I recently had a new patient referred from an amazing physical therapist. He sensed that she had TMJ issues that would prevent resolution of her cervical spine complaints and fatigue.
She was wearing Invisalign aligners from one of the top orthodontists in New York City.
There were three important findings. First, she was clicking bilaterally with slipped discs in both right and left TMJs. That is on opening and closing there was painful clicking as the disc slipped in and out of place. This was also associated with a retruded or deep retrognathic bite with loss of facial height. Second, she had a small airway which can often result in fragmented, disturbed sleep and unrefreshing sleep as well as potential potential oxygen desaturation and obstructive sleep apnea.
Ideally the dentist does a thorough examination with CBCT imaging and identifies potential TMJ and sleep issues and informs the patient. In this case, I assumed the patient was treated with Invisalign without mention of any TMJ or airway problems. I had contacted the orthodontist twice with no response.
This puts the orthodontist in an awkward position and leaves us with 3 options.
First option
Suspend use of clear aligners while we treat for TMJ and Airway, alleviating jaw, neck and shoulder pain with the help of a physical therapist. This would involve day and night oral appliances for about 3 months. The day appliance could be worn from an hour to six hours a day alleviating clicking and pain. Once the pain is alleviated and sleep refreshing, the bite would be reevaluated and the clear aligners would move the teeth into the potentially new position with less overbite and overjet.
Second option
Finish Invisalign over the next 3-4 months with straighter teeth and then begin oral appliance therapy and more effective physical therapy.
Third option
Discontinue clear aligners and begin oral appliance and physical therapy immediately. Most orthodontists have a difficult time finishing the case in a position with an open airway and no clicking. General dentists may have an easier time comprehending this philosophy. There are dentists and orthodontists in most communities who can finish these types of cases.
Who suffers? Unfortunately, it’s the patient.
The lesson is that TMJ, neck, shoulder and ear pain as well as headaches should be resolved first prior to clear aligners. The same can be said of unrefreshing sleep caused by narrowed airways. The reason for this is that the treatment of the TMJ and sleep condition may help the dentist and patient discover the healthiest position to ultimately finish the case. The cost of Invisalign or Clear Correct is the same whether the jaw is finished in a comfortable or uncomfortable position. It takes about 3-6 months of wearing the correct nightguard to discover the final stable bite where there is improved esthetics, reduced or no clicking and no jaw, neck or head pain.
