Written By: Kathy Soto
One of the first things most of us notice about a person is their smile. Smiling has been linked to an improved mood for only the person smiling, but others around them as well. Still many people may feel shy or embarrassed when smiling, which could be due to having crooked or misaligned teeth. Many patients end up seeking the help of an orthodontist (a dental professional who specializes in early detection and correction of malpositioned teeth and jaws). If done right, orthodontics can improve a person's quality of life, bolster self esteem and just feel better in general by smiling more often. Straight teeth are also easier to keep clean, which helps them look their best, and you feel your best. The effects of misaligned teeth reach far beyond the mouth however, and can even contribute to malformations of the jaw and mandibular arch, resulting in airway and sleep issues for example. On the other hand, improperly applied, orthodontics can lead to similar restrictions as well, by limiting the body’s natural growth or driving the development of poor oral habits. A patient may go on to suffer from airway issues for years without knowing that the suffering was caused by the orthodontic work they had years ago, with symptoms not rearing their heads for many years in some cases. Let’s examine the benefits of a straighter smile, the causes of malalignment and possible consequences of extracting teeth to make room for that beautiful straight smile.
“So, why did you decide to get braces at the age of 28?” I casually asked one of my new dental hygiene patients during an initial dental cleaning visit. At this point in my career I had been a dental hygienist for 10 years and I could see that he had a significant amount of gumline recession (likely due to orthodontic extractions of the first bi cuspids). He simply stated that he “wanted to do something nice for himself”, to improve his health and have a better smile. Jacob had been a mouth breather for as long as he could remember. He had suffered from allergies since he was a young child, which made it difficult to breathe through his nose which was always stuffy (even with the use of over the counter medications). His mouth breathing was not addressed as a child, leaving Jacob with a high narrow arch, lips that could not close fully at rest, and crowding of his anterior teeth. Living in Los Angeles, Jacob wanted to have that straight smile that he saw many people have and he decided to explore braces. He wanted to look better and perhaps more importantly, feel more attractive.
In Jacob’s case, like many who grow up with allergies or chronically stuffy noses, he always found it difficult to breathe through his nose and as a child, developed the compensatory habit of mouth breathing. His allergies were not addressed, leaving Jacob’s upper arch to develop in a high, narrow V shape, rather than a healthy U shaped arch (more like that of a horseshoe).
When the tongue rests at the palate or top of mouth it acts as a natural retainer for the maxilla development, and the body develops with straighter teeth as a result. Jacob, due to having his mouth open for breathing, developed with his tongue resting low on the floor of the mouth. Imagine pulling the scaffolding out from under a dome while it’s still being built. This certainly did not help much in the development of a healthy airway or upper arch. This also led to dental crowding, for which he sought out 3 orthodontic opinions as an adult. Two of the orthodontists suggested 4 first bicuspids be removed prior to orthodontics to make room for the other teeth to straighten due to the narrow maxillary upper arch. One orthodontist who was primarily trained outside of the US suggested Mandibular advancement jaw surgery - he was addressing the functional airway issue and was concerned about the actual physical airway space, suggesting he could widen the maxilla with orthodontics, but that Jacob would need jaw surgery. The thought of that surgery seemed extreme to him at the time so he decided to simply remove 4 teeth to avoid surgery and get straight teeth. Although he expressed to me that in the back of his own mind it didn't make sense to him to remove 4 perfectly healthy teeth to straighten his smile, but he ignored his gut feeling, and that seemed to be the standard practice so he decided to trust the US trained orthodontist and go that route.
Ultimately, Jacob had his 4 healthy bicuspids extracted, and additional 4 healthy wisdom teeth extracted at the request of his orthodontist who had apparently explained that he couldn’t keep those teeth clean, and down the line they would need to come out anyways. During the treatment, things seemed to be going good. He could see that his teeth were becoming straight, just like he’d always wanted.
Fast forward 18 months or so into his orthodontic treatment, and around the time elastics were being used to close the bite, Jacob started having trouble sleeping. He would wake up gasping for air. He had no idea that one had anything to do with the other. Due to his mouth breathing habit he was unconsciously gasping for air during the night, but the elastics were preventing him from opening his mouth enough to get a breath, which was of course reducing the air he was intaking. Shortly after orthodontics being removed, Jacob started developing symptoms of obstructive sleep apnea.
Unknown to him, when the dentist, at the request of the orthodontist, took out those healthy 8 teeth they inadvertently made his airway smaller. The tongue remained the same size, and using ortho elastics to push the lower jaw back further impinged on his airway. When I met Jacob he mentioned talking to many doctors and medical specialists explaining his symptoms of increased tiredness, unusual dependency on coffee and sugary substances, and weight gain even though he was an avid gym goer (2 hrs daily average 6 days a week). Thinking back on my training in orofacial myofunctional therapy, I suggested that he be evaluated by a specialist in the area of sleep medicine and airway health.
He had a consultation with Dr. Soroush Zaghi at the Breathe Institute, who was sympathetic and understood what was going on with his health condition. He suggested a sleep study which revealed moderate to severe obstructive sleep apnea. This condition can lead to high blood pressure, sleep deprivation, heart attacks and stroke among others. This diagnosis made sense to Jacob because he was already diagnosed with high blood pressure and had woken up many evenings choking on his tongue with rapid heat rate. He was then referred to Dr. William Hang, a functional orthodontist based out of Agoura Hills, CA. A cone beam CT scan was used to evaluate his airway and the decision was made that Jacob indeed had his lower jaw pushed into his airway and there was no room for his tongue to rest properly in mouth due to lack of space. With a new plan of action, crafted for him by a multidisciplinary team, Jacob underwent a year of ortho in preparation to see Dr. Reza Movahed for MMA surgery (a procedure in which both jaws are moved forward to create a more open airway), used a CPAP machine and underwent myofunctional therapy training to teach him benefits of nasal breathing, toning the tongue and keeping it up resting at the palate.
Jacob has since had his MMA surgery and is already experiencing the benefits of a wider maxilla and larger airway. His nostrils are a normal shape whereas before they were very narrow due to not being used for many years. He no longer suffers from sleep apnea, and states that his tongue naturally rests at the upper palate and now he breathes through his nose. He also reports that he now dreams again, and is not dependent on coffee or sugary sweets to keep his energy levels up. He, like many others wishes he knew about this sooner in life, because if he had simply learned to breathe through his nose and keep the tongue up to the palate as a child, he could have developed optimally and probably avoided years of health struggles that he experienced as an adult.
I am grateful that there are indeed many dental and health professionals acting as detectives, asking the right questions to optimize their patients paths to better health. Even something as simple as asking “why” when deciding on ortho as an adult, opened a conversation on this patient as a whole.