Palate Expanders - A Followup To The Airway Awareness Blog

I posted earlier this year about the "airway orthodontist" vs the "orthodontist that understands the airway", and since that time people have asked me if expanders are being recommended too frequently. The concern is that the airway orthodontists are now recommending palate expanders in nearly every patient, and it's creating a lot of skepticism from patients with the profession. It's also making a lot of orthodontists frustrated with these doctors that appear to be doing more than necessary. We need to need to not go to the extreme end of ignoring the benefits of expansion. The airway isn't susceptible to one singular issue (e.g. adenoids). Nor is expansion the silver bullet to fixing airway. It's so multifaceted that you need to look at the entire scope of the issue.

1. Where is/are the constriction(s)?

2. What anatomical features can we influence in that/those area(s)?

3. What method of treatment is appropriate?

4. When should we intervene?

5. Should we even intervene?

6. Was a sleep study performed?

When it's clear there's an issue with the a narrow palate we need to ask if it's constricted enough to restrict some airflow in the nasal passage? What other structures are there that impact airflow?

That would be the turbinates and the septum. You can add the mucosa into the mix because they will swell and relax with allergens, sickness, and overall weather. If you have a deviated septum it's worth investigating a septoplasty. If the turbinates are huge, consider turbinate reduction. If the maxilla is narrow, then look into expansion. All of these things attack a different issue, but all these things individually or combined can increase nasal airflow. Additionally, a sleep study needs to be performed before we even consider any treatment to address one's potentially constricted airway.

Some might think "I didn't have any airway issues and my parents didn't, so why does my kid have this now?" Well, cancer is also showing up in families with no history, so that argument doesn't apply when the environment is very different today than it was decades ago. The trees now have longer growing seasons, resulting in more pollen. There are more toxins from the industrial revolution and big oil's lobbying. Air quality has declined with both pollutants and allergens that it's worth considering the correlation. I'm not saying it's the reason, but there's some validity to the theory. Also, not all airway/sleep apnea patients are restricted in the nasal passage. There are Class I skeletal people that are bimaxillary retrusive, so they need bimaxillary advancement to open the mid/lower airway around the area of the soft palate and tongue. In these cases, expansion woudn't benefit them if they had a normal transverse dimension.

We shouldn't ignore airway discussions from orthodontists in general. Yes, "airway orthodontists" are trying to market themselves in today's world - good intentioned or not, and it unfortunately reflects poorly upon the profession. However, the great orthodontists today understand the impact a tooth borne palate expander has on an elementary school child and the impact a MARPE has on a tween/teenager going through adolescence.

I'll equate today's airway orthodontist to the 90s non-extraction orthodontist. A lot of docs were well intentioned and tempered in their approach. However, there was a faction that took the massive swing to the extreme and didn't extract in anyone regardless of the amount of crowding, and that led to a lot of periodontal issues. Of course, a portion of those vehement non-extraction orthodontists (which still exist today) were pushing a narrative to make themselves look better and standout from the typical good orthodontist. They were just as smarmy then as the ones pushing airway orthodontics on everyone today. Just realize that the majority of orthodontists are not trying to place expanders in every patient. Most of us understand when expanders should be recommended.

Let's simply ignore the airway for a minute. A high palatal vault usually signifies a narrow maxilla, and early expansion is always better than later expansion.

1. The suture is still soft, so it's easier to expand with simpler expanders.

2. You're establishing better skeletal harmony for better mandibular/TMJ development

3. Since the expansion is more effective, the periodontal risk is far lower. (Expanding when the suture is fused/mature means the teeth will move/tip instead of the palate expanding properly.)

4. You've created more space for the permanent cusipds and premolars to erupt more appropriately with less risk of impaction or damage to adjacent roots

So, without even touching on airway we've established several significant benefits to early expansion when a palate expander will ultimately be indicated at some point in that person's lifetime. Airway is just another area where our treatment has a positive impact. It's not the reason for expansion in most cases, but it is a reason for us to look into whether or not expansion makes sense.

I hope this post shows the value palate expanders serve in our patients. We haven't even touched upon the adult population that didn't have access to the care we're offering today. MARPE is now available to adults who want to expand their upper jaws without the need for full blown jaw surgery in many cases.

If you'd like to come in for a consultation to evaluate your or your child's jaws (or even airway), please give us a call at 781-337-1355 or get in touch with us in Plymouth or Weymouth.