Clinical dentistry by Michael C. DiTolla, DDS, FAGD
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IntroductionThe EMA oral appliance aids in a good night's sleep. This case study is an overview of the impression appointment and the seat appointment for the appliance.Figure #1INITIAL APPOINTMENT: Patient is presented with information on the design, benefits and fit of the EMA appliance. -
Figure #2The dental assistant demonstrates how EMA will work to reposition the mandibular motion of the mouth for the treatment of snoring and sleep apnea. -
Figure #3A custom tray is tried in the mouth. -
Figure #4An impression of the upper arch is taken. -
Figure #5Check the impression for any distortions, such as pulls, tears or bubbles. Retake impression if any of these imperfections exist. -
Figure #6Prepare another tray for lower dental impression. -
Figure #7Next, take an impression of the lower arch. Allow the impression to set fully in the mouth for two minutes. -
Figure #8The lower impression should extend beyond the gingival margins. -
Figure #9A good bite registration will simplify and minimize future appliance adjustments. For maximum bite registration results, take a bite registration with the patient in an unprotruded centric occlusion with the bite open 8 mm to 10 mm in the anterior region. -
Figure #10Ask the patient to bite gently into bite registration material and then to open wide. Carefully remove the bite registration. Once upper and lower impressions and bite registration are taken, send the completed case to Glidewell Laboratories. -
Figure #11SECOND APPOINTMENT: Fit the upper appliance without the EMA elastic straps to check for comfort and to make sure there is no gingival impingement. Remove. -
Figure #12Next, fit the lower appliance (also without the EMA elastic straps). Remove. NOTE: The EMA appliance may feel snug to the patient for the first five minutes. -
Figure #13Next, observe patient try-in upper and lower appliances together. If the patient expresses discomfort, first check the evenness of the bite page. If discomfort is in the right TMJ, the right bite pad may be too high; reducing height should provide instant relief. -
Figure #14Demonstrate to the patient how to add elastic straps to the EMA appliance. It is important to emphasis careful handling of the appliance. Start by holding the appliance on the side which you are working; catch the hole in one end of strap with pointed end of teardrop-shaped lower button. NOTE: For stiff straps, immerse straps in boiling hot water to soften. This prevents button or appliance breakage. -
Figure #15Stretch the strap anteriorly, along the side of the appliance, until it snaps over the rounded end of the button. Connect both straps to the mandibular section of the EMA first, and then attach to maxillary. The EMA logo on the strap should be facing the appliance. -
Figure #16Now that you've demonstrated how to add elastic straps, ask the patient to repeat the process. -
Figure #17Patient repeats steps and adds EMA elastic straps to appliance. Notice the ease in which this is done. -
Figure #18Ask patient to try-in the EMA appliance. -
Figure #19Seat the upper appliance first, asking the patient to move the mandible forward while pushing down on the anterior portion of the appliance until it snaps into place. -
Figure #20Once the EMA device is snapped into place, question the patient for comfort of the appliance on the teeth, as well as TMJ comfort. Next, check posterior bite pads for even occlusion. If either side is high, conservatively grind the high side until both sides occlude evenly in the protruded position with straps in place. -
Figure #21A properly fitting EMA appliance seated in the mouth; the patient comments that the appliance is snug yet still comfortable. -
Figure #22Ask the patient to call the office after wearing the appliance for the first time. Common initial side effects include clenching resulting in sore teeth, TMJ sensitivity and increased saliva flow. State that these symptoms will subside or disappear within 10 days. To avoid unnecessary office visits, you may send extra straps with the patient so they can either advance the mandible further or replace stretched out straps. Additionally, provide patients with the EMA patient brochure, which includes care instructions for the appliance.
