Airway? Stairway? Those two words rhyme and were more related to each other than either was to orthodontics when I started in the profession.
The word “airway” was literally not part of the conversation during my two-year orthodontic residency from 1972 to 1974. I was there to learn how to place fixed braces on teeth to straighten them, and I learned that very well.
There were a few articles on airway in the literature in the late 1970s and early 1980s, but I ignored them. None of my instructors mentioned airway or breathing during our training.
We learned that malocclusions were largely inherited and not preventable. Our role was to treat malocclusions. Kids came in with crooked teeth. I straightened them.
My experience was typical of orthodontists in that era.
In 1981, I realized I was producing unattractive faces when I extracted and retracted teeth and potentially creating TMJ problems.
That realization began a continuing education journey that has never ended.
I remember attending a course in Ann Arbor, Michigan, where an ENT discussed the importance of airway in facial growth. I learned how to identify adenoids on a lateral head x-ray.
I had been in the profession for an entire decade before learning to identify a problem that my eye now instantly recognizes in a fraction of a second.
I had been awakened to airway, but it took more than awareness for it to truly change my practice.
In 1992, a desperate 35-year-old woman suffering from severe chronic pain came to see me. She appeared over 50 and was suicidal.
Several orthodontists had told her she needed extractions. Instead, we proposed developing her mandible forward without removing teeth.
Her despair turned into radiant smiles until the appliance broke and she went without it for two weeks.
She told me, “I felt suicidal again. I felt like I would drown or choke to death.”
I examined her airway on a lateral head x-ray, not even knowing what normal was supposed to look like.
My oral surgeon explained that the airway behind the tongue should be 9–10 mm. Hers measured only 2–4 mm.
From that day forward, the first thing my eye goes to on a lateral x-ray is the airway along its entire length.
Thank you, Joan L., for Airway Lesson #1.
In 2000, I reviewed lateral head x-rays of two patients whose jaws I had developed forward using Orthotropics®.
I noticed dramatic improvements in airway size behind both the soft palate and the tongue.
I commissioned a research project involving a larger patient group. The results were published in Cranio.
The study showed a 31% increase in airway size at the dorsum of the palate, a 23% increase behind the tongue, and a 9% increase in the laryngopharynx.
I learned that orthodontics could significantly improve airway health, even though I had been doing it without fully realizing its impact.
In 2001, I attended a major orthodontic meeting where American Board of Orthodontics cases were on display.
I measured the airways pre- and post-treatment on every case.
My fears were confirmed. Most cases showed substantial airway reductions, with or without extractions.
The message was clear. Treating malocclusions must give way to treating people for better health and longer health spans.
No one can diagnose an airway problem solely from a CBCT.
Dr. David Hatcher’s research shows a relationship between airway size and the likelihood of obstructive sleep apnea, but many factors influence airway function.
That said, given the choice, I will always choose a larger airway.
Optimizing airway became the mandatory goal of all treatment in my practice.
The approaches I pioneered produced remarkable outcomes across all ages.
I’ve authored articles and lectured to major dental groups since the early 2000s, sharing ideas that improved patient health.
These ideas helped move the airway conversation forward, though the profession has yet to fully grasp that airway health is central to overall health care.
I don’t have all the answers, but I know I’m on the right path.
It will be a good day when optimizing airway becomes the number one mandatory goal for every orthodontic patient.
