the patient the arrow on the side of the screw. Have the patient place the key into the hole in the center of the screw mechanism and push or turn the key in the direction of the arrow. One turn in the direction of the arrow will advance the mandible 0.25 mm. As you would expect, placing the key in the hole and pushing the key in the opposite direction of the arrow will retrude the mandible 0.25 mm. The patient needs to contact the doctor prior to making any change in the mandibular position. Advise the patient No change in mandibular position (turning the screws) should be made without instructions by the doctor. 6. Instruct the patient to contact the doctor if the snoring continues or if jaw pain/TMJ symptoms occur. The doctor will instruct the patient to change the appliance/screw mechanism and make a notation in the patient's chart This interaction can be completed by phone. Schedule the patent for a follow up evaluation in 3 to 4 weeks.	Note: Additional visits may be needed if the patient is experiencing discomfort. Fourth Office Visit: Continue Evaluation of Progress, Examination, Adjustment of Appliance 1. Same as third office visit, #1. 2. Same as third office visit, #2. 3. Same as third office visit, #4. 4. If the appliance is effective and comfortable for the patient then the screw mechanism can be tied off with wire to avoid any changes in screw position during use that would alter jaw position (see Tying-off Screw section). 5. If the appliance is effective and comfortable the patient can be placed on a 6 month follow up (recall) after the screw mechanism has been anchored. Tying-off Screw Mechanism 1. To prevent changes in the screw mechanism during the use of the appliance over time, a wire can be placed to "tie-off" the screw. 2. A .012" gauge wire can be threaded through the holes in the screw. Grasp both ends of the wire with a hemostat and twist the wire until it is snug. Cut off the excess twisted wire and tuck the loose end of the wire into the screw mechanism. 3. In the future, if it is necessary to change the mandibular position, the wire can be cut and the screw turned to advance or retrude the jaw. Note: Patients currently using the PM Positioner can have screws added to their appliance to make it adjustable.
	Copyrights 1996 Dental Services Group