Airway Aware: The Next Step in Treatment Planning

In 2016, Spear Education introduced the airway prosthodontics concept. Over the last four years, airway has been woven into most of the workshops and seminars on campus. Spear dentists constantly hear, “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?

Dr. Frank Spear took a huge step in solving this problem in his presentation at 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 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. How would my proposed treatment plan impact a compromised airway? Would it be airway positive, negative, or neutral?

The beauty of this strategy is that it can be used by any dentist in any practice setting. It only requires awareness. The dentist makes assumptions based on reports of similar patients. Through it, we can begin addressing many 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 that there is no overjet. You also note that 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 expanding the arch with thick veneers on the premolars to camouflage the narrowness. Some offices would utilize a digital mock-up to give 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 that 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 that it would be neutral.

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

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 assume your answer is 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. While it cannot be promised, the Airway Aware plan could show the patient examples in the literature from people with similar issues who improved with the plan you suggested.

Next question about your original plan: What impact would opening the occlusal vertical dimension (OVD) have on the airway? The literature shows that 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) call for airway screening before fabricating a maxillary splint because it can negatively impact apnea due to the alteration of the vertical dimension. We tend to blame ourselves or the laboratory when ceramics break 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 need to ask if their treatment plan might have a positive, negative, or neutral airway impact. And finally, if they believe there might be an airway issue, is there a treatment plan that might positively impact esthetics, function, and the airway? The beauty of the Airway Aware technique is that it can be incorporated into any practice model without altering your daily practice or investing in screening devices.