September 16, 2020

What is “airway friendly” orthodontics (revisited)?

Occasionally, I revisit older posts that have been popular and deal with subjects that are attracting controversy. I spotted that the PCSO were devoting a large amount of their virtual programme in few weeks to airway issues.  So I decided to republish a post on the new branch of orthodontics called “airway friendly orthodontics”. I have also added the comments from the lively discussion that followed my original post.

I am sure that all readers of this blog are aware of the discussions around orthodontic treatment and the airway.  However, I am not sure that we are all up to date with the concept of “airway friendly” orthodontics. This is being touted as a new treatment method in orthodontic care. It is also heavily promoted by some companies and their KOLs. (see the PCSO programme).

Where should we start?

I thought that the best place to start on this was to attempt to define this term and I turned to the great source of orthodontic knowledge that is Facebook and asked.

“What is “airway friendly” orthodontics and how does this differ from “conventional” orthodontics”?

What did I find?

These are some of the responses:

“Better yet…what is airway unfriendly orthodontics”?

“It is a practice that screens educates and refers patients appropriately for suspected OSA”.

“Orthopaedic treatment to prevent OSA anatomical risks”.

“A catchphrase used to scare/motivate patients to request treatment for a condition that cannot be quantified or even defined well by the people providing the service”!

But this was my favourite.

“I don’t see why people call themselves “airway friendly” or “Damon Dr’ or “TMJ friendly” are they saying that other orthodontists are not”?

These definitions go some way to explaining why this area of orthodontics is becoming controversial.

What is our state of knowledge about Childhood OSA?

An excellent place to start this discussion is to consider the summary points of the AAO conference on OSA and orthodontics.  I have covered this before and here is the extended version of the AAO white paper.  I have also done a summary post on orthodontics and breathing.

My interpretation of the conclusions of the AAO meeting was:

  • Orthodontists should be familiar with the symptoms of OSA and refer appropriately for treatment.
  • If an orthodontist is going to treat OSA, they need to be competent
  • Orthodontic treatment with or without extractions does not cause OSA
  • Non-extraction treatment or expansion etc. is not the “cure” for OSA.
  • Orthodontic treatment may have a role to play in treating paediatric OSA, but the first-line treatment is medical/surgical.
  • There is no evidence in the literature that orthodontic treatment can prevent paediatric OSA from developing.
Advertising about “airway friendly orthodontics”.

I did a google search on “airway friendly orthodontics”. Interestingly, the first hit was this one from Henry Schein Orthodontics, promoting a course that they are running. It appears that sagittal first has a role to play!

It is also clear that the “orthodontic fringe” promote this type of care. Not surprisingly, it is now a central component of myofunctional or orthotropic orthodontics.

When I looked at “airway friendly” orthodontist’s websites. Many of them made claims that were not supported by the evidence. I also saw that a lot of the orthodontists were “prize-winning”, “passionate about orthodontics”, “did not do extractions” “used accelerated orthodontics” and “rapid self-ligating braces”. There is a pattern here.

It appears that the “innovators” in our specialty are the ones who are adopting this new form of treatment, in the face of evidence.

So how do we practice “airway friendly orthodontics”?

When I consider the AAO report and the current levels of advertising, I cannot help feeling that what may be good practice is being hijacked by those who want to make themselves different from “conventional” orthodontists.

I feel that there is nothing wrong with being a conventional orthodontist, as our work should speak for itself, without the marketing claims.

But, how do we deliver airway loving care? This is clearly stated in the AAO report.  We should screen our patients as part of our examination, preferably using a screening tool. If we detect that a patient may have OSA, then we should make the appropriate referral. Finally, we should provide the proper treatment following the relevant medical/surgical procedure, but only if this is not successful.

As a result, it is easy to practice “airway friendly orthodontics”. It is not different from good ethical orthodontics that most of us provide.  I wonder if it is a marketing ploy and is nothing special.

My original post on this subject generated a large amount of great discussion. If you want to read this it can be found on this link,  Airway discussion

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Have your say!

  1. “Non-extraction treatment or expansion etc. is not the “cure” for OSA.
    Orthodontic treatment may have a role to play in treating paediatric OSA, but the first-line treatment is medical/surgical.
    There is no evidence in the literature that orthodontic treatment can prevent pediatric OSA from developing.”
    Unfortunately, the field of orthodontics has their head in the sand. There are never any absolutes, but when a profession refuses, by and large in general terms, to fully research a subject, they are derelict in their duty as a healthcare provider. When nearly approx. 30-50% of my adult OSA patients have gone through ortho. and are the recipients of serial extractions, have their tongues sitting on the occlusal surface of the lower teeth since there is no room, never been instructed about tongue position and swallow patterns but have a lower fixed retainer to keep the lower anteriors in place, with nice straight teeth and the typical flat face and then be told we had no impact on the airway, I guess we can blame the butler. Virtually all high level research takes place in the dental schools but they refuse to acknowledge or even research the subject. One or two flawed studies to hang your hat on does not cut it. I can present 20+ studies on airway and all I hear is, “those studies are not very good or I don’t like them” and then the person shuts down the thread as if they are God almighty.
    Over time if this continues general dentistry will move into your field in a more impactful way. Actually during a discussion on Dental Town that took place a few months back the doctor that presented his case did not realize there were airway issues manifested in his photos. He went back and removed the photos and claimed they were never there. The administrator backed him up. Pathetic and I have never gone back nor will I. The cat is out of the bag and there is way to stuff it back.

  2. Thanks Kevin for bringing this up
    I say this with the greatest level of respect but any conversation about upper airway obstruction on children is not about OSA. It is about sleep disordered breathing (SDB). OSA is a type of SDB but SDB is the overarching pathology. It is imperative that any clinician discussing this topic upgrades their level of understanding and knowledge beyond OSA.

    As to some of your points made I will paste them but note the above as I shall not then repeat myself when you use OSA in the quoted material

    1. Orthodontists should be familiar with the symptoms of OSA and refer appropriately for treatment.

    This referral should be to an ENT, preferably a paediatric one.

    2. If an orthodontist is going to treat OSA, they need to be competent

    This sound like you are concerned that there are incompetent orthodontists. Is that general incompetence or specific incompetence when it comes to managing the airway? I am not sure if this comment is well worded and seems to reflect the notion that you are disparaging in the first place?

    3. Orthodontic treatment with or without extractions does not cause OSA

    This is supported by the literature but a complicating factor, potentially, may be that there is an inadequate time line to assessment. From my understanding of history, extraction orthodontics was popularised in the 1960s and it was an Australian orthodontist that found it delivered quick results with straight teeth and was “easy” compared to alternatives. I am sure you can correct the record on my basic knowledge. Regardless, research shows that having 5-8 missing teeth is associated with a 25% increased risk of having OSA as an adult. That’s the same number of teeth some kids have extracted so perhaps we need to look at some long term outcomes?

    4. Non-extraction treatment or expansion etc. is not the “cure” for OSA.

    There is no treatment that has 100% outcomes. Surgery in children is about 65% cure for the long term but we don’t disparage it because it’s not 100%. So your statement is misleading. Expansion provides benefits to the right kids in the right hands.

    5. Orthodontic treatment may have a role to play in treating paediatric OSA, but the first-line treatment is medical/surgical.

    This is a generalisation. Whilst it holds true that most kids need surgery or mediation, most kids is not all kids and I see a good number where the very thing they need is expansion.

    6. There is no evidence in the literature that orthodontic treatment can prevent paediatric OSA from developing.

    And there is no evidence that anything at all can prevent it from developing. The question we are faced with is can we mitigate against the long term outcomes with early attention to detail and guidance and encouragement of growth in the right direction.

    And finally, I agree that the “airway friendly” term is not helpful. Mostly because it leads to divisive discussions that lack adequate insight into the topic and lead to those that disparage it refusing to acknowledge the changing paradigm of orthodontics which is less about aesthetics and more about functional development of an airway by virtue of limiting skeletal deficiencies early on.

    If you have read this far, I’m grateful and if you can consider spending a moment of your time, this is an orthodontist in the USA discussing the topic in detail for what it really means when it comes to focussing on the airway

  3. Kevin, your last conclusion from the AAO conference is false. Studies from, especially Stanford, have demonstrated that Pediatric OSA in non obese children, which is the vast majority of Pediatric OSA cases, is a craniofacial structural issue, that needs structural changes to the oropharyngeal airway and a patent nosal airway. Their studies demonstrate that when these issues are addressed through Dentofacial Orthopedics and Orthodontics, you eliminate the Pediatric OSA and according to their papers, set the patient on a trajectory where it is significantly less likely that they would have OSA as an adult

  4. I agree with the conclusions reached by the AAO. I cannot understand why some attempt to get an “edge” over their colleagues by making unproven claims. Here’s one I found, on the website of a dentist practising in Beverley Hills and London: “Our orthodontic approach focuses on the entire face, not just the teeth, unlike traditional orthodontics. FAGGA makes it possible to straighten teeth without the risk of TMJ or Sleep apnea later on in life, and can cure existing TMJ and sleep apnea symptoms.” They use “FAGGA”, and “controlled arch braces”. Does this work, is it supported by good evidence?
    Of course, traditional orthodontics never looks at the face?

  5. Like Martin Denbar so eloquently noted, “The question is not if a theory or technique works, but more importantly, Can you prove that it does not?” Our allegiance MUST be to our theories – regardless of if they work or not, and ESPECIALLY if they don’t work. For instance, have “conventional orthodontists” ever had a patient whose previously normally inclined incisors are now parallel to the floor after Biobloc or Orthotropic Pneumopedics? Or created bimaxillary protrusion in patients by gently pushing the teeth forward? The tears in their eyes, their now unfettered tongue and their endearing lisp make it all worth it, Evidence or Not! If that doesn’t make one a 100% believer, what will? I totally agree that we must discard the evidence when it does not support our hypotheses…of what use is data if it doesn’t support what we do?
    We must indeed address the cause of malocclusion…normal arch development does that. If only the arches can be “fully developed” to their genetic potential – but they can! A new procedure called Geno-expansion ® gently stimulates the hemi-maxillae and the hemi-mandible to slide away from each other thus creating room for teeth, tongue, tonsils etc. In some cases, there is adequate space for a second tongue. This in conjunction with Premolarogenesis® (Iatrogenically increasing overjet and adding premolars) will allow us to meet the genetic potential of our hominid ancestors who had four premolars per quadrant. I totally agree that we must discard the evidence when it does not support our hypotheses…of what use is data if it doesn’t support what we do? If losing 8 teeth leads to decreases in the airway, should gaining 8 teeth not lead to stupendous increases in airway, and the ability to fly?

    Premolar extraction is a brutal and medieval travesty akin to amputation. Do we remove limbs when we are trying to enhance function? No. After all, esthetics, function, stability, periodontal and TMJ health are not everything. Who is to say that Bimax. protrusion, lip incompetence, drooling, loss of attached gingiva, uncoupled incisors etc. are undesirable? One has to do a better job of explaining to patients why their appearance has worsened substantially – once they understand our new concept of Atavistic© Orthodontics, they will leap on board like our primate ancestors. If malocclusion is a modern development, would harkening back to better times not surely resolve malocclusion by removing the cause?

    Edward Angle was right! However, along with expanding the arches limitlessly, one has to also apply gentle external forces to the maxilla and mandible so the nose and chin are obscured and the teeth protrude excessively beyond lips stretched in a rictus of appreciation! It might be wise to remember that alternative facts are also facts, as are specious facts. Australopithecus had awesome posture, 40 teeth, jaws that sit forward and no sleep apnea! Why then can we not use mechanical orthodontics to recreate our healthy ancestor?

  6. David McIntosh and Martin – Why should we care? This has nothing to do with orthodontics. As to some of your points made, I will paste in quotes them and respond.

    Point 1 – Orthodontic treatment with or without extractions does not cause OSA
    “This is supported by the literature but a complicating factor, potentially…..that’s the same number of teeth some kids have extracted so perhaps we need to look at some long term outcomes?”
    Response: There is no such thing as “Extraction Orthodontics”. It does not deliver quick or easy results. It is a decision made for a multitude of diagnostic reasons . Your Research showing missing teeth and OSA is false and completely inaccurate. Larsen and Rugh have nailed that coffin shut. Time for the pseudo-science to stop.

    Point 2 Non-extraction treatment or expansion etc. is not the “cure” for OSA.
    “There is no treatment that has 100% outcomes…. right kids in the right hands”.
    Response” The AAO white paper has nailed that coffin shut. No basis to believe that at all. Trying to expand to cure OSA is pseudo-scientific.

    Bottom-line – Extractions don’t cause OSA and Expansion doesn’t prevent OSA. Orthodontists need to stay in their lane and stop making silly statements about an area that has nothing to do with their specialty. I have seen Martin on DT and he has been very consistent about failing to produce any evidence of any sort at any time. Even by mistake, he does not let facts interfere. He also has a significant conflict of interest which he has not declared. I would definitely not take him very seriously.

    John R.

    • Thank you John R.

      Here is the evidence about tooth loss.

      Note this is not about extraction. It’s about tooth loss. One can be pedantic about the situation but there is reason to be at least concerned.

      As for “cure” you are possibly missing the point. In adults CPAP does not cure OSA. We are talking about reducing the severity of the disease rather than absolute abolition. This distinction is important

  7. Cannot believe we are still having this conversation. This whole myth has been disproven over the years by multiple CBCT studies and the Florida AAO conference. Even Guilleminault and Singh admitted that they were wrong about this! At this point, I fear this while airway debacle is being pushed by people with ulterior motives. Sad.

  8. Unfortunately, the plural of anecdote is not data. I have 5 children, 8 nieces and 7 nephews all treated with extraction of teeth and they look great. Should I now conclude that all patients would benefit from the same therapy?

    Of course not. I have seen Mew’s and his colleagues results and they look horrendous. I have to admit I did not realize that until a few years ago. I used these technics of Ortotropics, myotherapy even the Biobloc, ALF and DNA. They seemed to work ok for a few patients, but failed miserably in a lot of the others. The relapse was almost 100%. I had to refund several and referred patients to three orthodontists who were nice enough to accept and help re-treat these patients.

    One of them told me about Dr. O’Brien. When I attended to Dr. O’Brien’s lecture, I began to realize that the stuff I believed in was not based on good science. Orthotropics was just a made up word!

    I wish these therapy worked, but in fact, to my sorrow, it does not. Even though traditional orthodontics is more effort and discomfort, there is no doubt it works and very stable compared to myofunctional and orthotropics.

    I no longer do orthodontic treatments…only general dentist. But, it was painful learning experience.

  9. Thank you David. No reason to be concerned in the slightest. Extractions don’t cause OSA and help prevent OSA by reducing the # of premolars. Have a look.

    • Thank you- I have seen those papers before, and many others. However, it may not be quite so simple. For starters, genetic background may be an issue not previously considered:

      Effects of bicuspid extractions and incisor retraction on upper airway of Asian adults and late adolescents: A systematic review – PubMed

      And the other issue is time. We really need to be reviewing these patients when they are in the 50s and 60s and comparing good data from CBCT and sleep studies. Both of these are not done in many initial or subsequent cases so there is a huge amount of things we really don’t know. I follow the evidence and agree with what you’ve shared but the evidence is not universally in agreance so we need better research to be really sure of our beliefs

      • David, not sure if you managed to have a look at the papers quoted by John but they do not hold up in the slightest. 2 look at radiographic evaluation of airway space/size (which we know doesn’t say much) and the other one which audited health records to my understanding looked at how many people who had extractions got the diagnosis of OSA later in life. As you know well, many don’t seek care for their symptoms so this study also doesn’t mean much. If these are the papers being used to prove that ‘orthodontics can’t cause OSA’ then the ground is very shaky indeed. This is also ignoring the fact that OSA is but one subset of the entire problem. We’re unfortunately going to get nowhere if the foundational knowledge from the opposing side is in the state that it is.

  10. Dafne, is a psychologist graduated at age 13 and currently at age 18 she graduated from Harvard with a master’s degree, speaks 5 languages ​​and is pursuing her doctorate.
    Is this young woman and other is a glimpse into the near future in the next evolutionary step of the human species? Nature continues to previliginate the development of the human brain?
    We know that in human evolution the brain and skull have expanded at the expense of the dento-maxillo-facial complex and these changes continue, the skull has increased in height by almost one cm in this last evolutionary stage, and the jaws and tracts respiratory systems have to compensate for these changes.
    The jaws are changing, they are shrinking and the airways apparently follow the same trend, it is the same that we see with breeding dogs, for example: because of a directed breeding the faces of the pugs are more arthritic and it is well known from the malocclusions and respiratory disorders suffered by this breed, this is a magnificent laboratory to observe how genetics acts on morphological changes.
    The human has increasingly maxillary narrowing, more retrusive jaws, and even the length between the shoulders is reducing, anthropologists point out.
    The first teeth change is in shape and size before disappearing, in these phylogenetic changes the third molar is the first in the list followed by the upper lateral incisors and the last ones are precisely the premolars, the same ones that doctors indicate for extraction for orthodontic reasons. .
    Mother nature shows us the way: the jaws are getting smaller and all the teeth do not fit in the mouth, so evolution does its job while Orthodontists engage in an intense debate for almost 100 years without understanding the reality.
    In our pride we want to reverse what evolution is trying to do and we naively think that with our actions and devices we can alter this course.
    Dentists who perform extractions for orthodontic reasons are not irresponsible monsters who deserve to be brought to trial, we simply want the best for the patient and act aware of the great limitations we have in the face of malocclusions, we are simply compensating for a situation because the bone structures are deficient.
    And finally, as Dr. McIntosh says, orthodontic treatment with or without extractions does not cause OSA, as well as treatment with expansion and without extractions are not the “cure” for OSA.

  11. Moises Martinez Leyva – Dr. McIntosh did not say that. I said that. Please make the correction.

  12. David McIntosh – IT could not be any more simple. Genetic Background is irrelevant. It is the outcome measure we are concerned about. If they are in the 50s and 60s, what is the basis to claim something done 40 years ago, caused OSA? Can a femur fracture at age 15 cause Myocardial Infarction at age 60? We don’t need any more anything. IF you believe different, you need to provide the proof. We cannot disprove a negative.

  13. Emad – You are wrong. Extractions prevent OSA. Everyone knows that. The airway increases due to more room for the tongue. Do not bury your head in the sand.

  14. Kind of interesting to publish on a blog on something that you didn’t even watch? You mention the PCSO (which I was on the Board of this year) with sort of a chuckle regarding airway. Did you bother to even watch the lectures you decided to put down prior to them even happening? I just don’t get that. Did you care to notice, (of course not mention in this blog), that there were three presenters, all from very different perspectives of airway. We decided to have three different viewpoints presented for a reason. Something I actually thought you of all people could have appreciated. In fact, one presenter, Dr. Ben Pliska, was one of the main contributors to the AAO White Paper, which for the most part dismisses ‘airway friendly’ orthodontics. Dr. John Graham presents a lot of literature from the medical arena and from the dental world, supporting his feelings that orthodontists can have a positive effect on pediatric airway. And Dr. Rebecca Bokow shows a little of both.
    Again, I’m not sure why someone would make any comments about a series of lectures that had not even occurred, and then not taken the time to watch them and comment further on them. Keep firing from afar Kevin.

    • Thanks for the comments. I mentioned the PCSO meeting in the context of attracting my attention to airway issues and reposting an old blog post that was relevant. I also mentioned that several KOLs were speaking at the PCSO meeting. In fact, 5 out of the 8 doctor lectures were given by KOLs. As a result, I do not see why mentioning this was a problem. I do take your point about me not attending the meeting and seeing the lectures. I wonder if you could send me a link to access the recordings and I will view them, do a fact check blog post and if I was wrong to mention them, I will apologise. Best wishes: Kevin

      • Dr. O’Brien,
        I have communicated with you and given you the information to review the PCSO lectures a few weeks ago. I did not receive any communication that you had received the information or that you would review them. Have you had time to review? I am sorry to hear about the current state of the new Virus strain in the UK. I pray we can get the vaccine out quickly and return to some semblance of normalcy soon.

      • I believe Dr. Graham and Dr. Bokow cited well over 25 papers between them. Just because the literature differs from one’s bias doesn’t make them invalid. Interesting how whenever literature is cited, it is questioned unless it fits the narrative. To call those two lectures old fashioned? I’m not even sure what that means.
        Dr. Frost’s lecture had nothing to do with citing literature and was purely showing how he treats cases with his techniques. No claims made, just showing methods to achieve his results.
        Anyways, keep up the criticism of others work. Always an uplifting, inspiring, positive message you promote to the world.

        • The number of papers cited does not make them good. I think that the definitive view on this issue has been the AAO white paper on orthodontics and breathing. I know that Padhraig I try to constructive when we criticise papers etc and hope to just provide informed opinion on their scientific content. I am sorry that you do not like this approach. However, our blog is read 0.5million times a year. We do this for free and do not make any money from my blog. Unlike you and the other KOLs at this meeting who are paid for their “opinions”. If you don’t like our blog, don’t read it….

          • Dr. Bokow is not a KOL, not paid for her opinion. Dr. Graham is a KOL, but if one cared to notice, made no mention of any product in either of his lectures in this meeting. His lectures had nothing to do with any paid products. One was actually about giving back to the community in his Go Giver Lecture. These lectures had nothing to do with being a KOL and your continued attacks against KOL’s becomes tiresome. (and again, Dr. Bokow isn’t even a KOL). At some point the hate of KOL’s should subside, but alas, I’m an optimist by nature.

            The only reason I even knew about this blog was when I was informed about how I was attacked on it for my opinions, having never been contacted by you, never meeting you, never asked a single question by you. I’ve decided that I will periodically see who you are attacking and when appropriate, lend my support to them rather than continuing to allow you to throw arrows from the Ivory Tower. Unfortunately, it is a never ending job.

    • I have now had a look at the lectures at the PCSO. I also looked at the lecture by Dr Frost. I thought that the presentation by Dr Pliska was good clear and sensible. However, I thought that the other lectures were not so good. In effect, they were very selected literature reviews along with a couple of case reports. They were not very convincing and rather old fashioned style lectures that were light on high level evidence. As a result, I stand by my comments.

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