Dr. Marisa Santos in Buenos Aires has shown me what may be possible within early airway and craniofacial care.
After following her work, I reached out with questions about when she begins evaluating children, how her team approaches early expansion, and how nasal breathing and oral posture fit into the process.
The following exchange reflects that conversation. It represents one professional’s clinical approach and should not be interpreted as universal treatment guidance.
At What Age Do You Begin Evaluating and Treating Children?
At what age do you start measuring young children? Do you use a 3D CT scan, or is there another approach that does not involve radiation?
Dr. Santos’s documented response:
“I begin following children when they are babies, but I begin treatment at age three. In our transdisciplinary protocol, children are first referred to an ear, nose, and throat physician.
“At the university and within our master’s program, we have an ENT on the team evaluating each child. Our diagnosis is based on photographs, videos, and questions for the parents.”
What Determines Whether Early Expansion Is Considered?
Outside of having enough teeth to support an appliance, what else determines when you begin expansion with young children?
Dr. Santos’s documented response:
“Pediatricians around the world recognize that malocclusion and craniofacial abnormalities may tell us something is wrong with the airway, but relatively few pediatric dentists or orthodontists recognize this.
“I expand the upper and lower jaw in many children between ages three and six. I prefer expanding while the child still has primary teeth and before age six.
“But it must be done with a team. It is not only expansion. We need an ENT at the beginning to evaluate the nose, adenoids, and tonsils. After expansion, we use 90 days of GOPEX to work toward healthy oral posture.”
This describes Dr. Santos’s reported protocol. It is not a Project Airway recommendation that every young child receive expansion. Treatment decisions require an individualized evaluation by appropriately qualified professionals.
Do You Measure Nasal Resistance?
Do you measure nasal resistance in young children when determining whether they can breathe comfortably and whether expansion may be appropriate?
Dr. Santos’s documented response:
“Yes. It is a must. In every case, we evaluate nasal resistance.”
What Intermolar-Width Measurements Do You Use?
What measurements do you use to determine how much expansion may be needed or when development is adequate?
Dr. Santos’s documented response:
“We do not yet have established measurements for these ages. Within the master’s program, we are working on a paper measuring five-year-old children, so we hope to have more information.”
How Long Does Early Treatment Continue?
If a three-year-old has an intermolar width of 26 millimeters, would you typically expand for several months and stop, continue slowly for several years, or use multiple appliances as the child grows?
Dr. Santos’s documented response:
“At age three, I expand as much as I appropriately can. Treatment lasts approximately six months, followed by three months of GOPEX.
“Then I allow one year without the appliance. When the child returns, we evaluate chewing and oral posture. If those areas are doing well, the child may not require another round. If not, we may consider another period of expansion.”
Why the Team Matters
What stood out to me was not expansion by itself.
It was the coordinated process:
- Evaluation of the nose, adenoids, and tonsils
- Assessment of nasal resistance
- Structural evaluation
- Expansion when clinically appropriate
- Attention to chewing
- Attention to oral posture
- Follow-up rather than assuming one intervention completes the process
No single provider owns the entire airway story.
The strongest approaches appear to recognize the need for collaboration between medical, dental, sleep, feeding, and functional professionals.
Learning From Different Professionals
Dr. Courtney Donkoh is another professional whose work influenced my thinking about treatment and early prevention.
What stands out to me is the number of tools available within her approach.
A provider who understands several methods may be able to select an approach for the person in front of them instead of forcing every patient into one standard protocol.
Things do not need to be perfect.
The goal is to keep learning, study outcomes, understand where an approach succeeds or fails, and improve the decisions made for future children.
Dr. Kevin Boyd’s work also influenced my interest in early intervention.
His discussions about anthropology, craniofacial development, and younger pediatric patients encouraged me to question whether families and providers are waiting too long before beginning the conversation.
The Tension Between Evidence and Action
Parents do not want to make the wrong decision.
Professionals do not want to recommend an intervention before they feel confident in the supporting evidence.
Those concerns are legitimate.
Airway development is also an evolving and sometimes controversial area. Different professionals may interpret evidence differently, use different methods, and disagree about when intervention is appropriate.
Waiting is still a decision—but taking action without an adequate evaluation can also create risk.
The answer is not blind action or permanent inaction.
It is better information, appropriate screening, qualified professional collaboration, informed consent, careful follow-up, and a willingness to adjust when the evidence or the child’s response points in another direction.
Questions Before Treatment
Before pursuing an intervention, parents can ask:
- What specific finding are we trying to address?
- How was that finding measured?
- Is the concern structural, functional, medical, behavioral, or a combination?
- Which alternatives should we consider?
- What evidence supports this recommendation?
- What are the risks of treatment?
- What are the risks of waiting?
- How will progress be measured?
- Which other professionals should be involved?
- What would cause the treatment plan to change?
Paving the way does not mean pretending every answer is already known.
It means remaining curious enough to ask difficult questions, responsible enough to respect uncertainty, and committed enough to keep improving the process.
