Airway Aware: The Next Step in Treatment Planning

In 2016, the airway prosthodontics concept was introduced to Spear Education. Over the last four years, airway has been woven into most of the workshops and seminars on campus. Spear dentists are constantly hearing, “airway, airway, airway.” At times, it may feel like the go-to answer for anything from worn teeth to migraines. But if it is such an important concept, how can we make sure everyone, no matter the practice dynamic, can understand and use airway in their offices?

A huge step in solving this problem was made by Dr. Frank Spear in his presentation to the 2020 American Academy of Restorative Dentistry meeting. He introduced a concept we now call “Airway Aware” treatment planning. It begins with obtaining the skill to listen for and detect visually airway issues in children and adults – medical and dental histories and anatomic deviations from the norm. Then, the dentist must then learn what treatment options could improve or worsen the patient's airway condition. Spear Online and Spear Digest have a plethora of material to fulfill both requirements.

The Airway Aware model calls on practitioners to use the Facially Generated Treatment Planning (FGTP) foundation to examine, diagnose and plan treatment. Once an outline of a plan is completed, ask yourself two questions:

1. Could any of the medical and dental issues I have noted be related to a dysfunctional airway?
2. Theoretically, how would my proposed treatment plan impact a compromised airway? Would it be airway positive, negative, or neutral?

The beauty of this strategy is it can be done by any dentist in any practice setting. It only requires an awareness. The dentist is making assumptions based on reports of similar patients. Through it, we can begin addressing many of the skeletal issues that have made comprehensive care difficult.

Ask airway questions

For example, in cases where the maxillary anterior teeth have worn to an edge-to-edge position, you may want to lengthen the teeth to their original dimension. The problem is there is no overjet. You also note the posterior teeth are in a bilateral crossbite. Because we are trained to try and find a way to fix the chief complaint with a bur, one possible plan might call for opening the vertical dimension by adding restorations to all the occlusal surfaces of the posterior teeth, lengthening the maxillary anteriors, and visually expand the arch with thick veneers on the premolars to camouflage the narrowness. Some offices would utilize a digital mock-up to provide the patient a vision of their future smile to sell the case.

If you are an Airway Aware practitioner, you would begin asking airway questions about the diagnosis and treatment plan. Could the patient's small maxilla be caused by or associated with altered breathing? Many children who are mouth breathers will develop a small maxilla due to the lack of force from the tongue and nasal breathing to direct downward, forward growth. Researchers know the smaller the patient's maxilla, the smaller their nasal volume, and the greater the resistance to nasal breathing. So, could this person currently have stressful breathing? Yes.

Would visually widening the maxilla with veneers be airway positive, negative, or neutral? Veneers do not change the dynamics of the airway, so it would be neutral.

Would skeletally widening the maxilla with orthodontics be airway positive, negative, or neutral? The research would indicate techniques which create more oral and nasal volume would routinely be a very airway positive approach.

Let's take it one step further, what if I told you that your patient has moderate sleep apnea and expanding the maxilla might eliminate that problem, would you want to alter your treatment plan? I would assume your answer would be absolutely. This awareness allows you to have a different discussion with the patient about orthodontics as part of their plan. No one wants braces but most people want a chance to become healthier. And while it cannot be promised, the Airway Aware plan could show the patient examples in the literature from people with similar issues who were improved with the plan you are suggesting.

Next question about your original plan, what impact would opening the occlusal vertical dimension (OVD) have on the airway? We know from the literature it can be positive, negative, or neutral depending on how the patient reacts to the change. Wouldn't you want to know how the patient will react before you finalize your plan?

The American College of Prosthodontists 2016 Guidelines for obstructive sleep apnea (OSA) calls for airway screening before fabrication of a maxillary splint because it can have a negative impact on apnea due to the alteration of the vertical dimension. We tend to blame ourselves or the laboratory when ceramic breaks or the jaw hurts after a rehabilitation at an increased vertical dimension; however, it may, in fact, be a change in the biology of the system via the airway that precipitated the damage.

The Airway Aware approach calls for practitioners to ask themselves if the history or anatomy of the patient would lead them to suspect airway dysfunction. If so, they then need to ask if their treatment plan might have an airway positive, negative, or neutral impact. And finally, if they believe there might be an airway issue, is there a treatment plan that might provide a more positive impact for esthetics, function, and the airway. The beauty of the Airway Aware technique is it can be incorporated into any practice model without altering your daily practice or investing in screening devices.

Jeffrey Rouse, D.D.S., is a member of Spear Resident Faculty.