- KILLER IN YOUR BEDROOM
Estimated reading time: 18 minutes
This independent, expert review of the NOA mandibular repositioning device from OrthoApnea, examines whether it’s better than competitors.
Anti-snoring devices are typically worn in your mouth to hold your jaw forwards (known as protrusion).
‘Intra-oral devices’ like these have broadly synonymous technical names including:
👉 The NOA is of particular interest, as it claims to advance the science of custom-made, oral appliance therapy for snoring and sleep apnoea.
Indeed, the manufacturer (OrthoApnea) claim:
The NOA is the most advanced Mandibular Advancement Device ever created.
Their focus is on improving the risk / benefit ratio (see below) and as such, it’s worth examining and not dismissing as a nuance or minor technical difference.
But is it all just marketing hype?
For the record:
Here’s my video introduction to the NOA mandibular repositioning device.
In the complex world of sleep and OSA education and support (and often dubious scientific claims to sell ineffective products), Adrian is a touchstone for trustworthiness, rigour and reliability.
His knowledge and informed advice has helped considerably in my understanding of my condition and decision-making process over my care.
He is always my first port of call on the latest advice and developments, and he is a real champion of the sufferer’s right to know the fact from the fiction.
Historically, mandibular repositioning devices (MRDs) were one-piece, welded ‘gumshields’ known as ‘monobloc’ devices. (Where I began in 1994).
Over the ensuing years, various mechanisms appeared, to relate the two jaws. (Some of which were better than others!)
As the dental sleep medicine industry advances, old technology is obsoleted. As the dinosaurs found out, evolution can be cruel.
The NOA may represent an evolution of intra-oral, mandibular repositioning device design, by reducing the risks incurred with MRDs.
What risks are we talking about?
The risk / benefit ratio of a particular mandibular repositioning device for a given protrusion, would appear somewhere on the illustration (figure 1) below:
In this independent, sleep expert review, I provide my assessment as to where on the risk / benefit ratio the following devices are:
BEGIN THE JOURNEY TO QUIET SLEEP: https://www.snorer.com/stop-snoring-see-your-pharmacist/
SELF-HELP WAYS TO STOP SNORING: https://www.snorer.com/how-to-stop-snoring/#how-to-stop-snoring
DO ANTI-SNORE PILLOWS WORK? https://www.snorer.com/best-anti-snore-pillow-expert-review/
I first learned of the NOA device from OrthoApnea in 2020, and recently was reintroduced to the technology involved.
During their technical presentation, I heard a chance remark:
“We took the best features of each device and made our own”
Which sounds smart (they were comparing features and benefits of the NOA with competing intra-oral appliances for snoring and sleep apnoea).
But this approach takes expert knowledge, time, and money.
Was the investment worth it?
Let’s find out!
For the record, while I was given a demo NOA to write this review, that’s the limit of the arrangement. I don’t get paid to say nice things about the products I review.
It’s in my interest and yours, that I’m independent.
Reflecting on the:
‘we took the best features of each device and made our own’
statement, suggests we should review some principles of anti-snoring device design.
I’m calling these the ‘Golden Rules’.
Assuming we want the maximum benefit for the minimum side-effects (which would seem reasonable) then some technical principles apply:
(Don’t panic – I’ll explain without jargon!)
Prevent backwards movement of the jaw (focused on when opening your mouth)
Minimal mouth opening because:
Permit freedom of movement of the lower jaw (within limits)
Read about the importance of controlling mouth opening in this extract from “Whats the best anti-snoring device?” 👇
OrthoApnea claim the NOA is ‘the most advanced’ device available.
Is the NOA more custom than other custom devices? Hints of George Orwell’s “Animal Farm”, where all are equal but some are more equal than others…
🤔… how can that be?
Custom-made mandibular repositioning devices are just that – custom-made for you. Think of them as a tailor-made suit rather than an off-the-shelf ‘fits where it touches’ item.
👉 That said, when most custom-made, mandibular repositioning devices are prescribed and constructed, some things about you are routinely averaged and generalised.
We’re going to get inescapably technical now – but stay with me as this is essential background, and I will explain:
For example, the below things are averaged:
Don’t get too hung up about what ‘condylar angle’ means. Just know that as you open your mouth and/or move it forwards, your lower jaw moves in a certain way – an angle to your skull.
Now look at figures 4 and 5 below. You’ll see that the lower jaw has a range of motion:
The limit of each of these movements is known as ‘Posselt’s envelope of motion’.
Figures 4 and 5. Posselt’s envelope of motion
Rjmedink, Posselts envelope of movement, CC BY-SA 4.0
Figure 5. Posselt’s envelope of motion – for real!
In short, your jaw joint movement is averaged with most custom devices.
👉 OrthoApnea consider this less than ideal and they’ve developed the capability to make a device (the NOA) to improve on this.
So, it’s a reasonable question to ask: Why are averages routinely used?
In a word: Simplicity and cost (ok, that was 3).
‘Most’ people’s jaw joints move within similar limits (we’ve seen the limits in figures 4 and 5 above) and the human body is remarkably tolerant to a less than perfect situation.
OrthoApnea would argue that their unique NOA cam follower (hoop and rod) design is superior to competing MRDs as it eliminates any rearward movement of the jaw on opening.
And their device is made from one very resistant material (polyamide) without rods, screws, elastics or what not, which provides the patient with a robust and easy to maintain device.
Then read our free, definitive step-by-step how to stop snoring Guide.
Can the dentist reliably record more unique data about the individual’s anatomy?
Can the laboratory translate this extra data into a better oral appliance?
Going the extra mile for the Patient. Is the effort worth it?
Maybe. If they have a ~£50K GBP piece of equipment (CBCT scanner).
The important thing to note here is that your ‘condylar angle’ can vary from the average and it can also vary from left to right!
Dentists routinely take impressions of teeth. Increasingly, intra-oral digital cameras are used to reduce errors and shipping delays.
But what I’m getting at is:
Specifically, as you:
And it’s the whole premise (or in marketing speak the USP) of the NOA mandibular repositioning device; indeed, their principal claim is that the NOA is:
…totally adapted to the patient’s jaw biomechanics
Which I interpret as meaning, it does not dictate unnatural movements to your jaw joints. Instead, it respects the anatomy of the individual.
Which would seem ideal…
Theoretically then, a more bespoke (is that even a thing?) device should equate to a better balance of risk to benefit. ✓
To properly answer this question, I consulted an experienced, sleep-trained dentist [name removed]
Here’s how our technical conversation went (feel free to skip this part to what it all means!):
I’m reviewing the NOA mandibular repositioning device. Can I ask you about in dental clinic capture of the condylar angle left and right?
If you sent the lab data about a retruded, max protrusion, max opening position, this to my way of thinking does not account for lateral deviation on protrusion/opening.
What do you think?
So, you’re asking if we can reliably capture condylar angle (no) retruded (not always – as muscles can prevent us getting the retruded and may need deprogramming) max protrusion (again technically no if the muscles are not deprogrammed) and max opening (well again depends on condition of the muscles). Typically, sufferers of SDB are bruxing and the muscles can be suffering as a result.
Adrian: So, if I were to play Devil’s Advocate with you – would something like CT scans or lateral cephs help?
I think CT scans are ideal but not to see if MRDs are going to be effective but to see where the actual anatomical issues are and to help with planning structural movements…
But for MRDs I don’t do CT scans, if I had a scanner, it wouldn’t be for oral appliances.
👉 In short: no, it’s unlikely that a dentist can capture the extra data.
Because they don’t typically elect to spend ~£50k GBP buying a CBCT scanner (see Wikipedia for what a CBCT scanner is ↗).
Even an experienced sleep-trained dentist isn’t going to find it easy or deem it necessary to capture the extra data required for you to get a better outcome with the NOA.
So, without the extra data we’re full circle back to averages.
Roll with me here though – perhaps the OrthoApnea team know something we don’t?
Well, yes they could if they had it.
But without the extra data OrthoApnea must revert to their ‘standard’ device which uses averages as I mentioned above.
Which is no bad thing, the NOA is certainly a premium oral appliance.
The NOA is:
Summary so far: to my mind the jury is out on whether this means the standard NOA is superior to current competitors.
I’d suggest it’s a matter of clinical choice (the clinician balancing indications/contra-indications) and it’s for OrthoApnea to substantiate their claim that the standard NOA is superior to competitors.
👉 Yes, when the extra data exists.
The fully custom NOA mandibular repositioning device would technically be superior to current competitors (see figure 6) because:
So, would the extra effort and time spent by the dentist be worth it?
👉 Yes, it would be – particularly for people with faces that differ from left-to-right (morphological assymetry) and more complex cases.
I like the one-material manufacturing (nothing embedded etc.)
I like how it maintains a correct biting relationship on adjustment
I like how it maintains effect on mouth opening
Technical note re point 2 above. If you adhere to the full occlusal coverage school of thought and not the incisal guidance and posterior disclusion alternative!
Once we’re past the packaging (which I like and feel is important), we need to get more technical.
I like the fact the NOA is:
This last point is important for your jaw joint:
As devices are adjusted for effect, maintaining a good ‘biting relationship’ is critical.
What commonly happens is that only the upper and lower parts of the MRD touch on your back teeth when you adjust them – this causes jaw pain.
(Techno-babble: the NOA design eliminates posterior interference on adjustment of protrusion).
With the NOA, adjustment of protrusion is achieved by using a different lower ‘splint’ (the lower part of the device). Each lower splint (4 in total) is constructed to ensure even contact, minimum vertical opening and of course the desired increase/decrease in protrusion.
What’s the big deal?
In figure 7 above, the green arrow indicates the direction your lower jaw wishes to take, to return to the rest position.
👉 The NOA opts to place the mechanism inside the cheeks.
The blue highlighted contact surface of the follower or rod moves along the black curved line (the cam) as your mouth opens – the movement is intended to correspond with your precise jaw movement.
Whether it does this or not, varies:
First you need to know:
Then when you know what you’re dealing with, a prescription, custom-made mandibular repositioning device must be dentally prescribed – only if it is what you need!
It’s essential to find out, because an oral appliance is NOT the most appropriate treatment for sleep apnoea!
You should undergo a home sleep apnoea test (or if you live in the UK a sleep-trained pharmacist, sleep-trained dentist or your GP can screen you for obstructive sleep apnoea) prior to using any snoring ‘cure’.
For a dentist to prescribe a NOA mandibular repositioning device, they must undertake post-graduate training about ‘dental sleep medicine’ (how and when they can and cannot prescribe such devices).
The (current) difficulty the dentist has in capturing the extra data necessary to make the most of the fully custom NOA – plainly not OrthoApnea’s fault – is the situation now.
The price! It’s a premium product which limits access to those who can afford it.
Time is money – if dentists are to take more time capturing extra data it will cost patients more money.
The limited (incremental) range of adjustment – you need a new lower device for each change (it comes with 4) – if you need more then you’re into extra cost.
Re point 4 above, I mentioned this to the OrthoApnea team and their response is below:
And despite limiting/restricting the number of lower splints (4), as you are mentioning, we believe we cover enough protrusion range i.e. bite registration is taken at 60% protrusion, we cover from 50% to 80% protrusion (out of 10mm patient mandibular movement range). And, actually, titration sequence can be chosen by dentists (Bite registration plus 3 additional splints).
So, they’re aware and will work with the dentist to help you.
In essence, we know it works – the question is whether it’s better than competitors.
There’s plenty of evidence that custom-made, prescription, mandibular repositioning devices work in selected patients.
So, while I didn’t try the NOA, my personal experience is irrelevant. This expert review’s purpose was to assess whether the NOA mandibular repositioning device is superior to other currently available competitors.
The NOA is a competitively-priced, robust, premium product. Ask the dentist for an estimate. Their price will usually include the NOA device and clinical fees.
The NOA mandibular repositioning device has moved dental sleep medicine further along the risk / benefit ratio – which should be celebrated and OrthoApnea congratulated! 🎉
The Standard NOA certainly “does the job”, and OrthoApnea give dentists the option to ‘go the extra mile’ for complex cases with a fully custom version.
The fully custom NOA mandibular repositioning device, made with the extra data I’ve identified above, is the ‘shiny new thing’ and appears to answer the challenges I’ve identified with existing devices in my ‘Golden Rules’.
However, capturing the extra data necessary to deliver this technological advance to the patient is in my estimation, currently unlikely due to the scarcity of CBCT scanners (for cost reasons). This may change.
And of course the competition are not standing still. Subscribe to stay informed!
It just remains for me to say thank you to you the reader, and to OrthoApnea for letting me review their exciting advance in dental sleep medicine.
OrthoApnea’s YouTube video: https://youtu.be/stS_HeWNrME
OrthoApnea’s website: https://NOAsleep.co.uk/
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Anti-Snoring Device – generally considered a product worn in your mouth to stop you snoring.
Custom-made – a bespoke device made exclusively for you by a registered dental technician, working to prescription, using CE marked materials. In Europe working to the Medical Devices Directive administered in the UK by the Medicines and Healthcare Products Regulatory Authority (MHRA).
DSM Dental Sleep Medicine – the management of sleep-related breathing disorders using dental devices.
MAD Mandibular Advancement Device – Jaw advancing device, worn at night while asleep to hold forward the lower jaw to stop snoring and prevent obstructive sleep apnoea / apnea.
MAS Mandibular Advancement Splint – See ‘MAD’.
MRD Mandibular Repositioning Device – As MAD above with recognition that the jaw has an optimum vertical opening in addition to advancement.
OSA Obstructive Sleep Apnoea – (also spelt apnea) When an individual is unable to sleep and breathe at the same time. Visually, a repetitive pattern of breathing interruptions (apnoeas) occurring while the individual sleeps, due to a physical obstruction in the airway.
OTC – Over-the-Counter product sold over the pharmacy counter or on-line without prescription, medical or dental assessment and without a review of medical/dental history.
Sleep-trained Dentist – A dentist that has undergone special interest training in sleep. As such they are able to obtain professional indemnity insurance.
Created by Adrian Zacher