If Rip Van Winkle were a dentist who slept for more than 20 years, he might be the only dentist who has not heard that expansion is the “cure” for all airway problems.
With the airway paradigm now more than 25 years old, expansion has become an almost automatic recommendation in airway-focused dentistry. Read an article or attend a lecture from an “airway dentist,” and expansion is likely to be part of the conversation.
But is expansion alone really enough?
There is substantial evidence that modern human faces and jaws are more recessed than those of our ancestors. Harvard anthropologist Dr. Daniel Lieberman discusses this phenomenon in his book The Evolution of the Human Head, including experimental evidence examining how changes in human development and environment may have contributed to these differences.
The late Harvard-trained sleep physician Dr. John Remmers also emphasized the relationship between jaw position and obstructive sleep apnea, arguing that more forward-positioned jaws may significantly affect airway function.
There is much more research surrounding this concept, but the central point is simple: airway problems are not only about width. Forward and backward jaw position matters, too.
After decades of working in the “airway trenches” and trying to help patients improve breathing and overall function, I do use expansion with my patients.
But I consider expansion a starting point rather than the entire solution.
Lateral expansion can create additional space and may improve certain aspects of airway function. However, in my clinical experience, expansion alone too often leaves patients only moderately improved when the underlying anteroposterior relationship has not been addressed.
If part of the underlying problem involves an anteroposterior deficiency, then treatment should also consider the forward position of the teeth and jaws.
We have recently begun using the term Anterior Optimization to describe an approach that focuses on improving the position of the anterior teeth so they are more appropriately positioned forward within the face.
Rather than focusing exclusively on lateral expansion, Anterior Optimization combines attention to transverse development with forward development.
In other words, treatment may involve both:
In my experience, addressing both dimensions can provide a more complete approach for patients with airway-related concerns.
One of the biggest obstacles to anterior advancement has been the longstanding concern within orthodontics that moving teeth forward may contribute to gingival recession, instability, or eventual tooth loss.
Those concerns should be taken seriously, and treatment must always be planned carefully for the individual patient.
However, decades of my own clinical experience, along with multiple articles in the refereed literature, challenge the assumption that appropriate anterior advancement automatically leads to these negative outcomes.
This is an area where the profession should continue examining the available research rather than relying solely on traditional assumptions about tooth position.
Airway treatment should not simply ask, “How much can we expand?”
A more complete question is:
Are the teeth and jaws positioned appropriately in all three dimensions for healthy breathing, function, and facial development?
Expansion can be an important part of treatment, but width is only one part of the equation. For many patients, addressing forward development through Anterior Optimization may also be an important component of a more comprehensive airway-focused treatment strategy.
