Speaker 1: 0:00

Quick disclaimer the Airway Circle Radio podcast has been produced for entertainment, educational and informational purposes only. All of the content, views and opinions shared by our hosts and guests should not be a substitute for medical advice. Please consult your healthcare professional for any medical questions. Welcome to the Airway Answers podcast, expanding your Breath of Knowledge. Our wonderful host is Nicole Goldfarb. Nicole is a speech-language pathologist, certified orophacial myologist and an international speaker. Nicole is the owner of San Diego Center for Speech Therapy and Myofunctional Therapy. She has a special passion and interest in sleep-disorder, breathing and diagnosing restricted freenoms as they relate to myofunctional disorders. In the Airway Answers podcast, nicole will be interviewing specialists in the Airway Re-Aum in order to help our listeners learn and understand all of the components to Airway Focus treatment. You can help us by sharing this podcast episode with your friends and colleagues. Enjoy the show.

Speaker 2: 1:06

Hello everybody and welcome to Airway Answers Expanding your Breath of Knowledge, and we have, dr Jeremy Manuelle. Am I saying it correctly?

Speaker 3: 1:15

Manuelle. You probably say it better than me, so you know it's Italian and German Manuelle. And then now we just say Manuelle.

Speaker 2: 1:20

but you know, I was wrong, manuelle, I love the Italian.

Speaker 3: 1:24

There you go, okay.

Speaker 2: 1:25

But people, your patients, referred you as Dr J. Is that correct?

Speaker 3: 1:29

A little easier, yeah, A little shorter. The person is driving me, so you know that keeps it simple.

Speaker 2: 1:35

And Dr Manuelle is a dedicated orthodontist from Las Vegas, nevada, and he began his orthodontic journey at UNLV School of Dental Medicine and completed a two-year orthodontics residency at Louisiana State University Health Sciences Center. And he also continues to share his expertise as a part-time orthodontic instructor at the UNLV School of Dental Medicine. And Dr Manuelle has a private practice orthodontic practice in Las Vegas currently and this part of your bio I found also very interesting. Service is deep rooted in Dr J's story. Dr Manuelle's story.

Speaker 2: 2:14

Inspired by family tradition, he joined the Army National Guard at age 17, dedicating 21 and a half years of service to his country, including an 18-month field artillery deployment in Iraq in 2005 to 2006. His military journey culminated in retirement as a major from a local medical unit in 2022. Amazing and thank you for your service. That's amazing information. In his commitment to the orthodontic profession, dr J recently created the Marpe 360 online course, and that's one of the things we're going to talk a bunch about today. This course is a comprehensive continuing education course for dentists focused on airway health and non-surgical adult and teen skeletal expansion. Driven by a genuine passion for teaching, his focus continues to be on the professional growth of the orthodontic community as a whole. So welcome, dr J.

Speaker 3: 3:13

Thank you, and thank you so much for having me. I'm truly honored to be here.

Speaker 2: 3:16

This is going to be fun. I'm so excited because I have taken part of the course and I'm not finished and I said I need to get Dr J on here right away, even before I'm finished the course, because this course is so good Marpe 360 course. So do you want to talk a little bit about your background, your experience and then what the course is?

Speaker 3: 3:36

Sure, that's interesting, because if you would have told me about 10 years ago, when I was in residency, that I would be practicing orthodontics the way that I am, I wouldn't have believed you Like I would have said no, you're crazy, there's no possible way. My experience with airway orthodontics or even early treatment was very limited in residency, and that's the same story as many of us orthodontists. It's just not something that's very prevalent. The traditional last 20, 30 years of thinking has always been well, if you can do everything in phase two, just do it in one phase. Don't treat them early. And so I had professors that would pull baby teeth and that was their solution to crowding. They'd pull some baby teeth and then they'd pull more baby teeth and two teeth need to come in. So they'd pull four baby teeth and eventually just set them up for serial extraction. And the idea was like oh great, their teeth are straight, wonderful. Our profession as a whole has been so focused on straightening teeth, no matter what. If you can get the teeth straight, great, do it. I just never resonated with me. It never made sense to me to set kids up for serial extraction. I'm like why is this problem happening in the first place. Well, they probably don't have room for their teeth and their jaws, and really it's the increased prevalence of 3D imaging that's really allowed. What I feel like is leaps and bounds of understanding and treating these cases and making sure that the underlying anatomy and the underlying problems are corrected.

Speaker 3: 4:51

And so my journey out of residency. I joined a practice who was fairly pro expansion. They did quite a bit of expansion anyway, and this is before we had 3D imaging. And as we've continued to learn and more of the airway physiology sciences come out and more research has come out as far as what we can do in changing the underlying jaw structures and the bones, I just kept kind of going down that road. Going down that road, it was never an endpoint that I was seeking out or that I necessarily wanted. It was just once you see airway, you can't unsee it. I've heard that said before and it's so true. And so you start to learn things and you start to see and understand the changes that are happening with these patients.

Speaker 3: 5:26

And as soon as I realized kind of how important this was, my next goal was to be able to get the information in the best and easiest way possible to as many people as possible, because, at the end of the day, the only way that this is going to progress and the fastest way that it is going to be able to move forward is if more people are involved.

Speaker 3: 5:46

And so you know, my journey on this road was very laborious many, many in person courses, which were amazing Like I'm so grateful for all of the educators out there in this space yourself included, I mean that go out of their way to provide good education for people, but at the same time, with this specifically, specifically in Marpe's MSEs, the education was very, very difficult to find, and so I wanted to put some good, research-based, quality education online where people can go and they can watch it on their own time and then, you know, give them the overview. And then, once they have the overview, well then they can seek out, you know, whatever else they want, but at least they have a clear picture of what's going on in this world and where we are currently with the research and a good base to start from, and so that was the goal with the course.

Speaker 2: 6:29

Yeah, and so far I'm about halfway through. But what I really appreciate about the course is it's not just like jump into Marpe, here's how you do it, but it's a whole background about what is airway tongue ties. How does this all relate? You put in such a comprehensive nature to this course? How do you foresee the course being? Is it like an introductory course before taking other courses, or how does it fit into all the other? And there's only, I think, a select few Marpe type courses out there anyways. But what are your thoughts?

Speaker 3: 7:02

Yeah, here's how I see it fitting in. So, you know, I structured the course in a way that it is comprehensive because, at the end of the day, I think the biggest resistance we have is from people who don't understand the big picture of why we're doing what we're doing. And so they see one case that comes into their office and they don't understand what's happening or maybe where the other doc was coming from, and so you know, then they can just, you know, poke holes in whatever they're seeing right. And so we have all this resistance in our profession as a whole to airway treatments, to Marpe's, msc, these things like that, because people don't understand it thoroughly. And so, you know, in the beginning I said, okay, here's the framework, here's the history. Like this is what you know. I started from a place of where all orthodontists start, basically, which is what we learned in residency, and from there, you know, that's when I expound into well, okay, since we left residency and other things that are, you know, happening since then, this is how this all fits in and this is why this is important. So I felt like that framework was critical in the beginning. Now you know whether or not somebody takes my course and then starts doing Marpe's or MSC's. Certainly, all the information is in there and some people are very good at learning from things like you know online recordings and slide, you know shows and PowerPoints, and there may be some people that take the course and feel comfortable doing treatment.

Speaker 3: 8:16

But that wasn't the main goal. The main goal was to help people understand what they need to know, like give them the overall view. So if they're going through this and they're like whoa, like this is pretty foreign or like well, I didn't know that could happen, that's going to set the foundation for do I want to do this? Is it something that I want to get involved in? And so I wanted them to have an understanding of the big picture, to make sure that it is something. Because when I started doing these like I did not that's why I named the course that what I wish I knew before my first MSC. There were so many things I didn't know about scale or expansion and it had I know those things going into it, I would have gone into it a lot differently. Personally, I probably would have taken other courses before I started doing some of the treatments that I did, and so the goal is to kind of help curb that learning curve a little bit and help people not get into trouble. Help them know what they don't know so that they can then decide what they do need to know and they can seek out those courses appropriately.

Speaker 3: 9:09

So I don't view this at all as a standalone. This is the only course you're ever going to need to take, for that matter. I don't think any of the courses out there are like that, because you only ever get one person's perspective. I think the perspective I provide is good. It's research based, it's fairly thorough, but it's not the only perspective I mean, and there's some other you know. There's many other great educators out there in this space who you know. I would highly encourage you to get as many perspectives as possible the more involved you get with these treatments.

Speaker 2: 9:35

Yeah, and your Marpy 360 course, like I said, is so comprehensive but it's also so detailed, so somebody could go right to installing Marpy appliances. You go through every detail of what comes in the kit when you purchase it, what are the different sizes of tasks. I mean every specific detail, how to install video, everything. It's really great and I feel like even as me being just a myofunctional therapist, a speech pathologist, I have a lot of patients that I refer to, marpy providers, and it's important for me to know all of these details. So, as speech therapists, myofunctional therapists, I think your course is great for them also, who wouldn't obviously be installing appliances, but just to know all of the details of what our patients are going through, what the orthodontist does in the whole process. I just thought it was really great.

Speaker 2: 10:23

And no course, I believe, is standalone ever, because in any field, if you think you can stop learning by taking one course and you're good, that's not good, right, myofunctional therapy, we must take many courses. It's never like take this course and you're done and you're good to go. So I think that's wonderful how you present it. And can you tell me about other Marpy courses you've taken, because it seems like you've learned from tops as well.

Speaker 3: 10:49

Absolutely. Yeah, you know. So I started my journey way back. I took Dr Juan Moon's course. You know, like in hindsight, like I love Dr Moon, I love what he's done for our profession. I mean, honestly, I don't think any of us would be doing the level of marpies that we're doing if he didn't, you know, design the MSC and really popularize it right.

Speaker 3: 11:05

I think his intent was to take something that's complicated and marketed in a way that it's a little bit easier to digest, and I think he was very successful with that. You know, that being said, there was a lot I didn't know because most of my initial knowledge was based on one specific type of appliance. And so you know, I loved this course. I thought it was very good, I thought it was very well organized. I didn't feel like it was necessarily complete as far as Marpie expansion in general, but he's not promoting it as such. He's basically promoting his courses teaching you how to use the MSC. So I thought that was good.

Speaker 3: 11:35

But after I took his course and started doing some MSCs, then I realized, okay, well, there's definitely some things here that aren't like I thought or that I needed to learn more about. So I took Dr Ting's course I took Dr Lipskin's course. Anytime I was at the AEO or other meetings where I could hear like Becca Bacow, audrey Yoon and all these speakers speak, I mean I would just I would go in and I would listen as much as I could. I learned a lot about complications from Audrey specifically, I mean, and Marianna.

Speaker 3: 11:59

They're both like very, very great at showing all the things that can go wrong, and again, it's I don't know if you've got to that portion in my course as well, but yeah, there's a lot that can go wrong. You want to know these things before you get involved and discover it for yourself. Dr Ting's and Dr Lipskin courses I loved both of them, both in-person courses, both very comprehensive. They have a lot of similarities but also a lot of important differences in the way that they do things, both very successful in their treatment approaches and yeah. So I mean I would like I say I would highly recommend any of those.

Speaker 2: 12:28

Yeah, no, that's great. And you had a lot of mentors. You said and you show pictures of all these people. I remember Juan Moon. Do you want to name some of the other people?

Speaker 3: 12:39

Yeah, let me see. Yeah, so okay, so Jeff Rouse. So Jeff Rouse, he runs the spirit group and so he has an Airway to Prostadonis course and so that was really fundamental in understanding the physiology. So part two of my course is basically my attempt at a summary. I mean he has a book, 300 pages long, that he gives you when you attend this course. He presents, you know, even more research than I could ever present in one hour. Part two of my course was to try and condense the physiology and the learning to Stanford research everything into a concise thing.

Speaker 2: 13:07

But most of that came from Jeff Rouse we talked about that I think in that part two sorry to interrupt, but I think in part two it was you also talk about like Excite OSA, the like East Immune, the Tung Mouth Taping, nasal Dilators, all different types of expansion. So that's what I mean is like wow, this is really great information beyond just installing a Marpy. So that's great. I just had to put that out there because I haven't seen other people talk about all those details.

Speaker 3: 13:37

Well, here's the thing I mean the more you get involved with patients who need airway treatment and sleep well and I'm going to say airway treatment the more patients you get involved that have sleep disorder breathing right, the more you have to learn about sleep disorder breathing.

Speaker 3: 13:49

And so when you network with ENTs, when you're networking with pediatric pulmonologists, when you're networking with sleep physicians, you know you start to be exposed and to learn new things and it's like, okay, well, this is great knowledge to have. So I mean, like, as there's probably a ton of things I still don't know about, I mean I just tried to share as much as I've come in contact with in the patients I've treated and with the people I've networked with. You know, again, try to get it all out there. I mean the ExciteOSA thing. I mean I learned about that last year for the first time, but again, it makes sense, right, as myofunctional therapy. It probably makes even more sense to you, right, because you've seen it just through the exercises that you do. You know for some people something like Excite and you know kind of a tens unit for the tongue that might work better and there's some research behind it, and so it's important to know about these things for sure.

Speaker 2: 14:29

In fact, my husband just ordered one today, so we're going to see how that goes as a supplement to myofunctional therapy, because it, you know, obviously wouldn't replace. But yeah, no, it's really interesting to have all of the different parts and put all the pieces together. So you had Jeff Rouse as a mentor for you, and who else?

Speaker 3: 14:47

Yes, so we talked about Dr Lipkin, dr Ting Lou Chimura he runs a great airway or I don't know if he does anymore, but at the time he ran an airway course with Henry Schein's group and they did a phenomenal job of breaking down sleep disorder, breathing in general. Sean Carlson and Jase Quintero they taught me a lot about 3D imaging in general, both airway volumes, but also just understanding 3D imaging and the 3D superimpositions that you see in the course were derived from the knowledge I gained from them and their understanding of how 3D imaging works and how you can use it to understand what's happening with your cases, which, in my opinion, will become the standard dialogue for these types of cases, to compare all types of cases, because if you have a 3D superimposition, you can see exactly what's really really happening, and so they were instrumental in that. Todd Scherer he is a prosodontist. He teaches with Marianne Evans. He was very, very helpful in the technicalities of the piezotone procedure. Things to watch out for are also complications. We talked about Audre Eune and Becca Bacow. Diane Barr so she actually lives in Las Vegas, so we've worked on some cases together and she's helped me understand a lot more about the babies and their growth and development and how the myofunctional craniosacral and how all that world fits into the stuff that we do as orthodontists, which was very, very eye-opening. Sarah Hornsby she was at a course with Dan Hansen and Donnie I'm going to mess up his last name Mandrara. They do a great course on myofunctional therapy which I took a number of years ago and that really opened my eyes to how successful myofunctional therapy can be and how important systems are within a myofunctional therapy practice and how myofunctional therapy is not apples to apples. It really does depend on where you go and their systems, because compliance is so important. So they helped me to understand how creating good systems can increase compliance and success rates for things like myofunctional therapy.

Speaker 3: 16:35

Mike Gunson is a surgeon. He lectures a lot with Becca Bakau, but understanding the surgical side of things is when Marpier MSC is limited was super important. Patrick McCowan he wrote the books Breath and also not Breath, I'm sorry. He wrote the books the Oxygen Advantage and also Close your Mouth. So networking with him and understanding you know breathing and nasal breathing specifically, and nitric oxide and the benefits that happen there. Shuru Zagi is I'm sure many of your constituents know him and know of him, so his wife was actually one of my pediatric dental residents Early on when she was in residency. We worked on a few projects together but his understanding and the literature he puts out about tongue ties, and even in adults, was very, very eyeopening and understanding how that ties into the big picture.

Speaker 3: 17:18

And then the other ones I talked about are Glenn Krieger, scott Fry and David Alfie. So Glenn and Scott, they're both kind of big in the orthodontic world as far as you know, having influence and voice, and Glenn's very airway, aware of the research and a very big proponent, went on his webinar and networked with him to help spread this message. And Scott Fry I put him on there because it was his Facebook posts that really led me to try my first MSC. So I don't know how involved he is with it Currently. I haven't caught up with him lately, but yeah, he's a good guy, great orthodontist, and he posted an MSC case a number of years ago and that was kind of you know, after I saw his results I'm like, okay, I got to look into this more. And then many of you probably know David Alfie. He's a great surgeon. He does network and teach with Todd Shear as well and he has, again a great approach to the surgical side and understanding those things as you get deeper and deeper into it.

Speaker 2: 18:04

This just shows how well rounded you are, the Renaissance man of the airway orthodontic person. You have so many different sort of mentors or people that courses you've taken. It's just really great to hear that. That's why I just love those airway centered, airway educated orthodontists, because you really are getting the whole big picture and it just helps us all work together so much better. Because we know these issues are multifactorial and I wanted to ask you I think sometimes people are confused when they hear MSC and Marpe and what's the difference? Could you just explain that?

Speaker 3: 18:38

Yeah, okay, so one and it gets even more complicated. So you look at the white paper. So Marpe is kind of the most commonly accepted terminology for any type of an expander that has screws that go into the jaw. So if you remember that, like anything, if it's an expander and if it has screws that go into the jaw, it's a Marpe. Okay, so sometimes they call them Marmes, all right, and the Marpe stands for mini implant assisted rapid palatable expansion. So that's Marpe. So Marme is mini implant assisted rapid maxillary expansion. It's just a difference in terminology. But the most common that you'll see in the literature and what most people talk about is Marpe. But you know, just if people are reading things, marme is the same thing. Okay, so now there's different types of Marpes, right?

Speaker 3: 19:19

So MSC, specifically MSC type two, that is the most common type of Marpe and probably the most popular Marpe in the United States, and that's one moons Marpe. So it's a non custom Marpe, meaning that it's just an. It's an appliance. It's basically an expander that has four lumens in it, that you can put four screws in, and so you can customize it in that you can move it right. You can move it forward, you can move it back. It's typically designed and placed by a lab, but the appliance itself is, you know, it's not typically customizable. I mean, you could laser weld to it and customize it on your own, or your lab could customize it, but it's not like a custom Marpe like you'll sometimes hear about. Okay, so the MSC and most of them are four screws. They do make a six screw version, as we talk about in the course, but that's kind of MSC type two. That's sort of like you know you order a bunch of them and that's kind of like a standard expander that works really well on a number of patients. All right, but there are limitations to that because it's not fully customizable and we go over that in the course.

Speaker 3: 20:17

Now, a custom Marpe currently the only company that I'm aware of that are doing them right now is Partners Dental Studio and what that does is basically it is a Marpe, right, so it's an expander that has screws in the jaw, but with that you can stitch the cone beam of the patient to the STL file of their teeth and you can 3D design exactly where you want those screws to go. So basically, you can find the best bone and you can have them place those screws into the best bone, and then they'll also do the work of doing the measurements as far as how long of a screw you're going to need in this place versus that place, and then you can fully customize it to distalize molars or intrude this side versus that side. You can add stuff to the appliance, and so that's when they talk about a custom Marpe. Typically they're talking about, you know, partners Dental Studio stitching the cone beam and the intraroll scan together and planning it out that way.

Speaker 2: 21:06

Okay, that's great, because I think sometimes it's a little confusing when there's both people. You might use MSC and Marpe back and forth, but MSC is a type of Marpe and then there are types within there. So in the course you talk about different expansion appliances and techniques. You kind of go through our RPE rapid pellet expanders, slow turn growth guidance and then you get to Marpe. Could you talk a little bit about each type of expander and what they are, what they do, summarize the differences?

Speaker 3: 21:35

Yeah, so trying to keep it as simple as possible, you know, and this is one of the challenges, right, it's because we all have a different name, but we all just call them expanders. But what I try to go through in the course and point out is that you know, expanders are not expanders are not expanders. You know, the type of expander that you use really does make a difference depending on the type of goal that you have, right? So I mean, I've had patients come in and say, oh yeah, my orthodontist expanded me and I'm like, okay, cool, like what would they expand me with? It's like braces and wires. It's like, okay, cool. And I'm not going to say that you can't expand somebody with braces and wires. I mean Mike Deluxe, a great example of that. He shows a lot of, you know, before and after comb beams and you know you do get some types of expansion with braces and wires.

Speaker 3: 22:14

But my goal with going through the different types of expanders was to really highlight and understand what type of expansion you're going to get, depending on what type of expander that you use. And so if your goal is dental expansion, meaning you're moving the teeth and not the bones, that's great. There's a lot of different types of expanders that have been shown to do that Right. I mean, braces and wires are most notoriously known for dental type expansion, although they can get some skeletal Alpha appliances are mostly known for dental type of expansion. You know, and depending on the age of the patient and whatnot you know, you may be able to get a little bit of, you know, dental or bender and things like that. But really, you know, when you're looking at orthopedic expansion and that's really what most people are interested in obtaining, when they're going and looking at MSEs and Marpees right, or Marpees in general, they want to get orthopedic expansion. So when we look at the literature and what provides orthopedic expansion and just so your listeners understand what I'm talking about here orthopedic expansion means that the entire two halves of the top jaw are separating and getting wider. Okay, so that goes all the way up through the nasal cavity, because you know the top of the top jaw is the bottom of the nasal floor. So when we're talking about orthopedic expansion we're meaning expanding all the way up the entire two top jaws.

Speaker 3: 23:29

When you talk about that type of expansion, you really only have well documented, you know, a few types of expanders that do that. So traditionally it was all RPE rapid palatal expansion and then they found out over time that, you know, depending on the age of the patient, you can still use, you know, a rapid palatal type expander you can turn it a little bit slower, and now they call it a slow maxillary expander, and that can provide orthopedic changes as well. And then there are even some lower force expanders than that, leaf expanders. You know, sometimes even quad helix, depending on the age of the patient, that can provide some orthopedic changes as well. So when it boils it down, what you have to understand is that there's not just one set type of expander that's going to work and provide, you know, orthopedic or dental alveolar bending or tipping. It's all very patient specific. But if you want to understand it in a comprehensive way, there's really only two things that are involved in knowing what kind of expansion you get, and that's going to be, you know, the force applied and the resistance. Okay, so the reason that you know so many people present so many different cases and oh well, I got expansion with this, I got expansion with that is because they're looking at different patients. Different patients have different resistance. So when we look at a four year old, for instance, we might be able to throw brackets and wires on a four year old, or a quad helix on a four year old, or an alph on a four year old and you may get some orthopedic expansion Okay. But you know, typically with an appliance and I'm just using the out because it was the first thing that came to mind with something like that, the forces are so low that you're much more likely to get dental alveolar bending and dental tipping Okay. So orthopedic is the bones moving apart.

Speaker 3: 25:09

Dental alveolar bending is a type of skeletal expansion, but it's much different than orthopedic expansion. When we talk about dental alveolar bending, we're talking about the bone that supports the teeth. That bone is kind of moving along with the teeth as the teeth move. Okay. So it is skeletal, right, the bones following the teeth. It's not just the teeth moving out of the bone. Okay, that's dental alveolar bending and that does account for a number of, you know, a percentage of any type of expansion that you do, and in the course we go through a case and if you want I can throw it up here that really shows, you know what that looks like when you have a lot of dental alveolar expansion and not so much orthopedic.

Speaker 3: 25:46

And then the last one, and this is probably the least favorable type of expansion in most cases right, in most cases it's just dental expansion.

Speaker 3: 25:53

It just means you're moving to the teeth and although it's good because it does create more room for the tongue, a lot of times it can help with biofunctional goals.

Speaker 3: 26:01

If there is a true skeletal discrepancy and you use an expander that only tips the teeth outward, well, yes, you're making more room for the tongue, but you're also pushing those teeth, you know, possibly to the edge of the bone or even outside of the bone, and that's something that we want to avoid, because there's long-term periodontal consequences, and when you're tipping the teeth within the bone, they end up, you know, flared or tipped outward, and so from a stability standpoint, long-term, you know the forces of occlusion and everything else they're going to be doing throughout their life are not going to be upright and vertical within the bone as it's designed to be, and so that's kind of like the three types of expanders, and so our goal is to, depending on the goals of the case, pick the right expander in order to be able to get the type of expansion that we want.

Speaker 3: 26:43

Now as orthodontists, you know, like sometimes people don't understand well, why don't we do alfs? Why don't we do healthy start? A lot, you know, and, like I said, I'm not against either of those things right. It's just that if I want to get dental expansion and possibly some dental alveolar tipping, my expander of choice would be braces right or clarioners, because it's easier and I can get those type of results with either of those things. And so I would choose, you know, not to do an alf or not to do a quad helix or not to do, you know, healthy start appliances if my goal is to get mostly dental tipping, expansion and or some dental alveolar bending right, and so that's why I choose to do it that way. But it doesn't mean you have to do it that way. If you understand what type of expansion you want and what your appliance is going to do for you, you can use whatever you want.

Speaker 2: 27:26

That was so good. Is it possible to get dental tipping but not dental alveolar bending?

Speaker 3: 27:33

Yes, absolutely so.

Speaker 3: 27:34

Specifically, and that happens a lot in adults, right? So if you really really push out and a lot of these and again, I don't know how popular or not popular that the Aga appliance is, but people who have misused that have ended up on the news, right, and it's caused some problems. And that's a problem of using an inappropriate force system to try and do something that physiologically can't be done that way, when you're trying to get orthopedic expansion on an adult with a lot of resistance and you're using something that the only anchorage you have is the teeth roots, right? So if you're not anchoring to the bone, the only anchorage you have to the jaw is the teeth roots. And if you push on those teeth roots hard enough, yes, depending on the resistance, there may be some adults that you can actually, you know, use the teeth roots and push it open and get a diastema, even without mini screws.

Speaker 3: 28:19

But it's very, very, very unpredictable and highly risky, as you see, if you, you know, if you watch the news, you'll see these cases where they just kept cranking, cranking, cranking, cranking and they just pushed the teeth right out of the bone. I mean that's dental expansion with zero dental ovular bending and zero skeletal. I mean that's just pushing the T. Yeah, you don't want to do that.

Speaker 2: 28:36

This is so clear to me and I think I didn't truly understand the dental expansion component and how there's two sort of breakdowns of that. So let me sum this up because this is really. This is great. There's three different types of expansion. We can get orthopedic expansion, which is actually the skeletal bones, the midline palatal suture, the skeletal bones widening Okay. Then there's part two or another option. You can get dental ovular bending, where the bones that house the teeth are actually moving with the teeth, and then you can get dental expansion and there can be any combination of those. But when picking an expander you have to pick what type of appliance you want to use, depending on, probably, the age of the patient, the condition and considering force versus resistance. Is that a good set? You said it even better than me. Yes, no, it's so. It makes so much sense and that's why certain people are and ages are candidates for a Marpe type appliance. When we get orthopedic expansion, can you list some of the benefits of that versus maybe just the dental component, dental ovular bending or tipping?

Speaker 3: 29:46

Yeah, what would be easiest is to list the benefits that you get from the dental ovular bending and the teeth, because then all the other benefits are what you're only going to get through orthopedic expansion. Okay, basically, the benefits that you get from an airway standpoint with dental ovular bending and or dental expansion alone is an increase in arch perimeter and more room for the tongue Right. And so any of those benefits from a myofunctional standpoint of getting their tongue up and out and strengthening the muscles and having more room for it, you're going to get those benefits regardless of the type of expansion that you do, as long as you get that increase in arch perimeter. Okay, but that's really the extent of the airway benefits that you're going to get, unless you get orthopedic changes. So all of the other benefits that you get from an airway standpoint are going to be from obtaining orthopedic changes. So one of the biggest benefits and one of the most documented and well researched and most established benefit is a decrease in nasal resistance, meaning that it becomes easier to breathe through your nose after you have orthopedic changes, all right. So that's been well documented in kids and also well documented in adults. They do before and after a nasal rhinometry.

Speaker 3: 30:52

So basically, in the vast, vast, vast majority of patients, you are going to be able to breathe easier through your nose if you get orthopedic expansion and your jaw has become wider. And this really makes a lot of sense when you think about it, because it's the same bone. So as the upper jaw expands orthopedically, the nasal volume increases, right, the triangle gets bigger and you have more room. There's more space for that air to go in. I say the vast majority because there are a subset of patients where the soft tissues can swell and they can fill that space and even though the box is bigger, they still have trouble breathing it. And, like I say, there's lots of reasons and you know ENT and, like I say, you can have a lot of people on the podcast that could go into those details more. But, by and large, 90 plus percent of patients are going to breathe easier if they get orthopedic expansion. So that's kind of like number one.

Speaker 1: 31:39

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Speaker 1: 32:26

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Speaker 2: 33:11

And one thing about that is I had the MSC appliance and I was a nose breather, so I did not sit with my mouth open, sleep with my mouth open, but that MSC increased the nasal volume where I felt like I could breathe better through my nose and I didn't know that maybe I didn't breathe as well through my nose right. So you don't have to be a mouth breather to benefit from increased nasal floor volume. And when we decrease nasal resistance we're decreasing the collapsibility of the airway. So that type of expansion, that orthopedic expansion, could benefit any sleep disorder breathing patient, even if they're not a mouth breather or feel like they can't breathe well through their nose.

Speaker 3: 33:51

I would just be careful with the word any. And the only reason I say that is because sleep disorder breathing I mean you really cannot loop them all into one bucket. You can loop them into the majority of the bucket, right? So the majority of sleep disorder breathing patients, its collapsibility most likely in the tongue, pharyngeal area, sometimes higher up. That's the majority of patients. But there are a number of sleep apnea patients. They can have at proglottal stenosis, they can have, you know, obstruction in another area or they can have central sleep apneas, and so I wouldn't say any. But most or many of the sleep disorder breathing patients are going to benefit from orthopedic expansion. That is true.

Speaker 2: 34:26

Decreasing that, like the threshold for that collapsibility, opening that tube, that breathing tube, wider at any component.

Speaker 3: 34:35

And while you're talking about that, so we talked about the nasal part of it. But what else is important to understand is the maxilla is you know it's a broad bone. I mean, you know the maxilla is, you know, yay, big or whatever in your mouth. So as that's expanding, everything that's attached to the lateral walls of the maxilla, so the lateral walls of the pharynx are attached through the soft tissue to the maxilla. So as the top jaw gets wider, all of the pharyngeal walls, you know what holds the Palatine tonsils that all widens as well.

Speaker 3: 35:02

And it's not like a one to one, it's not like you get you know 10 centimeters of expansion. Oh look, it's 10 centimeters apart. But what we see, especially in growing kids, is that, you know, you get the width there over time. Those soft tissues tend to remodel and become wider over time, accounting for more of the increase in the posterior airway, specifically behind the tongue and in the area of the tonsils, and so that's kind of like a secondary benefit. The nasal benefit, the nasal breathing benefit, is almost immediate. I mean that happens right away with the change and then we tend to see more of the posterior walls expand over time as, essentially, the body adjusts and continues to grow if you're growing or if not, continues to adjust as an adult and basically that wider jaw you know helps to provide a wider posterior airway also.

Speaker 2: 35:43

Okay when we're talking and in the course they talk about, like more of a triangular expansion and the anterior expands more than the posterior aspect in any type of expansion. That's orthopedic.

Speaker 3: 35:57

Yes, there's always going to be a portion of the expansion. It's never going to be a hundred percent parallel, All right. And the reason it can't be a hundred percent parallel is because the resistance is never zero. Okay, you know what I mean. There's always going to be resistance in the maxilla, and where that resistance is is at the skull. So you have, you know, you have your. I should have brought my skull. You know you have your maxilla, and then you have, like, the rest of the skull back here, right? Well, the maxilla is attached to the skull back here. So the resistance is always posterior to where the maxilla is. It's also superior, right? The maxilla attaches, you know you, up here at the frontal bone and the nasal bones and the zygoma. So all these places where the maxilla attaches is where the resistance is happening, meaning that the forces fighting against your expansion are all back here and up here. So there's always going to be more expansion down here where there's less resistance. So from a vertical standpoint, you're going to see triangular expansion like this, and from an AP standpoint, because the resistance is further back here, you're going to see, you know, more in the front than in the back.

Speaker 3: 36:55

Now, when we talk about. You know we want parallel expander or this expander, you know, provides more parallel expansion than this one. There may be some truth to that, but I think that the biggest component of getting you know more parallel expansion. Meaning if you measure it A and S, which is at the front of the maxilla, and you compare that with the expansion at P and S, which is in the back of the maxilla, you want those numbers to be as close as possible, right? And then the closer they are, the more parallel quote, unquote expansion that you got.

Speaker 3: 37:23

And so, yes, there are some cases that you know a complication is splitting the maxilla between the maxillary bone and the palatine bone, which the palatine bone is behind the maxillary bone. So if you split the front part of the maxilla and the maxillary bone splits from the palatine bone, you may get zero expansion at P and S and in the back and all of your expansion in the front. Like. That would not be good, right, we don't want to shoot for that. So, however, you design your expanders and specifically your Marpees, and specifically in adults, you want to design it in a way that you can try and get parallel expansion and the back part of the maxilla is going to open up as close to as much as possible as the front part does, even though the front parts always can open a little bit more.

Speaker 2: 38:03

That totally makes sense and that was a really great explanation with the resistance at different parts of the bone, that makes sense. As to why the expansion is not necessarily parallel, okay, I don't want to back up because I want to move forward, but I got to back up. I have a question. Okay, just for my knowledge, I've heard of people saying, with the RPE, slow turn versus fast turn with RPE. Can you just explain that a little more?

Speaker 3: 38:27

Yeah, I'm glad you brought this up because this is such a huge source of confusion, not only among all of your listeners but in the orthodontic world as a whole. Like I've asked multiple orthodontists, I asked them well, what's slow maxillary expansion? Define it for me Pretty much like nobody can, and certainly there's no consensus on what it even is. And when you look at the research on slow maxillary expansion, there's so much differing information. But I'll try to break it down as simply as possible from where we're at today. So, rapid palatal expansion if they ever got a bad name, it was back in the day when they were doing multiple turns per day on very young kids. So when you go back and you hear research like oh, profit talked about how maxillary RPEs can mess up the nose and things like that, it's true, if you expand too fast and too young of a child, yes, there can be malformations and problems at the growth plates. So that's something that we discovered years and years and years ago that you shouldn't do. Okay, and rapid palatal expansion has transformed and we've understood that when we do rapid palatal expansion, it doesn't have to be four turns a day, six turns a day, which is equivalent to a millimeter or a millimeter and a half per day. We can do rapid palatal expansion at one turn per day, which is about a millimeter and a half per week, and in many seven plus old year olds that's going to work just as well in the long term as if we were turning it two times or four times or six times. Now understand, I am oversimplifying it, right, because again we have to always think about the anchorage and the resistance. So you could put an RPE on a 10 year old, but if they only have first molars in, and that's the only anchorage that you have and you can't attach that expander to anything else, you might not get the same type of orthopedic expansion even though you're using a quote, unquote RPE. That's just an anchorage problem.

Speaker 3: 40:10

But by and large you know modern day, I would talk about rapid palatal expansion as really anything one turn a day or faster, okay. So once you start doing less than one turn a day, like down to maybe like one turn a week, then it's more considered slow maxillary expansion. The irony is is that you know, when a lot of people think like, oh, rapid palatal expansion and slow palatal expansion, they're different, and the only way that they're really different when you look at the research is the rate of turning right. It's still the same type of appliance, it's just are you turning it faster or slower? But the confusion comes when people start looping a lot of other things into quote unquote.

Speaker 3: 40:46

Slow maxillary expansion, like quad helices, like alpha appliances, like all these other things that are out there that can provide expansion, they call them, you know, slow maxillary expansion. Oh, this is a slow maxillary expander, but that's not necessarily what the research accepts as slow maxillary expansion. When you look at the vast majority of the research, slow maxillary expansion is the same type of expander, just turn slower right and then, if you know, if it's one or more per day, then it's rapid yeah.

Speaker 2: 41:10

That's great. And then is there a benefit or a problem? Because there are benefit when you do one turn a day or more, but not too many, right? Not many turns a day versus the slow turn where you don't do a turn every day in a young child. Are there benefits or negatives with either of those?

Speaker 3: 41:27

So the biggest benefits of doing slow maxillary expansion and the reason that it has become more popular and there is a significant amount of research behind it is because it limits complications right and it's typically easier on the patient. So the slower you turn the expander, the less uncomfortable it will be for the patients, if that makes sense. And that plays out even more the older you get right. So if you're 12 years old and you're turning an expander slower, then that's going to be more comfortable because the teeth and the bone have more time to remodel it and adapt to the changes that are happening. Okay, now with the rapid palliative expander, the problem is you're always juggling the type of expansion that you want to get with the type and protocol the expander that you're using.

Speaker 3: 42:11

So I've had patients transfer in that had slow maxillary expansion and they were turning this thing like once every two weeks and they were young, I mean they were like 10, 11 years old. But when I look at their imaging there was not much orthopedic expansion at all. It was mostly dental alveolar bending. If you want, like I said, I can put this in the notes. If people want to look at it, I can show you a case where you have an extreme amount of dental alveolar bending. If you can envision it with me, picture like your square box of the maxilla and then at the very bottom where the teeth come out, it's just like it's stretched like Play-Doh, you want to show that?

Speaker 2: 42:43

Yeah, totally pull that up if you want to show that because it's good to just visualize and see the difference if one of the listeners is actually watching this versus just listening.

Speaker 3: 42:57

Absolutely. I'm going to share my screen now, here, and also after you talk about that.

Speaker 2: 43:01

I'm just my brain is going to. I see some practitioners use removable expanders where it almost looks like a holly retainer, but you turn the inside and maybe you could talk about that a little bit as well. Yeah. I think you have to enable the screen sharing at Saint Isis. Okay, so let me do that.

Speaker 3: 43:17

Let me comment on the removable expanders in general. Okay, so removable expanders again. Just because it's a removable expander doesn't mean that you can't expand with it. Okay, I would try again for that. Okay, awesome. So I'm going to share this one here and we'll share that. Can you see that Great.

Speaker 2: 43:37

It's coming up right now. Yep, there we go.

Speaker 3: 43:40

You can hit play. So, okay, perfect, is that big screen now? Okay, so this is the most extreme example I've ever seen of both dental and dental alveolar bendings. So you can see the dental tipping, you can see the angulation of the T right, so the molar's on the top. And just to orient you a little bit, this is the person like looking out of the screen right. So it's as if they're looking out at us and it's kind of a cross section right in the middle and we're at the level of the first molars. So what you're looking at is the first molars chopped in half, you know sideways, if that makes sense. Okay, so the eyes are up here. Can you see my cursor?

Speaker 2: 44:15

Yes.

Speaker 3: 44:15

Yeah, the eyes are up here, the nose. These are the sinuses, this is the maxilla and these are the teeth. So the first thing to note out here is do you see how thick the bone is in the midline?

Speaker 2: 44:24

Yeah.

Speaker 3: 44:25

Yeah. So that's gonna have a lot of resistance, right? So the more bone you have, the more resistance there is, because that suture is interdigitated. So when we're trying for orthopedic expansion, we have to overcome all of the midline and skeletal resistance before we can start moving the bones, okay. So like obstacle number one is you gotta get the maxilla to split. Okay, if you don't get the maxilla to split ever, then you're not getting orthopedic changes. It's all going to be dental alveolar and dental tipping, which is what we see here. So do you see how these teeth? They're still within the bone. There's bone on the buckle, there's bone on the palatal on both sides. They're still well within the middle of the bone. That's there. But do you see how tipped out they are and how the bone just sort of followed it? That's dental alveolar bending.

Speaker 2: 45:08

So add it. See, they're diagonal, exactly, they're not just bone, they're diagonally sticking out Because they're correct.

Speaker 3: 45:14

Correct. So when we go to treat this patient orthodontically, we're going to need to upright those teeth. Now, in this case there is bone there to do that. You can imagine like here if we upright those teeth, yes, the buckle of the root will be closer to the buckle plate of the bone, but there's bone there to upright them so we can keep them within that bony housing and we can get those teeth to fit together. But my point is, if this patient needed true orthopedic expansion which I would argue maybe they do, at a minimum they need to be nasal breathing.

Speaker 3: 45:41

You can see the inflammation both in the nasal cavity and the sinus, specifically on his left side. That is not going to happen if the expander you design is not sufficient to overcome this midline maxillary resistance and provide that orthopedic change. So this was a quote, unquote slow maxillary expander and this was done by an orthodontist. My guess is that, like most orthodontists, they have never been taught this. They've never like been presented the research and understood this in a way that they can make this predictable. I think that with AI, this will be a new standard. Like we'll be able to send in a cone beam and the AI will show us where the resistance is and where the bone is and how much we need and will these two throats be able to provide the resistance and, if so, how much force is there going to be needed, like in the future? I think that's where this will go and then we'll know like, yeah, you can use this type of expander, but if you do, you need to cover this many teeth and you need to have this much scrams of force. Or you need two tads, or four tads, or eight tads if it's an adult. I think that's all something that can be calculated. It's just that at the point it's so complicated to do that, we can't. We just guess, right.

Speaker 3: 46:47

So when we look at the midline we say, okay, that's pretty thick for a 10-year-old. I think I'm gonna have more resistance. So maybe I'm gonna err on the side of possibly even doing an MSC on this patient. If, depending on how critical the needs of the expansion are and how much of it needs to be orthopedic versus skeletal, with a traditional you know, rpe, bonded, rpe, hyrax, all the ones you see in the literature at best, when you're done, at best you're gonna get about 60% skeletal expansion at best. All right, so that's like a younger kid with not a lot of resistance. When it's all said and done, only 60% of it is gonna be orthopedic.

Speaker 3: 47:21

A lot of the new research coming out on MSCs is showing that we can get up to 90% orthopedic change when we anchor to the bone, that it's long-term stable, and so that is a true game changer, because if you don't need the dental alveolar tipping and or the dental tipping, then you can use something like MSC or a custom Marpy and you can predictably get just the orthopedic change that you're looking for and up to. You know, until these came out, we couldn't do that. There was no way that we could do that.

Speaker 2: 47:49

There were so many great points. If you leave this slide up, using a rapid palatal spanner, 60% orthopedic change versus at best, versus a TAD-implanted or Marpy MSC, 90% at best, would you say.

Speaker 3: 48:05

At best yes, at best yes.

Speaker 2: 48:07

Which is very significant. So this case that you're showing on the screen, where the upper teeth are tipped and need to be uprighted, how would this orthodontist who did this case finish this off? So the teeth are in alignment.

Speaker 3: 48:19

Yeah, so here's. The thing is like. You know, when you look at how big the top jaw should be, it really shouldn't be bigger than about five millimeters larger than the mandible. But most of the time and most patients that are gonna come through your office, their upper jaw is going to be either the same size as their mandible or smaller. So you can see here how I'm measuring it. I'm measuring from the middle of the basal bone of the maxlum that's gonna be housing the T.

Speaker 3: 48:41

That part of the top jaw should be three to five millimeters wider. That's how it always used to be, or at least mostly always used to be. When you look at prehistoric skulls dating from three to 500 years ago and back, that's how it was. You can go into all that and why we don't see crowding. We don't have to go into that discussion foods, eating, you know all that stuff but basically our goal is to get the top jaw three to five millimeters wider than the lower jaw. So in this case we actually have over expansion of the dental alveolar complex. So the bone that houses the teeth is actually too wide. You can see it's 55 millimeters, okay, and the lower jaw at the same level is 44 millimeters. So ideally that part of the bone would have only been, you know, 50 millimeters, maybe at most, you know, five or six millimeters bigger than the mandible. And when it's like that, we can upright the teeth within the bone and we can have the top fit on the outside of the bottom not in a cross bite in a harmonious relationship, minimizing or reducing the chances of long-term bite.

Speaker 3: 49:40

And, you know, jaw problems down the road. So that's what we're shooting for. So how do you finish a case like this? It's very challenging. We have to compensate is what we call that in order to get these teeth to fit together. So when this case finishes orthodontically, those upper teeth are actually gonna have to be tipped in a little bit and the lower teeth, rather than being upright, are going to have to tip out a little bit, and that's the only way we're gonna get these to fit with where these bones are right. I mean, hindsight's, 20-20. I mean, if we could go back and get more orthopedic change in this patient, but yet not the dental, alveolar and dental changes, that would have been ideal in my opinion. But again, it's never perfect.

Speaker 2: 50:16

The orthodontist who did this case would probably finish it off, or, if you got this patient, would finish it off by reducing some of the dental expansion on that part and then doing a little dental expansion on the lower to make things final. Okay.

Speaker 3: 50:31

You know, you might get a little dental alveolar bending. I mean, depending on the severity and again, this is a kid. So most likely that would be what we would do. We would just tip the teeth inward, you know. Would the dental alveolar bending go back the other way? Maybe? That's actually a great question. No one ever talks about that. Like we never try to constrict the maxillary arch because this is not natural right? You would never have a patient naturally come in like this. The only reason they're like this is because of the expansion that was done.

Speaker 3: 50:56

So, but that's an interesting question. I mean, in theory, if you bring the teeth in fast enough, it should bring some of the bone back with it. It should bend the other way. That may be helpful in trying to address this. But yes, to answer your question, yes, we're gonna move the teeth. Any dental alveolar bending we might get with the appliances that we use, you know, might help a little bit On the lower. As you upright, you might get a little bit of dental alveolar bending there. But yeah, you're just gonna try to get the teeth that fit together as best as you can with where the jaws are.

Speaker 2: 51:21

And this is why this is such a team approach, because if you had an ENT here, you're there. Me myofunctional therapist ENT would see the sinus and nasal congestion like we all see, because we're all educated in this. I see, you see teeth, I see tongue. Right, I see tongue. That would be faster.

Speaker 2: 51:38

Yeah so we all have to be aware of all of our specialties and all these multifactorial problems our patients have and see the big picture, because of course this practitioner was just treating teeth and I don't know if they were attending to tongue or nasal breathing. You know ENT medical components as well, so this is a great that's a great case and a great way to show the dental alveolar bending and dental tipping versus orthopedic changes. So thank you.

Speaker 3: 52:05

While we're on that, I'll just show you too. This is Juan Moon's research. This kind of is what I think will become the standard of care for how we measure this. So you can see here they're taking before and after comb beams. This is an MSC patient, so you can kind of see the triangular shape that we talked about with the expansion. You can see the split of the diastema here, but they measured in three places.

Speaker 3: 52:25

So they're measuring the orthopedics expansion, looking at the actual zygoma here, and then you can see they measure a little bit further down to get again another idea of how much the top part of the jaw is widening compared to the bottom jaw or compared to the bottom portion of the jaw, and then at the end they measured the middle of the teeth, which is gonna give them their dental measurements.

Speaker 3: 52:44

So there are ways to calculate out these three things. And this is where I think we're going as a profession, from a research standpoint, because if we're comparing apples to apples like this, well now we can actually start having that conversation about what types of expansion we're getting, what types of expander we're using to get that type of expansion, and then we can work that back to how much force do we need in order to overcome the resistance you can see here? This is an older patient than the one I just showed you, but look how we're relatively smaller. That midline resistance is in this patient compared to this one here, where it's much thicker. Again, you can't treat that with the same type of expander and expect the same type of result.

Speaker 2: 53:24

Yeah, and, like you said, this will be an AI thing at some point where you're sending your CT image right. It assesses the whole face, from the nose, sinuses all the way down, and like says what the patient needs. I could see that.

Speaker 3: 53:40

Yeah, interesting. Any residents out there looking to do research you?

Speaker 2: 53:45

know I want to be a bajillionaire. Yeah, with that sort of I know dr Rell is doing like a 3d facial analysis where you take a picture where your phone and it can analyze that. But, yeah, put all that together. You send it off. It tells you the appliance options, the resistance at the midline, the goals you know. Send this patient to ent for the. You know something with some formula. I feel like that could be Really an interesting future thought for the future and probably not so far away, right?

Speaker 3: 54:17

I would hope not, I would really hope not.

Speaker 2: 54:19

Question after Patient gets. So if you want to do you want to stop the share After a patient gets that sutural split, do we know it's bone that's filling in? Someone asked once is it cartilage or how do you know it's actually bone?

Speaker 3: 54:33

Yeah, I saw that question and I haven't done the dive into the literature, but it doesn't really make sense to me that any Cartilage would fill in that area just because there's not a lot of cartilage in that area. The nasal septum is above an endothelial layer, so like there's there's quite a bit in between there. So if anything, you know, if you didn't have bone fill in there, you know you could potentially have some normal, you know bone, like a scar, that could happen, or some keratinized tissue from the palate or something. I'm not aware of this being a big thing. I mean typically, by and large, yes, it fills in with bone, just like when you break a bone, like I mean you could ask the same question about like Well, how come when you break your arm and you know, and they put it back together, it fills in with bone. I mean this because this is bones there. You know what I mean, like bone, bone. I mean that's what usually fills in. I mean, maybe what they're asking is like, you know, if you expand too fast now the two pieces of the bone are too far apart and just whatever fills In there. Is that possible? Yes, it's possible, but I mean there's quite a bit of before and after combi mimaging. That shows that in in every patient that I've ever seen, I've never seen anything fill in there except for bone. So I mean, if there's anything specific that they are wondering about or know about, I mean I'm more than happy to look into it.

Speaker 3: 55:35

But this is not like a common problem. I would say the most common problem that you do hear about is not that bone doesn't fill in, it's that you know, with these piezotome osteotomy procedures you can create a situation where you have air, you know, where nothing fills in. Basically you have a communication between the nasal passageway, a fistula, and the oral cavity, and that can happen as a Complication to, like you know, piezotome procedure gone wrong and or, you know, communication between the nasal passageway in the oral cavity. It happens a lot in cleft patients as well, where you have holes between the nose and the mouth, and so that's not good. But that's not to be expected with normal expansion, meaning that if there's not soft tissue open in one cavity of the other that shouldn't be open, then that should never happen.

Speaker 2: 56:17

Okay, and then the suture fuses, just naturally the midline palatal suture. Can you kind of talk about what ages that begins to fuse?

Speaker 3: 56:26

Yeah, so basically and fuses the word that is commonly used but basically about four years old is when it kind of I'm not gonna talk about fusion.

Speaker 3: 56:35

Let me talk about it this way because I think this way is a more valuable way to explain it. We really want to understand when the resistance is increasing the most significantly. All right, because again it boils down to the resistance. So you know, basically, birth to four years old, there's not a lot of resistance in the maxilla and you know that is. You know more about that with babies and I do. I mean that. You know the craniosacral therapist and moving with the thumbs and everything. Like you know, I'm like wow, that's cool, but that's not my world. I don't really know a lot about that. But you know, suffices to say from zero to four there's not a lot of resistance in the midline maxillary suture, and from about four until about 13 to 16, depending on the patient, is when the majority of the resistance is increasing, and so you can call it fusing. Most of the research that's out today really describes it more as an interlocking. Some of the slides we go through in part one Demonstrate that on diagram form and on the histogram with the slides. But basically between four and about 13 the resistance is increasing and I would say you know the most significant increase or when it really starts to get more difficult to get true orthopedic expansion is Probably around the age in most kids of nine or ten and getting older. So at nine or ten it's like, okay, it might be a little bit more difficult to get true orthopedic change and or I might need to be more Proactive about planning my expansion with better anchorage to make sure that I'm getting that orthopedic changes that I want to see. The other challenge with nine or ten year olds is a lot of times they're losing teeth. So you know the baby teeth roots are short. When there's six or seven the baby tooth roots are big and those things are solid in the bone Right. So you start expanding on those and you can get great expansion. But now they start to lose the roots of the baby teeth, they start to dissolve. Now if you put that same expander on a nine or ten year old and there's only, you know, little bitty baby tooth roots left and that's what you're covering, well, now your anchorage has gone down significantly. So by time you know the sutural. You know fusion is not really complete until you're done growing in adulthood.

Speaker 3: 58:31

And they found that the level of resistance is not the same for all patients so it doesn't always go all the way from, you know, to complete sutural maturation. They call it stage E. It doesn't always get to that in every patient. Some people stop at stage D and then at this point there's really not a really easy way to just look at a comb beam and say, oh, this patient went all the way to stage E, this one went to stageD, this one, you know, barely got out of stage C. But it does impact the amount of resistance you have.

Speaker 3: 58:58

And this is where, again, ai would really help us if they were able to Analyze the data in a comb beam in a way that we couldn't right and process that in a way that's meaningful. Well, now we can get a resistance number, regardless whether it's stage E, stage D or how much it actually fused together. And I didn't mean to get too deep into the weeds, but I always hate answering questions Simply in a way that like, oh yeah, that makes sense, but it's not like complete, you know. I mean I don't want to give your listeners an impression that something is true that isn't I mean, so sometimes it's complicated that was such a good explanation and for me personally I don't remember things unless I know all the details.

Speaker 2: 59:34

Or, like you know, it makes sense and I'm like that's really important because the pictures in the course and I've seen this elsewhere it's not like a line that just like fuses together, but it's kind of like an interwoven bones, right? I guess it's interesting that there's Different resistance at different ages. When you've reached maturation, different people have different amounts of resistance, and is there ever an age or a person that you cannot Become successful with a tad expansion due to the resistance, or how do you work around that?

Speaker 3: 1:00:09

Yeah. So that question is still to be determined. There are many Marpy practitioners, you know, myself included, dr Ting, dr Lipkin, dr Evans. I mean that talk about you know pretty much being, you know, with the sense of case at home, all right since Piazza tome and being able to reduce resistance. And Mary on is probably an outlier here because she doesn't do Piazza tome, she prefers to do only tad supported. But she designs her appliances very, very well.

Speaker 3: 1:00:33

But to answer your question, a lot of us have not encountered patients yet that we couldn't expand Skeletally. Now there are a subset of patients that I mean at least me personally and I'm sure the other practitioners are similar when we choose not to even attempt it right, because, like, if there's a high chance of complication in that patient, then the chances of those complications are not worth the Risk of expanding, if that makes sense. So there are patients that when I review the anatomy, when I look at the combing, I say look this bone, this is paper thin on the lateral walls, like there's a high chance that that could fracture. There's not a lot of good anchorage, like I don't have places to put tads, and so I'm not gonna attempt to scale expansion on that patient, at least until we have better or more information to this, says Okay, yes, you know, the formula works out and we can do it.

Speaker 3: 1:01:19

So there are many, you know there are not many, but there are, you know, a few patients that have come to me where I've said you know, I don't feel comfortable doing an expander on you and this is why. But out of the ones that I have attempted, since I've had the ability to do the osteotomy and release essentially the vast majority of the midline resistance at delivery, I've not had a case that won't expand and I believe that you know, at least from what I've heard from Dr Ting and Dr Lipkin, they're experiencing the same thing. It's like, if I attempt, the patient like we typically you know, essentially always have gotten expansion using piezotone to help reduce the resistance at the midline. So I don't know, is there patients out there that can't split? I would say yes, there probably are, but I can't give you a description of what that patient looks like and until we have enough cases attempted to do that, and then we won't know.

Speaker 2: 1:02:03

Could you explain a little more about piezotone osteotomy?

Speaker 3: 1:02:07

Sure, yeah. So piezotone osteotomy basically it means that you are doing a midline incision down the middle of the pallet and you are literally cutting the bone in half, and so it sounds like really, really crazy and aggressive. But we talk about the details in the course. The tip that we use with the piezotone Is a quarter millimeter thick, and that's important to me. I mean, there are other piezotones that use, you know, half millimeter thick or somewhere in between, and you know, quarter millimeter, half millimeter, you know, does it make a big difference? Maybe, maybe not, but from my standpoint it does make a big difference in potential complications for starters, like one the further Apart that bone is. To start to your point about wanting union of the bone, you know, and not having a non-union incidence, because you do have to cut the top of the pallet so there is a hole that leads into the mouth. So if you don't want that hole to get bigger and cause a non-union problem where they have to then go in and graft and fill in Bone that didn't fill in, you want the smallest gap possible, okay.

Speaker 3: 1:02:59

So yeah, quarter millimeter is the burr that I use and basically it goes through and it creates a quarter millimeter Saw cut down the middle of the pallet and the goal is to cut as much of the pallet as you can Without cutting stuff you don't want to cut, like you don't want to cut into the nasal cavity, you don't want to cut into the nasal septum. So I'm always a little bit conservative with that. I don't even go through the second cortical plate. I go through the entire first cortical plate and into the basal bone as much as I can. I swing back and get as much of the Palatine bone as I can, but I don't go all the way to the end of the Palatine bone because I don't want to, you know, poke it into their throat. And then I very seldom do an A&S cut, which is the one in the very front between the front teeth. And again, the reason for that is that usually the problem is not getting Expansion in the front. Usually we always get expansion in the front. So if I design my expander.

Speaker 2: 1:03:44

Well, resistance in the front right, least resistance in most cases yes, in most cases.

Speaker 3: 1:03:51

Well, once the midline is split, there's no resistance in the front right, it's all apart. But when you're initially splitting the maxel you have midline resistance and there can be more midline resistance in the front. But the goal of orthopedic expansion is splitting the pallet. As soon as you split the pallet, all of the resistance is up top and behind Right. So, but before you split the pallet you do have to pay attention to the midline resistance. So, yes, there is resistance in the front part of the jaw where those two pieces come together, and in some patients it's more than in other patients. But it's an area that I, at least to date, have not had to split with a piezotome in order to get it to split on its own later. So typically I won't, because there's a lot of things that can go wrong when you do a piezotome in the front. The roots of the anterior teeth are there, so if you get too close to those, you can have Divitalization and or sensitivity. If you cut too far down when you're expanding, the part of the bone that connects to the teeth the ppl connects to the tooth the part of the bone that connects to the pdl can split off of one tooth and Travel with the maxel on the other side. That can also happen if you expand too quickly, and so there are just a number of complications that I don't want to deal with, and so I choose to let mother nature Break apart the bone in the front via the forces of the expander, and the protocol that I use is very conservative in nature Until that split happens, because I want to make sure that, you know, I'm minimizing the risk of complications, right, and so that's why I do it that way. So the piezotome osteotomy in my office, you know, is on the palate, so it'll run from, you know, kind of the front part of the palate all the way to the back part of the hard palate. So I don't go into the soft palate like I'm not, you know, I don't want to have to suture everybody up and do all that kind of stuff. So it just goes straight down the palate in the middle and we relieve as much of that midline bone to reduce the resistance in the middle as Possible. So anywhere that I don't cut is going to be the part that the expander has to work to, you know, overcome the resistance. And so back to your point about how the suture works in the interweaving. You know my protocol when I do an expander, a Marpy, is to activate it at delivery. So I want there to be force on the bones and in my mind, like these bones are starting to pull apart, these inner woven portions of the top jaw in the middle are starting to pull against each other. And when you push bone against each other it starts to resolve. And so I give that five to seven days to start happening, to allow that physiology to start pulling that suture apart. And then, after that first five to seven days, then I'll have the patient start turning.

Speaker 3: 1:06:15

But I never prescribed for them. I never say you two turns a day, you know, do three turns a day, do one turn a day. I tell them, do up to two turns a day. And I tell them the force should never be Excessive, it should always be a moderate force. So if you crank that thing only one turn or even a half a turn and it's like whoa, that's a lot of force, well, you're not ready to turn again yet. So don't like, just do two turns, because you know we think we should do two turns.

Speaker 3: 1:06:39

Right, it's a process. So I try to educate my patients to understand what's trying to happen. I also explain, you know, why they shouldn't turn too fast after the split of the max. Let occurs because some patients want to do that so they think they can get their expander off earlier. But that can cause problems. So I always tell them up to two turns a day. So if you're not feeling a ton of resistance, sure go up to two turns. I mean the body's telling you that the resistance is not, you know, sufficient. Yet Once you feel that moderate level of resistance, just stop and wait until the next day and try again.

Speaker 2: 1:07:07

And Following that protocol has been very successful in my practice to again help minimize the complications and Maximize the amount of patients that get the orthopedic changes that we're looking for the patient can feel that pressure you have and I felt when the suture split so this will be interesting to talk about like who needs the P is at home, who doesn't, what that feeling is. But I have a question. You said when you install it you do the turns right then and then you have them not turn for five to seven days and then start the protocol of up to two correct, and the reason for that is that you know there is a number of physiological things that have to be in place in order for that bone turnover to be efficient.

Speaker 3: 1:07:45

Right? So, when you first do that injury to the bone, the body has to recruit all types of healing cells to that area the osteoclast, the osteoblasts and so unless you give it time for all of that physiology to be in place, the rate of, you know, bone turnover and healing is going to be slower. And so you give it, you know, five to seven days just to allow the body to respond and get all of the players in the game, so to speak, and then, once all those players are there, well, now you can turn and you can start to have a more efficient, you know, physiology happening, if that makes sense and is that only when you do the P is at home that you wait the five to seven days, or even without the P is at home?

Speaker 3: 1:08:19

So I only wait the five to seven days with the P is at home because by by and large, the vast majority of Adults that I do I'm almost always going to recommend the P is at home and I don't require it. The reason I don't require it is because I don't want anybody to feel like they have to have that procedure in order to get expansion and Marianna Evans is a great example that she doesn't use it and she gets great expansion in adults. What I tell my patients is you know, if you don't want to do the P is at home, then if we need a second expander to get the expansion that we want, then you'll cover the cost of that because the chances of us needing A second expander go a lot higher. If the resistance is higher and if you don't do the P is at home osteotomy the resistance is higher. That's the way that I do it.

Speaker 3: 1:09:00

As far as the you know not doing the loading period with the expanders, I mean you actually bring up a good point. I mean you could make an argument that that would be a good idea, right? I mean just, you know, start turning it a little bit and because the same physiology has to be there and it's not naturally going to be in the midline palette. So I just do so few of adults that don't do the osteotomy that I haven't really thought about it. To be honest with you, that's actually a really good.

Speaker 2: 1:09:20

I might start now, wasn't even bringing up a point.

Speaker 3: 1:09:26

It's a great point because I mean the same physiology has to be there to basically split the palette as needs to be there to heal the osteotomy site and continue to split the palette. So that's a great point.

Speaker 2: 1:09:36

Like yeah, with the osteotomy is probably a lot more like trauma to the bones. I see why you'd probably want to give it more time than if you're on the osteotomy. About the osteotomy, the piezo, from your course you said reasons why you may use it is to reduce the skeletal resistance, which of course makes sense at the maxillary midline, to provide more predictable expansion. Maybe less side effects may be better expansion experience, so patients might not feel like they're ripping or when the suture splits that get tolerate. That that's better, which I definitely felt when the suture split because it was before. Piezo was a thing, I guess, for this procedure. So I had the cortupuncturist. So the night the suture split. I definitely felt that. Yeah, yeah, I called it. It was very weird.

Speaker 2: 1:10:20

I called it a palette labor because I woke up in the middle of the night with like throbbing between my front teeth, this like throbbing, throbbing, and I was coming down to the wire where the expander might not work and I might need a surgery at that point. That was the option because it was a few years ago, but it was this throbbing between my front teeth and I had been trying to eat really hard crunchy foods. I'm like I'm gonna get the suture to split and I'm eating, like love crunch cereal, granola carrots, like biting with my front teeth. I know if that helped. But after doing that all one day, that night, the throbbing occurred and I was like, oh my gosh, I feel like I need to take Advil, like this is really bad.

Speaker 2: 1:10:54

And then all of a sudden my nose started running like crazy. I'm like, do I have a bloody nose? Like I never get a bloody nose? No, but I know it was clear like just running, and then it stopped. When away I woke up in the morning and I had a little Diaspora, I was like, oh my god, it was like my water broke, like my nose. It was like a labor thing on my palate. It was totally a random, weird thing, but that's how it happened. So I felt that and I know patients sometimes feel it really strongly or whatever, but with the piezo they're not gonna obviously feel that because you've done the split for them. So when do you choose to use the piezo? Is it a certain age?

Speaker 3: 1:11:27

Yeah, non-growing patients. Yeah, so pretty much for me. If it's like non-growing patients, almost always that's what I'm gonna recommend. And again, it's just a predictability thing for me, and so it's like you know, if can I expand you without doing it? Yeah, probably so. It might take a couple expanders, but we can probably get there. But back to your point about the complications and this is something again and this is something we need more research about.

Speaker 3: 1:11:48

But you know, one of the most problematic Conflictations is a fracture somewhere that you don't want it. Okay, so maybe it's a fracture between the palatine bone and the maxillary bone, maybe it's a fracture between the maxillary bone and the frontal bone, but or maybe it's a fracture between the pack of the maxilla and the pterogoid plates. But most of the time we have a fracture that we don't want. That's not a good thing. I mean, take the pterogoid plate one out of the conversation because that's a bigger conversation, but let's talk about the other ones, like maxillary to palatine bone. If you have a split of either both or one Sides of the maxilla and the palatine bone, that means that from your first molar forward, that portion of the jaw is going to expand and from your second molar back. It's not okay. So that's a problem can create big asymmetries, right. So if I'm gonna do like you know, I can't predict or tell you what the resistance is between the maxillary and the palatine bone and if that's less or more Than the resistance between the two palatine bones in the back, okay. So two ways to address that. Either one I can make sure I put two screws in the palatine bone all the way in the back so that I'm at least screwed to them. So that you Know, as I'm expanding it's putting force on each of those bones individually. But when you look at the anatomy of the palate, that's pretty far back there and in some patients all the way back into the soft tissues almost, and so not every patient. You might not be able to get two screws into the palatine bone unless you're trying to drill through soft tissue and soft palate, which is gonna be super uncomfortable and in general it puts it pretty far back in the palate. So that can be challenging, right. So if I go in there and I'm using a piezotome and my incision is in the hard palate, but I can rock that tip back and get into the palatine bone, at least I'm reducing some of the resistance in the midline of the palatine bone so that when we start turning there's less resistance at that suture and the chances of the suture breaking between the maxillary and the palatine bone goes way, way down. Right. So now the chances of that happening are reduced, all right. So another thing is the pressure that happens up in the nasal bone between.

Speaker 3: 1:13:50

This became famous on Reddit. I don't know if you saw that patient that had an expander. They had. I think it was an MSC, it might have been a Marpy, this was years ago and basically one side of their entire face, all the way from the cheekbone down, expanded and the other side expanded much less or didn't expand at all and it created a situation where, literally from the cheekbone down, you could see the eye. There's like more. Yeah, if you search it on Reddit, you can find it. But you know the eye is down like this, the cheekbone is down like this, the maxillary is. You know it's canted down to the side. It's a big problem, right.

Speaker 3: 1:14:19

So when we have what's called a maxillofrontor or maxillonazel suture split, that's not good, that's a complication that we pretty much have to stop and sometimes even back turn and we get. So I'm gonna do everything I can to avoid having that. So in my mind and again, there's not a lot of good research on this, just because there's not a lot of good compiled data on the number of cases that this has happened on to be able to really analyze it but in my mind, you know, the only thing I want to break apart is the midline palvel suture. Like that's it, like that's really the only thing that I want to break apart completely from the maxillary bone all the way down to the palatine bone. I want all that to separate. Everything else I don't want to break right?

Speaker 3: 1:14:57

So once I get that split of the palette this is a finesse game after that, like, after that, it's always up to one turn a day and the same rules apply.

Speaker 3: 1:15:06

Like, if it starts feeling like it's excessive pressure, don't turn that day or back, turn it once. Like, take your time, because all the other bones have to bend. Bending is the only thing you really want to happen, right? So if you start cranking too fast, you are at risk of overcoming the resistance at one of the other sutures whether it's here, here, here, back here and having an unwanted fracture, and so that's what I'm trying to avoid. If I can eliminate the midline resistance as soon as possible, then I know that now I can slow down everything and then they're only going to be feeling the resistance of the sutures we don't want to break or we don't want to separate. It's a little bit easier to understand and feel what's going on. I tell my patients the same thing so that they can understand it, so they're not just like oh, I want to turn fast, you know. I want to get done fast, you know.

Speaker 2: 1:15:50

It doesn't always, yeah, Wording that the other bones have to bend Like. I never pictured that's what's happening, but yeah, there's a pressure like a torquing of all the other bones that have to come in. That's an interesting way to visualize that. What is the youngest age and the oldest ages that you've done, marpeon.

Speaker 3: 1:16:09

So I think my oldest is a 72 year old female. Airee was part of it with her but honestly she had had a narrow smile her whole life and she had a bunch of recession because her teeth were tipped out and she wanted to correct it and have a more broad smile. So we worked with the periodontist on that case. He did some grafting and some SFOT. She's getting to the end part of her treatment now. She's doing really, really well, got a great split custom Marpe. That's the oldest patient I've done. The youngest patient I've done is actually eight and they're in treatment right now as well.

Speaker 3: 1:16:36

And this is a craniofacial patient. So this was a patient whose skeletal cranial sutures did not. They fused early, essentially, and so they had to go in and the surgeons had to actually physically cut the sutures, expand the bones and correct the skull. But because the skull bones weren't fusing incorrectly, the maxillic was very, very, very underdeveloped. Yes, so we needed solid scale. We needed pure orthopedic expansion, like we couldn't afford any dental tipping or any dental alveolar bending. We needed this top jaw to become wider and we needed it to come forward. We're doing we're still in treatment. We're doing a protraction face mask along with an MSC to widen the upper jaw, cause I didn't know.

Speaker 3: 1:17:12

I mean, I worked with the team and I'm like well, you know, there's no reason that I can think that we shouldn't do this. I mean, you know, looking up the condition that she had, it doesn't affect the maxillary sutures, it only affects the cranial sutures and so there was no reason why it wouldn't work. But you know, I was obviously hesitant. So we took some progress CBCT images and you could actually see, you know, the bones moving apart. That was very encouraging.

Speaker 3: 1:17:30

What I will tell you is that the protraction side of things has been way, way, way slower than I would have anticipated, and my guess is that has something to do with that fusion of the skeletal sutures, because you know, when you're protracting, you literally are protracting all of the bones in the face and all of the bones in the face are connected to the skull, right? So if the skull is not responding the way that it normally would, it would make sense that protraction would be more difficult. So she's progressing, which I'm super excited about. When I get the case done, I'll likely publish it so that you know more people can be involved.

Speaker 3: 1:18:01

But I do think that you know skeletal anchorage in these craniofacial patients will be something that is a real game changer in the way that they're treated, because even before Marpe's they've always done, you know, crazy skeletal things on syndrome patients in order to get the results they needed. You know cutting the jaw in half using distractors. This is just a relatively simple way to possibly get some really big bone changes that we used to have to do, really really aggressive things to do.

Speaker 2: 1:18:26

So we'll see what a great way. You know what a great way to handle that case, and I assume you didn't have to do a piezotome because you have a fusion of the maxillary. Her cranial stenosis did not affect the maxillary suture. Really definitely share that case when you finish. That would be really interesting if you published that.

Speaker 2: 1:18:42

Question about deviated septum. So I know that Adju Yung is doing research and her research is showing that the septum doesn't straighten out. That's nothing I was ever taught. That it straightens out. Dr Ting had taught me, and maybe other people, that you're just making it less of a problem because you're widening the nasal floor and the nasal volume, but the septum doesn't straighten out. So if you have a patient who needs a septoplasty, do you have them wait until after your expansion to do a septoplasty or are there any negatives about doing a septoplasty or rhinoplasty before Marpy?

Speaker 3: 1:19:16

I'm always careful to opine on things that are not directly in my wheelhouse, if that makes sense. You know what I mean. So I'm not an entity. So I don't do septoplasty, I don't do rhinoplasty, but I'll let you know the way that I think about it and the way that I explain it to the patients. So most of the time when patients are seeking out a septoplasty or a rhinoplasty, they're seeking it out to improve nasal breathing. So the way that I think about it is yes, septoplasty, rhinoplasty, both of those are ways that can potentially, when done correctly, improve nasal breathing and decrease nasal resistance right. But if they're in a situation where they have orthodontic and or aesthetic changes, if they wanna do an expander for other reasons anyway, then my thinking is well, if you want all of these other benefits and you wanna do the expander anyway, why would you put yourself through surgery if this may fix the problem? So I'm never gonna tell them this is gonna fix your problem. I'm gonna say it's up to you. You can go get the surgery and then we can do this and maybe both will help.

Speaker 3: 1:20:11

I talk about tonsils and adenoids the same way. Like should I get the tonsils and adenoids out right now. Well, I mean, like, how big of a problem are they causing? I mean, like that's an immediate way to make the box bigger. There's a lot of research on that but I would say more adenoids than tonsils. If it's not like a big, big resistance, it's not like totally blocked or almost totally blocked, I always give them the option. I'm like, well, your kid's mouth breathing, they're probably gonna be able to nasal breathe. If you get the expansion and you have the nasal passage ways wider, they're probably gonna be able to nasal breathe more. There's a good body of evidence that suggests if you nasal breathe full time, the tonsils and adenoids will shrink faster.

Speaker 3: 1:20:43

And so, like you know, it's up to you and I have a fair number of patients that the level of their sleep disorder breathing is so severe that they wanna go get the tonsils and adenoids out. You know before and there are some that I'm like you know, if it were my kid, that's what I would do, because these things are huge, like literally blocking off 100% of the posterior airway that the adenoids are huge and I'm like, well, I mean, yeah, they might shrink over time, but like a lot of time, like, and if it was my kid I'd probably just go get them out. So that's how I approach it with them. I mean, in my mind I always try to go to the least invasive option first, the least risky option, first right. So with the Marpy you're not sedating them, you're not putting them under, so the risks associated with traditional surgeries, where you do have to be sedated or put under, are inherently lower right. So I'm always gonna start with the lowest risk possible and then work our way up, depending on the needs of the patient.

Speaker 2: 1:21:28

What if a patient already had a septoplasty? Are there any problems with then having a Marpy after?

Speaker 3: 1:21:34

From septoplasty specifically, I'm not aware of any Like if something was crazy weird about the surgery or there was some, like you know, perforation of the nasal septum that was, you know, close to the inferior border.

Speaker 3: 1:21:44

Yeah, I would be really careful. And so we always try to seek out clearance from patients who have had prior nose surgery just to get an understanding of what was done and if the ENT feels that there's anything that we should be aware of or any reason that we shouldn't attempt this, most of the time we're educating ENTs on what this even is. So we have to explain hey, this is what we're doing. You know, expander, you know we're doing a cut down the middle. It's gonna be widening and they'll let us know like is this something that they're worried about? You know, today I haven't had a patient that we got clearance on where the ENT was like, you know, no, don't do that. So most nasal surgeries, I would say, are not a contraindication from RP expansion. But again, I'm on ENT, so I haven't seen every nasal surgery possible and what there is. So we continue to seek their guidance before jumping in with patients who have had a history of that.

Speaker 2: 1:22:28

Okay, that's really good to know. It's not like sort of black and white, like you had a septoplasty you should not get a Marpy or vice versa. So that's great, okay. So before I get into some other really good questions and we won't be too much longer, but I have a couple quotes from your course that I thought were great.

Speaker 2: 1:22:43

So in one of the parts of your course you show a patient with a jaw size discrepancy, so very narrow maxilla, and you mentioned how orthodontists are good at getting teeth to fit together.

Speaker 2: 1:22:53

But you say something about but should they really try to get the teeth to fit together with such a jaw size discrepancy?

Speaker 2: 1:22:59

So specifically, what you said is can we get the teeth to fit together with a nine millimeter jaw size discrepancy?

Speaker 2: 1:23:06

I would argue most of us can, as orthodontists were really good at getting teeth to fit in the absence of ideal size jaws. But the more important question is should you get the teeth to fit together with this large of a jaw size discrepancy? And I would argue that in most cases the answer is going to be no. We should look at the root cause and we should idealize the anatomy as much as possible to set these patients up for the most ideal result, both dentally and health-wise, for the rest of their lives. And I just love that because when you think of, maybe, an orthodontist who's not thinking of the airway and the breathing but just aligning teeth, then yeah, they could bend and tip teeth for things to fit together well. But should we really be doing that? When there is a narrow palate and even without a dental cross bite, if that maxilla arch is not wide enough for the mandible, then it would be good to attend to that versus just straightening teeth.

Speaker 3: 1:24:01

Absolutely and honestly so. One of the challenges I know that many of you face is finding orthodontists who are willing to do this kind of treatment and to learn about this, even to step out and take a CE course or dig deeper into what's going on here. I mean, there are so many great practitioners who understand and know what's going on, but either they don't treat it or they don't want to treat it and they don't have anybody else who will. So it puts them in a really tough spot. As it relates to talking to your normal quote, unquote everyday orthodontist who's had traditional training, I think one of the best places to start would be with the literature about long-term dental bite TMJ type problems, because that's been established in our literature for a long, long time the amount of compensation or tipping of the teeth that you have to do to get them to fit together. There is a very significant and definitive correlation between their chances of having TMJ problems down the road, their chances of having a fracturing of teeth. Even just dentition wear down. If the teeth have to compensate in order to fit together, they are more likely to have problems later.

Speaker 3: 1:25:01

And a lot of that research we present in the course and we provide you with the articles so that you can have a place to start talking and having this conversation and hopefully, if that opens up a door, they say, okay, well, this kind of makes sense. Well, maybe then they start looking into some of the newer research that talks about how having this anatomy right really does decrease the long-term risks of kids either having or developing sleep disorder, breathing problems, and these are the areas that we don't have 30 years of solid research to say that this is happening, but we have a growing number of studies that indicates that 30 years from now we will. And so like getting them on board with being a little bit more progressive. If it makes sense to them and they understand it and they can reconcile it back to the existing research that they have, then there's a lot less reasons that they would choose not to do it.

Speaker 2: 1:25:45

So for orthodontists who might not be interested in learning about adult expansion or Marpe, is that maybe the best approach is to kind of share with them articles on the TMJ problem aspect?

Speaker 3: 1:25:58

The more you can speak their language and the more educated you are, the better conversation you're going to be able to have. Because if you go to somebody and you start talking about this E-line and I'm not saying like, say, I'm not knocking on any of the ways that people measure things but if you start talking about the E-line or you start showing them two profile photos without X-rays and it, it's just that's not a result of the data that we have, right. But the intent with this course, in addition to teaching orthodontists and dentists who want to do these procedures, is to provide everyone with the language that they will need and the background that they will need to have an intelligent conversation with their orthodontists, with their paradigm, whoever they want to work with in their area, they can now speak the same language. And when the orthodontist says something like oh, you know, well, you know yeah yeah, yeah expanders.

Speaker 3: 1:26:41

Like you know, I just do braces and I get the same type of expansion. You know you can ask the question well, is the type of expansion you're getting like more orthopedic or like more dental, older bending or more dental tipping, like what kind of expansion are you seeing? You know, and so, yeah, it's just like you know it's a conversation needs to have. There are some out there, unfortunately. I mean they've been doing things the same way. They don't even have a comb beam. They're not even interested in getting a comb beam. You know what I mean. They've just, you know, they've been straightening teeth for so long. That's what they're gonna do. That's probably not your best bet as far as seeking somebody out. If somebody has a comb beam, that's a great first start because at least they're seeing things and they have the ability, you know, when you say something or when you put a bug in their ear, they have the ability to go back and look at some patients and say like, oh, that's true.

Speaker 3: 1:27:22

I had a conversation with an orthodontist in Texas and it was funny because my niece lives in Texas and they went to see this orthodontist and the orthodontist sent me the plan that they wanted to do, which involved, you know, braces to kind of make room for some impacted canvans that were coming in.

Speaker 3: 1:27:35

And so I sent him a video and I said, hey, thank you so much for seeing her, thank you for getting all this imaging. I really, really appreciate it. And I was, like you know, I'm kind of an expandodontist, so, you know, take it with a grain of salt. But like, here's what I look at, you know what I mean, here's what the bones look like. So, you know, I was thinking, like you know, maybe if we did, like you know, a bonded maxillary palatal expander and we got that job wider, that it might create, you know, and I'm showing it before and afters, and it was funny because, like, I didn't really know how he took it at the time. But a year later I saw him at a meeting and he's like you know that video you sent me, he's like you have to be rethinking my entire practice.

Speaker 3: 1:28:05

Like my entire you know what I mean, because he's been doing things for so long and it's just again. It's not that he was resistant to it, it's just that he didn't know, like no one had ever presented it to him in that way, and so that's what I believe will happen, and that's 100%. The reason why I created this course was to have more conversations like this happen across all of our fields and specialties, because if we start, you know seeing the same things and understanding the same language. Well, now there is so much knowledge out there that currently isn't being used because they're not involved in this, and they don't know about it, but as they learn about it.

Speaker 3: 1:28:37

Man, we will bring in so many great minds to help move this forward, and that's honestly what I'm most excited about.

Speaker 2: 1:28:43

Yeah, and that's funny how you had to tread kind of lightly, talking to the orthodontist as well. Oh yeah, I mean, I don't want to call him orthodontist, I mean like I say.

Speaker 3: 1:28:51

I mean I respect these guys, I respect the vast majority of my colleagues, I have a high level of respect for it and so you know I don't want them to feel like you know I think I'm better, I'm doing something you know better. I just want them to understand where I'm coming from and why I think the way that I do.

Speaker 2: 1:29:05

Yeah, and that was successful because he opened his eyes and you changed his life and many other people's lives because he was interested in listening and hearing. What about? As myofunctional therapist? We might get patients who are referred maybe not referred by the orthodontist. Maybe they're referred to as they find us on Google or whatever it is, and the technique the orthodontist is using is retractive, maybe extractive, and not an expanding type of approach. Or how do you suggest we handle that with the from one orthodontist to another? How would we handle that with their current orthodontist?

Speaker 3: 1:29:40

Well, all I can say is, like you know, this isn't a conversation I've had because unfortunately, the collaboration between orthodontists, you know, in cases where they're transferring or switching, is not high. I have had a couple of times. But I would want, you know, the respect of at least understanding where they're coming from. So, in my opinion, the first thing I would do is go to the orthodontist and just address the concerns, just be like hey, you know, this is what I'm seeing. You know, help me understand the goals for your case and what you're trying to accomplish, and then just explain, like this is what I'm seeing. Like you know, if you have a combi, great, I mean, do the cross section measured out? Like you know, when I measure out that kind of how wide the bones are, I'm noticing that, like the top jaws like three or four millimeters more narrow and I'm wondering, you know, with everything I'm seeing on the myofunctional side of this kid is having a really hard time getting their tongue to the roof of the mouth. They're having a really hard time, you know, nasal breathing, swallowing, all these kind of things. I'm thinking like if this jaw were wider, that would really really help me accomplish the goals of the myofunctional goals that we have for this patient. And so, like you know, what ideas do you have about how we might be able to do that? So I would start there. If they're just completely resistant and they don't want to hear anything, then you know, I feel like at the end of the day, I need to be honest with my patients. So I'm going to work as hard as I can not to throw the other guy under the bus. I'm just going to say, hey, look, you know we had a conversation. This is what we talked about. This is how they view things, as far as I understand it, and we just kind of view things a little bit differently. And he's a great orthodontist. He's been around for a long time. There's a lot of great words, I've seen a lot of great smiles. But you know, these are my concerns and you know, if you want to look into that a little bit further, you know, maybe you can talk to this person who kind of sees it a little bit differently. That's kind of how I would do that.

Speaker 3: 1:31:05

I've had conversations with orthodontists just about tad cases, like I had a patient come in Subsequently. They did have an MSE, but severe maxillary can't. So the maxillary was like really, really slanted and it was narrow. And so I was a second opinion to a well-respected orthodontist in my community and so I just reached out to him directly and I said, hey, like when I saw this patient second opinion you know, they live close to you, they love you. I'm not telling him to come here, but this is where I'm coming from and what I explained and I was like I'm happy to send him back. If you think that that's the right treatment plan or anything that might be better, like you can do it. And eventually he's like you know, I don't really do tad. I really appreciate you reaching out. Like you know, why don't you just treat them and like, let me know how it goes? And I think that most of us like that would speak for how most of us would deal with something like that If I had a patient.

Speaker 3: 1:31:47

I did, actually, I had a patient come to my office that wants to know about the ease procedure, right, and I said you know, dr Casey Lee, the ease, are you familiar with that? Yeah, yeah. So they want to know about the ease procedure. And I'm like, okay, well, I don't do the ease procedure, right, I know a little bit about it. I said I actually respect Dr Lee a lot.

Speaker 3: 1:32:01

I have looked into the data that he's presented and he does get true orthopedic expansion. I don't really know how he does it. You know he's not an orthodontist, so you're still going to need an orthodontist to get your teeth straightened afterwards. But I'm like, yeah, if you want to go see Dr Lee, like go see him, like see what he's doing, I mean like this is what we do, this is how we do it you can find out how he does it. And he went and saw Dr Lee and he chose to get the ease procedure. So you know he's going to be having it soon.

Speaker 3: 1:32:22

I'm actually really, really excited because I have initial imaging on this person and now they're going to go get the ease procedure and now I can take some imaging afterwards, and so then I'll at least have, like firsthand, 100% complete images. Because you know at this point, not that I have any reason to suspect that Dr Lee doesn't present his data. Honestly, I think he does. But now I'll have my own view of it. Right, I can look at it in any section. I want any detail. I'm going to be able to see exactly the type of expansion that's achieved, where it's achieved, and now it'll be?

Speaker 2: 1:32:49

Let us know. Let us know. I had one patient who got the ease procedure from Dr Lee a while ago as well. So what about if the it's okay? So my last question was if it's not, the patient's not referred by an orthodontist and the orthodontist might be using retractive techniques or not expanding, what if the orthodontist refers a patient to us and it's the same situation where now we can't really tell them to get a second opinion, or can we?

Speaker 3: 1:33:14

Yeah, I mean, here's the thing, like. So I lose sleep over, like you know, this is why I lose sleep, all right, like I lose sleep over people not getting the best care, or at least what I believe is the best care. Like I say, nobody knows what the best care is, right, we all have our opinions based on the current knowledge, but I am more am, so. This is me. So it's like at this moment in time, I want all of my patients to receive the best care. So for me, it's more important for them to receive the best care or, at a bare bare minimum, not to receive what I would think of as bad care, right? So, if ever there's a patient who I feel like in my mind, you know, right or wrong, maybe it's bad, maybe it's not, but in my mind it's not good care, like you know, just because of, probably a lack of education, right, I'm not going to do that. I'm going to tell them. Yet I'm going to give them a second opinion. I'll just call and tell my did. I was like hey, I know you sent me this patient. And here's the thing, like, it's just like. I just really felt like in this specific scenario, this practitioner would be best for them.

Speaker 3: 1:34:05

A lot of times this will happen with TMJ. I've had people you know come over from TMJ and you know it's somebody who manages TMJ but then they're trying to send me. They're not having good luck and I'll send them off to another TMJ specialist because, like, I feel like that's where they're going to get the best care, and I'll just let them know. I said, hey, with this case, this is what I did, and I think you know, if we're open and honest about it, will I lose that referral source? Maybe if I do, though I mean honestly, it's one referral source, like if my whole career and practice is going to be ruined by one referral source. Like I've done something wrong you know what I mean Like I made a mistake that's much bigger than I should have. But yeah, I don't know of any referrals that I have lost doing that. I mean, maybe I have, but I don't know. And if I did, though, like I say, my sleep is worth more than one referral source.

Speaker 2: 1:34:45

Yeah, and it's great hearing from you as an orthodontist how you handle these things and how we should with other orthodontists, and what I tend to do is really like what you said.

Speaker 2: 1:34:54

I speak of it from the myofunctional perspective, like be really great if we had more tongue space and you know all those types of concerns, but put it in terms of like tongue space and nose breathing, so to help us accomplish our goals, and so I kind of put it in that wording and I've had many cases where I've had to tell the parents like, look, this is my opinion, this is where we're coming from, this is what I see.

Speaker 2: 1:35:15

Your orthodontist might not agree with this. So if you did want to ask for other opinions, you know you're welcome to do what you want, but this is just where I see it. So, kind of you know careful with your wording, because I've spoken with the orthodontist who might not see the same perspective or might say, oh, there's no such thing as a skeletal cross bite. The patient's on a cross bite, they don't need expansion, and I'm like patient has sleep apnea, you know. So it's like I actually did have a case and the parents went to a different orthodontist and who recommend expansion, and this kid's life is like totally different than you know well seen.

Speaker 3: 1:35:47

Well seen it. Like I said, you can't let them see, right, so exactly.

Speaker 2: 1:35:51

And we all care so much that, yeah, we lose sleep when we feel like a patient might not be getting a treatment that we might think could benefit them. Okay, so last thing, first of all, to sum this up, you're amazing, your course is awesome. This is so good. We've covered so much today. I just really appreciate hearing from you as an orthodontist who has such an airway, minded, focus and you see the big picture and you can, in the very end, after my last question, you can let everybody know how to access your course as well. But I did see a post on Facebook that well, dr Ting posted it and maybe you did as well. Also in the MSc group, it was you, rebecca Bacao, audrey Yoon, ilya Lipkin, richard Ting, mariana Evans, and they said something exciting. Exciting news is coming up with all of you. Can you talk on that, or is it top secret?

Speaker 3: 1:36:43

I wouldn't call it top secret, as much as I would call it unfinalized.

Speaker 2: 1:36:47

So you can just say top secret, it sounds way better. No yeah, Right.

Speaker 3: 1:36:51

So here's the deal. I mean, like, basically, you know, I approached them because exactly the same thing we started talking about, like why did I create this course in the first place? Like this is going to be the more people that we can get collaborating on getting education out there, the better. So those individuals that you listed were, you know, were the ones that I have, you know, the absolute highest regard for in this space and I feel like I've been contributing so much for so long, and so I asked them to get together in order to see if we could collaborate on a project. And the goals are the same.

Speaker 3: 1:37:21

You know that we've talked about the goals are to get quality education out there, but also with a, you know, with a support component, meaning, like you know, being able to have, especially newer practitioners, have ongoing support, but not only even just, you know, ongoing from you know, the five or six of us or whoever it may be, but like, continuing to have, you know, systems to be able to bring more people in, so that you know, as you, you know you're the mentee, but then you progress and become the mentor. So, again, like, all of the details are not worked out yet, but you know, if it all works out, I would be honored you know, truly honored to be able to work with them on a project to help make Marpy education better, more accessible and more self-sustaining going forward. So that's what we're working on, but we'll hold off on any of the final details until we actually have them. So we're still collaborating.

Speaker 3: 1:38:05

we're still, you know, talking. We just haven't worked it all yet, Not yet quite.

Speaker 2: 1:38:08

Let us know what you decide and how you know what it's going to be when that time is ready, because that sounds so great and what's so great about all of you people and everybody in the airway field is that everybody is here to help and it's not competitive, but everybody is teaming up to help our patients get the best care possible and to get patients who are unidentified get identified and get treatment. So it's just such a great like unity. So I know we were here for a long time. I wanted to thank you so much for all of your time, your support, your enthusiasm, your education. What's the best way for someone to find access to your course?

Speaker 3: 1:38:45

So the course, we'll go ahead and just put a direct link in the description. I'll send that over to you. That's the easiest way because it's a new course. It's not like indexed on Google. So if you search like Marpy 360 or Marpy manually, you're probably going to find a lot of articles, but not the course If you are searching it. What I found by mistake actually is if you go on the Duck Duck Go search browser. So if you go to Duck Duck Go, which is kind of like a Google but different, and you type in Marpy 360, it's the first thing that pops up. But for some reason on Google like if you type in Marpy 360, you got to go like four or five pages to find it. So if you're searching it, just go on to Duck Duck Go, search Marpy 360, and we'll provide a direct link in the description so that you know you can get to it there.

Speaker 2: 1:39:23

Okay, great. Is there anything final word you want to say before we close?

Speaker 3: 1:39:28

Only thank you for all that you're doing. I mean, it's so awesome that we have a platform now to reach like-minded individuals and to provide resources and support like we never have been able to. I mean the podcast, the YouTube like online lectures all that kind of stuff is just so awesome, and I know that you could be spending your time doing a lot more things. It would probably be a lot more financially to your benefit and your practice and whatnot, but the fact that you commit yourself to furthering this cause and creating this collaboration is just awesome. It's truly inspiring. So thank you for all that you do and thanks for having me on today.

Speaker 2: 1:40:03

Oh, thank you so much, and same to you. Thank you for all of your time and we look forward to talking to you again at some point in the future.

Speaker 3: 1:40:09

Awesome, thank you.

Speaker 1: 1:40:11

Thank you for listening to our radio style broadcast, where we bring different perspectives to the airway world in an easily digestible format. Different hosts, different views, same airway talk. Don't forget to leave us a review, bye, bye.