Patient Name: ____________________________________________________

Date: ____________________________ Date of Birth: __________________

Baseline Polysomnogram

Apnea Hypopnea Index without oral appliance: _________________ events/hr.

Advancement Information (patient awake)

Maximum dental protrusion: number corresponding to hole the upper pin comes closest to while the patient moves mandible as far forward as possible: ______  Note: Patient’s mandible may come forward more asleep than while awake.

Range of mandibular advancement: maximum dental protrusion minus centric dental occlusion: ________________ mm. (Holes are 3 mm apart.)

First Advancement

Example: Centric occlusion number: _3 Maximum protrusion number: 12_

Range of advancement: 12 – 3 = 9 . First advancement will be 3 mm.

Polysomnogram

Amount of advancement needed to stop apnea: _________ mm.

Apnea Hypopnea Index with appliance: ______________ events/hr.