Orthodontics that asks: does this smile breathe well?

Eight years of training, seven named specialists

Airway-focused orthodontics isn't a weekend certification. It's a framework that requires learning from the entire team that treats airway disorders — orthodontists, oral surgeons, ENTs, sleep medicine physicians, myofunctional therapists, and frenulum specialists. Most orthodontic continuing education stays within orthodontics. Dr. Andros has spent eight years deliberately training across all of these disciplines.

Specifically, he has trained directly under:

• Dr. Rebecca Bockow (Seattle, WA) — dual-trained periodontist-orthodontist, one of the leading voices in pediatric sleep-disordered breathing and airway-focused orthodontics in the Pacific Northwest. Recurring lecturer in Dr. Andros' OrthoPreneurs RD study group.
• Dr. Audrey Yoon (Stanford-affiliated orthodontist) — pediatric airway, OSA, growth modification, and MARPE complications. Multiple lectures at the 2022 Stanford Sleep and Airway Symposium.
• Dr. Stanley Liu (Stanford-affiliated oral & maxillofacial surgeon) — sleep surgery, the surgical side of airway intervention when orthodontic and medical management aren't enough.
• Dr. Soroush Zaghi (founder, The Breathe Institute, Los Angeles) — world-recognized expert on tongue-tie, frenulum restrictions, and how restricted oral function shapes craniofacial development.
• Dr. Sharon Keenan — sleep medicine specialist; polysomnography (sleep study) interpretation, the diagnostic foundation for airway-related orthodontic decision-making.
• Sarah Hornsby — leading myofunctional therapist; how to retrain tongue posture and oral muscle function in conjunction with orthodontic treatment.
• Dr. Anil Rama (Stanford-affiliated sleep specialist) — adult sleep medicine and the orthodontist's role in coordinated care.

That roster is essentially the multidisciplinary team behind modern airway medicine. Dr. Andros has trained under all of them — not as a passing introduction, but as part of a deliberate eight-year arc that included two Stanford Sleep and Airway Symposiums (2019 and 2022) plus a 2026 sleep-study course with Dr. Rama and a confirmed December 2026 course at the Arizona Biltmore.

Why this matters — the link between airway and craniofacial development

The connection is well-documented in the peer-reviewed orthodontic and sleep medicine literature, even if it isn't yet routine in mainstream orthodontic practice. The simplified version:

Healthy craniofacial development depends on nasal breathing with the tongue resting against the roof of the mouth. The tongue, sitting against the palate, provides the gentle outward force that keeps the upper jaw growing wide enough. The nose, used as the primary breathing route, helps drive vertical and horizontal growth of the midface. Lips closed at rest helps seal the system.

When any of these is disrupted — chronic nasal congestion forcing mouth breathing, enlarged adenoids forcing the tongue to drop, a restricted tongue tie pulling the tongue away from the palate — the craniofacial system develops differently. The palate narrows. The jaw can grow long and narrow. Crowded teeth and a high arched palate are visible markers of an underlying breathing pattern that started years earlier.

By the time a child is in braces or an adult is asking why they snore, the structural pattern is already set. Airway-focused orthodontics treats the structure that contributes to the airway problem — and coordinates with sleep medicine, ENT, and myofunctional therapy to address the rest.

Signs your child might benefit from airway evaluation

The American Association of Orthodontists recommends a general orthodontic screening by age 7. For airway specifically, the right age is case by case. If a child has been diagnosed with pediatric sleep apnea, referred by a pediatrician or ENT, or if parents are concerned about sleep patterns or chronic mouth breathing, earlier evaluation makes sense — even in toddlers and preschoolers. None of the signs below is diagnostic on its own; together they often indicate an underlying airway component that benefits from orthodontic assessment.

• Chronic mouth breathing — during sleep, during concentration, or as a baseline resting state. A child whose lips don't naturally close at rest.
• Snoring at any age, especially if loud or accompanied by pauses
• Restless or non-restorative sleep — frequent waking, thrashing, unusual sleeping positions to keep the airway open, sweating during sleep
• Daytime fatigue or behavioral issues — children with airway-related poor sleep often present with attention difficulties, irritability, or ADHD-like behaviors. The behavior is the visible symptom; the sleep disruption is the cause.
• Dark circles under the eyes — "allergic shiners" caused by venous congestion related to chronic nasal blockage
• Frequent congestion, sinus infections, or ear infections
• Bedwetting past the typical age
• Long, narrow face — a developmental pattern often associated with chronic mouth breathing
• Narrow palate, crowded teeth, or a high-arched palate — visible signs of altered jaw development
• Tongue scalloping — wavy edges along the sides of the tongue from resting against the teeth instead of the palate
• Low tongue posture — a tongue that rests on the floor of the mouth rather than against the roof

Parents are often the first to notice these patterns. Pediatricians and family dentists sometimes flag them. When several of these are present together, an airway-focused orthodontic evaluation is worth scheduling — even if your child isn't yet at the typical "braces age."

Signs an adult might benefit from airway evaluation

Adult presentations are different, but the underlying mechanism is the same — structural narrowing of the upper airway contributing to chronic symptoms that the patient may have lived with for decades. Common patterns:

• Chronic mouth breathing or chronic nasal congestion — including waking with a dry mouth
• Snoring, witnessed pauses in breathing during sleep, or a known diagnosis of sleep apnea
• Morning headaches or non-restorative sleep — feeling tired despite a full night
• Persistent TMJ symptoms not adequately addressed by traditional dental treatment
• Tooth wear or grinding — sometimes a manifestation of airway-related arousals during sleep
• A narrow upper arch with dark corridors at the corners of the smile
• Recessed lower jaw or chin — structural patterns associated with reduced airway volume
• Daytime fatigue not explained by other factors
• A previous CPAP intolerance — patients who couldn't tolerate the mask sometimes benefit from a structural approach as an adjunct

Many adults arrive at airway-focused orthodontics because something else didn't work — a sleep study they ignored, a CPAP they stopped using, TMJ treatment that didn't resolve, or chronic congestion that ENT visits didn't fully fix. The structural component of these problems is often what was missed.

What an airway-focused evaluation includes

The first visit looks different from a standard orthodontic consultation. In addition to the usual orthodontic workup — bite, jaw alignment, tooth crowding — Dr. Andros also evaluates:

CBCT imaging with airway analysis

A cone-beam CT scan provides a three-dimensional view of the nasal cavity, palate, sinuses, and upper airway. Volume measurements and minimum cross-sectional area give an objective starting point. The same scan supports the transverse skeletal analysis used in MARPE/MASPE planning.

Clinical assessment of tongue posture and frenulum

Where the tongue rests, how it functions during swallowing and speech, and whether there's a restrictive frenulum (tongue tie) under it. Dr. Andros' training with Dr. Soroush Zaghi at The Breathe Institute focuses specifically on this assessment.

Palatal width and dental compensation

How wide the palate actually is, and whether the molars are tipped inward to compensate for an underlying skeletal narrowness. The CWRU-style transverse analysis Dr. Andros uses (described on the MARPE page) is specifically designed to detect this compensation pattern.

Nasal breathing assessment

Whether the patient can comfortably breathe through the nose with the mouth closed. Persistent inability often indicates an ENT issue (deviated septum, enlarged turbinates, adenoid hypertrophy) that should be addressed before or alongside orthodontic treatment.

Sleep screening

A structured intake of sleep-related symptoms. When the screening suggests sleep-disordered breathing, the next step is referral for a formal sleep study with a sleep medicine specialist — the orthodontic plan is built around their findings.

Treatments we offer and coordinate

Airway-focused orthodontics rarely uses one tool. Depending on the case, treatment may include any combination of:

• Skeletal palatal expansion — MARPE/MASPE in adults; conventional rapid palatal expansion in growing children. Widening the palate increases nasal cavity volume and creates room for the tongue to rest properly.
• Growth modification in children — using the remaining growth potential to guide jaw development toward a more airway-friendly outcome
• Conventional or self-ligating braces for tooth alignment after the structural foundation is addressed
• Clear aligners (Invisalign) in cases where the skeletal foundation is sound and only tooth movement is needed
• Coordination with ENT for adenoid/tonsil evaluation, septum or turbinate treatment, or chronic congestion management
• Coordination with myofunctional therapy for tongue posture retraining — often before, during, and after orthodontic treatment
• Coordination with frenulum specialists when a restrictive tongue tie is contributing
• Coordination with sleep medicine for sleep studies, CPAP titration, or oral appliance therapy where indicated
• Referral to oral and maxillofacial surgery when surgical advancement of the jaws is the right answer — typically severe adult cases where orthodontic and medical management alone won't address the structural narrowing

What airway-focused orthodontics is not

Honesty matters here. The airway-focused orthodontic community has its share of overpromising, and Dr. Andros doesn't want to be associated with claims the evidence doesn't support. Specifically:

• Orthodontic treatment alone does not cure sleep apnea. Sleep apnea is a medical diagnosis requiring evaluation by a sleep medicine physician. Orthodontic treatment can address structural contributors and meaningfully improve outcomes in coordination with sleep medicine — but it is not a replacement for proper sleep medicine care.
• Not every crowded smile is an airway case. Plenty of patients have orthodontic issues that are purely dental. The airway-focused evaluation determines which category each case actually belongs in.
• Children with attention difficulties don't always have airway problems. Sometimes they do. The airway evaluation helps determine whether structural factors are contributing — but it doesn't replace pediatric or psychological evaluation.
• Treatment results vary. Some patients have dramatic improvements in sleep quality, headaches, and breathing after orthodontic treatment. Others have measurable structural changes without dramatic symptom relief. Realistic expectations matter.

The honest framing: airway-focused orthodontics addresses anatomical contributors to airway function, in coordination with the rest of the medical team, and produces measurable improvements in many — not all — cases. Dr. Andros will tell you which category your case is likely to fall into based on the evaluation.

The case for early evaluation

One of the most important reasons to evaluate children for airway involvement early is the developmental window. The upper jaw and palate are still actively growing through about age 10-12. The midpalatal suture (the seam down the middle of the upper jaw) is more pliable in younger patients, which means palatal expansion is simpler and produces better long-term results.

That doesn't mean every child needs treatment at the first visit. Early evaluation often results in a plan that includes monitoring growth over time, coordinating with pediatricians, ENTs, or sleep specialists, and starting myofunctional therapy long before any braces or expander is placed. The goal of seeing kids early isn't to start treatment before it's needed — it's to put the right team in place and intervene at the right moment.

The contrast matters: the same problem, identified for the first time in adulthood, often requires MARPE/MASPE — a more involved procedure — or in some cases jaw surgery. By contrast, a 7-year-old with a narrow palate, mouth breathing, and chronic congestion can often be expanded with a conventional pediatric expander, treated for the underlying ENT issue, retrained on tongue posture with myofunctional therapy, and sent into adolescence with a wider palate, better breathing, and a more favorable craniofacial pattern.

The economic and quality-of-life math favors early evaluation by a wide margin — even when the conclusion of that evaluation is "monitor for now."

What to expect at your evaluation

An airway-focused consultation typically runs longer than a standard orthodontic visit — generally 45-60 minutes. It includes a detailed intake on sleep and breathing symptoms, the clinical airway assessment described above, a CBCT scan if not already on file, and a discussion of findings and recommendations. If the case has a significant airway component, Dr. Andros will outline which specialists to coordinate with and in what order. If the case is purely dental, he'll tell you that too.

You'll leave the consultation with a clear understanding of what the workup shows, what the realistic options are, and what your next step is — whether that's orthodontic treatment, a sleep study referral, an ENT consult, or a combination.

Why the diagnosis comes first

The most expensive mistake in airway care is treating the wrong obstruction.

A child snores, an expander goes in, and the snoring continues — because the actual obstruction was adenotonsillar, not skeletal. Or the tonsils come out, things improve for a year, and the symptoms return — because nobody assessed a palate that was far too narrow to begin with. Both scenarios cost families years, and both are avoidable.

Sleep-disordered breathing can originate in the nose, the adenoids, the tonsils, the jaws, the tongue, or several of these at once. Each has a different answer. Determining which one is driving the symptoms is what the workup is for.

A sleep study is the diagnostic standard. Polysomnography, interpreted alongside clinical symptoms by a sleep medicine physician, is how obstructive sleep apnea is diagnosed. Home sleep testing has made this considerably less burdensome than it once was, and pediatricians order it routinely.

Imaging informs planning, not diagnosis. The CBCT scan described above provides genuine structural information — nasal cavity volume, minimum cross-sectional area, transverse skeletal measurements — and that information drives treatment planning. What it cannot do is diagnose sleep apnea. The airway is a dynamic structure, and a scan of an upright, awake patient does not establish what happens lying down and asleep. Current American Association of Orthodontists guidance is explicit on this point, and Dr. Andros treats it as a hard line: the scan plans the orthodontics, the sleep study makes the diagnosis.

The referral is specific. When screening raises a concern, patients leave with a documented reason to bring to their physician — not a general suggestion to have it looked at. When screening does not raise a concern, Dr. Andros says so directly. Reassurance is a legitimate clinical outcome.

Common questions

Why does my child snore?

Something is obstructing airflow, and the cause determines the treatment. The common contributors are enlarged tonsils and adenoids, chronic nasal congestion or allergies, and a narrow upper jaw — often in combination. Snoring most nights, particularly with pauses, gasping, restless sleep, or daytime behavioral changes, warrants evaluation rather than watchful waiting.

What is airway-focused orthodontics?

Airway-focused orthodontics is an evaluation and treatment framework that looks at how jaw position, palatal width, tongue posture, and breathing pattern interact — not just how the teeth line up. For some patients, the way their jaws have developed contributes to chronic mouth breathing, snoring, sleep-disordered breathing, persistent congestion, or TMJ symptoms. An airway-focused orthodontist evaluates these connections and coordinates care with sleep medicine, ENT, and myofunctional therapy when appropriate. Dr. Andros has completed eight years of continuing education with Stanford-affiliated faculty in this specific framework.

How is airway-focused orthodontics different from regular orthodontics?

Standard orthodontics focuses on moving teeth to a good bite and an aesthetic smile. Airway-focused orthodontics asks an additional question first: is the underlying jaw and palate development supporting healthy breathing, sleep, and tongue posture? If it is, treatment is similar to standard orthodontics. If it isn't, the treatment plan may include skeletal expansion (MARPE/MASPE), referral for sleep evaluation, myofunctional therapy, or coordination with an ENT — alongside the orthodontic work. The goal is a result that breathes well, not just one that looks good in photographs.

What are the signs that my child might benefit from airway-focused orthodontic evaluation?

Common signs in children include chronic mouth breathing during sleep or while concentrating, snoring, restless or non-restorative sleep, daytime fatigue, dark circles under the eyes, frequent congestion or sinus infections, attention difficulties or ADHD-like behaviors, bedwetting past the typical age, a long narrow face, a narrow palate or crowded teeth, scalloping along the edges of the tongue, and a tongue that rests low in the mouth rather than against the roof. None of these is by itself diagnostic, but together they often indicate an airway component that benefits from orthodontic evaluation.

What are the signs that an adult might benefit from airway-focused evaluation?

In adults: chronic mouth breathing or nasal congestion, snoring, witnessed pauses in breathing during sleep, morning headaches, persistent TMJ symptoms, daytime fatigue not explained by other factors, tooth wear or grinding, a narrow upper arch with dark corridors in the smile, history of sleep apnea, and chronic poor sleep quality. Adults presenting with these patterns are often candidates for a coordinated workup involving a sleep study, ENT evaluation, and orthodontic assessment of the airway.

Does my child need a sleep study?

If screening suggests sleep-disordered breathing, yes — that is the diagnostic standard, and treatment decisions should follow it rather than precede it. Home sleep testing has made this substantially easier than it used to be. Dr. Andros will provide a specific documented reason for the referral to bring to your physician.

My child needs an expander for crowding. Is that an airway treatment?

Not necessarily, and the distinction matters. Palatal expansion for crowding, crossbite, or a narrow arch is standard, well-established orthodontic treatment with decades of evidence behind it. Because the palate forms the floor of the nose, widening it increases nasal cavity dimensions as a consequence — but that is a secondary benefit, not the justification. The uncertainty discussed in the orthodontic literature concerns expansion prescribed specifically to treat diagnosed sleep apnea, not routine expansion for orthodontic indications.

Do my child's tonsils need to come out first?

That depends on what is obstructing them, which is precisely why diagnosis precedes treatment. Where adenotonsillar hypertrophy is the primary obstruction, adenotonsillectomy is the recognized first-line treatment and an ENT referral is the right next step. Where the tonsils are normal and the jaw is narrow, the orthodontic contribution is more relevant. A meaningful proportion of children have residual sleep apnea after surgery, which is one reason coordinated follow-up matters.

Can airway-focused orthodontics treat sleep apnea?

Orthodontic treatment alone does not diagnose or cure sleep apnea. Sleep apnea is a medical diagnosis that requires evaluation by a sleep medicine physician — usually based on a sleep study. What orthodontic treatment can do is address structural contributors to sleep-disordered breathing: a narrow palate, a recessed lower jaw, restricted nasal volume, or impaired tongue posture. In appropriate cases, these structural improvements meaningfully reduce sleep apnea symptoms — sometimes enough that CPAP therapy is no longer needed. But this is always in coordination with a sleep medicine physician, never in place of one.

What specialists does Dr. Andros coordinate with for airway cases?

Airway-focused orthodontics is inherently a team approach. Depending on the case, Dr. Andros coordinates with sleep medicine physicians (for sleep studies and CPAP titration), ear-nose-throat specialists (for tonsil, adenoid, or septum evaluation), myofunctional therapists (for tongue posture and oral muscle retraining), oral and maxillofacial surgeons (when surgical advancement is indicated), and primary care or pediatricians (for ongoing care coordination). Dr. Andros has trained directly under leaders in each of these specialties, including Dr. Rebecca Bockow (perio-ortho, Seattle), Dr. Audrey Yoon (Stanford-affiliated orthodontist), Dr. Stanley Liu (Stanford-affiliated oral surgeon), Dr. Soroush Zaghi (The Breathe Institute, frenulum specialist), Dr. Sharon Keenan (sleep medicine), and Sarah Hornsby (myofunctional therapy).

At what age should children be evaluated for airway issues?

It's case by case. The American Association of Orthodontists recommends a general orthodontic screening by age 7. For airway specifically, evaluation can be earlier — especially if a child has been diagnosed with pediatric sleep apnea, has a referral from a pediatrician or ENT, or if parents are concerned about sleep patterns, chronic mouth breathing, or snoring. When there is a real airway issue, identifying it early and getting help early is always better. That said, treatment at younger ages often looks different from traditional braces — it may involve monitoring growth, coordinating with sleep medicine, ENT, or myofunctional therapy, and intervening orthodontically only when the timing is right. The goal of an early evaluation is to put the right team in place, not to start treatment before it's needed.

Is airway-focused orthodontics evidence-based?

The relationship between jaw development, palatal width, and airway function is well-documented in the peer-reviewed orthodontic and sleep medicine literature. Skeletal palatal expansion has been shown to increase nasal cavity volume on CBCT in multiple studies. The connection between pediatric mouth breathing and craniofacial development is well-established. Specific claims — for example, that orthodontic treatment alone will cure adult sleep apnea — are not supported by the evidence and Dr. Andros does not make them. The honest framing is: airway-focused orthodontics addresses anatomical contributors to airway function, in coordination with sleep medicine and ENT, and produces measurable improvements in many — not all — cases.

Where this comes from

Airway-focused orthodontics attracts more confident claims than the evidence currently supports. Dr. Andros's position is that the structural rationale is sound, the coordinated-care model is correct, and the outcome evidence — while pointing in a favorable direction — remains limited. Several of the studies most often cited in this field are small, and more research is needed before stronger claims are warranted. These are the sources behind what appears on this page.

• Current professional guidance on orthodontics and sleep-disordered breathing, including the role of orthodontists in screening and referral, the limits of imaging for diagnosis, and the conditions under which expansion is appropriate: Palomo JM, Cohen-Levy J, Flores-Mir C, Khosravi R, Levine M, Pickard M, Hittner J, Callahan J, Siegel SM. Sleep-disordered breathing and orthodontics: An American Association of Orthodontists white paper update. Am J Orthod Dentofacial Orthop. 2026;169(4):419–427. doi:10.1016/j.ajodo.2026.01.014
• Pediatric sleep apnea prevalence, and adenotonsillectomy as first-line treatment where adenotonsillar hypertrophy is present: Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics. 2012;130(3):576–584.
• Residual sleep apnea after adenotonsillectomy, and the conditional role for orthodontic treatment afterward: Ehsan Z, Ishman SL, Soghier I, et al; American Thoracic Society. Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children. Am J Respir Crit Care Med. 2024;209(3):248–261. doi:10.1164/rccm.202310-1857ST
• The role of dental professionals in early recognition: Fagundes NCF, Flores-Mir C. Pediatric obstructive sleep apnea — Dental professionals can play a crucial role. Pediatr Pulmonol. 2021. doi:10.1002/ppul.25291
• Evidence on expansion and pediatric sleep apnea — the favorable synthesis: Yu K, Li Y, Ngan P, Li L, Huang J, Hua F, Zhao T, He H. The effect of rapid maxillary expansion on children with obstructive sleep apnea: a systematic review and meta-analysis. Sleep Breath. 2026;30(1):77. doi:10.1007/s11325-026-03606-1
• Long-term follow-up in children with isolated maxillary narrowing and normal adenotonsillar tissue: Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion for pediatric obstructive sleep apnea: a 12-year follow-up. Sleep Med. 2015;16:933–935. doi:10.1016/j.sleep.2015.04.012
• And the counterweight — a same-year review reading the controlled evidence more cautiously: Fernández-Barriales M, López de Luzuriaga M, Lafuente-Ibáñez de Mendoza I, Alonso Fernández-Pacheco JJ, Álvarez Ruiz de Larrinaga A, Aguirre Urizar JM. Controlled Prospective Evidence of Rapid Maxillary Expansion Efficacy in Pediatric Obstructive Sleep Apnea: A Systematic Review Update. J Clin Med. 2026;15(8):2976. doi:10.3390/jcm15082976