Dr Derek Mahony is a world-renowned specialist orthodontist. He is a strong advocate and educator on the benefits of interceptive orthodontic treatment (early intervention) to minimise the unnecessary extraction of teeth, and to improve airway, breathing and sleep quality. His notable achievements include 9 fellowships, 3 postgraduate degrees and he has written over 1000 articles and shared his knowledge as a keynote speaker in 120 countries. Dr Mahony is the director of Full Face Orthodontics which has clinics across Sydney.

Traditionally, orthodontics focused on aesthetics via teeth alignment. Orthodontists would work with children who have lost all their baby teeth, usually around the age of 13. At this age, children’s jaws are already developed and there is little that can be done to correct jaw size and position.
Modern orthodontics are airway health professionals! They target airway by correcting the jaw (upper and lower) structures so that it grows forward (which also supports aesthetics!). A child can have a high and narrow palate for a number of reasons including genetics, oral habits (e.g. thumb sucking) and a low resting tongue posture.

Orthodontists and interceptive treatment are critical to support airway and facial growth. There is significant research on the relationship between mouth breathing from an early age and the jaw growing downwards and backwards. In addition, there is a 90% correlation of children with malocclusion (bad bite) and sleep disordered breathing.

Early intervention aims to support the proper development of orofacial muscles’ form and function. This will ensure nasal breathing with closed lips and the tongue on the palate. Altogether, promoting better health, sleep quality and overall development.

• Orthodontists works on the size of the jaw to enable the tongue to rest on the palate. This will naturally support teeth alignment in later years.
• Speech Pathologists are sometimes the first to identify the need for interceptive orthodontic treatment. For example, a 2-year-old late talker who presents with upper airway issues and a history of ear infections, or a child who makes limited progress on speech intelligibility goals. Speech Pathologists also work on correcting resting tongue posture, eliminating oral habits and supporting breathing retraining.
• Ear, Nose Throat specialists are involved to clear nasal obstructions.
• Audiologist should be involved if there are recurrent ear infections and they also support the work of speech therapy for speech and language development.

The American Association of Orthodontists recommends interceptive intervention by age 7. At this age, the palate’s sutures are wide open so there is still room for expansion without removing teeth. Also, by addressing the tongue resting posture, we are able to promote maximum jaw growth.

However, earlier intervention is warranted when there is an underlying medical condition that is affecting jaw growth. The main conditions are sleep apnoea (which can be diagnosed as early as 4 years old), recurrent otitis media (middle ear infection) and tongue ties.

Once the path of facial growth has altered, it is difficult to effect change. More importantly, if there is a functional problem affecting growth, we shouldn’t wait. A child’s craniofacial growth finishes around age 9-10, before puberty. So, a 14 year old who has been a mouth breather his whole life, snores, has poor sleep quality and has a narrow palate, has limited options. Intervention for this population involves more drastic intervention. Typically, orthodontic work is done to camouflage the jaw positioning. True recovery will require surgical input to move the jaw.

Interestingly, facial structure and function can change over life span. For example, if one starts to mouth breathe due to a stressful job, changes in weight or lifestyle habits, they could see changes in their teeth alignment.

For younger children around 6 years old, there is still time. If a parent is uncertain about treatment, the best course of action is the take records of mouth breathing, snoring, the face angle etc. This evidence can be compared after a year to see if intervention is necessary.

In today’s society, there is much more motivation to improve facial aesthetics with social media and use of video conferencing. An example is the popularity of John Mew, an orthodontist who created a program of ‘mewing’ to support facial growth.

A child’s eustachian tube is parallel until the age of 2-3. This means that when they swallow, their eustachian tube does not clear. This increases their risk of recurrent otitis media. Most ENTs use grommets as a method to artificially drain a blocked eustachian tube. However, this does not address the underlying issues and some children end up having multiple sets of grommets which pose the risk of scar tissue. Interceptive treatment should be trialled first, with grommets as a follow up treatment if needed.

Interceptive treatment can work on the size of the palate which is connected to the eustachian tube. An example is to place resin on a 2-3 year old’s teeth (with no harm to the child). This influences how the muscles connecting the soft palate to the ear move and help clears the middle ear. As face matures, the eustachian tube changes so that it can drain naturally.

Families are most familiar with ‘plates’ which are removable plastic devices. However, they move the teeth with minimum effect on the jaw. Interceptive treatment uses appliances that anchors onto the bone which is designed to change the jaw structure so that the jaw grows forward. In some cases, there may be braces placed in the front four teeth in preparation of canine teeth growth. This treatment is much less intrusive and reduces the need for full orthodontic work later in life. By working with a child’s growth, the best outcome can be achieved without any extractions to create space.

Orthodontists are able to identify nasal obstruction through their x-rays which note teeth and the upper airway (nose, nasal septum, tonsils). An ENT referral is indicated when there is nasal obstruction. Sometimes, it is necessary to remove enlarged tonsils and adenoids which are blocking the airway. Surgery may also be needed in the absence of tonsillitis as enlarged tonsils are not always inflamed.

It is important to NOT assume that function will improve without further intervention post-surgery as mouth breathing can become habitual. Similar to a knee injury, physiotherapy is needed post-surgery. Post-ENT intervention, oro-myology therapy is needed for breathing retraining.

Sleep apnoea and snoring should not be normalised and intervention is warranted. Dr Mahony recommends ‘Breath’ by James Nestor, a New York Times best seller which talks about the benefits of nasal breathing including its calming effect.
​
It is also important to note that dentists are taught that a child only needs palate expansion if one or both sides of their upper jaw is misaligned to their lower jaw (cross bite). However, the latest research show that most bedwetting children have a normal bite but a high palate which is affecting their breathing. 

About 30 years ago, tongue ties were readily released by midwifes and nurses on the ward, followed by breastfeeding for address post-release management. Today, there is much controversy and caution around releases due to medico-legal issues. Only in Brazil is it compulsory for tongue ties to be screened at birth.

Tongue and lip ties are assessed via functional evaluation e.g. a baby’s lip seal and latch onto the breast. They should be addressed in early intervention as it can affect speech, feeding and facial growth development. However, if the palate is not the right size, orthodontic work may be needed prior to a release to ensure there is room for the tongue to rest on the palate post-surgery.

Key pointers in finding the right professional to release a tie:

• They routinely perform releases
• They are able to use different methods of release (traditional cut and laser) depending on the presentation of the tie
• They use quantitative measurement
• They understand pre-release and follow up care (exercises should be done pre- and post- surgery to prevent scar tissues)
• They work in a multidisciplinary model (e.g. with an orofacial myologist or a Speech Pathologist)

Orthodontists can support chronic bedwetters by improving nasal airflow through the intervention of the palate. This is because there is an 80% correlation between sleep disordered breathing, sleep apnoea and bedwetting.

Having good nasal breathing ensures a balanced exchange of filtered oxygen and carbon dioxide. This supports the release of the antidiuretic hormone. This hormone controls the smooth muscle around the body, including our bladder and skin. It is only released during the deep stages of sleep. Children with sleep disordered breathing do not achieve this level of sleep and subsequently experience bedwetting. Adults with this issue would get up in the middle of the night to go to the toilet. If experiencing chronic bedwetting, it is best to get a sleep study which involves an oxygen saturation test. The solution is to improve airway and sleep quality to enable release of the antidiuretic hormone to control the bladder muscles.

To find out more, contact us at SPOT Therapy Hub on spottherapyhub@gmail.com or 02 9389 3322. Also check out our podcasts and blogs on a variety of topics at www.spottherapyhub.com.au