The shape of your face says a lot about your health—and, potentially, your sport. Dr. Patricia Simon, an orthodontist at Lakewood Orthodontics, has a hypothesis she’s working on. She says elite Olympic swimmers tend to have long, narrow faces and gummy smiles, traits typically associated with mouth breathing. Think Michael Phelps.
“They have airway issues, so they’re used to breathing through their mouths,” Simon says. “You put somebody like me in the pool, I freak out because I can’t breathe through my nose. They’re used to that, right? I should do a study of it.”
In her practice, Simon regularly sees lives changed by proper airway management. She mentions an older woman who had obstructive sleep apnea (OSA). After undergoing orthodontic treatment to align her teeth and surgery to advance both her upper and lower jaw, the patient was immediately able to stop using her continuous positive airway pressure (CPAP) machine—a life-altering change.
“CPAP is the gold standard for treatment for obstructive sleep apnea,” Simon says. “But, obviously, people don’t particularly like sleeping with a CPAP. The compliance with it is terrible. So this is an option.”
Braces are an orthodontist’s main money-maker, as parents know all too well. But in addition to straightening and aligning the teeth, orthodontists are concerned with the jaw that houses them. The health and structure of the jaw and teeth matter for myriad reasons, but the most important—and perhaps most overlooked—is breathing.
Malformations in the jaw can impede the airway. Typically only the quality of breathing is affected, as opposed to being blocked completely. But the consequences can be significant. Narrowed or obstructed airways can impact sleep, increasing the likelihood of hypertension, cardiovascular disease, stroke, pulmonary hypertension, cardiac arrhythmias, and systemic inflammation. And then there’s your oral health. People with untreated OSA are more susceptible to dry mouth, tooth decay, gum disease, TMJ disorders, even bad breath.
The shape of your face says a lot about whether you will develop OSA. A 2009 study showed that your risk level can be predicted by measuring the width of your face and eyes, the length of your jaw, and the angle of your neck. Misaligned or malformed teeth and jaws generally lead to OSA if the tongue doesn’t have enough room, either because the lower jaw is positioned too far back or because the upper jaw is too narrow. The airway then becomes constricted during sleep. The condition worsens over time as tissues become more lax with age.
This is where your orthodontist comes in. Proper airflow, and thus better sleep, can sometimes be restored by expanding the upper jaw or moving the lower jaw forward.
Research suggests that various oral malformations found in newborns and young children can manifest as obstructive sleep apnea in adults. It also works the other way around. If the nasal airways are blocked by environmental factors such as allergies, it leads to mouth breathing, a behavior that actually changes the shape of the face and jaw. While allergists and otolaryngologists (ENTs) are best equipped to deal with congestion and allergies, correcting the issue from the other side involves orthodontic airway management.
Simon, who has more than 25 years of experience as a practicing orthodontist, is an expert in craniofacial abnormalities. She holds a doctorate of dental surgery from the SUNY at Buffalo School of Dental Medicine, and she completed her orthodontic residency at Boston University and a fellowship in Craniofacial and Dentofacial Abnormalities at UT Southwestern Medical Center. She is fascinated by the chicken-and-egg nature of airway disturbances and mouth-breathing behaviors. She cites a classic primate study published by researcher and orthodontist Egil P. Harvold in 1981, in which he discovered that chimps who were forced to breathe through their mouths developed signature dental malocclusions such that their teeth stopped aligning properly, and their faces gradually changed shape. In the study, the chimps’ noses were blocked with silicone plugs; in humans, blockage can be caused by bone structure, allergies, or even generally poor air quality.
“We live in Dallas, for God’s sake,” Simon says.
Chronic mouth breathing, she explains, accelerates the accumulation of plaque and changes the muscle tone of the mouth in a way that begins to shift the teeth. “If you’re breathing through your mouth, that tongue is not sitting at the roof of the mouth, helping to expand it, helping in the development of the dental arch to be as wide as it possibly should be for that tongue to fit up there.” The narrowed palate, in turn, encourages mouth breathing.
CPAP and BiPAP machines are the most common treatment for sleep apnea, but some alternatives do exist, such as dental appliances that move the lower jaw forward or keep the tongue from blocking the throat. In children, the upper jaw can easily be expanded with a palatable expander, and the lower jaw can be moved forward with a functional appliance that works like a retainer.
“A lot of kids who have been diagnosed with ADHD actually have airway issues.”
Unfortunately, not much can be done to prevent orthodontic airway disturbance. Most of the time, this is up to genetics. If your parents have long, narrow faces, it’s more likely you will, too. And a long, narrow face predisposes you to mouth breathing. Aside from managing environmental factors such as allergies, you can’t do much to mitigate an unlucky roll of the genetic dice.
You can reduce the damage, though, with early intervention. Simon says that moving teeth in the jawbone of a growing child is easy, “like butter,” but by the time the child reaches puberty, the bone will have nearly solidified. Once everything locks into place, aligning the teeth can only do so much. It can’t create space in the jaw where there isn’t any.
“I can expand the jaw with just moving the teeth,” Simon says. “I can make them move wherever I want to. But are the roots still going to be in bone when I’m done? No. That’s not real stable.”
Surgical intervention is often the only way to correct it at that point. Proactively getting potential problem areas checked out just might mean the difference between a simple expansion appliance and full-on surgery. “From the standpoint of orthodontics, generally we want an exam by age 7,” Simon says. “I do see kids earlier sometimes if it’s clear they’re having some sort of airway trouble.”
Maxillary expansion is the answer for some kids, but many receive pediatric ENT referrals. She says, “They may need ear tubes. They might need a tonsillectomy or adenoidectomy because that tissue is blocking the airway, and those things affect the long-term development of the face.” Adults or children who snore, mouth breathe, gain weight inexplicably, or are tired and inattentive even after regularly getting a full night’s sleep should mention their symptoms to their dentist or ENT and ask about possible misalignment issues.
One less obvious symptom to watch for is hyperactivity. “A lot of kids who have been diagnosed with ADHD actually have airway issues,” Simon says. “They’re not sleeping well enough, they have pediatric obstructive sleep apnea, and the criteria is smaller. Bedwetting is often a sign of pediatric obstructive, fluid apnea.” Children may go under diagnosed because their symptoms don’t present in the same way as an adult’s. And, of course, these symptoms can have many other causes. The only way to know for sure is to perform a sleep study.
No one gets excited about palate expanders or jaw surgery, but getting your airway fixed can seriously improve your quality of life. The problem is likely to worsen over time if left unaddressed. So tell your doctor if you can’t breathe through your nose. Mention any issues you’re having that might be sleep related, such as daytime drowsiness, trouble concentrating, or irritability. If you have a child who shows signs of possible airway obstruction, get it checked out right away. Choose doctors who are not just proficient in their own field but also understand how the various medical disciplines interact holistically.
And come summer 2024, take a look at the facial structures of the Olympians to see if Simon’s theory about mouth-breathing swimmers holds water. Her prediction?
“You’re going to go, ‘Yeah, I see what she’s talking about.’ ”
This story originally appeared in the August issue of D Magazine with the headline, “Shut Your Mouth.” Write to [email protected].
