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Episode #299: The Missing Piece in Skeletal Growth and Development with Dr. Rebecca Bockow

the best practices show podcast May 10, 2021

Airway dysfunction can lead to a number of comorbidities — anything from tooth decay to behavioral concerns. And to prevent them, it’s important to understand the possible causes. One of them is an undersized jaw, and Kirk Behrendt brings on Dr. Rebecca Bockow to talk about what influences skeletal growth and development, and the importance of early treatment and intervention. For more on identifying and treating tongue and respiratory dysfunctions, listen to Episode 299 of The Best Practices Show!

Main Takeaways:

  • Dentists may be the first providers to identify airway issues in patients.
  • Key things in skeletal growth and development happen as early as during breastfeeding.
  • Breathing and tongue placement habit strongly influences skeletal growth.
  • Undersized jaws can lead to comorbidities.
  • Ask patients open-ended questions to identify possible issues.
  • Look to early treatment and early intervention.
  • Treat the “why”. Look for tonsils, airway issues, and tongue-ties.
  • Understand structure, function, and behavior.


  • “When we see malocclusion, we might be, as dentists, the first providers to identify for some of these patients that they do in fact have an airway issue. So, this can present, for example, grinding. Grinding in kids and adults is a sign that airway is not great. We can pick up tongue- ties. Certainly, the easy ones to pick up would be a crossbite, open bite, underbite, overbite. These are all linked to airway dysfunction. So, once you see it, you can't not see it. And you'll start to see how prevalent it is.” (05:11—05:48)
  • “As care providers, we can sometimes ask open-ended questions for the patient, ‘How do you sleep?’ And it opens up Pandora’s box. ‘Oh, I wake up through the night. My child couldn't breastfeed. She’s still wearing Pull-Ups at age eight. We've got a lot of behavioral concerns, not paying attention in school, comes into my bed every night, tired during the day.’ And we, as orthodontists, see the crossbite. And so, all of a sudden, we’re tying things together for these families that they didn't even know were connected.” (05:49—06:28)
  • “If we think about skeletal growth and development, a lot of the key things that happen happen really early on, going back even as early as breastfeeding.” (07:20—07:28)
  • “Thinking about the tongue, all of those movements [when breastfeeding] require a great deal of coordination, as well as flexibility and strength. And so, if you have a child that has a condition called apraxia, and there's a lot of nuances to this, but globally thinking about a child’s ability to move the tongue in a way that's healthy, so getting that tongue up and forward, things like muscle incoordination or things like tongue-ties are going to adversely affect what's going to happen with the tongue.” (08:12—08:49)
  • “The nose is a natural filter. When you have the ability to breathe through your nose, the nose is going to humidify the air. It moistens the air. You filter out all the dust, the allergens, the pollens. Adenoids and tonsils are hypertrophic tissue, so if you have a child that's a mouth-breather, we tend to see bigger tonsils, bigger adenoids. And so, this cycle continues because they're more driven to breathe through their mouth, because now they have nasal respiratory obstruction.” (10:21—10:48)
  • “There's great documentation that links nasal respiratory obstruction with undersized jaws. And then, we start to see other comorbidities that we would notice as dentists, which include grinding, high carious incidents, hypertrophic tissue such as the gum tissue. And the cycle goes on and on. As orthodontists, we see this as crowding because the jaws are small. So, there's insufficient bone to accommodate the eruption of the adult dentition. And so, it’s sort of this aha moment when we start to link what goes on early with breathing and tongue function or dysfunction and the way that we see the jaws grow.” (10:49—11:32)
  • “It’s the way we breathe and what we’re doing with our tongue that really influences skeletal growth. And so, you can take one child that has a deficient maxilla, maybe deficient mandible, and we expand, and we get growth back on track, tongue is able to come up and forward, we establish proper nasal breathing, we establish lips together. And that particular child’s growth is going to progress in a really positive, healthy way.” (14:30—14:55)
  • “This young man, [at eight years old], we did expansion. But the tongue continued to come forward. He saw ENT. ENT said, ‘There’s nothing to do here.’ I don't think they made it to myofunctional therapy. But they saw the pediatrician, they saw a lot of other providers, and no one really had answers for them. And so, they did nothing. Now, we see him again at 12, and the lower jaw is still small. And so, was it a bad grower? Did we not do the right thing? Is it maybe that kids are breathing with their mouth open that that tongue is coming forward? . . . In orthodontics, we would label these as “bad growers”. But maybe we’re missing something.” (15:43—16:41)
  • “Historically, a lot of orthodontists will use things like tongue tamers. Which, yes, it prevents that child from bringing their tongue forward. But once you take the tongue tamers away, who’s to say that's a stable change? We need to really try to identify the etiology. So, looking for tonsils, look for airway issues, and then look for tongue-ties.” (18:48—19:11)
  • “Try to understand structure, function, behavior. So, structure, meaning the jaws. Function, meaning can a child breathe through his or her nose, does the tongue have the physical mobility to come up. And then behavior being, is the child or the adult able to breathe with lips together, able to breathe through their nose in a habitual manner.” (19:26—19:47)
  • “I've seen adults that have had four teeth taken out, and orthodontic mechanics to try to retract everything, retract everything. The tongue pushing is going to lead to the teeth in this proclined manner. So, you could bring everything back, and you could go so far as to take out teeth to bring it back even more. But airway will always win.” (19:55—20:20)
  • “If we see a child, let's say a five-year-old, six-year-old, and they constantly are biting their lower lip. So, now, they’ve become their own functional appliance, but in the wrong direction. So, that constant lower lip entrapment, if we as orthodontists do nothing about that and we let them continue into age 12, of course the mandible is going to be small. Of course they're going to have a persistent overbite. And then, talk about mouth-breathing, they can't get their lips around the teeth because the upper teeth are so protrusive. And so, the cannons of orthodontics say don't treat a small mandible until the patient is in their pubertal growth spurt. I can't say that that's wrong, but I also have a lot of questions about that. So, maybe we have to look at what's happening in terms of habits early on.” (26:46—27:36)
  • “It’s forming these connections and looking at things in a really different way. We’ve never asked the question: why do we see crowding? As orthodontists, we’ve always thought, ‘How can we fit the teeth together?’ So, this is a real paradigm shift saying, ‘Why? Why is there crowding? Why do we have the open bite? Why do we have the crossbite, the underbite, the overbite?’ And when we treat the why, when we treat the etiology, not only can we get a more stable result, potentially, but we’re also going to hopefully have a healthier patient.” (30:45—31:14)


  • Dr. Bockow’s background. (03:27—04:22)
  • Why this is an important topic in dentistry. (04:51—06:33)
  • Apraxia, mouth-breathing, and mandible growth. (07:15—11:32)
  • How the pandemic mask-wearing is changing how we breathe. (11:45—13:12)
  • What influences skeletal growth? (13:52—16:45)
  • Identify the etiology. (17:32—20:52)
  • Work on structure, function, and behavior. (22:02—23:22)
  • Advice for dentists looking for a myofunctional therapist. (23:53—24:44)
  • Early treatment and early intervention. (25:12—28:21)
  • Coaching for kids and adults. (28:56—29:56)
  • The future of airway and orthodontics. (30:41—31:17)
  • How to get started. (31:38—32:16)
  • Dr. Bockow’s practice. (32:49—33:08)

Reach Out to Dr. Bockow:

Dr. Bockow’s website: https://inspiredortho.com/

Dr. Bockow’s Instagram: @rbockow

Further Reading:

Spear Education: https://www.speareducation.com/

Dr. Rebecca Bockow Bio:

Dr. Rebecca Bockow is a dual-trained orthodontist and periodontist – the only dual-trained provider in Seattle and one of only a handful in the country.

She grew up in the Greater Seattle area and attended University Prep for high school. She received a B.S. in Biology with Honors at Haverford College, where she also played Soccer, Squash, Tennis, and ran Cross Country and Track. She completed her DDS training at the University of Washington Dental School in 2007. Dr. Bockow practiced as a general dentist in Seattle for two years while simultaneously teaching at the UW dental school.

Dr. Bockow completed a highly selective dual-specialty program combining Orthodontics and Periodontics at the University of Pennsylvania. She is a board-certified orthodontist and periodontist. While simultaneously enrolled in two residency programs, she also received a Master of Science in Oral Biology, focusing on intranasal Ketorolac for postoperative implant pain management.

Dr. Bockow lectures nationally on periodontics, orthodontics, interdisciplinary orthodontics, airway, and skeletal growth and development. She contributes to multiple professional journals as an author and editor. Dr. Bockow is also a resident faculty member at Spear Education.


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