How Does the Provision of Clear Aligner Therapy Affect Patients with Breathing Disorders?

Sam Lee, DDS, MS, maintains a private practice in Irvine, California, and is is a diplomate of the American Board of Orthodontics and a part-time clinical assistant professor in the Graduate Orthodontic Department at the University of Southern California.

Thomas Shipley, DMD, MS, is a diplomate of the American Board of Orthodontics and maintains a private practice in Peoria, Arizona.

Payam Ataii, DMD, MBA: I have found that clear aligners can be both beneficial and injurious to patients who suffer from sleep-disordered breathing. The potential for injury arises when patients are provided with anterior correction without regard for possible airway deficiencies. I have noted situations in which clinicians accept therapy recommendations from the clear aligner manufacturer that include excessive interproximal reduction. For patients with breathing disorders, this can result in their airway becoming further compromised.

In contrast, to improve patient outcomes, my practice employs the use of cone-beam computed tomography (CBCT) technology to identify the areas of the patient's airway that that might be the most compromised. A proper airway and craniofacial evaluation helps me determine the best treatment option for the patient. In many cases, the clear aligner therapy alone allows me sufficient opportunity to increase the oral cavity space, which in turn, may assist patients who are suffering from a velopharyngeal deficiency. For patients who present to the practice with primarily oropharyngeal deficiencies, I typically use an appliance (Aligner Sleep Appliance^®, Sleep Architects Inc.) concurrently with clear aligner therapy. This allows me to address the orthodontic deficiencies while maintaining the patency of the patient's airway at night.

However, I didn't always handle clear aligner cases with airway management in mind. In fact, back in the early 2000s, I didn't fully understand the entire craniofacial complex and its impact on the airway, or more directly, how malocclusions may be a physical representation of a compromised airway. Gradually, after ongoing continuing education in the subject matter, my mind finally was able to fully grasp the complex ways in which these systems are intimately connected.

Given that I have treated thousands of clear aligner cases throughout the years, it was important for me to understand how this newly found information would allow me to help my patients beyond just giving them a beautiful smile. Through extensive communication with my patients, I discovered how these clear trays could used to improve the condition of the airway, ultimately enabling them to breathe better. It is imperative for clinicians to improve their understanding in this area in order to avoid creating improper treatment plans that could cause patients with possible airway deficiencies to worsen their condition.

Sam Lee, DDS, MS: At my practice, I have noted the benefits of clear aligner therapy in treating and/or finishing patients who have presented to the practice not only to correct their malocclusion, but also specifically to treat their accompanying breathing disorders. In certain cases, the space created by aligner therapy to address minor tooth crowding is also useful in allowing more room for the tongue. In turn, I feel that this increase in the intraoral cavity space helps patients breathe better.

Although there are a number of articles published in the scientific literature documenting improvements to the upper airway when intraoral cavity space is increased, such as with rapid maxillary expansion in children, not many articles have been published to confirm my findings at the office regarding the performance of minor tooth correction on adult patients who also present to the practice with airway deficiencies. However, in applying similar principles to those used in treating children when making orthodontic correction in adults and noting their airway improvements, I have found that these concepts regarding clear aligners apply to the treatment of adults as well.

It should be noted that to properly treat patients with breathing disorders, we must understand the condition of the entire upper airway. Focusing, for instance, on only addressing oropharyngeal deficiencies by correcting minor mandibular tooth crowding could result in no major improvement, or any improvement, if the patient's primary point of restriction is related to the nasal cavity.

So, although I have achieved great airway improvements by correcting malocclusions with clear aligners, that has not always been the case because initially, I was not considering the entire upper airway in my treatment protocol.

Thomas Shipley, DMD, MS: My practice treats patients who suffer from sleep-related breathing disorders. I find that using clear trays is beneficial for these patients because I can often address their malocclusions while avoiding retractive techniques that would otherwise be contraindicated for patients with breathing disorders. For example, when treating patients with sleep-disordered breathing, I avoid interproximal reduction as much as possible because the last thing that I want to do is compromise the patient's airway. By ensuring that my clear aligner therapy corrects the malocclusion without the need for major retractive techniques, my patients generally enjoy a simultaneous improvement to their breathing disorders.

Treating patients' sleep-disordered breathing, however, is much more complicated than simply correcting malocclusions and/or moving mandibles forward. Patients with breathing disorders should be evaluated through various methodologies so that clinicians can collect enough "clues" to allow them to determine the specific cause or causes at the root of the problem. In many cases, the tongue may be the primary contributing factor. This is particularly relevant for patients who present to the practice with an inability to naturally rest their tongue at the roof of the mouth.

The presence of narrow arches, mouth breathing, and any other dentofacial comorbidities should be identified prior to selecting the best course of treatment for patients with breathing disorders, because introducing clear aligner trays may further prevent the tongue from properly resting if these other conditions are not considered during your treatment planning.

If all of these concerns are not addressed during diagnosis and treatment planning, using clear aligner therapy for patients who suffer from breathing disorders has the potential to improve or worsen their condition. The difference between benefit or detriment depends heavily on properly evaluating the patient and designing the most appropriate treatment option.