Special Article 2, Issue 13.2

A Standardized Protocol for Enhancing Oral Appliance Therapy: Integrating Morning Occlusal Guide and Jaw Exercises    

http://dx.doi.org/10.15331/jdsm.7436

Subha Giri, BDS MS¹; Emily Kahnert, DPT PhD²
 

Obstructive sleep apnea (OSA) is a globally prevalent sleep-related breathing disorder characterized by the repeated collapsing of the upper airway, resulting in partial or complete obstruction to airflow during sleep. Positive airway pressure (PAP) therapy is the gold standard treatment for the management of OSA. Recently, oral appliance therapy (OAT) has emerged as an effective treatment alternative to PAP therapy for OSA management.¹ OAT increases the airway dimension and reduces airway collapsibility by repositioning the mandible into a protrusive posture and moving the tongue anteriorly.^2,3 OAT has been demonstrated to be effective across the severity of OSA, and to be noninferior to CPAP for many systemic health-related outcomes related to cardiovascular health as well as sleep-related quality of life.^4,5

OAT has been associated with adverse effects including excessive salivation, dry mouth, tooth movement, and jaw pain.⁶ Specifically, tooth movement contributing to malocclusion as well as jaw pain is noted with long-term use of OAT. Although transient occurrence of these adverse effects can temporarily interfere with oral appliance use, persistent adverse effects can lead to overall treatment intolerance and ineffective management of OSA, thus warranting strategies to prevent as well as manage the adverse effects.

Oral appliances for OSA management consist of custom-fabricated removable trays over maxillary and mandibular dental arches, with attached or unattached hardware components designed to propel the mandible into a protrusive position to expand the airway dimension and to anteriorly position the tongue. The force against the teeth from mandibular protrusion, over a prolonged period of time, contributes to tooth movement within the dentoalveolar bone. Tooth movement associated with OAT results in proclination of mandibular anterior teeth, retroclination of maxillary anterior teeth, reduced overjet, and overbite.^7,8

Jaw pain is another common adverse effect reported with OAT. The pain is an initial response to the alterations in lateral pterygoid activation that have been documented with mandibular protrusion.^9,10 Forced positioning in mandibular protrusion bilaterally activates the inferior head of the lateral pterygoid muscle, which has been shown to produce increased muscle fiber activation via intraoral electromyography and nearly doubled the force on the pterygoid muscles with OAT use in finite element simulations.^10,11 Although these muscles may return to their resting length upon removal of the appliance, prolonged activation leads to neuromuscular changes that can produce short-term discomfort and functional limitation.^10,12,13 The initial onset of temporomandibular joint pain after OAT insertion may be transient, but Perez et al. ¹⁴ reported a 49% study dropout rate that was mostly due to early onset of pain with initial device use. The onset of pain or functional limitation during this time frame could reduce patient compliance and even prohibit OAT tolerance.

To manage occlusal changes associated with OAT, a morning occlusal guide (MOG) is provided to the patient. The MOG serves as a template for repositioning the mandible to the habitual position and restoring occlusion following the use of an oral appliance.¹⁵ The patient is instructed to wear the MOG every morning following overnight use of OAT, by biting into the guide for as long as it takes until the maxillary and mandibular teeth are fully seated to reestablish the habitual occlusion. This task may require the patient to exert considerable retrusive and compressive force to reestablish occlusion risking the occurrence of jaw pain and further misalignment of teeth if habitual occlusion is not accurately re-established because of pain-related muscle tension and splinting. Biomechanically, because the effectiveness of MOG is reliant on the ability of the pterygoid muscles to relax and return to their original position, adaptive shortening of these muscles with prolonged OAT can further interfere with accurate occlusal repositioning with MOG. If the occlusion is forced without concurrent muscular rehabilitation, this can result in jaw pain, inaccurate occlusal repositioning, and reduced tolerance to both the MOG and OAT.

Exercise-based strategies such as isometric contractions and passive jaw stretching exercises have been demonstrated to effectively manage jaw pain associated with OAT. Ueda et al. ¹⁶  and Ishiyama et al. ¹⁷ reported reduction in morning discomfort following the removal of the oral appliance. Cunali et al. ¹² found that jaw exercises significantly reduced pain intensity in patients with temporomandibular disorders (TMD) after 120 days of OAT, compared with a placebo neck exercise group. Ishiyama et al.¹⁷ also demonstrated that preventive jaw opening stretches, used prior to OAT insertion, reduced initial morning pain and chewing dysfunction in patients without preexisting TMD. The jaw exercises and frequencies of performance were slightly different across studies, yet in all cases they improved OAT tolerance, particularly in patients experiencing pain.

Because all patients receiving OAT are at risk of development of adverse effects of jaw pain as well as occlusal changes, establishing a unified method of combining MOG use with jaw exercises could be an effective preventive approach. Moreover, combining jaw exercises with MOG use can serve as a comprehensive rehabilitative technique for the masticatory system, with each approach complementing the effect of the other, respectively. Establishing such a technique as a standard protocol for rehabilitating the masticatory muscles could improve patient outcomes, therapeutic safety, and treatment efficacy.

Therefore, the purpose of this report is to propose a standardized approach combining MOG use and jaw exercises to prevent and manage adverse effects associated with OAT. The proposed method integrates both occlusal and biomechanical rehabilitation strategies, offering a comprehensive solution to the limitations of current methods.

Physical therapy literature demonstrates that a multimodal, individualized approach is effective to treat patients with painful TMD.^18,19 As a result, there is significant heterogeneity in the specific exercises used to manage TMD pain that precludes recommending any one specific exercise or intervention.²⁰ The approach proposed in this protocol, grounded in empirical evidence supporting the individual components of the approach, aims to address the muscle adaptations that occur with prolonged mandibular protrusion.^{12, 15-17}

The biomechanical changes seen with forced mandibular protrusion primarily affect the pterygoid muscles.^10,11 The Rocabado 6x6 exercises are a group of six exercises, performed six times per day, designed to restore neutral posture and return postural stabilizer and masticatory muscles to their natural resting length.²¹ The “rest position of the tongue” and “controlled rotation” exercises from the Rocabado protocol are defined as follows:
 

• Rest position of the tongue (6x6 #1): Repeated upward tongue positioning on the anterior one-third roof of the mouth area while performing slow diaphragmatic breathing. Cues given to find the position include saying the letter “N” or clucking the tongue. This “tongue-up, teeth-apart” activity has become the standard recommendation given by physical therapists and orofacial pain specialists to disrupt jaw clenching behaviors and relax masticatory muscle tension.
  ^21,22

• Controlled rotation (6x6 #5): Repeated open/close movement of the mandible while holding the tongue to the roof of the mouth and monitoring the temporomandibular joint with index fingers, limiting movement to the range allowed by the tongue-up position. This movement isolates temporomandibular joint rotation and prohibits translation, thereby inhibiting lateral pterygoid muscle contraction and shortening. The tactile feedback provided by the fingertips allows self-limitation and correction to ensure proper activity performance without pterygoid activation.^21,22 Cunali et al. ¹²  used controlled rotation as one of the exercises in their study demonstrating improved OAT tolerance after exercise.

The recommendation for MOG use includes utilization of bite force to achieve full occlusion and reverse the protrusive effects of the oral appliance.¹⁵ However, habitual performance of clenching behaviors has been consistently identified in TMD literature as a contributing factor to painful TMD.²⁰ The masseter,  temporalis and the medial pterygoid muscles, are the primary clenching muscles and repetitive high-intensity activation of these muscles during teeth clenching, is identified as a risk factor for masticatory myalgia and myofascial pain.²³ Stretching the jaw by opening wide lengthens the masticatory clenching muscles to restore relaxed neutral positioning. Ueda et al. ¹⁶  found that jaw stretching in combination with guided retrusion resulted in improved morning occlusal contact area and bite force after OAT.

Altogether these exercises are effective to establish jaw retrusion to counteract jaw protrusion and stretch the masseter and temporalis muscles that perform clenching, independently integrating specific jaw exercises with the use of the MOG can help overcome pain-related obstacles to compliance, promote accurate repositioning of the occlusal contacts, and enhance overall comfort and effectiveness of OAT. This proposed protocol is repeatable and testable and provides opportunities for future research concerning clinical effectiveness and feasibility.

Protocol for Integrating MOG and Jaw Exercises

Given the considerable diversity in MOG design, materials, and fabrication methods, this protocol defines a MOG as a partial maxillary anterior coverage guide lacking any posterior extension. Chairside fabrication is performed by a qualified dentist using thermoplastic material, meticulously adapted to the maxillary anterior teeth while the patient ensures maximum intercuspation. This approach ensures an accurate occlusal impression of the mandibular teeth within the guide. The dentist may modify the approach as appropriate should an alternate MOG design more effectively meet the patient's clinical needs.

Phase 1: Occlusal Guide Placement 

Upon removal of the oral appliance after its bedtime use, it is important for the patient to avoid clenching the jaw or occluding the teeth immediately. Instead, the patient is instructed to maintain a resting tongue posture, gently resting the tongue against the hard palate with the teeth apart and lips closed. This position is to be held for up to 6 seconds, repeated six times.²¹ At this stage, other relaxation techniques can be introduced, including heat, gentle stretching, or self-massage as directed by a physical therapist or healthcare provider. When ready, the patient is instructed to open their mouth fully, as if to yawn, before placing the MOG on their anterior teeth.

Phase 2: MOG Occlusion With Jaw Rotation and Muscle Relaxation

Once the MOG is in place, the patient is guided to place the tip of their tongue as far posteriorly as possible along the hard palate, using controlled jaw rotation to help guide the tongue (Figure 1). During this process, the patient may experience a sense of restriction due to the position of the tongue. The goal is to rest the tongue gently yet firmly against the hard palate, posterior to the rugae, while gently bringing the teeth together to achieve maximum intercuspation (MIP) on the MOG. If pain is experienced in the anterior teeth or muscles of mastication, the exercise must be discontinued, and the patient can reinforce the resting tongue posture.

Phase 3: Alternating Jaw Rotation and Relaxation With MOG Use

The patient is then instructed to use the controlled rotation exercise to work toward full occlusion in MIP on the MOG, alternating between opening in the tongue-limited range and guiding the back molars together incrementally closer each time while closing (Figure 1- controlled rotation). After six repetitions, the patient is encouraged to resume the resting tongue posture for six breaths or tongue “clucks” before returning to controlled rotation to work again toward full MIP occlusion. This process is recommended continually for up to 15 minutes or until they can fully achieve MIP and without pain or discomfort. If the patient experiences persistent pain or is unable to reach MIP without discomfort, additional options can be discussed to tailor an individualized management strategy. Many adverse effects of OAT are transient, so providing appropriate treatment information and pain education will set expectations and improve patient compliance. If pain is ongoing, using moist heat at night before OAT use or in the morning upon device removal can facilitate muscle relaxation and decrease pain. Medication management, increased frequency of exercise performance, and other elements of palliative care are good initial strategies to address pain or discomfort.^15,20

Occasionally, the patient may be fearful or hesitant to continue therapy due to the onset of pain or occlusion changes. Multidisciplinary management following the biopsychosocial model is the recommended care model for care of patients with TMD, as collaboration with other disciplines can address the multifactorial etiologies seen with these conditions.²⁰ Physical therapists are movement specialists trained to identify functional limitations and create a customized rehabilitation plan including exercises, manual therapy, modalities, and self-care to gradually increase tolerance to the mandible’s extreme positioning. Partnerships between physical therapy and dentistry can improve patient outcomes and maximize care team efficiency.^15,24

 

Figure 1.

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Figure 2.

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DISCUSSION

The proposed protocol (Figure 2 – protocol integrating MOG and jaw exercises) integrates evidence-based practices from OAT, physical therapy, and TMD management. This exercise combination—the tongue-up procedure, relaxation, maximal opening exercises, and controlled rotation—draws from existing literature and aims to improve patient tolerance to the MOG. It is grounded in sound biomechanical principles and supported by empirical findings from real-world clinical practice in dental sleep medicine and TMD care. This protocol represents a step forward in establishing a testable and effective approach for managing OAT adverse effects, with a particular focus on malocclusion and TMD symptoms.

As outlined in the consensus recommendations proposed by Sheats et al. in 2017, conservative management including watchful waiting, palliative care, and exercise are the first strategy to address the onset of painful adverse effects of OAT.¹⁵ Without having a standardized protocol for exercise, the existing heterogeneity leaves patients and health professionals to experiment with finding a strategy that works for them. By combining evidence-based exercises with MOG use, health professionals have a common starting point from which additional individualized modifications can be made to streamline clinical reasoning and problem-solving. This protocol adds to the existing recommendations by providing a detailed roadmap to conduct conservative management.

Goals of the Proposed Standardized Protocol:

• Integration: Combines OAT, physical therapy, and TMD rehabilitation into a unified approach.
• Evidence-based: Grounded in current OAT research, physical therapy, and TMD management.
• Feasible: Provides a practical approach that can be integrated into clinical practice.
• Testable: Offers a framework for evaluating the efficacy and applicability of the protocol in clinical settings.

Further research is required to determine the feasibility, reliability, and validity of the protocol among diverse users and practice environments. Additionally, clinical trials should be conducted to assess the protocol's effectiveness in minimizing adverse effects and enhancing tolerance to OAT. Individualized treatment plans will remain critical, particularly for patients whose adverse effects fall outside the scope of the proposed protocol. However, this approach can serve as a foundational strategy to address common OAT-related risks related to occlusion and TMD, with the flexibility to be tailored to individual patient needs.

CONCLUSIONS

Adverse effects associated with OAT—particularly malocclusion and TMD symptoms—pose significant challenges to therapy success and patient compliance. There is an urgent need to establish standardized approaches for managing these side effects. The novel approach presented here, which integrates MOG use with targeted jaw exercises, offers a promising standardized method to mitigate common OAT side effects. Further research is required to assess the effectiveness and feasibility of this protocol in clinical practice.

CITATION

Giri S, Kahnert E. A Standardized Protocol for Enhancing Oral Appliance Therapy: Integrating Morning Occlusal Guide and Jaw Exercises. J Dent Sleep Med. 2026;13(2).

REFERENCES

1. 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.
2. Schmidt-Nowara W, Lowe A, Wiegand L, Cartwright R, Perez-Guerra F, Menn S. Oral appliances for the treatment of snoring and obstructive sleep apnea: a review. Sleep.1995;18(6):501-510.
3. Brown EC, Cheng S, McKenzie DK, Butler JE, Gandevia SC, Bilston LE. Tongue and lateral upper airway movement with mandibular advancement. Sleep. 2013;36(3):397-404.
4. Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2013;187(8):879-887.
5. Trzepizur W, Cistulli PA, Glos M, et al. Health outcomes of continuous positive airway pressure versus mandibular advancement device for the treatment of severe obstructive sleep apnea: an individual participant data meta-analysis. Sleep. 2021;44(7):zsab015.
6. Martins OFM, Chaves Junior CM, Rossi RRP, Cunali PA, Dal-Fabbro C, Bittencourt L. Side effects of mandibular advancement splints for the treatment of snoring and obstructive sleep apnea: A systematic review. Dental Press J Orthod. 2018;23(4):45-54.
7. Bartolucci ML, Bortolotti F, Martina S, Corazza G, Michelotti A, Alessandri-Bonetti G. Dental and skeletal long-term side effects of mandibular advancement devices in obstructive sleep apnea patients: a systematic review with meta-regression analysis. Eur J Orthod. 2019;41(1):89-100.
8. Tsolakis IA, Palomo JM, Matthaios S, Tsolakis AI. Dental and skeletal side effects of oral appliances used for the treatment of obstructive sleep apnea and snoring in adult patients-A systematic review and meta-analysis. J Pers Med. 2022;12(3):483.
9. Lafrenière CM, Lamontagne M, el-Sawy R. The role of the lateral pterygoid muscles in TMJ disorders during static conditions. Cranio. 1997;15(1):38-52.
10. Hiyama S, Ono PT, Ishiwata Y, Kuroda T, McNamara JA Jr. Neuromuscular and skeletal adaptations following mandibular forward positioning induced by the Herbst appliance. Angle Orthod. 2000;70(6):442-453.
11. Duggal I, Sidhu MS, Chawla A, Dabas A, Dhimole VK. Effects of miniplate anchored Herbst appliance on skeletal, dental and masticatory structures of the craniomandibular apparatus: A finite element study. Int Orthod. 2021;19(2):301-309.
12. Cunali PA, Almeida FR, Santos CD, et al. Mandibular exercises improve mandibular advancement device therapy for obstructive sleep apnea. Sleep Breath. 2011;15(4):717-727.
13. Heidsieck DSP, Koolstra JH, de Ruiter MHT, Hoekema A, de Lange J. Biomechanical effects of a mandibular advancement device on the temporomandibular joint. J Craniomaxillofac Surg. 2018;46(2):288-292.
14. Perez CV, de Leeuw R, Okeson JP, et al. The incidence and prevalence of temporomandibular disorders and posterior open bite in patients receiving mandibular advancement device therapy for obstructive sleep apnea. Sleep Breath. 2013;17(1):323-332.
15. Sheats RD, Schell TG, Blanton AO, et al. Management of side effects of oral appliance therapy for sleep-disordered breathing. J Dent Sleep Med. 2017;4(4):111–125.
16. Ueda H, Almeida FR, Chen H, Lowe AA. Effect of 2 jaw exercises on occlusal function in patients with obstructive sleep apnea during oral appliance therapy: a randomized controlled trial. Am J Orthod Dentofacial Orthop. 2009 ;135(4):430.e1-7.
17. Ishiyama H, Inukai S, Nishiyama A, et al. Effect of jaw-opening exercise on prevention of temporomandibular disorders pain associated with oral appliance therapy in obstructive sleep apnea patients: A randomized, double-blind, placebo-controlled trial. J Prosthodont Res. 2017;61(3):259-267.
18. Kraus S, Prodoehl J. Outcomes and patient satisfaction following individualized physical therapy treatment for patients diagnosed with temporomandibular disc displacement without reduction with limited opening: A cross-sectional study. Cranio. 2019;37(1):20-27.
19. Dickerson SM, Weaver JM, Boyson AN, et al. The effectiveness of exercise therapy for temporomandibular dysfunction: a systematic review and meta-analysis. Clin Rehabil. 2017;31(8):1039-1048.
20. National Academies of Sciences, Engineering, and Medicine. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press; 2020.
21. Rocabado M, Iglarsh ZA. Musculoskeletal Approach to Maxillofacial Pain. Philadelphia, PA: Lippincott; 1991.
22. Mulet M, Decker KL, Look JO, Lenton PA, Schiffman EL. A randomized clinical trial assessing the efficacy of adding 6 x 6 exercises to self-care for the treatment of masticatory myofascial pain. J Orofac Pain. 2007;21(4):318-328.
23. Schiffman E, Ohrbach R, Truelove E et al; International RDC/TMD Consortium Network, International association for Dental Research; Orofacial Pain Special Interest Group, International Association for the Study of Pain. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache. 2014;28(1):6-27.
24. Prodoehl J, Kahnert E. Physical therapy for temporomandibular disorders: evidence-based improvements and enhancements for diagnosis and management. Frontiers of Oral and Maxillofacial Medicine. 2021; 4.

SUBMISSION & CORRESPONDENCE INFORMATION

Submitted for publication September 16, 2025
Submitted in final revised form November 18, 2025
Accepted for publication January 8, 2026

Address correspondence to: Subha Giri, BDS, MS, FAAOP; Email: giri.subha@mayo.edu

DISCLOSURE STATEMENT

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