Patients do not experience bite changes with mandibular advancement devices in the same way. Some develop only temporary morning changes. Others show gradual reductions in overjet or overbite, altered posterior contacts, or changes in tooth position over time.¹⁻⁵

Risk may be greater when treatment begins with unstable occlusion, reduced periodontal support, missing posterior teeth, or complex restorations. Greater advancement and many years of nightly use may also increase the need for closer follow-up.

The 2015 clinical practice guideline from the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine recommends ongoing oversight by a qualified dentist. That follow-up should include surveillance for dental side effects and occlusal changes.⁶

The practical question is not whether bite changes can occur. They can. The more useful question is which patients may need closer monitoring and how that risk should influence treatment planning.

Patients may need closer monitoring when they have:

• Minimal overjet or overbite
• An edge-to-edge anterior relationship
• Unstable or limited posterior contacts
• Reduced periodontal support or tooth mobility
• Missing posterior teeth
• Multiple crowns, bridges, implants, or extensive reconstructions
• Pre-existing occlusal instability
• Limited jaw mobility or poor tolerance for protrusion
• A need for substantial mandibular advancement
• Many years of expected nightly treatment
• Existing TMJ symptoms or functional limitations

No single finding automatically excludes a patient from oral appliance therapy. However, several factors together should lead to stronger baseline records, individualized consent, cautious titration, and closer follow-up.

Mandibular advancement devices place repeated forces on the teeth and supporting structures. However, every patient starts with a different occlusion, periodontal condition, restorative history, and functional range.

The appliance may be similar. The dentition receiving the force is not.

Doff and colleagues compared oral appliance therapy with continuous positive airway pressure. After two years, the oral appliance group showed significant reductions in overjet and overbite. Researchers also found more anterior-posterior change and fewer contacts in the premolar and molar regions.¹

Almeida and colleagues documented additional cephalometric and study-model changes during long-term therapy.²˒³ Marklund also found that orthodontic side effects and their predictors varied among patients using mandibular advancement devices.⁴

These findings support individualized risk assessment. Some patients begin treatment with stable contacts and strong support. Others have less room to accommodate even a modest shift.

A recent JADA narrative review recommends a comprehensive dental and medical evaluation before oral appliance therapy. The assessment should include occlusion, TMJ range of motion, and intraoral conditions. The review also identifies active periodontitis and major TMJ pathology as possible contraindications that require attention before treatment.⁹

Baseline occlusion is central to risk assessment. Dentists cannot identify meaningful change unless they know where the patient started.

Before treatment, document:

• Overjet
• Overbite
• Intercuspation
• Anterior and posterior contacts
• Dental midlines
• Existing open contacts
• Occlusal irregularities
• Tooth mobility
• Areas of reduced support

A patient with stable occlusion may still develop change. However, the consequences may be greater when overjet, overbite, or posterior support is already limited.

For example, a modest reduction in overjet may be manageable for one patient. The same change may be more important for someone who begins close to an edge-to-edge relationship.

Long-term research commonly identifies reduced overjet, reduced overbite, and altered posterior contacts.¹⁻⁵ These features deserve careful baseline documentation.

Photographs, detailed clinical notes, digital scans, and study models can create a reliable comparison point. Their value increases when the patient begins treatment with an unusual or unstable occlusal relationship.

Practices can also use a practical workflow for monitoring occlusion during oral appliance therapy to compare future findings with the original records.

The dentist should identify and manage active periodontitis before oral appliance therapy begins.⁹ Patients with bone loss, tooth mobility, or a history of periodontal instability may also need additional evaluation.

Current evidence does not provide a simple formula that predicts the amount of occlusal change in each patient. Still, reduced support is a reasonable reason for caution.

The dentist should review:

• Stability of each tooth used for retention
• Areas of mobility
• Bone support
• Previous periodontal treatment
• Current maintenance status
• Distribution of appliance forces

Periodontal findings may influence appliance selection, retention design, recall frequency, and coordination with the patient’s general dentist or periodontist.

A history of periodontal disease does not automatically rule out therapy. The key question is whether the remaining support is stable enough for long-term appliance use.

Missing teeth may reduce occlusal stability and change how forces move through the arch.

This concern is especially relevant when posterior support is limited. A patient with fewer stable contacts may have less capacity to accommodate further change.

Missing teeth do not necessarily increase the biological rate of tooth movement. However, they may increase the practical consequences of a shift.

Before treatment, consider:

• Number and location of missing teeth
• Quality of the remaining posterior support
• Whether tooth replacement is planned
• How the appliance will retain on the remaining dentition
• Whether existing spaces are stable
• How future restorative treatment may affect appliance fit

When posterior support is limited, closer follow-up may help identify changes before they affect chewing, comfort, or restorative planning.

Patients with multiple crowns, bridges, implants, or extensive reconstructions require careful planning.

Complex restorations do not automatically predict more tooth movement. However, they can make a small occlusal shift more important.

A minor change in a minimally restored dentition may require observation only. The same change in a complex reconstruction could alter contacts, loading, or comfort.

Before selecting an appliance, review:

• Crown and bridge margins
• Implant locations
• Pontic and connector design
• Existing wear or fracture
• Retention on restored teeth
• Planned restorative work
• Ability to modify or repair the appliance

The dentist should also determine whether the current occlusion is stable because of the restorations or despite them. That distinction may affect appliance design and follow-up.

The amount of advancement changes the force environment created by treatment.

Greater protrusion may be necessary for some patients. However, it may also justify closer monitoring when other dental risk factors are present.

The JADA review reports that initial settings commonly range from 25% to 75% of maximum protrusion. The dentist should select the final position based on therapeutic need, patient tolerance, and clinical response.⁹

Dieltjens and colleagues also emphasized individualized titration rather than aggressive advancement by default.⁸

Current evidence does not support a simple rule in which a specific amount of advancement produces a predictable amount of bite change.

A more useful principle is:

As treatment demands increase, the dentist should reassess whether the dentition and supporting structures continue to tolerate the selected position.

For higher-risk patients, gradual titration allows the clinician to evaluate comfort, fit, jaw function, and occlusal response before advancing further.

Bite changes often develop over time. Therefore, treatment duration is an important part of the risk profile.

Doff and colleagues identified significant dental effects after two years of therapy.¹ Venema and colleagues later documented continued changes during a 10-year follow-up.⁵

A patient in the first year of treatment has not had the same exposure as someone who has used an appliance nightly for eight or ten years.

Long-term follow-up should not become less important simply because the patient is comfortable. Patients who tolerate therapy well may continue for years without noticing slow occlusal changes.

Annual examinations should include a direct assessment of the bite. Patients with several risk factors may need more frequent reviews.

TMJ findings do not predict bite changes through a simple relationship. However, they may affect appliance tolerance, titration, and the interpretation of early symptoms.

Before treatment, assess:

• Maximum opening
• Protrusive range
• Lateral movement
• Joint sounds
• Muscle or joint tenderness
• History of locking
• Existing stiffness
• Tolerance for the proposed construction bite

The JADA review recommends evaluating TMJ range of motion and identifying major pathology before treatment begins.⁹

A patient with limited mobility or poor protrusive tolerance may need slower titration. More frequent reassessment may also be appropriate.

John Viviano describes early effects as generally short-lived during the adjustment period. These may include temporary morning occlusal changes, masticatory muscle tenderness, and TMJ discomfort or stiffness. He distinguishes them from long-term effects, which mainly involve bite changes.⁷

That distinction helps guide follow-up. A morning bite change that resolves may represent temporary adaptation. A change that persists through the day requires closer evaluation.

Informed consent should reflect the individual patient rather than rely only on a standard form.

Every patient should understand that oral appliance therapy may cause long-term changes in tooth position and occlusion. Patients with several risk factors need a more detailed discussion.

Additional emphasis may be appropriate when a patient has:

• Minimal overjet or overbite
• Reduced periodontal support
• Missing posterior teeth
• Extensive restorations
• Unstable baseline occlusion
• A need for substantial advancement
• A long expected treatment duration

The dentist should explain:

1. What changes may occur
2. Why the patient may need closer follow-up
3. Which baseline records will be collected
4. How often the bite will be reassessed
5. What the patient should report
6. How treatment may change if the bite continues to shift

The goal is not to create unnecessary fear. Bite changes do not always mean that therapy has failed or must stop.

Instead, the discussion should support shared decision-making. Patients need to understand both the benefits of treatment and the dental changes that require ongoing observation.

For a more complete consent framework, see how to discuss bite changes with patients during informed consent.

Appliance selection

Choose an appliance that accounts for:

• Number and condition of available teeth
• Periodontal support
• Existing restorations
• Retention needs
• Titration requirements
• Functional range
• Repair or modification options

Starting position

Select the starting position based on tolerance and therapeutic need. Avoid advancing beyond what treatment requires.

Titration

Advance gradually while monitoring:

• Comfort
• Retention
• Morning occlusion
• Persistent contact changes
• Jaw mobility
• Muscle or joint symptoms
• Evidence of tooth movement

Morning management

When appropriate, morning exercises or an occlusal guide may help the patient return to the habitual mandibular position after appliance removal.⁹ These strategies do not replace professional monitoring.

Documentation

Record why the appliance and initial position were selected. Document each adjustment and the clinical response.

Good records help the dentist determine whether a change followed a specific adjustment or developed gradually.

Before treatment

• Record overjet, overbite, contacts, midlines, and intercuspation.
• Evaluate periodontal support and mobility.
• Identify missing teeth and restorative complexity.
• Assess TMJ function and protrusive tolerance.
• Obtain photographs, scans, or models when appropriate.
• Discuss individualized risk during informed consent.

After delivery

The JADA review recommends clinical reassessment within 30 days of delivery, followed by regular continuing evaluation.⁹

At the early visit:

• Confirm fit and retention.
• Review insertion and removal.
• Ask about morning bite changes.
• Evaluate muscle and joint comfort.
• Confirm whether temporary changes resolve.
• Document any adjustment.

During titration

• Advance only when clinically indicated.
• Record each adjustment.
• Recheck comfort and function.
• Compare contacts with the baseline.
• Ask about chewing or bite changes.
• Investigate changes that persist beyond the morning.

During long-term follow-up

• Reassess the bite at least annually.
• Compare overjet, overbite, and posterior contacts with baseline records.
• Repeat scans, models, or photographs when indicated.
• Evaluate periodontal and restorative stability.
• Confirm continued appliance fit.
• Review whether the current protrusive position remains necessary.
• Discuss progressive changes before they become harder to manage.

Monitoring should not depend on the patient recognizing a problem. Many occlusal changes develop slowly and may not produce immediate symptoms.

A risk factor does not automatically require treatment modification. A documented and progressive change may.

The clinical response depends on:

• Extent and direction of the change
• Whether the change is stable or continuing
• Effects on chewing, comfort, or occlusion
• Patient concern
• Treatment effectiveness
• Available alternatives
• Medical risk of interrupting therapy

Possible responses include:

• Reinforcing morning repositioning
• Pausing further titration
• Reducing advancement when appropriate
• Modifying or replacing the appliance
• Increasing follow-up frequency
• Coordinating with the dentist, periodontist, orthodontist, or physician
• Reviewing alternative or combination therapies

The dentist must balance dental risk against the clinical benefit of managing obstructive sleep apnea. The goal is not to prevent every measurable change. It is to identify change early enough to make an informed decision.

Patients at greater risk for clinically important bite changes are usually those with several overlapping factors.

These may include:

• Unstable baseline occlusion
• Minimal overjet or overbite
• Reduced periodontal support
• Missing posterior teeth
• Complex restorations
• Greater advancement requirements
• Limited functional tolerance
• Long treatment duration

None of these findings automatically rules out oral appliance therapy. Instead, they should influence how carefully the dentist documents, explains, delivers, and monitors treatment.

Long-term studies confirm that reductions in overjet and overbite and changes in posterior contacts may occur during therapy.¹⁻⁵ The AASM/AADSM guideline places ongoing dental oversight at the center of side-effect management.⁶ More recent guidance also supports comprehensive evaluation, early reassessment, informed consent, and continued follow-up.⁹

The best risk-management strategy is preparation. Record the starting occlusion. Identify vulnerabilities before treatment. Titrate according to clinical need. Compare future findings with the baseline. Most importantly, address progressive changes before they affect function, comfort, or future treatment options.

For the complete Panthera discussion, read Managing Bite Changes in Mandibular Advancement Therapy

1. Doff MHJ, Finnema KJ, Hoekema A, Wijkstra PJ, de Bont LGM, Stegenga B. Long-term oral appliance therapy in obstructive sleep apnea syndrome: a controlled study on dental side effects. Clin Oral Investig. 2013;17(2):475-482. doi:10.1007/s00784-012-0717-5
2. Almeida FR, Lowe AA, Otsuka R, Fastlicht S, Farbood M, Tsuiki S. Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: part 1. Cephalometric analysis. Am J Orthod Dentofacial Orthop.2006;129(2):195-204. doi:10.1016/j.ajodo.2005.10.004
3. Almeida FR, Lowe AA, Otsuka R, Fastlicht S, Farbood M, Tsuiki S. Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: part 2. Study-model analysis. Am J Orthod Dentofacial Orthop.2006;129(2):205-213. doi:10.1016/j.ajodo.2005.10.005
4. Marklund M. Predictors of long-term orthodontic side effects from mandibular advancement devices in patients with snoring and obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 2006;129(2):214-221. doi:10.1016/j.ajodo.2005.10.006
5. Venema JAMU, Doff MHJ, Joffe-Sokolova D, et al. Dental side effects of long-term obstructive sleep apnea therapy: a 10-year follow-up study. Clin Oral Investig. 2020;24(9):3069-3076. doi:10.1007/s00784-020-03266-6
6. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827. doi:10.5664/jcsm.4858
7. Viviano J. Managing Bite Changes in Mandibular Advancement Therapy
8. Dieltjens M, Vanderveken OM, Van de Heyning PH, Braem MJ. Current opinions and clinical practice in the titration of oral appliances in the treatment of sleep-disordered breathing. Sleep Med Rev. 2012;16(2):177-185. doi:10.1016/j.smrv.2011.06.002
9. Glick A, Chiang HK, Huynh N, Levine M. Dentistry’s role in the evidence-based management of adult obstructive sleep apnea: a narrative review. J Am Dent Assoc. Published online 2026. doi:10.1016/j.adaj.2025.12.020

• Managing bite changes in mandibular advancement therapy
• Informed Consent for Oral Apppliance Therapy: How to Discuss Bite Changes with Patients
• How common bite changes are with oral appliance therapy
• How to discuss bite changes with patients during informed consent