My worst airway case involved every known method of improving an airway. It included reopening previous orthodontic extraction spaces, orthognathic surgery, and myofunctional therapy including tongue-tie release. The patient was willing, dedicated, and highly motivated to reverse what both he and I believed was compromised health caused by retractive orthodontic treatment at an alarmingly early age. We will get to the case shortly, but first it is important to understand the background that prepared me to treat a patient like this.
My experience with orthognathic surgery began immediately during my orthodontic residency. I scrubbed with surgeons and assisted in the operating room on ten of my own cases while still in residency. I have never met another orthodontist who had that experience in the 1970s or since. I have heard of residents who never treated ten routine orthodontic cases and never assisted on a surgical case at all. I never shied away from surgery cases the way many orthodontists do, trying anything possible to avoid surgery by forcing teeth to fit on jaws that do not fit. Over my 50-plus-year career, I treated hundreds of surgical cases and was the first to innovate several approaches to optimize facial balance and airway improvement. I had the necessary tools at my disposal.
I did not wake up one day and decide to do something I had never seen another orthodontist attempt. In 1989, I was more or less forced into reopening previous orthodontic extraction spaces for a desperate and persistent patient. She insisted that I try to eliminate her headaches. She had suffered from a constant headache for fifteen years following orthodontic treatment completed at age twelve. I reluctantly tried, innovated as I went, and was fortunate to succeed. I ran into this woman on New Year’s Eve in 2025, and she is still fine. She is happy with her dramatically improved appearance and has not had a headache since we treated her. Her teeth are stable, with no more recession than any other sixty-three-year-old woman, and they certainly did not fall out as my orthodontic training would have led me to believe.
Based on that initial success, I have reopened extraction spaces for hundreds of people, including myself. Patients from more than thirty states and several foreign countries have trusted me to do this. I have sleep reports signed by MD sleep specialists documenting elimination of obstructive sleep apnea when extraction spaces were reopened, although I will be clear that there are cases where reopening spaces is not appropriate.
I have been a strong advocate of myofunctional therapy for decades and have spoken to myofunctional therapy organizations many times. I refer all surgery patients for myofunctional therapy because no one requiring orthognathic surgery has proper resting oral posture, or they would not need surgery in the first place. Surgery alone does not fix poor rest oral posture. I also refer many children to myofunctional therapy to support better facial growth and adults to help resolve chronic pain patterns.
I am familiar with all surgical approaches to treating obstructive sleep apnea. I am well aware of the role of vitamin D as outlined by Dr. Stasha Gominak. Over the decades, I have tried nearly everything except witchcraft to help desperate patients breathe and sleep better. I have seen remarkable successes, including normalization of extreme blood pressure readings within days of MMA surgery, with improvements sustained for years. I am not a novice. That is why this case was so humbling.
A thirty-three-year-old male consulted with me regarding problems that developed following orthodontic treatment that began when he was twenty-seven. That treatment included removal of four bicuspid teeth. Partway through treatment, he began experiencing serious breathing and sleep issues. He awakened gasping, choking, and with tachycardia. A neighbor once rushed to his apartment to check on him. He developed daytime fatigue, choking while eating, and worsening headaches. As a child, he had asthma and used a pacifier long after most children stopped. He had a scalloped tongue, a posterior tongue-tie, an inter-molar width of only twenty-seven millimeters, a blood pressure of 149/96 with a pulse of ninety-two, and a minimal airway cross-section of only 28.5 square millimeters. This was someone we should not be surprised might make an early exit from the planet. I was highly motivated to help, but I made no promises.
I knew that reopening extraction spaces alone would not be enough. I knew he needed maxillomandibular advancement surgery performed to the absolute physical limit of what was possible. I knew myofunctional therapy and tongue-tie release were essential. We did all of that. The patient improved substantially, but he was not fully free of symptoms, despite everything we had done.
The reason this case was not a grand slam was not that we did anything wrong. I do not believe that at all. This patient had been a chronic mouth breather from early childhood. His parents were immigrants who did their absolute best while navigating a new language and system. His face grew predictably downward and backward throughout development. By adulthood, his facial imbalance was so severe that even the most aggressive surgery could not bring his jaws fully forward to where they needed to be. The surgeon did everything that was physically possible. I even reopened extraction spaces after surgery, which is not ideal. He was better, but not where either of us wanted him to be.
The lesson is unmistakable. We must treat children early and ensure nasal breathing in the primary dentition. This is the only way to prevent cases like this from ever occurring. We are still in our infancy in the airway arena, and there is much to learn. Failures should not be viewed negatively. They are learning opportunities that help us develop better approaches. Failure worked well for Thomas Edison, and it will work for us too.
