Clinical Takeaway
Airway dysfunction can contribute to TMD and bruxism, but it is not a universal explanation and should not be assumed. Airway-focused interventions, including mandibular advancement devices, orthodontic arch expansion, and surgical procedures, are appropriate only when an airway disorder has been confirmed through proper history, examination, or sleep study, not applied by default to every patient presenting with jaw pain or clenching.
Over the past 10 years or so, “The Airway” has become an inescapable topic in dentistry. Providers are increasingly offering, and patients are increasingly seeking, “Airway Dentistry”. Temporomandibular disorders (TMDs) and bruxism (clenching/grinding/bracing the jaw) are increasingly being attributed to airway dysfunction.
What are airway disorders?
“The Airway” refers to the passage from the nose/mouth to the lungs. Anything that impedes the flow of air at any point along this passage is an airway disorder. This can include anatomic issues (narrow airway, large tonsils, deviated septum), inflammatory issues (asthma, allergies), and neuromuscular issues (loss of muscular tone leading to airway collapse).
Airway disorders can be roughly divided into sleep and awake disorders.
While a wide variety of sleep-related breathing disorders (SRBD) exist, obstructive SRBDs are most common and familiar to patients and doctors. In a person with an obstructive SRBD, the airway partially or fully collapses when sleeping.
This leads to obstructive sleep apnea (OSA; collapsed airway causing fragmented sleep and decreased oxygen levels), upper airway resistance syndrome (UARS; collapsed airway causing fragmented sleep but no major change in oxygen), and snoring (noisy flapping of tissues due to partial airway collapse).
Awake breathing disorders also occur. Obstructions in the airway can lead to behavioral compensation (mouth breathing, changes in swallowing patterns, altered head posture). Childhood airway obstruction is associated with anatomical changes (high arched palate, retruded lower jaw), though the cause-and-effect relationship is controversial.
What is Airway Dentistry?
Airway Dentistry aims to maintain or improve the patency of the airway during sleep and/or waking hours. This may include use of removable appliances to keep the airway open (most commonly during sleeping hours) or orthodontic or surgical procedures intended to expand the airway.
It is this author’s viewpoint that enthusiasm about Airway Dentistry may outpace the evidence for some of its practices.
Myth #1: Every person with a TMD problem has an underlying airway issue that needs to be corrected.
Reality: There is no question that breathing difficulties can contribute to TMDs. However, many, if not most, people suffering from TMDs can breathe just fine.
Airway disorders should be treated, but only if they are confirmed to be present. Awake breathing disorders are diagnosed based on patient report (e.g., “I can’t breathe through my nose.”) and appropriate examination. Sleep-related breathing disorders are diagnosed through sleep studies, which may be ordered by a doctor when suspicion of a sleep-related breathing disorder exists.
Airway-focused treatments come with costs (financial, potential side effects, delay of treatments that may be more appropriate). They should only be offered when there is evidence of an airway disorder – not for every patient who has a jaw-related concern.
Whether an airway disorder is present or not, other jaw pain risk factors must always also be considered and addressed, to include behavioral jaw overuse (daytime clenching, fingernail biting, etc.), sleep disturbances not related to the airway (insomnia, insufficient sleep time, etc.), and medical conditions (autoimmune disease, metabolic disorders, etc.), among others.
Myth #2: Sleep bruxism is proof of an airway issue
Reality: Sleep bruxism has a recognized but complex relationship with sleep-related breathing disorders.
Studies have shown that clenching events tend to cluster around breathing obstruction events during sleep. If someone stops breathing during the night, the sympathetic (“fight-or-flight”) nervous system kicks in. The jaw muscles activate, either as a byproduct of the sympathetic surge or as an attempt to re-open the airway, and the result is tooth clenching or grinding.
This phenomenon, however, is not linear, as there are countless patients with severe apnea that exist with no evidence of excessive bruxism activity. And, it should be remembered that there is no absolute association between sleep bruxism, pain and the onset of a TMD problem.
But the airway is only one of many potential causes of sleep bruxism. Other factors may include genetic predisposition, stress, other forms of sleep disturbance, substance use (to include caffeine, nicotine, alcohol, and many common medications), acid reflux, and various neurologic movement disorders.
If a person has evidence of persistent sleep bruxism (such as pain predominantly on awakening or quickly grinding through nightguards), then a sleep study is an appropriate next step. If a sleep-related breathing disorder is present, then treatment of the airway is likely (though not guaranteed) to help the bruxism problem.
Myth #3: Extraction orthodontics shrinks the airway and causes sleep apnea and TMD.
Reality: In some people, the dental arches are not large enough to accommodate all the permanent teeth. In these cases, there are three basic options:
- Extract one or more teeth (typically the premolars)
- Shave down the sides of the teeth to make them smaller (interproximal reduction, or IPR)
- Expand the dental arches
There are providers and patients who blame premolar extractions for subsequent airway and TMD issues. The truth is that comparative studies looking at patients with and without premolar extractions show no difference in rates of sleep apnea diagnosis or airway volume, and most studies show that orthodontic treatment in general is not a major risk factor for TMD.
Myth #4: Palatal expansion is necessary to prevent and/or treat sleep apnea and TMD.
Reality: The palate of the mouth is comprised of left-side and right-side bones that are joined in the center (midpalatal suture). This suture fuses during early adulthood, but in children it is somewhat pliable.
In children, palatal expansion is achieved by attaching an appliance, with a screw in the middle, to the molars. Each time the screw is turned, either half of the palate is pushed slightly outward and the suture in the center of the palate gets slightly bigger. Eventually, the suture fills in with bone, and the child ends up with a wider upper dental arch.
In adults, where the midpalatal suture is already fused, palatal expansion is more challenging. A typical palatal expander will just push the molars outward, rather than truly expanding the palate. This can be overcome with MARPE (Miniscrew-Assisted Rapid Palatal Expansion) or SARPE (Surgically-Assisted Rapid Palatal Expansion). With MARPE, small screws are placed into the palatal bone and act as anchors through which expansion forces can be applied. With SARPE, a cut is made through the midpalatal suture, allowing the two halves of the palate to be pushed apart.
There is no question that these treatments can expand the width of the maxillary arch and the nasal cavity (the palatal bones, in addition to forming the roof of the mouth, comprise the floor of the nose). Studies demonstrate decreased sleep apnea in children following palatal expansion, but critics point out that these are largely uncontrolled studies (sleep apnea in children will commonly improve on its own).
The studies we have on the adult procedures (MARPE/SARPE) are generally small with only short-term follow-up, but they do consistently show improvements in sleep apnea in patients with narrow palates. It’s important to note that the adults in these studies are carefully selected – they have narrow palates. There’s no evidence that expanding a normal-sized palate will be of benefit for sleep apnea.**
Palatal expansion should be considered as part of an overall orthodontic treatment plan if the oral palate is narrower than usual, or if there is evidence that a constricted palate is contributing to obstructive sleep apnea.
Where this author sees issue is when palatal expansion is offered as a first-line treatment for TMD problems. There is currently little to no high-quality evidence supporting this approach. There are evidence-supported, more effective, and less costly methods for treating most TMD problems.
To our colleagues in the New York City metropolitan area
If your practice is located in the New York City metropolitan area, New York TMJ & Orofacial Pain has four locations staffed by board-certified orofacial pain specialists ready to help your patients. We provide evidence-based, multidisciplinary care and collaborate closely with referring providers to assist in the diagnosis and management of patients with complex TMD and orofacial pain conditions.
Contact one of our offices →
The providers at New York TMJ and Orofacial Pain consider the airway one very important variable among many that may be contributing to jaw pain concerns.
We are experts at providing Mandibular Advancement Device (MAD) therapy for patients suffering from sleep-related breathing disorders. MAD therapy involves use of custom-designed mouthguards that hold the airway open during the night. This offers similar effectiveness to CPAP therapy in patients suffering from mild-to-moderate sleep apnea.
It may be used in severe sleep apnea if a patient cannot tolerate CPAP therapy. It can also be used to treat primary snoring (noises without full airway collapse).
We also commonly provide referrals to both dental and medical providers to further assess and treat airway conditions, as appropriate.
An open airway is necessary for life. A constricted or collapsed airway comes with real consequences. Dentists have an important role in maintaining or expanding the airway in some patients, but not every patient with TMD has an airway problem.
About the author
Dr. John Dinan is a board-certified orofacial pain specialist and a diplomate of both the American Board of Orofacial Pain and the American Board of Dental Sleep Medicine. He practices in our New York City and Springfield, NJ, offices.
If jaw locking or restricted opening comes up with a patient, Dr. Donald Tanenbaum, co-founder of New York TMJ & Orofacial Pain, has a new book for exactly that conversation. Lockjaw: A Human Problem explains why it happens and what helps, in language patients can actually use. Learn more on Amazon →
Citations:
*Extraction of premolars in orthodontic treatment does not negatively affect upper airway volume and minimum cross-sectional area: a systematic review with meta-analysis. Papageorgiou SN, Zyli M, Papadopoulou AK. Eur J Orthod.
**Controlled Prospective Evidence of Rapid Maxillary Expansion Efficacy in Pediatric Obstructive Sleep Apnea: A Systematic Review Update. Fernández-Barriales M, López de Luzuriaga M, Lafuente-Ibáñez de Mendoza I, Alonso Fernández-Pacheco JJ, Álvarez Ruiz de Larrinaga A, Aguirre Urizar JM. Journal of Clinical Medicine. 2026
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Frequently asked questions about TMD, bruxism, and the airway
Does every TMD patient need to be evaluated for an airway disorder?
No. Airway disorders should be treated when confirmed, but many, if not most, patients with TMD breathe normally and have no underlying airway problem.
Does sleep bruxism confirm the presence of a sleep-related breathing disorder?
No. Clenching events often cluster around breathing obstruction events, but sleep bruxism has many potential causes, and there is no absolute association between sleep bruxism, pain, and the onset of TMD.
Does premolar extraction in orthodontic treatment shrink the airway and cause TMD or sleep apnea?
No. Comparative studies show no difference in airway volume or sleep apnea diagnosis rates between patients with and without premolar extractions.
Is palatal expansion necessary to prevent or treat TMD and sleep apnea?
Only in selected cases. Evidence supports palatal expansion for patients with a narrow palate contributing to obstructive sleep apnea, but there is little evidence supporting it as a first-line treatment for TMD.
