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How Early Orthodontic Treatment
Can Prevent Temporomandibular
Dysfunction, Snoring, and Sleep
Apnea: Two Different Treatment
Philosophies
Brock Rondeau, DDS
Private Practice
London, Ontario
Founder
Rondeau Seminars
London, Ontario
When treating patients orthodontically, general dentists, pediatric dentists, and
orthodontists need to be aware of the short-term as well as the long-term benefits and
consequences. This article discusses the treatment of younger patients who present with
Class II skeletal malocclusions. These malocclusions traditionally present with Class II
molar and cuspid relationships, large to moderate overjets, constricted maxillary arches
with normally positioned maxillas, (anterior-posteriorly) and retrognathic or
underdeveloped mandibles.
Orthodontic clinicians have basically two options to correct Class II skeletal
malocclusions in children. One option is to wait until all the permanent teeth erupt and to
treat the case with fixed braces. The other option would be to treat the children earlier,
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
using functional appliances in the mixed dentition and fixed braces in the permanent
dentition.
Retractive Technique
The retractive technique is used by the majority of orthodontic practitioners worldwide.
With this method, patients are treated between 12 and 14 years of age, after all the
permanent teeth have erupted. The technique uses fixed orthodontic braces and,
sometimes, cervical facebow headgear. For patients who present with large overjets, the
upper incisors are retracted after either bicuspid extractions or distalization of the molars
with headgear.1,2 The removal of two upper bicuspids results in a more constricted
maxillary arch and a narrow smile. When the upper bicuspids are extracted and the upper
incisors retracted into the extraction sites, this often results in a flattening of the upper lip
and the nose appears to be longer. The extraction of the upper bicuspids often results in a
more deficient maxilla to go with the preexisting deficient mandible, and therefore, there
is no noticeable improvement in the patient’s profile.
Many Class II skeletal patients develop temporomandibular (TM) disorders
caused by underdeveloped mandibles, which in turn cause the condyles to be displaced
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
posteriorly. When the maxillary incisors are retracted, the mandible can become trapped,
which can create the TM joints problems, snoring, and sleep apnea later in life.
Functional Technique
The functional technique, originated in Europe more than 100 years ago, is basically a
nonextraction, nonsurgical approach. Patients are treated at a much younger age in an
effort to prevent problems from becoming more serious. Because 90% of the face is
formed by 12 years of age, if the patient is treated before that age, the growth of the face
can be modified.3 Parents and children prefer this technique and often ask their general
dentists for this type of treatment. In the literature, it is often referred to as two phase
orthodontic treatment. The objective is to solve the functional and skeletal problems in
Phase I and the dental problems in Phase II.
Phase I: Orthopedic Phase
Oral habits such as thumb sucking and anterior tongue thrusts must be treated as early as
possible. Functional appliances with tongue cribs may be fabricated to stop these habits
in 5 to 6 months.4 In the case of blocked airways caused by enlarged tonsils or adenoids,
referrals should be made to an ear, nose, and throat specialist to solve the problem,
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
normalize the airway, and restore nasal
breathing before treatment. The removal of
tonsils in children routinely eliminates snoring
and sleep apnea.
Many clinicians worldwide, including
two renowned orthodontists, James A.
McNamara Jr. and William Clark, have stated
that the overjet in class II skeletal patients with
retrognathic mandibles is caused by the
Figure 1 Extraoral photograph of
patient’s profile before treatment. The
patient had a deficient or retrognathic
mandible.
retruded mandible and, therefore, this should
be treated by advancing the mandible with a
functional appliance.5-7 This treatment can be
accomplished with either removable
appliances, such as the Twin-Block (Figure 1
and Figure 2), or fixed appliances, such as the
mandibular anterior repositioning appliance
Figure 2 Extraoral photograph of
patient’s profile after 7 months of
treatment. Note that the patient now
has a straight profile.
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
Figure 4 Intraoral photograph of MARA
appliance. This appliance advanced the lower
jaw 5 mm.
Figure 3 MARA appliance on a plastic
model. The MARA is a mandibular
advancement appliance.
(MARA) (Figure 3 through Figure 6), in approximately 7 to 9 months.8,9 Parents much
prefer to have their children’s malocclusions corrected early with functional repositioning
appliances rather than to subject them to surgery at 17 years of age.
Figure 6 Extraoral photograph of patient’s
profile after 7 months of treatment. Note
that the patient now has a class I skeletal
occlusion with a straight profile.
Figure 5 Extraoral photograph of
patient’s profile before treatment. The
patient had a class II skeletal
malocclusion with a deficient or
retrognathic mandible.
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
Functional clinicians believe that crowding is not caused by large teeth, but by
excessively narrow arches resulting from mouth breathing or other oral habits. Patients
with narrow, constricted arches are also ideal candidates for functional appliances.10 The
design includes an expansion screw to develop the arches to their normal size, which
relieves crowding and avoids the possibility of the extraction of permanent teeth.
Phase II: Orthodontic Phase
The objective is to solve the functional and skeletal problems in Phase I and the dental
problems in Phase II. This phase involves the use of orthodontic fixed braces to correct
the dental problems including crooked teeth and spaces between the teeth.
Relationship Between Orthodontics and TM Dysfunction
One of the main causes of TM dysfunction is when the mandibular condyle is displaced
posteriorly, which causes a compression of the nerves and blood vessels behind the
condyle. This displacement also causes the disc to become displaced anteriorly, which
becomes evident clinically when the patient’s jaw clicks on opening and closing. When
the disc becomes dislocated, the muscles of mastication spasm to protect the joint. These
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
muscles, which are contracting constantly, cause headaches, ear symptoms, and pain in
the neck and shoulders.11
Functional appliances routinely reposition the condyle downward and forward in
the glenoid fossa, which moves the condyle away from the nerves and blood vessels
distal to the condyle, positively affecting the health of the TM joint (TMJ).12-14 It has
been the author’s clinical observation during the past 30 years of treating patients with
malocclusions and TMD that those patients treated with the functional technique have far
fewer problems after treatment than those treated with the retractive technique.
Many malocclusions frequently have preexisting TM dysfunction, including deep
overbite, unilateral crossbite with facial asymmetry, narrow maxillary arch, and class II
division 2 and class II division 1 skeletal patients with retrognathic mandibles.15 General
dentists and orthodontists must learn to evaluate the health of the TMJ before, during, and
after treatment. The author’s office uses a TMJ health questionnaire, range of motion
measurements, muscle palpations, joint vibration analysis (JVA), and x-ray tomography
to evaluate the health of these joints.
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
The BioJVA™
(BioResearch Associates Inc,
Milwaukee, WI) (Figure 7) is a
diagnostic device that has been
used for more than 22 years to
diagnose the presence or
absence of an internal
derangement within the TMJ.
Figure 7 A dental assistant taking a JVA.
During treatment, this device
may be used to determine if the proper condyle-disc-fossa relationship has been
achieved.16 After treatment is completed, the device can confirm the results.
Having evaluated cases for more than 16 years using the BioJVA, the author has
observed that patients who presented with existing TM dysfunction did not improve with
the retractive technique and, in some cases, the problems worsened with age. Conversely,
patients who were treated with the functional technique showed significant
improvements.
The symptoms of TMD include headaches, neck aches, ringing in the ears,
stuffiness in the ears, pain around the eyes, dizziness, fainting, ear pain, numbness in the
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
arms and hands, and shoulder and back pain. These symptoms can be extremely
debilitating. Some patients cannot work, and some may experience different levels of
depression.
The medical profession provides important treatment for the symptoms of TMD
using muscle relaxants, anti-inflammatory medication, pain medication, and
antidepressants. Members of the dental profession have the ability to prevent many of
these problems if they treat younger patients with functional appliances to establish a
correct condyle-disc-fossa relationship.
Relationship Between Orthodontics and Snoring and Sleep Apnea
Snoring is caused when the tongue partially blocks the airway. Snoring is not dangerous
to a person’s health, but it can be extremely detrimental to one’s relationship with his or
her spouse. Obstructive sleep apnea (OSA) is caused when the tongue completely blocks
the airway for 10 seconds or more, at least 35 times per night.17,18 There is a direct
relationship between OSA and cardiovascular diseases, including high blood pressure,
heart attacks, strokes, hypercapnia (increase in carbon dioxide), and cardiac arrhythmias.
OSA also has been linked to type 2 diabetes and gastroesophageal reflux. When OSA
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
causes a patient to stop breathing, sometimes 40 times per hour, the amount of oxygen in
the blood is reduced, which poses serious health risks.
Patients with class II division 1 skeletal malocclusions with retrognathic
mandibles are prime candidates for snoring and OSA later in life. The cause of OSA is
the retruded tongue, which occurs naturally when the mandible is retruded. As many
patients grow older, they gradually gain weight, increasing the fat in their necks and
lessening the muscle tone, which reduces the size of the airway. Women with a neck size
> 16 in and men with a neck size > 17 in are candidates for snoring and OSA.19
It has been estimated that the prevalence of sleep apnea in North American is
approximately 15% of men (53 million) and 5% of women (19 million).20 In the author’s
opinion, OSA is one of the most dangerous and underdiagnosed conditions worldwide.
When bicuspids are extracted in class II division 1 skeletal patients and the
maxillary teeth are subsequently retracted, the patient may be predisposed to snoring and
sleep apnea later in life. Before treatment, the mandible and tongue are in a retruded
position. When the maxillary teeth are retracted, the tongue and the mandible are
prevented from obtaining their normal forward position.21-23 The treatment of choice
would be to bring the lower jaw forward with a functional jaw orthopedic appliance,
which repositions the lower jaw forward to its proper position. Appliances used in
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
orthodontics for this purpose include the Twin-Block, Herbst, and MARA. When the
lower jaw is brought forward nonsurgically with these functional appliances, the tongue
comes forward and opens the airway, which prevents snoring and sleep apnea.
For cases of severe sleep apnea, the medical profession recommends a continuous
positive air pressure (CPAP) device, which forces air up the nose all night using an air
compressor. Many patients with less severe OSA, especially those with mild to moderate
sleep apnea, cannot tolerate this device.24 Patients much prefer to wear an oral appliance
that comfortably moves the lower jaw and tongue forward and opens up the airway to
prevent snoring and OSA. The dental profession is in the position not only to prevent
snoring and sleep apnea by using functional appliances when children are growing, but
also to solve the problem in adults using oral appliances.25
Conclusion
As mentioned at the beginning of this article, it is critical that the correct diagnosis and
treatment plan be implemented for our younger patients with Class II skeletal
malocclusions and underdeveloped lower jaws. The ideal treatment is to utilize some
type of functional jaw orthopedic appliance such as the Twin Block or MARA Appliance
to reposition the lower jaw forward. This improves the health of the TMJ by moving the
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS
condyles downward and forward, thus decompressing the TM Joint. It helps solve or
prevent snoring and obstructive sleep apnea by moving the lower jaw and tongue
forward, which opens up the airway.
References
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Garry, James F. Presentation: Airways, Orthopedics, Craniofacial Growth,
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Respiratory and Critical Care Medicine. 163, 19-25.
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Orthopedics, 2nd edition, 2002,18-19.
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Eckhart, James E., The Mandibular Anterior Repositioning Appliance, 107-109.
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25.
Lowe AA. Efficiency of oral appliance therapy as an adjunct to CPAP. American
Academy of Dental Sleep Medicine. Convention, Baltimore Maryland, June 8,
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Early Orthodontics preventing TMD, Snoring and Sleep Apnea – Brock Rondeau DDS