Mary, 30, presented with an anterior open bite, frequent headaches, jaw locking, neck pain, and shoulder pain. She clicked in her right and left jaw joints and her jaw joints hurt if she ate hard food and if she talked for a long time. She also reported poor sleep quality and said she did not feel rested in the morning when she woke up to begin her day.

Mary said she had seen previous dentists and one wanted to make her a sleep appliance due to her reports of poor sleep quality. Another dentist wanted to make her a joint appliance due to her reports of joint issues.

Her experiences are common with patients who have both sleep issues and joint issues. As Dr. Frank Spear said many years ago, “We treatment plan what we see first.” In her case, the dentist who recommended the airway appliance recognized the airway problem first. The dentist who recommended the joint appliance recognized the joint problem first.

Many dentists tend to become focused on their area of expertise. Airway dentists tend to think problems are airway based and joint dentists tend to think problems are joint based. In many cases, such as Mary's, the airway dentist and the joint dentist are treating the same patient. In order to help Mary and other patients like her, it is necessary to assess both the joints and the airway as part of a comprehensive exam.

As we examine Mary, it becomes clear she had an injury to her TMJs as a growing child. It has been well documented in the literature that injuries to growing joints that result in disk displacement increase the likelihood for growth interruption or incomplete growth of mandible and the maxilla. There are extensive structural changes in her jaw joints as observed in the coronal CBCT scans (Figs. 1 & 2).

X-rays of extensive structural changes in Mary's jaw joints.
Coronal CBCT scan shows Mary had an injury to her TMJs as a growing

Mary's right ramus length is 54.19 mm, and her left ramus length is 54.81 mm. Normal ramus lengths should range from 60-70 mm. A short ramus is typically indicative of injury to the joint during growth resulting in a herniated disk.

The lack of growth in the TMJ results in a lack of maxillary and mandibular projection. In these types of cases, the oropharyngeal airway space of often compressed which negatively impact the patient's ability to breathe. As we review Mary's imaging, it is apparent there has been significant compression of the oropharyngeal airway space (Fig. 3).

Apparent compression of the oropharyngeal airway space.

While maxillary and mandibular advancement surgery is a possible option to help increase the airway anatomy, the risk in this procedure increases significantly with the structural changes in the joint jaws as demonstrated in Mary's case. The treatment planning question is whether the result of the maxillary and mandibular advancement surgery would be stable given the structural changes in her jaw joints.

Recognizing joint and airway issues are integral to a dental practice seeking to offer patients predictable treatment options. It is important to remember there is a good chance that we are not only treating an airway patient or a joint patient, but we are in fact treating a patient with both an airway issue and a joint issue.

Jim McKee, D.D.S., is a member of Spear Resident Faculty.


Piper, DMD MD, M. (2020). Temporomandibular Joint Imaging. In Kerstein RB, Handbook of Research on Clinical Applications of Computerized Occlusal Analysis in Dental Medicine. (pp. 582-697). Hershey, PA: IGI Global.

Schellhas KP, Pollei SR, Wilkes CH. Pediatric internal derangement of the temporomandibular joint: effect on facial development. American Journal of Orthodontics and Dentofacial Orthopedics. 1993;104(1):51-59.

Arnett G, Milam S, Gottesman L. Progressive mandibular retrusion—idiopathic condylar resorption. Part II. American Journal of Orthodontics and Dentofacial Orthopedics. 1996;110(2):117-127.

Bryndahl F, Eriksson L, Legrell P, Isberg A. Bilateral TMJ Disk Displacement Induces Mandibular Retrognathia. Journal of Dental Research. 2006;85(12):1118-1123.


Commenter's Profile Image Drew M.
November 12th, 2020
Thank you Jim for your great post! The role of the TMJ in facial growth and airway development is so important to understand when we are diagnosing the etiology of the malocclusions we see in our everyday ortho patients. Looking forward to more posts on this subject from you and Jeff!