Innovations in Dental Sleep Medicine with Sonnie Bocala

Innovations in Dental Sleep Medicine with Sonnie Bocala

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Hello everyone. Welcome back to The More Than Teeth Podcast. I'm your host, Dr. Michael Bennett, and I'm here with Sonnie Balala.

Nice to see you, Dr. Bennett.

Thank you. It's always good to see you. Sonnie and I have been friends for years. He's been a vital part of my practice in treating patients with pain and sleep disorders, and I just couldn't do this without him. He’s got a wonderful wife and daughter—great family. He’s an entrepreneur and innovator, and it’s been fun to ride his coattails quite a bit. So what do you have to say for yourself?

We’ve had quite a journey there.

We sure have.

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Sonnie’s Background and Expertise

Just by way of a little more introduction, Sonnie is the owner of Apex Dental Sleep Lab. And Sonnie, correct me if I’m wrong on any of these things, but you have several patents on appliances, and you produce FDA-cleared oral sleep appliances—among other types—and you do incredibly high-quality work. I’ve used them for years, and as a dentist treating sleep disorders, you simply can’t be successful without a good lab. You can try to make them on your own, but it’s a real challenge. I appreciate your expertise.

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A Personal Story: Father-in-Law’s Medical Journey

I want to set the stage for this episode with a recent experience involving my father-in-law. He gave me permission to share this. He’s 88 years old and recently drove himself—toughest generation—to the ER because he was having medical problems: swelling, inability to urinate. They discovered cardiac issues and transferred him to a higher-level cardiac center. He was strapped flat on his back in an ambulance, hands and feet, needing to urinate and unable to, handed a cup while bouncing down the road. Miserable.

At the hospital they ran an EKG and other tests and determined he needed an angioplasty. He had 90–95% blockage in some coronary arteries. How do you stay alive with that? They said he was essentially having a heart attack right then and needed immediate intervention. They opened him up, started Lasix and other medications for cholesterol and blood pressure. After three to four days, the swelling in his legs decreased and he was finally able to urinate. We pushed hard for follow-ups. My wife advocated like a lion, and we got him to the urologist, who took care of the urinary issues.

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The Importance of Sleep in Medical Treatment

Meanwhile, I’m thinking as a sleep dentist: has anyone asked him about his sleep? Has anyone screened him? The answer—big zero. Why? I understand that in critical care you stabilize breathing, circulation, heart function. I don’t diminish the amazing lifesaving work. But where’s the long-term plan? How do we reduce the load on the cardiovascular system and every other organ by restoring sleep? How do we unlock his innate healing at night while all the great medical therapy is happening?

I ran an unattended sleep test (two nights) using SleepImage. The results were off-the-charts severe. Nearly sixty events an hour. His oxygen nadir dropped to 73%. In surgery, if a patient dips to 90%, I am required to stop and administer oxygen. He was seventeen points below that at times. His average oxygen saturation was 86%—at our elevation we typically expect 92–94%. That constant hypoxemia beats the life out of the heart.

Ordinarily, when my patients are referred for CPAP or any PAP therapy, it routinely takes two to six months to get a device after pre-auth. In his case—sixty apneas an hour, lows of 73%—we didn’t have that luxury. I called a friend and got him a loaner PAP. I’m excited to see what that does for him. At the urologist’s office, a nurse said, “It’s amazing—when we put people on oxygen, they can urinate.” Still, no one asked him about his sleep anywhere along the way.

Two takeaways. First, each of us must advocate for ourselves and our loved ones when we enter the medical system. Second, go in asking: what are we doing to unlock the healing power of sleep?

It’s amazing—and I’m glad your father-in-law is getting the help he needs. And the fact he was able to drive himself to the hospital is remarkable.

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Sonnie’s Brother’s Heart Attack and Sleep Apnea

My brother, at 34 years old, coded at home from a massive heart attack. The ambulance revived him and got him to a hospital less than a block away—that proximity saved his life. In the ER they asked if he was on drugs. He’s military—tested frequently—so no. They placed five stents over time. They focused on his smoking, and no one looked at sleep apnea. I told him to ask for a sleep study. He finally did—motivated by potential disability benefits—and it came back as severe OSA. They put him on CPAP, but because he grinds, no one connected bruxism with sleep apnea. He struggled with high pressures. Years later, they’re finally open to combining oral appliance therapy with PAP to make it tolerable. It shows how far we’ve come.

The clinician in me hears that and thinks: smoking creates oxidative stress, plaque, systemic inflammation—one hit. Then I recall a study showing smokers have around eight-times higher risk of stroke or heart attack than nonsmokers, while untreated sleep apnea increases risk roughly twenty-three-fold. Your brother had the perfect storm—both risks pushing together at age 34.

Exactly. He’d come off ship smoking two packs a day, less activity—lots of lifestyle drivers. The severity even made the ER doc look at me and ask if I was okay. I’m just grateful he eventually got a sleep study and stuck with CPAP and a night guard. Now medicine is more open to integrating therapies.

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Innovations in Dental Sleep Medicine

You mentioned the future of dental sleep medicine and “killing two birds with one stone.” I often explain to patients: a thoughtfully designed oral device can support the entire craniofacial system—opening the airway while balancing and decompressing the TMJs and musculature. If you choose CPAP alone, that’s fine, but if the anatomy is constricted, pressure requirements go up, straps get tighter, and the mask becomes a bigger irritant. Open the airway structurally and PAP pressures can drop—like opening a door so air flows freely instead of trying to blow through it at tornado speeds.

And we’ve seen the field evolve. Years ago at AACP and the early AADSM meetings, people asked what TMJ had to do with sleep apnea. Now you’d never separate them. Historically, we compromised: treat one and aggravate the other. Rigid appliances locked in cranial distortions. With new materials, we can allow cranial micro-motion during breathing. Demand has driven innovation: more pliable, flexible materials; thinner, stronger, clearer designs; and manufacturing with CAD/CAM, AI, 3D printing, and milling. We aren’t limited to old acrylics anymore.

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Advancements in Oral Appliances

For anyone who hasn’t done sleep dentistry, the leap is massive. Traditional appliances were thick, crowding tongues already short on space. We compensated by pulling the jaw down and forward, stressing the stomatognathic and craniofacial systems just to open the airway. Big irritant meets low oxygen—tough combo. In our practice we transitioned to in-office digital workflows and 3D-printed or milled devices. Materials as thin as bleaching trays—top and bottom—have been game-changers. I still wear mine; it’s the most comfortable appliance I’ve ever used, printed on a LuxCreo system.

Exactly. Materials and design used to be limited by orthodontic-era equipment and wiring. Now we can make thinner, stronger, clearer appliances and democratize the workflow. Software lets clinicians control occlusion, contacts, and cranial balance in ways that used to be hard to communicate to a remote lab. We’re hitting a sweet spot: dentists can still treat patients while having same-day options for cases that can’t wait, and commercial labs continue to play a crucial role.

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Addressing Cranial Distortions and Airway Support

Everything in the mouth influences joints and muscles, whether we acknowledge it or not. Many patients who present for sleep also have orofacial pain and headaches. If we support the airway while respecting TMJs and musculature, symptoms often recede. Cranial distortions—postural changes, foot neuromas, GI issues—can twist the face and airway. The question is how to unwind those patterns while maintaining airway support.

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Introduction to Hybrid Clear Aligner Systems

That’s why your hybrid clear-aligner EMA concept excites me more than almost anything I’ve seen lately. Can you explain it?

We call them m-aligners. The idea is to combine aligner-based tooth movement with simultaneous airway maintenance using EMA-style mechanics. The comorbidity between sleep apnea and anterior crowding is significant. Current workarounds stack plastic on plastic—aligner plus a thermoformed overlay—to jerry-rig airway support, which adds bulk. Our hybrid integrates the functions: one aligner applies tooth-movement forces while the companion aligner maintains airway with EMA-type attachments.

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Combining Aligners with Airway Maintenance

In theory you could try to do this with vacuform models, but labor and waste are huge, and redesigns are painful. With direct-to-print, there’s no model printing required, far less material waste, and you can adjust treatment on the fly. The economics make it attainable and clinically elegant.

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Direct-to-Print Technology and Its Benefits

Direct-to-print reduces plastic waste dramatically and lets us iterate quickly. Clinically, that means truly preserving airway night after night while we correct occlusion and arch form—without forcing patients to choose between breathing and alignment.

Exactly. Direct-to-print is the long-term future as efficacy data accumulates and adoption grows. We already have solutions under FDA review for traditional workflows, but direct-to-print is where this truly shines.

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Future of Direct-to-Print Aligners

Adoption takes time. Once more practices embrace direct-to-print aligners, EMA-integrated direct-to-print becomes the natural next step. No more suffocating during ortho and “treat the airway later.” Many aligner patients today are in their 40s, 50s, 60s—often on their second or third round of ortho. They won’t (and shouldn’t) give up airway for cosmetics.

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Clinical Applications and Business Models

I can see phased plans: addressing a maxillary cant, coordinating with craniosacral therapy, and systematically untwisting structures while maintaining airway. Could doctors print phases in-office?

We’re building two models. First, “design-with-lab, print-in-office.” You send clean scans; we do the planning and send print-ready files back so you eliminate shipping time. Second, “design-and-print-in-office” with intuitive software for teams who want full control. Most dentists will likely choose lab-design/office-print to stay chair-focused. Either way, labs remain vital—design services are the future.

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FDA Approval and Research Studies

Timeline?

As fast as the FDA moves. The concept won Project of the Year at AAO last year, which helps. Biocompatibility for aligners and EMA components is done; now it’s about claims: demonstrating clinical efficacy for both alignment and airway maintenance. We have active studies, including at a Vietnamese dental university, where red tape is lighter. That data will support U.S. submissions. Fun fact: my first 3D-printed EMA prototype was over ten years ago—we only launched broadly this year. Innovation often happens quietly before the U.S. market sees it.

Until then, clinicians can still help patients breathe while they move teeth: optimize nasal patency, manage allergies, moisturize airways, collaborate for CPAP or BiPAP when indicated, and use interim oral appliances. There are creative temporary solutions, and a good lab partner can guide you.

Build a relationship with your lab. We have multiple pathways to support airway during aligner treatment, including temporary options and EMA-based solutions doctors have used successfully over aligners. It requires some clinical hands-on, but the tools exist today.

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Collaboration Between Dentists and MDs

What excites you most right now in dental sleep?

The growing, real collaboration between MDs and dentists. Companies like Tulu are knitting teams together: sleep studies completed, diagnoses shared, referrals routed, mutual portals where MDs and dentists see the same data, and integrated wearables feeding remote-patient-monitoring dashboards. Everyone stays in their lane clinically but communicates in one ecosystem. It declutters the workflow and keeps patients from waiting months while providers pass letters back and forth.

That acceleration matters. It took me nearly twenty years to build my airway team. With my father-in-law, a DNP who knew me saw the data I forwarded and moved immediately; not ideal to skip steps in a perfect world, but when someone is crashing—CHF, edema, urinary retention—you can’t wait six months for authorizations. I’m encouraged to see the system evolving toward timely, coordinated care.

Absolutely. To be clear, I’m not advocating direct-to-consumer. I’m advocating MD–DDS collaboration supported by modern tools—shared portals, validated wearables, remote monitoring—so we can be proactive. A dentist can now say, “Your last week looks rough; let’s adjust bands or revisit fit,” without waiting for an in-person visit. That’s where this is headed.

And that’s the reminder I’ll close on: be excellent in your lane and collaborate relentlessly. Advocate for your patients’ sleep every step of the way. Unlocking healthy sleep unlocks healing.

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If you found this episode valuable, share it with a colleague or friend who wants to breathe better, sleep deeper, and live healthier. Your support helps us expand the conversation around airway-focused care and whole-body wellness.

Together, we can move dentistry beyond the chair.

Michael Bennett, DDS, PhD

Board-Certified Dentist | Healthcare Professions Educator

Empowering total health through airway-focused dentistry

Advanced Dental Care – Dr. Bennett’s clinical practice and patient-centered services

Connect on LinkedIn – Join the movement for airway-first, total health dentistry

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About Guest:

Sonnie Bocala was born into a family with five generations of 16 Dentists, so it wasn’t a surprise when he decided to pursue the same career path. He graduated from San Diego State University in 2004 with a Bachelors in Cellular Molecular Micro-Biology. While awaiting acceptance to dental school he began working for a private practice as a dental assistant. Very quickly Sonnie found his passion in the dental lab side of the industry and assumed the position as Director of International Lab Certification for TMJ and Sleep Research International from 2004-2016. He opened T & S Dental Lab, which he owned and operated from 2006-2016. This is where he began his journey that has led him to where he is today; having lectured internationally on TMJ, Sleep Therapy and oral appliance designs, and trained and certified international dental labs on the fabrication of TMJ orthotics. Currently, Sonnie is the President and owner of Apex Dental Sleep Lab, President of Sketchpad Innovations, Developer and Patent holder of Kava Mandibular Advancement device and a manufacturing consultant to Oravan OSA.

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