If you have obstructive sleep apnea (OSA) and are considering oral appliance therapy (OAT), but also interested in Invisalign (orthodontic) treatment, read on.
Oral appliance therapy involves wearing a custom dental retainer that encompasses upper and lower teeth portions and prevents the lower jaw from collapsing back into the airway.
The ideal type of oral appliance has a mechanism that allows for small incremental jaw advancements if needed. Click here for more on oral appliance therapy.
When using an oral appliance, the goal is to have a retentive fit over the teeth but not provide active “pushing” forces that can result in tooth movements.
Oral appliance therapy aims to prevent the teeth from shifting.
With orthodontics, whether Invisalign or traditional ‘braces’, active forces are present and result in teeth movements. Additionally, traditional braces have brackets and wires attached to the teeth that would create issues with impressions and construction of a well-fitting oral appliance.
Can you have both oral appliance therapy and orthodontics at the same time?
The quick answer is no.
You cannot be undergoing orthotics through conventional braces or an Invisalign type of treatment and be wearing an oral sleep appliance at the same time. The forces that occur during these treatments would work against each other.
To go a little further into this, let’s review the 3 different types of patients who may be considering this question.
Has been considering Invisalign or traditional orthodontic treatment for bite or cosmetic improvement but has never worn an oral sleep appliance.
They have been diagnosed with obstructive sleep apnea or primary snoring and are interested in oral appliance therapy in lieu of CPAP.
This type of patient has to choose either oral appliance therapy or orthodontics.
The choices for this patient would be to obtain an oral appliance and dismiss orthodontics, at least for now.
Or the opposite, move forward with orthodontics and consider CPAP therapy or no therapy until the dental treatment has been completed, and then consider obtaining an oral appliance.
I find that most individuals’ main focus is their sleep health more than teeth straightening by the time they have reached a sleep medicine provider. These patients often have moderate side effects from the apnea that they are anxious to treat.
These side effects may include one or more of the following: snoring, excessive daytime sleepiness, poor sleep quality, morning headaches, and even insomnia-like symptoms.
In the future if they want to proceed with orthodontics, they can try CPAP therapy while moving through the Invisalign or orthodontics process, which can often be 1-2 years.
After they have completed orthodontics, they would need to obtain a new oral sleep device if they want to resume use of oral appliance therapy.
Has been successfully wearing an oral appliance for obstructive sleep apnea.
They are interested in orthodontic treatment to correct a form of malocclusion (bite issues) that was present PRIOR to the start of oral appliance therapy.
If this patient decides to move forward with orthodontic treatment, they would need to stop using the oral appliance and consider alternative treatment until the dental treatment is completed.
After the orthodontic process is completed, this patient would need to obtain a new oral appliance as the original oral sleep appliance will not fit.
Strong communication is prudent between dental sleep medicine providers and the patient to prevent relapse/shifting of the teeth.
A person with recent orthodontic treatment is more susceptible to teeth shifting, which can be prevented with proper instruction.
Bonded or overlay retainers also made by the dental provider performing the orthodontics could be helpful with aftercare.
Has been wearing an oral sleep appliance for snoring or OSA and has noticed that their teeth have shifted AFTER the start of wearing an oral appliance.
This patient is considering going through orthodontics to correct bite issues. However, this patient is still interested in wearing an oral sleep apnea appliance.
If this is the case, I would recommend the patient see their dental sleep medicine provider as soon as possible. The provider dentist can evaluate options that may revert the current bite back to the original bite. This may prevent unnecessary orthodontic treatment.
The patient would likely be instructed to take a break of varying length from wearing their appliance determined by the sleep apnea dentist.
Another check would occur to observe potential changes in the bite closer to the original bite pattern.
In many situations the original bite will return if caught early on, and clear guidance is essential to prevent further changes if the patient resumes oral appliance therapy.
Instructions by the dental sleep apnea provider may involve strict adherence to morning jaw exercises, use of a custom morning aligner, or other retainers.
Some patients may have a hard time maintaining their original bite and be guided to take 1-2 nights per week off from wearing their sleep device.
Depending on the severity of the patient’s diagnosis and the amount of symptom relief they normally obtain when wearing their device, the patient may want to institute CPAP therapy to be used on the “off oral appliance nights”.
If the original bite pattern does not return after taking some time off from wearing the device, the patient will need to decide if they will want to stop oral appliance therapy and undertake orthodontic treatment.
If this is the case, the same protocol will follow as in the Patient Two Scenario above. The patient must decide between orthodontics or continued use of the oral sleep apnea appliance.
After treating snoring and apnea patients for over twenty years, I have witnessed that the majority of patients with bite changes will not stop using their oral appliance.
In these cases the patients find that the benefits far outweigh the bite changes that have occurred. When this happens I help patients prevent further changes by tailoring their protocol.
Interesting to note is that when bite changes do occur, the majority of patients do not notice that changes have occurred.
Bite changes can be favorable or neutral
Many bite changes during oral appliance therapy may be considered as ‘favorable’ or ‘neutral’.
People always assume that when changes in bite occurs during oral appliance therapy that the bite changes are ‘bad’ or ‘not favorable’. But this is not the case.
One of the most interesting research articles I have come across was a study following long term bite changes.
The end result showed that although 44.3% was considered undesirable, 41.4% were considered positive, and 14.3% were considered neutral. That leaves the majority of changes positive and neutral when combined.
Some positive changes may include a decrease in ‘overbite’, or lessened crowding.
Oral Appliance and Provider Choice Selection
Some types of oral sleep appliances are considered to cause less bite changes. To date, I have yet to see any one particular ‘brand’ of device that will never result in tooth movements in all patient cases.
But I do believe that choosing a particular type of OA can help limit the chances of teeth shifting. Avoiding internal clasps as well as designing the device to include the back of the furthest most teeth can help lower chances.
This is why it is important for patients to seek treatment from dentists who are well-educated in dental sleep medicine. Most general dentists have little to no training in dental sleep medicine.
Over-the-counter self-made anti snoring devices can change bites too
There are many differences between professional oral appliances and over-the-counter(OTC) anti-snoring mouth devices.
One of the largest concerns with self made devices is the large possibility of teeth shifting. With lack of dental guidance, a person is making their own device and pressure may be placed on teeth that can result in tooth movements.
Because there is no professional guidance on fit or design of the device, bite changes can occur fairly quickly, often irreversible without orthodontics.
Most knowledgeable sleep professionals support professional oral appliances for both primary snoring patients (have no apnea) and obstructive sleep apnea patients.
However, I occasionally hear that a physician or advanced practice provider may recommend an over-the- counter type of device to their primary snoring patients.
I believe this is a large disservice to these patients as oral appliance therapy remains the best option for them.
CPAP Masks Can Also Cause Tooth Movements
Many apnea patients as well as sleep apnea providers may not realize that CPAP therapy can lead to changes in a patient’s bite. However, because dental sleep medicine dentists are not directly involved with follow-up care for CPAP therapy, this is an area that is rarely researched and often overlooked.
For those interested in learning more about this, I have included some research articles below.
A note on medical insurance benefits for these circumstances: The majority of medical insurance coverage plans do provide benefits for oral appliance therapy approximately every 3-5 years depending on the insurance plan.
If an oral appliance patient goes through substantial dental work, orthodontics included, eligibility may arrive sooner than their normal time frame.
This however takes a little more paperwork including notes from your general dental provider and sleep apnea providers.
This article is general in nature and for educational purposes only. Please consult with your sleep health provider before starting any treatment option for snoring and apnea.
- Sutherland, K., Vanderveken, O. M., Tsuda, H., Marklund, M., Gagnadoux, F., Kushida, C. A., & Cistulli, P. A. (2014, February 15). Oral appliance treatment for obstructive sleep apnea: An update. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899326/
- Fransson, A. M. C., Kowalczyk, A., & Isacsson, G. (2017, October). A prospective 10-year follow-up dental cast study of patients with obstructive sleep apnoea/snoring who use a mandibular protruding device . Academic.oup.com. https://academic.oup.com/ejo/article/39/5/502/2840153
- Almeida FR;Lowe AA;Otsuka R;Fastlicht S;Farbood M;Tsuiki S; (2006, February). Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: Part 2. study-model analysis. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. https://pubmed.ncbi.nlm.nih.gov/16473712/
- Karadeniz, C., Lee, K. W. C., Lindsay, D., Karadeniz, E. I., & Flores-Mir, C. (2022, March 1). Oral appliance-generated malocclusion traits during the long-term management of obstructive sleep apnea in adults. The Angle orthodontist. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8887395/
- Clinical side effects of continuous positive … – wiley online library. (n.d.). https://onlinelibrary.wiley.com/doi/full/10.1111/resp.13808
- Pliska, B. T., & Almeida, F. R. (2018, April 15). Tooth movement associated with CPAP therapy. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5886451/#:~:text=Follow%2Dup%20questioning%20revealed%20that,returned%20to%20their%20pretreatment%20positions