# Episode 5 — Great Tools, Great Cases: Why Some Results Relapse **Length target:** 14–16 minutes (~2,400 words) **Publish:** Week 3, Tuesday 6:00am ET **Season 1 · Episode 5 · Full** --- ## Show notes Thirty to seventy percent of orthodontic cases relapse within ten years. Retainer compliance gets a lot of the blame, but Kirsten makes the case that there's a bigger piece of the puzzle: resting tongue and lip posture. In Episode 5: the force math behind why teeth drift back, a five-check screen that flags higher-risk cases before treatment even starts, and how to sequence myofunctional (MY-oh-funk-shun-ul) therapy alongside a clear aligner case for a more stable result. Aligners are an excellent, precise tool — this episode is about giving them the best possible foundation to hold their result. Plus: two live CE sessions with SureSmile — September 23 virtual and October 23 in person at the Academy. **In this episode:** - (00:00) The refinement patient who did everything right - (02:30) The force math: 4–8 pounds, 2,000 times a day - (05:00) Why retainers hold, and myo helps them succeed - (07:00) The four case types where myo adds the most value - (09:30) The 90-second, five-check screen - (12:00) Sequencing: before, during — ideally not after - (14:00) The two live sessions, and what's in them **Resources:** - Live CE sessions (Sept 23 virtual · Oct 23 in person) → optimizedairway.com/events/aligner-airway - 1-Hour CE Course → optimizedairway.com/ce-course (code PODCAST20) - Full OAE Certification → optimizedairway.com/oae-certification --- ## Script Welcome back to Optimized Airway. Whoever's listening — hygienist (hy-JEE-nist), doctor, assistant, therapist, or industry partner — I'm Kirsten Trevisonn, registered dental hygienist and certified myo (MY-oh) therapist. Today I want to talk about a patient I think many of you have met. Maybe this week. They finished an aligner case. Beautiful result. Everybody was happy at the final scan. Then, eighteen months later, the lower anteriors have started to rotate again. Or the open bite is creeping open. Or the arch has quietly narrowed and nobody can say exactly when it happened. The chart note often reads something like "patient not compliant with retainer." [BREATH] Sometimes that's exactly what happened. But I want to make the case today that in a meaningful share of these cases, there's another piece worth looking at — one that has nothing to do with the aligner itself, and everything to do with what the tongue and lips are doing twenty-four hours a day. The aligner did its job beautifully. The question is what the muscles around it were doing the whole time. [PAUSE] ## The force math Let me give you the numbers, because they make the case better than I can. The literature puts orthodontic relapse somewhere between thirty and seventy percent within ten years, depending on the study and the definition used. That's a wide range, but even the low end is worth pausing on. Think about what a modern aligner does. It applies gentle, continuous, carefully planned force to move a tooth along a designed path. It's a precise, well-engineered tool, and it works — that's not in question. Now think about what the tongue does. Twenty-four hours a day, seven days a week. A resting tongue exerts somewhere between one and six ounces of continuous pressure against the dentition. Every swallow adds another four to eight pounds of force, and we swallow roughly two thousand times a day. If the tongue is resting low and forward instead of up on the palate, that's a lot of continuous, untrained force working against a beautifully planned outcome — not because the appliance failed, but because the muscle environment around it was never part of the plan. This isn't a flaw in the aligner or in the provider's case design. It's a gap in the broader picture that muscle function is part of — and it's one that's very fixable. ## Retainers hold. Myo helps them succeed. Here's a sentence worth remembering: *a retainer is a passive appliance. It holds teeth where they are.* That's simply what retainers are built to do, and they do it well. Myofunctional therapy is the active complement — it retrains resting tongue posture, lip seal, and the swallow pattern, so the muscle forces acting on the teeth after treatment support the result instead of working against it. I like to call it retention insurance. The patient is already committed to wearing a retainer; myo is what makes that retainer's job easier and more likely to hold for good. ## Which cases benefit most I don't think every aligner case needs myofunctional therapy — plenty of crowding is just crowding, and case selection by the treating doctor is exactly what determines that. But there are four categories where adding it tends to make a real difference to long-term stability. **One: open bites.** Especially anterior open bites, which are frequently tongue-driven. Addressing tongue posture alongside the orthodontic correction gives the result a much better chance of holding. **Two: crossbites and narrow upper arches.** A narrow palate is often a palate the tongue never rested against. Pairing expansion with tongue-posture training helps the new arch width hold. **Three: Class II cases with a retruded mandible.** Often linked to breathing patterns and tongue posture during growth, and worth a look alongside the orthodontic plan. **Four: any patient with a history of mouth breathing, snoring, or a sleep concern**, at any age, in any malocclusion. This one is worth flagging regardless of the other three. Flagging these at the consult, before the case is finalized, gives the treating doctor useful information to factor into planning and gives the whole case a stronger shot at long-term stability. ## The ninety-second screen So how do you find these patients without adding twenty minutes to a busy day? Five checks. Ninety seconds. It fits inside the exam you're already doing, and it's meant to hand the doctor useful information — not to diagnose or direct the orthodontic plan. **One — lip seal at rest.** Watch the patient while they're listening to you, not posing. Are the lips together, effortlessly, or is there strain or a gap? **Two — tongue posture at rest.** Ask them to close and swallow, then ask where their tongue is sitting. Most patients have never been asked. If it's resting low, that's worth noting. **Three — frenulum and restriction.** Tongue to the palate, mouth open. Can they get there and hold it? **Four — tonsil grade.** A quick look and grade. A three or four is worth mentioning to the treating doctor. **Five — nasal patency.** One nostril at a time, or a mirror for fogging. Nasal breathing supports lip seal all day long. That's the screen, and it's designed to generate a useful conversation with the doctor and the patient — not a verdict on anyone's case. ## Sequencing — where the details matter most The question I get most often: when should myo start relative to the aligners? Ideally, four to six weeks *before* delivery. That window lets the patient start establishing nasal breathing and better resting tongue posture before the tray goes in, so the two are working together from day one. If that timing isn't realistic — and it often isn't, because patients understandably want to start right away — concurrent works well too. Starting myo within the first month of aligner wear still gives a strong result. Starting after the case is finished is the least ideal sequence, simply because by then the patient feels done, momentum has shifted, and it takes more to re-engage them. Before or during tends to work best. One more thing worth noting, because it's part of why aligners are such a great fit for this pairing: aligners are removable. The tongue can train against an open palate. Lip seal isn't blocked by brackets. The swallow can be rehearsed at every meal, out of the tray. That's a real advantage over some fixed appliances, where the hardware itself occupies space the tongue is learning to use — meaning myo sometimes needs to wait a bit longer to begin. That's not a knock on fixed treatment at all — it's simply a sequencing consideration, and it's exactly why aligner providers and labs are especially well positioned to build this into their workflow. ## What this does for the practice — and for aligner providers Quickly, because I know some of you are listening on the way into a practice where you might want to bring this up. Refinements can drop, because the muscle environment is supporting the plan instead of working against it. Chair time can drop with them. Case acceptance can go up, because the aligner conversation becomes part of a fuller health conversation the patient cares about. And for aligner providers and labs, this is a genuine opportunity: pairing myo with a case doesn't compete with the appliance, it protects the investment everyone — provider, lab, and patient — has made in the result. The loop is simple. The hygienist screens. The doctor selects and sequences the case. The myo therapist retrains the swallow. Everyone on the team contributes a piece. ## The two sessions Which brings me to the thing I'm genuinely excited about. I'm teaching two live CE sessions on exactly this, in partnership with SureSmile. The first is **Tuesday, September 23, 7 to 9pm Eastern, live on Zoom. Ninety-nine dollars a seat.** Ninety minutes of teaching, thirty minutes of open forum where you bring your own cases. Everyone gets the recording, so if your team is spread out or somebody's on a night shift, it still works. The second is **Friday, October 23, in person at the SureSmile Academy. A hundred and ninety-nine dollars,** and a hundred and forty-nine for each additional person from the same office — this works best when a whole team learns it together. Both sessions cover the five-check screen, case selection considerations, the sequencing framework, and the language for turning a finding into a booked consult. Registration for both is at **optimizedairway.com/events/aligner-airway**. That link is in the show notes, with both dates and both prices. And if live doesn't fit your schedule, the one-hour on-demand CE course covers the screening framework. That's at optimizedairway.com/ce-course, and podcast listeners can use the code PODCAST20 for twenty percent off. ## The one thing If you take one sentence out of today, make it this one. *Teeth are held in place by the balance of muscle forces around them, and the tongue is part of that balance.* The aligner, the retainer, and the ten-year outcome all benefit from that balance being addressed early. Once you start looking for it, you'll see it everywhere, and your refinement rate will tell you it was worth the look. Thanks for listening. If this was useful, the biggest thing you can do for the show is send it to a colleague who'd enjoy digging into this with you. I'm Kirsten Trevisonn. This is Optimized Airway. New episodes every Tuesday.