Sleep Apnea Is A Craniofacial Problem

As a resident during otolaryngology training, I rotated in the medical center’s craniofacial clinic, seeing various disorders that lead to underdeveloped or malformed facial or skull structures. These syndromic children clearly had severely asymmetric faces or underformed jaws. In many cases they had breathing problems requiring surgery.

One of the more common conditions you’ll see in such a clinic is Pierre Robin sequence, where due to improper maturation of the lower jaw, the lower chin is recessed severely. You’ll see milder variations of this all the time, but if severe enough, these people can’t breathe, especially at night.

Treating Only The Extremes

One of the problems with modern medicine is that we name and treat only the extreme end of a continuum, or only when significant problems result. Having a slightly recessed chin may be thought of a the person’s normal facial feature, and his or her ability to breathe is never even considered.

The entire basis for my sleep-breathing paradigm is that all modern humans have constricted facial structures, not due to a congenital or genetic problem, but due to our eating and lifestyle habits. Genetically, we’re all programmed to have relatively wide jaws, with room for all your wisdom teeth. Now, that rarely ever happens. This is why obstructive sleep apnea can be described as a mild craniofacial condition that can significantly affect your upper breathing passageways.

Small Jaws, Small Airway

It seems that almost everyone these days will need braces to fix crooked teeth or narrow dental arches. Dental crowding by definition means that your upper and lower jaws are underdeveloped. This creates less total volume inside your mouth, leading to overcrowding of your tongue. Your tongue can then fall back easier when on your back, and when in deep sleep, due to muscle relaxation, you’ll stop breathing more often at night.

Even your nose can be affected by this problem. Since your nasal sidewalls follow your upper molars, the side to side distance in your nose will be more narrow, and as the roof of your mouth (nasal floor) gets pushed up, it’ll also cause your septum to buckle.

If you add additional inflammation and swelling in your nose (due to colds, allergies or nonallergic rhinitis), your nose will become stuffier faster, and even worse, your nostrils will cave in easier.

Having underdeveloped upper jaws prevents proper cheekbone fullness, giving your mid-face a sinked-in look. This type of facial appearance is so common these days that it’s almost accepted as normal. I remember reading in the New York Times a few years back where they reported that women’s preferences for male actors has changed from the classic square-faced, angular facial features, to softer, more feminine, rounded faces.

Despite having some good first line options such as CPAP or oral appliances, these approaches don’t really address the root cause. If your child’s jaw was severely underdeveloped and your choice was either lifetime CPAP or jaw enlargement, which would you choose? What if, rather than cutting the jaws and pulling it forward, you can apply distraction plates that can be pulled slowly, little by little, to normalize the jaws and improve the airway significantly? What about advanced dental appliances that can expand your upper and lower jaws in three dimensions, making more room for your tongue? With current technology, we can modify your jaws significantly. But for adults with obstructive sleep apnea, any kind of surgical or dental modification of the jaws is only considered as a last resort.

I describe obstructive sleep apnea as the end extreme of a continuum of sleep-breathing disorders. Similarly, if you look at obstructive sleep apnea as being a craniofacial problem, everyone will have various degrees of jaw underdevelopment. If you have impacted molars, or had to have your wisdom teeth taken out, then your breathing passageways are compromised.

Not only are your jaws more narrow, but the soft tissues that line your breathing passageways will be much more likely to become inflamed and cause even further obstruction. Frequent obstructions can cause a vacuum effect in your throat which literally suctions up your normal stomach juices into your throat, promoting more inflammation and swelling. These juices (which include acid, bile, digestive enzymes and bacteria) can then also reach your nose, sinuses, ears and even your lungs, causing additional inflammation and swelling. If your nose is stuffy, then a vacuum effect is created downstream in your throat and the tongue can fall back much easier, whenever you’re in deep sleep (due to muscle relaxation).

Our Airways Are Like Plumbing

In the medical community, craniofacial problems are generally treated surgically. Even with plumbing, if you only open up one area of multiple clogged areas, the pipes will still be clogged (like doing a UPPP). Sometimes you can put in drano to soften the clogging and open up the passageways (like allergy medications), but after years of buildup and accumulation, you have to physically open up all the blocked areas. You can also use a plunger to force the water down the drain (like CPAP), but you know that sooner or later, it’ll get clogged again. The older the pipes, the worse it becomes (old age).

CPAP and oral appliances are both important and necessary tools to treat the vast majority of people with sleep apnea, but we also need to open our minds to the idea that we shouldn’t have to sleep with gadgets or devices for the rest of our lives.

A Modern, Western Dilemma

It’s commonly known that our brains are getting bigger over time. As modern human’s mid and lower faces get smaller and smaller, I predict that in a few hundred to a few thousand years, everyone will be tethered to a hose while sleeping, like in the science fiction movies. Maybe vocal speech and communication will not be needed anymore, and we’ll be able to communicate with mental telepathy. We’ll all begin to look like that alien in the old Star Trek episode with the huge brain and a tiny face.

Sadly, it’s already started. If you look at the younger generations, you’ll see how narrow their dental arches are, along with flat cheekbones and narrow nasal widths. Recently, I happened to see an Amish chorus singing songs in the Grand Central subway station. I was amazed how most had very prominent cheekbones, well-formed jaws, and good looking smiles. It’s not surprising that cultures that eat organically and off the land will have more fully developed jaws.

So the next time you’re sitting in an auditorium and a public place with lots of people, think about that classic first day of college speech by the dean or president:

“Look to your left…and look to your right. At the end of this year, one of the two that you see will not be here with you.”

Similarly, every other person sitting next to you will most likely have smallish jaws, and have an undiagnosed sleep-breathing problem. From a craniofacial standpoint, they won’t be able to sleep well due to narrowed breathing passageways. If you end up befriending or marrying one of these people, now you’ll understand what makes them tick, or sick.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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21 thoughts on “Sleep Apnea Is A Craniofacial Problem

  1. Doctor,

    I suffer from the malady of OSA from birth, and a poor prognosis for longevity from onset of multiple OSA co-morbidities. My comments on the present and future world.

    The evolutionary pressure to increase cranium, decrease jaw (and associated accomodating female anatomy of wider hips) is a sub-species flaw. The genetic modifications in process, would naturally and invariably result in failure to thrive. This is good, not to be confused with ethical. In the adulturated realm of medical intervention the traits will be promulgated and increased.

    The selection of traits is disturbing and radical as mate choice is processing attractiveness to wide hips, round face, large brain/cranium hominid architecture. Reason and Purpose aside, this may result in a world of surgical manipulation, machines and plastic tubes.

    Darwin’s observation of species survival implicates nature and nature’s course of alteration and/or termination. It is possible the neck and jaw could radically change for accomodation with rapid evolution naturally. However, it is conceivable the hominid species, now Endowed with the Capability of genetic DNA manipulation, will be motivated to make the necessary structural changes.

  2. They do apnea related re-structuring of the jaw by orthodontics. More room, less apnea. I wonder if todays technology would be up to making “noseodonics” (ok, it does not really work, but you know what I mean). Perhaps some physical splints supplemented by some biochemical “encouragements” and some very special physical therapy could make the changes without surgery in the future.

    May we find a less painful way!

  3. Thank you for your site full of good information! I stumbled on it today after researching what a new doc told me. I have had insomnia, fatigue, and sleeping very lightly since i was a child. My sleep problems have gotten much worse in the last 10 years as well as my depression, anxiety and other medical conditions. I was completely dependent on Ambien for 6 years, could not sleep hardly at all without it. Last fall I saw a sleep doc in my town who I felt barely listened to me, regarding my poor sleep and concern of my Ambien dependence. He had me wear and “Actiwatch” for 2 weeks and reported to me the study showed I “don’t move a lot when I sleep or get up frequently”. I already knew this as I sleep so lightly I know when I get up. He refused to do a sleep study, said I was too thin for sleep apnea and sent me to a sleep therapist. I did very strict sleep hygeine/restriction in the spring this year with a therapist to come off Ambien, and did so successfully. I was finally falling asleep without meds and often not waking up much in the night (but i was still more than he preferred). But i was still so tired. I was even more tired than when i was using Ambien. And now I am dozing frequently during the day (which is a new thing since stopping Ambien). I haven’t for a few years been able to actually take a nap over 5-10 minutes despite how sleepy I am. My sleep therapist ran out of ideas, said i was doing everything he could have me do, and referred me to a Neurologist who specializes in sleep disorders 2 hours away from me. When I was seeing him I informed him I had upper and lower jaw surgery for a large underbite 11 years ago and he mentioned my large tongue appears too big for my mouth. He mentioned physical problems you have listed on your site that my primary doc could find no reason for….cold hands and feet, cold intolerance, dizziness, headaches, IBS, GERD, ear and sinus pains/fullness, etc. He told me I might have sleep apnea. I was blown away…I am female, thin and live alone…no one has ever heard me snore or breathe weird, but I sleep so lightly if someone stirs next to me or wakes up, i wake up with them.
    So to finish my long comment, I have a sleep study coming up in a few weeks. I am afraid I will not sleep but am looking forward to a possible answer for my debilitating issues. Reading your site confirmed some of the new things he told me. I hope this information can get out there more so more sleep docs don’t overlook thier desperate patients who don’t fit the “overweight, snoring, male” mold. Thank you!!

  4. Jeanette,

    Thanks for sharing your story. Good luck with your sleep study. However, there is a chance that you may not officially have obstructive sleep apnea for the following reason: You could stop breathing 20 to 30 times every hour, but each episode may not last long enough (over 10 seconds) to be classified as an apnea. Please take a look at my articles of upper airway resistance syndrome.

  5. I knew I’d been reading your website too much when yesterday I saw the Disney movie “Brave” with my 5 year old and couldn’t stop thinking about how the heroine, Princess Merida, had a small, recessed jaw and other facial features that surely would lead to her suffering from sleep apnea. Meanwhile the rest of the theater was concerned about her being eaten by bears or whatever…

  6. Thank you so much for this article as well as What Everyone Should Know About Tonsilectomy! You just put everything I have been searching for in one great site. My 7 year old son was diagnosed with sleep apnea a few weeks ago and the ENT wants to put him on a cpap instead of remove his tonsils (his adnoids were removed at age 2). This decision was based on the fact that his tonsils were only 2+ at the office visit. What this doctor didn’t bother to listen to was that he had just completed 21 days of antibiotics due to a sinus infection which contributed to their current size, otherwise they would be and have been much larger. He has a history of chronic sinusitis, chronic allergic rhinitis, tonsilitis(never cultured since they were treating with antibiotics anyway), ear infections, asthma, reflux, sensory issues, craniofacial abnormalities, and now possible ADHD and sleep apnea. He is taking the max of everything possible to control symptoms so I feel like treating the cause is more in order, right? He let me know that he didn’t feel that removing his tonsils would open the airway enough to benefit him then told me that he won’t have to use a cpap his whole life because his tonsils would shrink as he gets older creating more room for him to breath. Yeah, he said that! I realize that the doctor may be causious because he also seen a history of pulmonary stenosis in the chart but it is very mild and he has been cleared for another surgery that has been put on hold until this is dealt with. I have lots of questions for you. Isn’t there enough indication for a tonsilectomy with a diagnosis of sleep apnea even if you don’t consider the remaining list of indicators? What can I do to convince this man that this will help him even if it doesn’t cure sleep apnea 100%? How the heck do you keep a cpap or bi-pap on a 7 year old with sensory issues when grown rational adults can’t tolerate them well? Aren’t cpaps contraindicated for people with reflux due to aspiration and bi-paps contraindicated for those who have chronic congestion? The most important question is can you move your practice to WV and bring a good peds group with you, we REALLY need you? LOL ;-)

  7. Hi Dr. Park – I’m very interested in what you say about the removal of teeth and sleep apnea. Ever since i had my upper and lower wisdom teeth removed i’ve been having progressive trouble breathing, feeling like a constriction at the back of my throat. It doesn’t help that I’ve had my premolars removed too. Is there any way to correct this situation in an adult, without jaw surgery?

  8. Dr Park,
    I really appreciated everything you had to say. I had several mouth problems that were not corrected until I was 20. Which meant I finally had all my permanent teeth by my 21st birthday. Lol
    I also had to have my upper wisdom teeth removed at 40. There are none on the bottom.
    I also have to purchase my glasses in the children’s section, because my face is small.
    I have had nose surgery to correct a deviated septum. And was diagnosed with Ménière’s disease.
    Recently I completed a sleep study, two I fact, because the insurance company wouldn’t approve the hospital study. I’m not heavy, I don’t have a big neck, and don’t have any breathing problems. So after the in-hospital study I have been given a cpap machine with a petite mask. I have had it a week and I’ve had a blister under my nose on the little part where your nose and upper lip area join. I followed all instructions to correct and now I have a red, bruised and painful nose, which the glasses do not help. All that said they are going to try to fit me with a pillow mask today. I aw string to do some research on what would be best for someone like me and that’s how I found your web-site. I know none of this is surprising to you, based on your findings. I was just wondering what you would suggest? I have been sleeping better, minus nose pain. I am not experiencing the sleepiness, and feel more equipted to do the things I need to do daily. I really appreciate your findings and it really explains several things for me. Thank you for helping feel like I’m not crazy. I look forward to hearing from you, and what type of mask would work well for this small faced women. Have a great day!

  9. Dr Park,
    I am preparing myself for MMA surgery for severe sleep apnea. I got my braces done and now waiting for the big day but my surgeon wants to remove my wisdom teeth but I disagreed because it made no sense to me. He said it will be easier for him to do the surgery if those teeths are removed. But I read and follow everything you write. I gain so much from your blog, videos and interviews.

    Thanks for making us aware of this issues. May god bless you and your family.

  10. Fuad,

    I’m not an oral surgeon, but my understanding is that technically, it’s sometimes easier to take out wisdom teeth when undergoing the MMA. Since your jaws will be moved forward, it’ll address any detrimental effects of teeth removal.

    Best of luck with your upcoming surgery.

  11. Oh my gosh, Dr. Park I almost want to cry when I read this! It finally all makes sense. Finally someone who understands. I’ve seen dentists and doctors saying “my jaw is to small! My chin is tiny! I can’t breathe!” And for them to say I’m fine, I have allergies, or I need braces… but not acknowledgeing the physiological cause that I can see in the mirror. I’ve been to 2 dentists asking if they’ll do adult palate expansion. They won’t. I’ve tried numerous other devices (nose cones, nasal sprays) but really I know it’s my long jaw, overbite and recessed chin that has narrowed my airways and leads to mucus blocking my throat at night. I wake up gasping and a cpap doesn’t work with the mucus. I can’t find a dentist in my country (thailand) willing to do palette expansion in adults so the only option (other than surgery) that I’m now working on is trying to expand my upper jaw by pushing my toungue up against the roof of my mouth. It’s painful on my toungue. It exacerbates my tiny chin by using the chin muscles in order to push my toungue up and keep it up (otherwise there’s no pressure) so I don’t know if this is good in the long run, but it’s the only technique I can use to try to expand my upper palette. Do you have any advice on this? Could it work, and how long might it take to reverse 41 years of toungue in lower position and mouth breathing? Feeling pretty hopeless and a bit let down by my previous dentists and current ones who can’t help. :(

  12. Kim,

    Sorry to hear. I hear about similar situations here in the US. Palatal expansion can help in adults, but not as well as for kids. Tongue exercise can help to various degrees but won’t give you dramatic changes in overall jaw volume.

  13. Yes, I have something to say! What do we DO ABOUT THIS?!!! I am recently married (for 5 years now) and my husband has a small jaw – he has severe obstructive sleep apnea and no one seems to be able to help us!!! The CPAP machine is not working. We have a doctor who does not seem to know what he is doing and does not understand the extent of how this problem is affecting our lives together. My husband is young – only in his mid to late 20’s when this problem started. He is not overweight. He is exhausted all of the time because he cannot sleep properly.

    I have had a suspicion that it has had to do with his thicker neck and small chin. He has tried every solution imaginable and is at his wits end. WHAT DOES A PERSON DO IF THEY HAVE A SMALL CHIN? WHAT IS THE SOLUTION? This article is great and probably the best I have read about sleep apnea, but it does not say what a person (adult) should DO to remedy this issue. What can be done? We are desperate for answers. What can an adult do in order to be able to breathe at night if they have an overcrowding issue due to the development/shape/size of their jaw, neck, and face? Thank you so much as any help would be tremendously appreciated.

  14. Great essay Dr. Park!

    I think you and your readership might be interested in anthropological and ultrasound data which suggest that initial detection of isolated/non-syndromic retrognathia in industrialized populations, is first in utero; however, fetal skull specimens from our Penn Museum crania studies suggest that in utero retrognathia did not significantly occur in humans until after the Industrial Revolution. And given what is now published about how maternal SDB/OSA during pregnancy can increase risk for IUGR, it seems that a general lack of catch-up/compensatory craniofacial growth during infancy/early childhood, secondarily to lack of (‘ancestral-type’) breastfeeding and Baby-led weaning, is at play here and at least in part helps explain the modern epidemic of chinlessness in fetal through adult life

  15. Dr. Boyd,

    Thanks for commenting. I have mentioned in my articles and lectures the importance of a healthy pregnancy in relation to craniofacial development of the developing baby. This is in line with a study showing higher rates of sleep apnea in premature babies.

    Do you have references to the studies you mentioned?

  16. Dear Dr Park,

    Thank you for your article! This view is consistent with Orthotropic principles developed by the orthodontist Dr John Mew.

    Resting oral posture is the primary driver for the expression of genetic blueprint a child undergoes during their growth and development. Poor development of the jaws is the consequence of open mouth resting posture with in particular how close together the teeth are and how far off the palate the tongue is during sleep periods.

    The jaws are unique in the hard bony complex of the body due to the enormous variation of dentoalveolar (teeth bone) form based on tooth position changes from the teeth eruption and changeover process. In addition and in particular the mouth houses the one and only striated (movement) muscle of the body that has a free end. Unlike all other striated muscles our tongue has only one fixed end at the hyoid bone. As a consequence the tip and top is excessively free to move and can rest in any number of positions. There is however a theoretical point of hard tissue insertion, the palate. Whether the tongue rests fully on or off the palate actually determines if the jaw circuit is complete or broken and paired correctly or not.

    If in the growing child they rest mouth open, even slightly then their growth in these bone structures will be compromised. Would it really be a surprise if you cut off the Achilles’ tendon in a child, to see the lower leg develop crookedly?

    Actually this brings on the spotlight of a very important misconception. The jaws have always been perceived as a pair but anatomically they are nothing alike and must actually be considered a set. Sets of course must be arranged in order to make any sense.

    Jaws held shut fully with lips touching, teeth in contact evenly and tongue simultaneously on the palate and floor of the mouth is a complete circuit and have no choice but to grow in balance and to full dimensions. It is only when jaws are held in this position at night when growth hormone is released that they grow correctly (the Orthotropic Tropc Premise). This is the only way growth balances evenly in order to correctly house the tongue completely in the mouth and carry it fully out of the pharngeal throat space.

    Every organ in its place with its own space.

    Every intraoral mm of crowding has no choice but to drive the tongue to share throat space. Extractions, early tooth loss, and any form of retraction appliance; whether it be CPAP mask pressure, fixed orthodontic braces or functional orthodontic appliances pulls the growth child’s face down and back.

    If the jaws are not widened, protracted and raised and held by pressure from an upward and outwardly rested to tongue in a habitually fully closed mouth resting posture, then indeed out future is bleak.

    A child’s posture must be monitored and corrected. Spinal, oral as well as mental and moral for their growth to be upright and true. crookedness needs to be straightened out into the light and not hidden in the dark recesses, for the consequences of poor vs good form run through our lives.

    Regards,
    Dr Simon Wong

  17. This piece is brilliant Steven and thank you so much for it. Every parent needs to hear this. There’s one piece that you did not mention…

    You did mention the size of the airway secondary to craniofacial form as being important. So true. You did mention the condition of the airway which can lead to further obstruction. Also very important, but you did not mention the speed at which the air moves through the tube. The velocity and volume of air passing through the airway also dramatically affects how the airway behaves. I know you understand all this because you’ve had breathing physiologists as guests on your show but it deserves another mention.

    When you over breathe – that is, when you breathe at a faster rate and larger volume then you need to – you also create more suction in the airway which of course creates more collapse.

    Just as our faces are changing in the modern environment so is the way we breathe. We are metabolically challenged by the food air and water that we now consume. Overbreathing is just as common is crooked teeth and also needs considered in our diagnosis and treatment planning of poor Airway function.

  18. Barry,

    Thanks for the reminder. You’re absolutely right! This is something that I am seriously mulling over, and will be incorporating this concept more fully in future discussions.

  19. Thank you Dr Park for writing this! I am new to the pediatric craniofacial development community. Pushed into this because I have 5 children with OSA. I am an Airway Dentist that has been helping adult OSA patients with Oral Appliance Therapy for over a decade. I wish I could have gotten to these adults when they were 4 or 5! What different lives they may have!
    Do you have any suggestions on how I can reach out to the ENT community in St Louis? How can I help show them that we should all be working together collaboratively if we really want to HELP these kiddos?
    Stacy Ochoa, DDS
    Diplomate, ABDSM

  20. Dr. Ochoa,

    Sadly, most ENTs and most mainstream sleep specialists seem not very interested. They go strictly based on the AHI, which is not very useful with craniofacial airway narrowing. I even presented a session at our recent otolaryngology academy meeting showing severe multilevel obstruction during sleep endoscopy in patients with AHI < 5. Most of the feedback given was skeptical. Sleep apnea is still seen as seen only in obese people and since medical insurance doesn't cover most orthodontic dental airway options, then it's not something that MD/DOs will recommend readily. My recent focus has been reaching out to orthodontists, who are much more receptive to this concept.