Hinman Connects Blog

Dr. Cristi Cheek - before surgery (hidden issues!)

Large tori and flat posterior teeth – posterior tongue position

Open bite that developed over many years of bruxism and TMJ changes

Decreased airway space

Profile before surgery

Profile after surgery

Panoramic image after surgery

Sept 2018 – post-surgery and still undergoing orthodontics

My friends and colleagues were skeptical... “How could you possibly have sleep apnea?  You’re young and thin and always so full of energy,” they said to me.  An ENT had a hard time believing it was a possibility as well even after I detailed all my signs and symptoms... “Your throat looks wide open, and you’re a trim, healthy, younger female, so I don’t think you have sleep apnea, and insurance will likely not cover a sleep study for someone like you.”  Luckily, I had just attended a lecture on sleep disordered breathing given at one of our Hinman Dental Society meetings and was sure a polysomnogram would confirm my suspicions, so I pressed the ENT to move forward, and he agreed to sign the order for the test. A few days later in the fall of 2015, my sleep study showed that I had moderate sleep apnea.

Before receiving this diagnosis, for a couple of years I had been waking up during the night with my heart racing and having trouble falling back asleep.  I often dreamed of drowning or being choked. My MD prescribed me an anti-anxiety medication and Ambien for sleep, but even on these medications, I woke most nights with my heart pounding, sometimes with a gasp, and then lay there awake for a couple of hours.  I assumed that my sleep issues as well as my new inability to concentrate and remember things could be attributed to being in my mid-40s and having the stress of a busy practice and three elementary aged kids. I also had a lot of headaches that started from the neck area, so I was getting regular massages, chiropractic adjustments, acupuncture and dry needling.  For several years I had worn a hard occlusal guard at night for the bruxism that had worn my posterior teeth flat.

But from the Hinman course on sleep disordered breathing I learned that some people brux as a response to airway limitation and that the forward head position I had been holding for years (my dad commented many times over the years that I needed to stand up straight with my head and shoulders back) was my body’s way of helping to create a more open airway but was also straining my neck muscles, contributing to my headaches and neck soreness.  I now understood that not sleeping well can LEAD to anxiety and concentration/memory issues. The heart racing I experienced during the night was my body’s way of saying, “Hey, I need more oxygen!” 

Now with the correct diagnosis I sought a “cure.” The pulmonologist I saw concerning the results of my sleep study commented that I didn’t really have to treat my sleep apnea since I didn’t have any associated health problems....no high blood pressure, heart disease, diabetes or obesity, etc.  The preventative philosophy we dentists have didn’t seem to be one held by the MD, but I convinced him to let me try a CPAP.  After 3 different masks and switching from CPAP to BiPAP, which helped to decrease the air pressure that was creating resistance when I breathed out, I gave up. The masks leaked and woke me up, and the air went not only into my lungs but also into my esophagus and created horrible pressure in my stomach and intestines. So I took a couple of courses on mandibular advancement devices, consulted with a colleague skilled at making them, and made myself a device. Unfortunately, the device caused pain in my TMJs which had been damaged by years of bruxism.  I had already managed to displace permanently both disks sometime in college after having been a teenager with a popping and locking jaw.  Back then, I thought that because it wasn’t making noises anymore, my jaw had fixed itself. The anterior open bite I developed meant nothing to me (or my dentist) back then.

I graduated from dental school in May of 2000 and soon after took a series of courses with Dr. Pete Dawson.  This was when I first really recognized that I had some occlusion and TMJ issues, so I sought the opinion back then of a well-known TMJ surgeon who told me that I would need surgery to correct my bite.  My forward-thinking surgeon said that without the correction, I may develop sleep apnea in the future.  I decided against the surgery at the time since I was a new dentist about to buy a practice, get married, and start a family.   After all, I was functioning fine and was relatively asymptomatic. I had no idea of the maladaptation of my occlusion that was going to occur over the next 15 years.

Years later I recognized that my anterior open bite had increased and that I was holding my mandible forward to get the anterior teeth to approximate. Eventually my retrusive mandible and loss of overall muscle tone due to aging contributed to a posterior tongue position that was now cutting off my airway when my jaw muscles relaxed.  

So in 2016, after having had bad experiences with CPAPs and mandibular advancement devices, I began my journey for a more permanent fix.  I had my massive mandibular tori removed to give my tongue more room, hoping that that would be enough to help improve the apnea, but a second sleep study gave disappointing results.  I then had orthodontics placed and a surgical procedure called PAOO (periodontally accelerated osteogenic orthodontics) so that my arches could be widened orthodontically without pulling my roots out through the facial bone...all in preparation for orthognathic surgery. Then on June 27, 2018 I underwent LeFort I and BSSO to correct my occlusion and airway issues. Now, just a few months later, I am amazed at how I can sleep on my back...all night long! No gasping or heart racing! I have more energy and don’t tire as easily.  The surgery was not an easy one, and the recovery as I continue orthodontically straightening my teeth and waiting for the feeling to return in my chin is certainly going to be a journey over this next year, but I would do it all again.  Breathing trumps everything!

When I first was diagnosed with sleep apnea, I was frustrated to have to deal with this problem during such a busy time of my life.  But God has used my journey to transform my practice and make me a better dentist.  I became a dentist because of my desire to help people.  I had never thought about my role in diagnosing sleep apnea and other breathing-related problems until I had such a problem myself. Now I am helping families by looking at tonsils in children as well as jaw development, narrow arches, continued thumb sucking, bed wetting, allergic shiners, hyperactivity, snoring....all signs of sleep disordered breathing in children.  And I am helping tired adults and those with worn or broken teeth become not only dentally healthy, but healthier overall by recognizing potential sleep breathing issues that are showing up during dental examinations as TMD, tooth wear, broken teeth, scalloped tongues, etc.  And I know that God is using me to encourage you, my colleagues, to look for the signs and symptoms of sleep disordered breathing we see in our patients every day that could be decreasing their quality of life and may lead to health issues and dementia. I hope your practices will become transformed, too!