Breathing & Airway

Airway Dentistry: Why We Start With the Small Wins

By Douglas Sandquist, DDS and Jeannie Lee-Mirzayan, DDS

Airway has become a busy corner of dentistry, and a lot of what gets said about it is louder than the evidence behind it. So it is worth being plain about where we stand, including where we have changed our minds.

We look for airway problems. We have looked for them for years, before it became a marketing category. We work closely with an orthodontist who performs palatal expansion and facilitates jaw advancement surgery, and we refer for both when they are warranted. But we have also become more careful about what we claim can be fixed by changing anatomy alone.

What we actually look for

These are structural findings, and a dental exam is a good place to catch them:

A narrow or high palate. The roof of your mouth is the floor of your nose. A narrow upper arch usually means a narrower nasal floor above it.
A tongue that cannot reach the palate, whether from a tie or from years of resting low.
Tongue posture. Where the tongue lives at rest shapes the arch during growth, and holds space at the back of the throat at every age.
The downstream signs. Gum inflammation confined to the upper front teeth, scalloped tongue edges, lips apart at rest, wear that does not match the diet. Mouth breathing leaves a signature.

Finding those things is genuinely useful. It is the next step where the field goes wrong.

The part we got wrong, and corrected

For a while our instinct was straightforward: find the anatomical restriction, fix the anatomy, problem solved.

We do not think that any more, and the honest reason is that the data does not support it as cleanly as it is usually presented. Fixing the anatomy is often part of the answer. It is rarely the whole answer.

Circadian rhythm matters. Diet matters. Weight matters. Environment and allergy load matter. Nasal function matters. None of those are addressed by changing the shape of a jaw, and all of them are still there afterward.

The container and the contents

This is the clearest way we have found to explain it.

Your airway is a space, and two things determine how open it stays: the size of the skeletal container around it, and the volume and behaviour of the soft tissue inside it. Surgery and expansion work on the container. On their own they do nothing to the contents.

That distinction is not theoretical. When researchers looked at why weight loss improves sleep apnea, the improvement in the apnea-hypopnea index was mediated specifically by reductions in tongue fat. The soft tissue volume was doing the work. The same literature notes plainly that most current therapies do not target tongue fat at all, which is offered as one reason some patients remain difficult to treat.

Wang SH et al. Effect of weight loss on upper airway anatomy and the apnea-hypopnea index: the importance of tongue fat. Am J Respir Crit Care Med. 2020;201(6):718-727.

So if you enlarge the container and leave whatever is driving the contents untouched, you should expect the benefit to erode over time. The long-term surgical data is consistent with that: improvements hold up over the medium term, then the apnea-hypopnea index drifts back toward moderate over many years.

That is not an argument against surgery. It is an argument for treating the function as well as the structure, which is exactly how we sequence it.

Being fair about MARPE and MMA

We are not going to undersell these. They are serious tools and the evidence behind them is better than the sceptical version of this article would suggest.

Maxillomandibular advancement is among the most effective surgical treatments for obstructive sleep apnea there is. Meta-analysis reports the apnea-hypopnea index falling from roughly 64 to roughly 10 events per hour, with surgical success around 86% and cure in about 43%.
Miniscrew-assisted palatal expansion in adults with a genuinely narrow maxilla has reported meaningful improvement, including substantial reductions in the apnea-hypopnea index in a multi-centre controlled trial.

For malocclusion in adults, both are excellent, and that is often the clearest reason to do them.

Here is the care we think the numbers deserve. Those studies were done in patients with severe, diagnosed apnea – a mean starting index around 64 events an hour is profound disease. That is a very different person from someone with a narrow palate, a low tongue, mild symptoms and no sleep study. Applying one group’s success rate to the other is where the overclaiming happens.

Can these procedures improve an airway? Yes, and sometimes dramatically. Would we present them as the first move for someone who has not had a sleep study and has never tried anything simpler? No. Those are different questions and they get answered differently.

Myofunctional therapy before and after, every time

This is the part of our approach we would defend hardest, and it applies to the surgical cases just as much as the conservative ones.

Before, because it costs little, risks nothing and is reversible, and because it tells you how much of the problem was functional rather than structural. That is information you want in hand before anyone operates, and occasionally it is enough on its own.

After, for the reason this whole article has been building toward. Surgery gives you a larger container. It does not teach the tongue to rest in it, or the lips to seal, or the swallow to behave. Retraining that afterward is the piece that works on the contents, and it is the most direct answer we have to the drift the long-term data shows.

Expansion and advancement create the space. Myofunctional therapy is how you keep it. Doing one without the other is doing half the job, in whichever order you leave out.

Dr. Lee-Mirzayan is certified in myofunctional therapy and handles that side here.

So where do we start

The question we actually put to patients is this: is it better to start with myofunctional therapy, or with breaking a jaw?

Put that plainly and most people arrive at the same answer we do. Start with the small, cheap, reversible wins. Then see what is left.

Make the nose work. Saline rinses, treating allergy properly rather than seasonally, and a real ENT opinion when the obstruction is structural. A nose that works is the precondition for everything else.
Retrain the pattern. Myofunctional therapy. No appliance, no surgery, nothing to wear.
Release a genuine tether first. No amount of therapy helps a tongue that physically cannot reach the palate. Tongue-tie release is sometimes the precondition, not the treatment.
Fix the timing. Sleep timing and light exposure are unglamorous and they move the needle. So does not eating late.
Address the soft tissue burden where weight is part of the picture, because that is the one intervention shown to work on the contents rather than the container.
Get a diagnosis. If apnea is a real possibility, that means a sleep study, from a physician. We cannot diagnose it from a dental chair and we will say so.

Every item on that list is low cost, low risk and reversible. Between them they also tell you something you cannot learn any other way: how much of the problem was behavioural, and how much is genuinely structural.

And when the answer is structural, we say so

Sometimes the simple measures get a fair run and the problem is plainly skeletal. Then expansion or advancement is the right conversation, and we will have it without hedging.

We work closely with an orthodontist who performs MARPE and facilitates maxillomandibular advancement. Referring for either is a normal part of what we do, not a last resort we avoid discussing. The surgery happens with surgeons, not here. The therapy on both sides of it happens with us.

What we are not

We are not a sleep clinic and we do not diagnose sleep apnea. We are a dental practice that pays attention to the airway, catches the anatomy that contributes to it, treats the parts a dentist can treat, refers the parts we should not, and is honest about which is which.

If you have been told you need your jaw expanded or advanced and you are not sure how you got from a dental exam to that recommendation, a second opinion costs you very little. We will tell you what we see, what we would try first, and what the evidence does and does not support.

Worth a conversation

Call us at 702-734-0776 or tell us what is going on.

Common Questions

What is an airway dentist?

A dentist who looks at how you breathe as part of the exam rather than treating it as somebody else’s department. In practice that means examining the shape of the palate, whether the tongue can reach the roof of the mouth, whether it is tethered, where it rests, and the wear and gum patterns that follow from breathing through the mouth. Diagnosing sleep apnea is a physician’s job. Recognising the anatomy that contributes to it, and treating the parts a dentist can treat, is ours.

Do you recommend palatal expansion or jaw surgery?

Yes, when it is warranted. We work closely with an orthodontist who performs MARPE and facilitates maxillomandibular advancement, so we are not hesitant about referring for either. What we do not do is start there. We recommend myofunctional therapy before and after in every case, including the surgical ones.

Can expanding the palate or advancing the jaw fix sleep apnea?

Both can help substantially in the right patient. Meta-analyses of maxillomandibular advancement report the apnea-hypopnea index falling from about 64 to about 10 events per hour, with success rates around 86%. Palatal expansion in adults with a narrow maxilla has reported meaningful improvement too. What deserves care is who those studies were done in: patients with severe, diagnosed apnea. That is a different person from someone with a narrow palate, no sleep study, and mild symptoms.

Why myofunctional therapy before and after surgery?

Before, because it is low cost and reversible, and it tells you how much of the problem was behavioural rather than structural, which is worth knowing before anyone operates. After, because surgery enlarges the space but does not change how the tongue and lips actually function inside it. Retraining that afterward is what helps the result hold rather than drift back.

If the surgery works, why would the benefit fade?

Because surgery changes the container, not the contents. Advancing the jaws enlarges the skeletal space around the airway, but it does not by itself reduce the soft tissue inside it or change how it behaves. Research on weight loss found that improvement in the apnea-hypopnea index was mediated specifically by reductions in tongue fat, and most standard therapies do not target that at all. That is the reasoning behind treating the function as well as the structure.

Does a tongue tie cause airway problems?

A tongue that is physically tethered cannot rest against the roof of the mouth, and tongue posture is part of how the upper arch develops and how the airway is held open. Releasing a genuine restriction is sometimes the precondition for everything else, because no amount of therapy helps a tongue that cannot get where it needs to go. It is not a treatment for sleep apnea on its own, and we would not present it as one.

Do I need a sleep study?

If sleep apnea is a real possibility, yes, and from a physician. We can tell you what we see in your mouth and why it matters, but we cannot diagnose apnea from a dental exam and neither can anybody else. Anyone offering to treat your airway without a diagnosis is skipping a step.