Why Dr. Shapiro Wouldn't Commit to a Plan on Limited Records

Why Dr. Shapiro Wouldn't Commit to a Plan on Limited Records

In a recent TikTok, Dr. Lucas Shapiro of Wall Street Orthodontics reviewed a case with an important caveat attached: with limited records available, it was genuinely hard to tell whether the patient's bite, as shown, reflected how they actually bite together day to day.

Watch the original TikTok here: https://www.tiktok.com/@drshap/video/7664230158752091406

That hesitation is the real lesson in this video. Rather than jumping to a recommendation based on a single photo or a quick look, Dr. Shapiro laid out how the treatment plan would change dramatically depending on whether that bite is the patient's true, habitual bite, or something else, like a shifted jaw position captured in that moment.

Why "How Someone Bites" Isn't Always Obvious from Limited Records

A single photo or a brief clinical glance can be misleading. Patients can posture their jaw forward, backward, or to one side without realizing it, especially during a quick exam. Determining someone's actual, functional bite typically requires a full diagnostic workup, not a snapshot. This is why comprehensive records, including 3D CT Scanning and detailed Digital Impressions (iTero), matter so much before committing to any treatment plan, especially one that could involve surgery.

This is the same principle we've emphasized across other cases: a treatment plan is only as good as the diagnosis behind it. Skipping that step, or working from incomplete information, risks recommending (or ruling out) surgery based on a bite position that isn't actually the patient's real, day-to-day occlusion.

If This Is the True Bite: Why Expansion and Jaw Surgery Together

If the bite shown does turn out to be the patient's real, habitual bite, Dr. Shapiro is clear about the ideal treatment: a combination of expansion and jaw surgery. This combination typically comes up when a patient has both a transverse problem (a maxilla that's too narrow) and a skeletal jaw discrepancy significant enough that braces or aligners alone can't fully correct it.

As we cover in more detail on our Expansion page, a narrow upper jaw can contribute to crossbites, crowding, and airway limitations. In growing patients, that width problem is often corrected through early intervention and traditional palatal expanders, since the mid-palatal suture hasn't fused yet. In adults, that suture has matured, so achieving true skeletal expansion requires a different approach.

The Adult Expansion Spectrum: FME, MARPE, MSE, and SARPE

For adults, expansion isn't one-size-fits-all. Depending on the patient's skeletal maturity, the amount of width needed, and whether jaw surgery is already part of the plan, treatment may involve:

• FME (Facegenics Midface Expander) – a midface expansion approach that can address broader maxillary and midface deficiencies, often considered for patients whose needs extend beyond the dental arch alone
• MARPE (Miniscrew-Assisted Rapid Palatal Expansion) – uses temporary anchorage devices (mini-implants) placed in the palate to deliver expansion force directly to the bone, allowing many adults in New York City to achieve meaningful skeletal expansion without more invasive surgery
• MSE (Maxillary Skeletal Expander) – a bone-anchored expander design that, like MARPE, relies on direct skeletal anchorage rather than tooth movement, often considered for patients needing more robust expansion forces
• SARPE (Surgically Assisted Rapid Palatal Expansion) – involves a minor surgical procedure to release the fused maxillary suture before activating the expander, typically reserved for more skeletally mature adults or cases requiring a larger amount of expansion

When a patient also has a jaw base discrepancy severe enough to need orthognathic surgery, expansion (often SARPE) can be planned alongside that surgery so both the width and the position of the jaws are corrected together, rather than treating one issue and leaving the other uncorrected. Our Surgical Orthodontics page covers how these more complex, jaw-based corrections are approached.

The Alternative: Compensating with Braces or Aligners Alone

Dr. Shapiro also acknowledges the other path: it's often possible to compensate for this kind of bite using only braces or clear aligners, without expansion or surgery. But he's honest about the trade-off, and it's an important one for patients to understand.

Compensating this way typically means flaring the upper front teeth (incisors) outward to close the gap between the arches, rather than actually correcting the underlying width or skeletal discrepancy. While this can be a reasonable option for patients who aren't candidates for or don't want surgery, it comes with real downsides:

• The smile often doesn't look as balanced, since the incisors are angled outward beyond their ideal position
• Excessive flaring can put the front teeth at greater risk for bone or gum recession over time
• The result may be less stable long-term compared to correcting the actual skeletal discrepancy
• The underlying airway or transverse issue driving the bite problem isn't actually resolved

Both Braces and Invisalign can achieve this kind of dental compensation when that's the right choice for a patient, but it's a decision that should be made with full understanding of what's being traded off, not just as a default to avoid surgery.

Why This Ties Back to Airway, Too

Expansion isn't just about making room for teeth. A narrow maxilla can also restrict nasal airway volume, which is part of why airway dentistry principles are built into how expansion cases are evaluated at Wall Street Orthodontics. When expansion is genuinely indicated, whether through MARPE, MSE, FME, or SARPE combined with jaw surgery, patients often see airway and breathing benefits alongside the bite correction, something dental compensation with braces or aligners alone cannot provide.

The Bottom Line: Get the Diagnosis Right First

This case is a good reminder that the "ideal" treatment and the "possible" treatment aren't always the same thing, and that neither can be determined accurately without complete records. Before recommending expansion, jaw surgery, or compensation with braces or aligners, a full diagnostic workup, including imaging of the actual habitual bite, is essential.