Jaw Surgery and Orthodontics Overview

Speaker 1 0:59

Hello everybody and welcome to Airway . Answers Expanding your Breath of Knowledge , and my name is Nicole Goldfarb . Answers Expanding your Breath of Knowledge and my name is Nicole Goldfarb . I'm a speech pathologist and certified oral facial myologist and an airway fascinator . I'm just fascinated with all the airway information in the airway world .

Speaker 1 1:17

So I have two legends here with me , dr Brian Hockel and Dr Bill Heng , and the conversation today is about jaw surgery . So we're talking about MMA surgery and I thought it would be just a really wonderful , interesting thing to talk to Dr Hockle about his experience and to talk to Dr Heng about him working with Dr Hockle . You guys have hard names to say together Hockle , Heng , about your jaw surgery experience . So let me do a little introduction for these wonderful , wonderful people here and then I'll have you guys talk a little bit about your experience as well , because I know I will not do it justice . So I'm going to start out with Dr Brian Hockel , who is an orthodontist in Walnut Creek , california , so in Northern California , and he graduated from UCSF School of Dentistry in 1989 and currently is involved in many different organizations . He's an airway advocate and is involved in the Academy of Airway and Nathologic Orthopedics , the American Academy of Cosmetic Dentistry , the North American Association of Facial Orthotropics , the American Academy of Dental Sleep Medicine , physiologic Medicine and Dentistry , so AAPMD , the ADA , california Dental Association , contra Coastal Dental Society , and some of Dr Hockel's specialties and expertise is understanding both cosmetic and restorative dentistry , airway orthodontics and nathology . So the study of how the bite fits together and that allows him to implement comprehensive treatment that offers significant improvements in both dental and overall health .

Speaker 1 2:58

And notably , dr Hochul stands out as one of the few Northern California dentists who practices and teaches orthotropics , which we love . We've talked about this before . I talked to Dr Heng , maybe about a year ago , and we talked a lot about orthotropics , which is amazing , and it's a groundbreaking process for guiding facial growth , for growing children , and I want to touch on that a little bit today as well . And then I'm going to also introduce Dr Bill Heng . And I know Dr Heng from when you were living in California , in Westlake Village and recently retired . How long ago did you retire , dr Heng ?

Speaker 2 3:35

About a year and a half ago , we retired after more than 50 years of practicing ortho .

Speaker 1 3:41

Wow . So can you talk a little bit about your background , because I have like pages of like your history , which is amazing .

Speaker 2 3:47

And I'm not going to read it , although I want to orthodontic surgery and I was very interested in it and I giving you my background and that I actually treated 10 of my own cases while I was a resident and went into the operating room with the surgeons assisting them with the surgeries . I've been heavily involved with orthodontic surgery for my entire career . I was traditionally trained and I taught for a year . Then I decided to get out of academia . I didn't want to be there and I was taught for a year . Then I decided to get out of academia . I didn't want to be there and I was going to go practice . So I moved to Vermont to get away from the burning cities in the 1970s , to get away from the cities , and I practiced exactly as I was taught . But within a few years I started looking at the faces that I was producing , didn't like what I saw and realized I had a lot to learn and I began to question what I'd been taught . So I started doing continuing education , taking courses all over and I mean it was in airplanes and hotels , going here , there and everywhere because I was ready to get out of the profession . I couldn't stand to do retractive orthotics anymore , so I started not taking out teeth . I had been taking out teeth in more than half of my cases and I started just pioneering stuff on my own , learned from other people . I was practicing in a town of 20,000 people where what you do gets home . Before you get home People know what you're doing . If it works out , great . If it doesn't work out , then you might as well pack your bags and leave the general dentists in the state . The entire state loved what I was doing and I built a huge practice there . People would come from other cities where there were other towns , where there were orthodontists and people wanted to have what I was doing . It was going very well , going very well . Along the way . During that process I learned from John Mew , went to London , learned from him , began doing orthotropics , which is the diametric opposite of traditional orthotics , moves the upper teeth forward first and then the lower jaw forward , correcting the poor restoral posture that caused the problem in the first place . And I saw and documented how this improved the airway and so we published on that a consecutive study on how we improve the airway on these growing patients . And when I saw that I got huge into airway In 1989 , I began reopening extraction spaces for people and in my practice previous orthodontic extraction spaces , getting rid of headache patterns , sleep apnea , and in my practice in California I had people from more than 30 states and several foreign countries coming mainly for that and got heavily involved in orthodontic surgery . I think one year I did 22 cases . I prepared them for surgery , which is quite many orthodontists won't do that many cases in their entire career . But I've developed some protocols of how to optimize facial aesthetics and airway and you know I'm retired , but I'm not retired , I'm semi-retired and I get on the internet almost every day and I get people contacting me still from around the world . So I enjoy what I do .

Speaker 2 7:11

And Brian , he got into my mini residency right at the beginning and he was there for every session there and he learned from me and he's been my right-hand man . If I drop dead , which I don't plan on doing , I always say he knows my slides as well as I do . He could take over . But he's been a great person . He's an innovator . We've actually together really get good conversations and together come up with things that probably other people would not come up with . So , brian , of course he came on and early on he realized he had sleep apnea , but like so many , I mean , he didn't have time to deal with it but nobody does right , there's never the right time and so he finally came around to it . Something pushed him over the edge , and so he finally came around to it . Something pushed him over the edge , and so , a few years ago , we got him started .

Speaker 1 8:09

Well , I want to hear what pushed you over the edge . Hold on , I want to pause for a second . Go ahead , ryan . So many thoughts are popping into my head , one big thing , is . 1989 is when you started reopening extraction spaces . Dr M , oh my gosh , I was 10 years old . I grew up really close to your office . If my parents only turned me up and down the freeway .

Speaker 2 8:33

This was a woman in rural Vermont and she forced me to try to do it . I wasn't on some mission to change the world , but once I realized that she'd had headaches since the time her treatment had been finished , she was 27 years old and I promised her nothing . I figured out how to do it . I did it . I didn't push the teeth off the bone support like I thought I might , and her headaches went away and have stayed away ever since . Her face the facial change was amazing . She looked like an old woman because her teeth had been pulled back in her face and when she got the process redone , she actually went to visit her mother in Florida and I won't give you her first name , but she said first name gee , you have lips Like before . They were literally pencil thin and because we pushed the teeth back forward , she looked like more like her age rather than someone three times her age .

Speaker 1 9:27

Yeah , that's amazing . I saw on your website , dr Hing , you were saying . This is what you wrote .

Sleep Disorders and Orthodontic Treatment

Speaker 1 9:33

According to the United States Center for Disease Control , about 70 million Americans suffer from chronic sleep problems . Lack of sleep is associated with injuries , chronic diseases , mental illnesses , poor quality of life and well-being , increased healthcare costs and loss of work productivity . Sleep problems are major contributors to some chronic conditions , including obesity and depression , but are rarely addressed . Your mission now is to help clinicians identify , diagnose and treat the millions of children and adults who have a breathing disorder . 25 to 40% of young people have sleep problems right . That could be close . That's a close to half . 60 to 70% of children with ADHD have mild to severe sleeping problems right .

Speaker 2 10:21

If you listen to Steve Sheldon , who retired from being head of Lurie Children's Hospital Sleep Clinic , he would say he does not and he's a researcher with books published on sleep apnea pediatric sleep apnea . He would say and he's said it many times he does not believe there is such a thing as ADHD . He believes it is always a sleep and breathing problem , which is a very interesting word . When a researcher uses the word always , that gets my attention . I am not a researcher , I'm a wet gloved guy .

Speaker 1 10:53

Yeah , you're not supposed to say always , so that's like a really big deal .

Speaker 2 10:57

That's a dangerous word for anybody to say in this world .

Speaker 1 11:01

Yeah , imagine that . I mean , we know right , when your sleep cycle is fragmented , your body pays consequences the next day . And I'm just going to be honest , my son the other night got one hour less sleep . He went to bed one hour late . Totally different kid the next day . Some bodies are more vulnerable to slight disruptions . I was like this is a different kid and we went to bed too late . It's just interesting . Also , 25 million adults in the US are affected by sleep apnea . 11 to 12 million adults in the US suffer from TMJ pain . So we kind of have a world of a lot of suffering people who aren't getting help . So , dr Hossel , let's get to you because you had sleep apnea , like , can you tell us about your ? Your sort of history of what inspired what kind of treatment you had ? What's inspired you ?

Speaker 3 11:55

Sure , the sleep apnea wasn't really severe . I was getting through and it's like so many people with sleep issues it's just your normal and you figure out ways to work around it . Excuse me so it wasn't debilitating for me like it is for so many of my patients , and maybe that's one reason why it was very easy to put it off and not deal with it over a long period of many years . I knew that there was this thing called sleep apnea when I learned about it early on doing orthodontics and dentists were first getting into making oral appliances , so I knew that there was this possibility . I think I did an early polysomnogram many years ago and there was something very mild there . And then , after I met Bill Hang and realized that oh , there's a lot that we do in orthodontics that can be affecting what's happening with the airway for better or for worse , I did a watch pat a sleep study early on , maybe 20 years ago , and it was pretty mild . The RDI was elevated which , if they did a really decent polysomnogram , might indicate that it was more what some people call upper airway resistance syndrome or rera , predominant sleep apnea . So just give it whatever words you want .

Speaker 3 13:14

It wasn't ideal sleep , but what I really knew was that my jaws had not developed as far forward as they should have and that that put me at risk . But it wasn't high on my list . I had a lot of little kids at the time , a lot else going on , the practice is busy and I had too many people to treat rather than worrying about treating myself . And in the back of my mind was really how could I ever take a month off of work in order to do surgery myself ? So I just kind of put that way on the back burner or maybe behind the stove behind the back burner and didn't think about it much .

Speaker 3 13:53

And then I tried an oral appliance just to try things out , see if that would help . I felt like I slept a little bit better with it but never stuck with it . I tried not reopening spaces , but opening spaces on my upper arch to just create more room for the tongue and allow room for the lower jaw to come forward if it would , and it felt great to have the upper front teeth a little further forward . But again , I didn't really stick with it . I knew that it was dealing with jaws that should be here , but were actually down here and trying to just do little minor changes with them down here . I knew that really someday the ultimate was going to be to just put the jaws where they belong , but I didn't think concretely about it until the time arrived when I got a CBCT in the office here and did an image on myself early 2022 and measured the airway to be at 22 square millimeters on the treatment software .

Speaker 1 14:57

Was the first time you ever did a CBCT on yourself .

Speaker 3 15:01

No , it wasn't the first time I had done one before , and the earlier ones were not great either . I mean , who's going to brag about a 48-square-millimeter airway ? Or I'm sure it was under 100 . Wow , and before we had CBCTs , nicole , we looked at 2D CEFs and that was all we had for looking at just kind of the rough outline of the airway . And I knew from those that I did not want to be bragging about my airway in the South . So , yeah , when I it was , the wake up call for me was seeing that image of my airway , realizing I'm 61 years old now . I am not going to want to have this airway when I'm 71 , 81 , or , god willing , 91 , if I even make it that far with that kind of an airway . 81 or , god willing , 91 , if I even make it that far with that kind of an airway .

Speaker 1 15:52

That for me personally , that was where I picked up the phone and said , Bill , would you put my braces on ? I got to do this . Wait , can we talk about that conversation ? You call Bill .

Speaker 2 16:00

I knew it was coming .

Speaker 3 16:02

He would have loved to have had that conversation 10 years before I'm sure . He would have loved to have had that conversation 10 years before , I'm sure , and would have been just as happy , but I don't remember much more than next time I'm there . Can you put my braces ?

Speaker 2 16:16

on Sure , okay , we'll do that .

Speaker 3 16:16

We both knew what was needed and where it was going .

Speaker 1 16:19

Yeah , you knew Dr Hang that he was going to .

Speaker 2 16:23

Well , I knew that he had the problem , but everybody has to get to that point on their own . You can't force them and shouldn't . They have to make that decision and so it was just a matter of getting him in the braces and properly setting him up , which we have a protocol which I've really kept modifying it but really got it , mostly since 2015 , made it even more better by expanding both arches dramatically prior to the surgery . Most orthodontists would shudder at the thought of expanding the lower arch , thinking that they're going to push the teeth off the bone support . Of course , that's what I was taught , but I know full well that doesn't happen and part of the protocol .

Speaker 2 17:08

If you're going to do orthodontic surgery right , with a goal of getting proper restoral posture , improving the airway as much as you can , then you need to make the box that the tongue lives in as big as it can be , and the only way to do that is to , one way or the other , expand both arches , and that's what Brian you know . Brian knew full well what needed to happen . I got the braces on . He didn't need me after that , so he did it himself and he knew what he was doing . He'd have his assistants in his office , change the wires and all . But he got himself very nicely set up for the surgery . And , Brian , I think you were one of those ones that woke up after the anesthesia and said , oh my God , I can breathe , which most . That's pretty much a common thing when , when people wake up in the recovery room they'll often say , oh my gosh , I can breathe . They never have before .

Speaker 1 18:01

You had double jaw surgery , right , Dr Hockle Right jaw surgery , right , Dr Hockle Right . So the first step is braces and Dr Hing , how long did he have the brace on ? What did you do with the braces ? What's the first ?

Speaker 2 18:13

I just put them on . But the protocol that we use , which I developed , is to first align the teeth and broaden the arch and get it rounded out with the arch for the broadest arch forms you can do , which makes instead of a .

Speaker 2 18:25

U-shaped arch , a big U-shaped arch . Do that with fixed races . Then you put in an upper removable expander and a fixed lower expander and you do additional expansion over what those wires will do . We typically want to get the intermolar width from usually where most people are in the low 30s to over 40 millimeters 42 , 44 , if we can do it , the idea being that John Mu feels that you know to get the tongue to the palate , where a myofunctional therapist like you would be happy , so that that tongue can easily fit there .

Speaker 2 19:02

John Mu has been saying for several years 42 to 44 millimeters and that doesn't exist in nature . We don't have people walk into an orthodontic office with that molar width . And yet if you want to get the best result with your orthodontic surgery and do it once and do it right , you darn well better set up the case properly and not go and do the MMA surgery and then afterwards say , oh well , I still have sleep apnea . Oh well , maybe we should have expanded before we did the surgery . That's like putting the foundation in the ground after you have the skyscraper 100 stories in the sky .

Speaker 1 19:41

So you're kind of it's like a dental , dental alveolar tipping and then the bones get lined up to fit .

Speaker 2 19:46

Most people will tell you that adults I mean the traditional treatment , and there are people who are in the literature right now will say that the adult maxilla cannot be expanded without surgery . I expanded my own maxilla seven millimeters and reopened an extraction space back in the early 90s and I've expanded adult maxillasus in excess of 10 millimeters without doing surgery . I'm going to push the teeth off the bone support . Brian's doing a little more surgically assisted things . He'll talk about that . Why don't I let you talk about the kind of some of the things that you do , brian ?

Speaker 3 20:20

Yeah , I mean , there are surgeons out there , nicole , that would say you don't even have to bother doing orthodontics first , just do the surgery and then we'll make the teeth fit afterward , and the results are so spotty . There's so many different protocols out there , or lack of protocols , and also kind of lack of teamwork . The surgeons kind of just do their thing , sometimes without even contacting the dentists who are involved or worrying about there being any orthodontics . And this is one thing that really has made a difference in treating our patients and the people who've learned from Bill Heng is that there are ways to approach this that are methodical , that can set you up for success , and it's not as simple as you might think . And it's not as simple as you might think . Bill taught the orthotropic mini residency . For what was it ? 18 years , 2003 to 2020 , right .

Speaker 3 21:15

So and then a little bit , yeah , but we would always be asking him so , bill , what do we do for the people that can't do orthotropics ? What do we do about them ? And here's a case what do you think of this ? She's 12 years old and there's like no jaw there , and the discussion came up over and over again . These people really probably have two choices live with their jaw the way it is or move it surgically if they really want to be in the right place . And so , after a while , he developed the mentorship the ERS mentorship that was able to go over these protocols in a lot of detail and make it possible for people who certainly for specialists but non-specialists alike to be able to take on some of these tougher cases . I've got a list of I don't know what it is 12 , 13 , 14 things , things to consider when you're doing orthodontic surgery , and the first one is you do orthodontics as part of it to get the teeth prepared in a specific way .

Speaker 3 22:15

So I followed Bill's protocol .

Speaker 3 22:17

I did the alignment of the teeth and I used a lower fixed expander to widen out by lower as wide as I could get it , and the plan then is to have the surgeon segmentally expand the upper to match up with the lower .

Speaker 3 22:33

The surgeon can't really widen the lower during the course of the surgery , but he can widen the upper , so this has been kind of the one of the one of the things that is important for getting the best result . Now , with the advent of MARPEs and I know you've had an MSC yourself the ability to do skeletal expansion ahead of the surgery has opened many new doors too , and this is for most of my patients it's becoming a preferred way of doing the expansion ahead of time , and we can talk about why that is and why it makes the surgery itself simpler , the recovery simpler . So it's kind of exciting being able to take these tools that are out there , like the MARPI and the skeletal expansion , and apply them within the framework of the protocols that Bill has found successful over so many years and make make them work in the best way possible .

Speaker 1 23:30

And does a MARPI maybe allow you to get more expansion , or how does that fit into a jaw surgery ?

Speaker 3 23:39

That's one . It can allow you to get more expansion , because there's only so much . The surgeon can expand the maxilla during the course of Laforte procedure

Laforte Procedure

Speaker 3 23:47

.

Speaker 1 23:48

Can you describe the Laforte procedure where they're cutting ? Can you describe the Laforte procedure and exactly where the cuts are like , what they're doing ?

Speaker 3 23:56

I can tell you what it sounds like . Yeah , no , I won't do that , but so everything's done from inside the mouth . People think you're cutting part of the face away and then moving .

Speaker 3 24:11

It's all done from the mouth and a cut is made above the roots of the upper jaw so that that upper bone and teeth almost looks like you're holding onto a denture and it's movable inside the mouth and the surgeon knows at least the surgeon I work with knows exactly where it's going to go and how it's going to be positioned and he'll use what's called an intermediate splint tied against the lower teeth to position the upper where it's supposed to go , and plates and screws are used to fasten the jaw in that new position . But while he's in midway through that process he's actually looking in at the top part of the upper jaw . So he's looking at basically the floor of the nasal cavity and if expansion needed , segmenting the upper jaw is possible at that point in the procedure . So he basically separates the upper jaw into the two back teeth sections and a front teeth section Okay and then uses a splint on the inside it's like a retainer that goes inside the upper teeth to mobilize it and hold the three segments where they are .

Speaker 1 25:29

So the forward , or are they widening ?

Speaker 3 25:32

the whatever he needs is three dimensional . He can go wider , he can go higher , one side lower . Let's say there was some asymmetric expansion during the Markey phase of the treatment . He can correct that . The inclinations of the molars can be corrected .

Speaker 1 25:49

Are they cutting along the midline palatal center ?

Speaker 3 25:52

He's going paramedian , he goes right next to the midline , so during the orthodontics we'll leave a little gap between the canines and the laterals . Okay , that gives him room to go in and start the cuts in those two places , come toward the center and then go backward along the midline of the palate . So the septum of the nose is attached to the midline , so you stay right and left of the septum on each side .

Speaker 1 26:19

Okay , this is interesting . And did you have lower jaw surgery also , or did you just upper ? Um say the question again were there any cuts on your lower jaw ?

Speaker 3 26:32

yeah , yeah and and in fact that's that's actually done first in the operating room .

Speaker 3 26:36

The surgeon at least the surgeon I work dr movahead , he's an amazing surgeon and I think this is a a question of how the surgeon prefers to do it , but the way Dr Moved does it is he'll treat the lower jaw first and put the lower teeth where they need to be in relation to the rest of the back of the jaw . So they're advanced , they are , you know , corrected front to back if they need to be . Generally there's a rotation we call it a counterclockwise rotation that allows the back part of the lower jaw to be going down while the front part is coming up . That allows the movement of the upper jaw such that the airway is going to open up maximally . So that's done .

Speaker 3 27:19

First , the lower jaw is now stabilized . There are plates and screws holding the lower jaw where it is . Then the intermediate splint is put on the lower teeth and the upper jaw is positioned forward and into that intermediate splint to finalize its position . So you can kind of picture the upper teeth and the upper jaw are now tied to the lower jaw with this splint and you could technically open and close . The lower jaw and the upper teeth are moving up and down with it .

Speaker 3 27:50

It's wild to see , but then it's all put in the right position and he's done all this digitally ahead of time so he knows where it's going and it's it's . It's a very precise procedure . His focus is going to be on minimal damage to the soft tissue . Don't injure the nerves . Do it in a way so the healing is going to be on minimal damage to the soft tissue . Don't injure the nerves . Do it in a way so the healing is going to be as smooth as possible . The surgeon's got a lot of things to keep in mind , but how everything's positioned mechanically is just one part of it .

Speaker 1 28:19

That's why it's like amazing . Now , with all the technology and all the digital imaging that they can do , they can show you what you're going to look like . They know where everything is going to be placed ahead of time . Did you have any joint replacement or genioglossus advancement ?

Speaker 3 28:35

Did not . In fact , on my virtual plan he did plan for genioglossal advancement , but it's not as simple as just . We did it on the computer and now we're going to follow it . That's like people thinking that with Invisalign , oh , we can do it on the computer . So this must be what's going to happen in real life , and there's a certain element of that there too . It is planned out precisely on the computer .

Speaker 3 28:57

But in his judgment the surgeon may decide you know what we need to do this or that midstream , and he's not going to completely change the whole plan . But in my case he changed the plan to do the genium glossal advancement because he thought it would have given me too prominent of a chin . It might have helped with opening the airway more , I don't know . But I think it was absolutely the right judgment call to make . Yeah , my joints were in decent shape so I didn't need it . But I just had a consultation this morning with a patient in China who's going to need total joints now to fix the previous two surgeries that he's had .

Speaker 3 29:40

And this is where it's really complex . Nicole is not just helping someone like me with sleep apnea , airway issues be treated in a way that's going to maximally impact what needs to be changed . But what if this has been done and it didn't work , or it made things worse , and then it was done again after that to try to fix it , and that was made worse , and now they're being treated for the third time ? So this is where Movahead is incredible , as he's the guy to go to when everything else has been messed up ahead of time . I'd rather not be that guy , so for me it was just let's try and do it right the first time .

Speaker 1 30:14

Exactly . That's a horrible situation that other patient is in and they're lucky they found you and Dr Movahead , because a third time would not . They would not want to have any problems doing that a third time . Oh , that's stunning . How did you feel ? Okay , well , before you went into the surgery and knowing like , were you feeling anxious or what were your thoughts ?

Speaker 3 30:36

It's funny because I was not really nervous or anxious during the entire time of preparing and it got to be like the day before or the night before , right , and I just thought all of a sudden I got a little bit , just the anxiety . I think he prescribed Ativan or something for me . He said that's a pretty normal thing right before the surgery . Take some of this , you'll sleep well the night before , and I did , and it was a very temporary nervousness . But having gone through this many times with my patients , I think it runs the gamut . There are some people that are nervous the whole way through the preparation , some people that never get nervous , some people that want to know all the details of how it's going to work , some people are just want to have it done . So I think it's like any medical procedure . You know this is something serious about to be done . But it didn't really hit me until very shortly before I thought , wow , this is really going to happen .

Speaker 3 31:34

I'm going to go into the operating room and this is going to happen , and I'm glad I wouldn't change my mind at all . But whoa , I think I'd be a little bit nervous here .

Speaker 1 31:43

Of course , I feel like exactly , and people's innate , like personality styles of how they handle things like that , like it's just that's how it is . And then , when you woke up , dr Heng said you felt you could breathe really well . How did , how was that for you ?

Speaker 3 31:57

Oh , it was so wild . I mean , you've coming out of the anesthesia , you're kind of loopy anyway . But my first recollection of what I could feel was not the bandaging around my head or the tubes that go in the nose to make sure the nasal airway stays clear or anything else . My first recollection was breathing in and going whoa , I've got an airway . I can feel like this wind tunnel back there .

Speaker 2 32:26

That the air is going through .

Speaker 3 32:28

Wow , that sensation doesn't stay with you long term because you're feeling the change . It's like an elevator . You feel it when you start accelerating , but then , once you're moving and that's kind of your normal , you don't feel that sensation long term . But it was there for quite a while , right after the surgery .

Speaker 1 32:47

Wow , that's a good analogy , the elevator analogy . Like you feel the movement , because I feel like so many of our patients whatever that makes them better , they forget how they were before . So many of my TMD patients , and we get them out of pain and I always say we need a quantitative number , I always say on a scale of one to 10 , because they completely forget how much pain they were in a few weeks prior and I'm like do you remember ? You were like a nine out of 10 and now you're a one or two and they're like oh really , so we kind of adapt to our new normal and it's so great . You remember that feeling of just so . You just kind of like inhaled through your nose and it felt open in your throat .

Speaker 3 33:29

Yeah , yeah , that was it . And the other thing I remember right away is you can I don't know if you can do this , you probably can but make that kind of snoring , feeling snoring sound by making your soft palate go backward against the back of the airway and just kind of , but I can't do that anymore now . And right after the surgery I was like , wait , I can't make myself snore . The soft palate was far enough away from the airway that it was just a very different sensation . Yeah , so they were great motivators , because then it was like , hey , I don't care what I have to go through now going forward here , this is all I'll take it for that .

Speaker 1 34:07

Yeah , and how was ? Yeah , I mean , that must be a good feeling and I remember , Dr Heng , you lectured and you've said patients . Well , you've had quite a few reports of patients who they wake up from surgery and they take their first breath of life and it's so open , just like what you're describing , and patients within a day have gone off of blood pressure medication , Dr Heng of blood pressure medication , dr Hanks .

Speaker 2 34:33

Well , that's really important . I think you need to understand that there are and I'm not a physician , please don't think that I know anything about medicine because I don't but I've seen a number of people have dramatic drops in blood pressure from stratospherically high blood pressure associated with sleep apnea , and typically the cardiologist has never even suggested a sleep study , nor have they even asked if somebody snored . But I mean , I had someone with a blood pressure 170-something over 128 , and within 10 days post-surgery it's down to 120-something over 78 and remains down . And I had a . About 20 years ago I had a woman who was 5'10" , 144 pounds , very tall and thin , and nobody ever I always think of huge linemen on the NFL having sleep at me . Well , both of her jaws were back , she'd had retractive orthotics . She had again stratospherically high blood pressure which went down into the normal range . Nobody's going to promise you that , but if it's done properly and you have enough tongue space , then there's a good chance that you're going to have that kind of thing happen . We never promise any results ever .

Orthodontic Surgery Preparation and Teamwork

Speaker 2 35:42

But I think Brian brought up a very important point here . Do it once and do it right . He's got a patient from China who's going to go to massive expense to come and visit him many times and to have the surgery done for the third time . I think you have to understand that the standard of care because people don't really have a good protocol A the surgeons . There are not that many surgeons who truly understand how to do this and most orthodontists have no clue how to set up the case properly to maximize the outcome . So I mean , I have a segment in my lectures of published cases that are supposedly successful surgical cases and Brian's seen some of these and you look at it and if you really analyze it , they're not successful at all . And there's currently been a trend in orthodontics and orthodontic surgery to do surgery first before you do the orthodontics , which is literally like building the skyscraper and then putting the foundation on the ground . But you have to understand . If you understand the geometry of it , you can actually do surgery first and advance the lower jaw . Advance the lower jaw and have the chin go back and you say , wait a minute , how could you bring the lower jaw forward and the chin itself goes back and with the chin going back you could have the tongue go back . It's very simple If you have a deep bite like this , and now it's a class two like this with a deep bite , and you just bring the lower jaw forward and do what we call an opening rotation . We go from here to here . Great , the teeth fit . Well , that's very nice . Doctor , I expect you , as the surgeon , to make the teeth fit . But that's number 27 on my list . My wish list , tied for number one , are optimizing facial aesthetics , optimizing airway and optimizing TMJ Health , and if you can't make the teeth fit , then I don't want to work with you . But the point here is you can literally and I've seen it happen where you can advance the mandible to what's known as an opening rotation and the chin can go down and back and the genioglossus muscle can fall back and you can have an airway . That's literally worse .

Speaker 2 37:51

I've retreated so many cases , I've had so many that have surgery many times and , like Brian , he's going to get this patient and hopefully it gets done right this time . The standard of care we have a long ways to go . There are surgeons who do a great job , there are orthodontists who do a great job , but we have very few teams who truly understand how and why you must be doing all this very meticulous setup before you do the surgery . The post-treatment orthodontics in these cases should be a walk in the park . It's like big deal . You come back , you've set the case up orthodontically right , the surgeon knocks it out of the park . A home run in the upper deck with the bases loaded , comes back to me and I have some tidying up to do . I shouldn't have a lot to do , but it all comes in teamwork planning , knowing what you're going to do , and this is not . This is not where you want to be thinking on your feet in the operating room making major decisions . This should all be worked out with the orthodontist or the general dentist doing the orthodontics and the surgeon .

Speaker 2 38:59

And on top of that , by the way and I really believe this passionately and you're going to agree with me , I know this there's not one person who ever goes to orthodontic surgery who had good rest oral posture . If you have every face that needs surgery , it's down and back , got that way by not having their teeth together , not having their tongue to the palate , not having their lips together , not being a nasal breather . Now how naive are we to believe that suddenly we send you . You've had 30 , 40 , 50 , 60 years of poor restoral posture and now the surgeon and the orthodontist work together and you've got this great result the teeth fit and the airway's there . But do you think the muscles somehow understand what they're supposed to do ? They've been lazy the whole time .

Speaker 2 39:45

Now I know Brian is , you know he has done his thing and I would for all the time post-surgery , to have the myofunctional therapy done , because these people have to learn to keep their tongue to the palate . They have to learn . Some of them will just become nasal breathers , but that's only part of the picture . Nasal breathing , yeah , we need that . We want that , but we need that tongue to the palate . We need the teeth together and none of the . You'll never find articles in the referee literature that when they're talking about relapse , they really discuss the term rest oral posture . There are all these things they say well , all the case is nice and stable . Nothing's stable unless you change the rest oral posture .

Speaker 1 40:30

Yeah , we've had patients in our office who have relapsed after their jaw surgery . We just had a patient that my college treated . So my mentor . She recommends myofunctional therapy two years prior to any jaw surgery . Two years Now , does that happen ?

Speaker 2 40:46

I would refer the patient . When we need orthognathic surgery , they should get referred right away . There are things that can be done to prepare that patient and they've learned the process and you go about making the tongue space bigger . As you well know , there's a zillion of them that have tongue tie and the myofunctional therapist needs to be involved with that discussion about , okay , if we're going to do a tongue tie release , when in this whole thing are we going to do it ? We do it before the surgery , do it after the surgery , do it before expansion , we do it after expansion , and that's a give and take that everyone has to have . It's again , there's no one person that does this . It's a plan , there's a team of people , and if you're going to be serious about this and get good results and not end up having people end up in my office when I was practicing or Brian's office , gee , dr Hang , I've had surgery done two or three times and I still have sleep apnea . Oh , by the way , my teeth don't even fit . I mean , those are not nice discussions to have with patients .

Speaker 2 41:54

Patients I have in my practice by the time I , years before I retired , I had probably I quit counting it more than 30 people who'd had total joint replacements . I had done hundreds of surgery cases in my career and you know the results just kept getting better when you really built on what you'd learned in the past . But a lot of this stuff is still not mainstream at all and if you read the journals there's a lot to be desired . I don't want to get critical , it's just there's so much that needs to go in and Brian's very well trained and he knows what the deal is and he's setting up cases really well and he's got a good track record going . He's a classic example . I had to start getting used to seeing the new Brian . I've been here many years . I said who is that ? Who is that ? I know that guy , but why do I know him ? But I knew when he woke up .

Speaker 3 42:47

The first time you run into somebody who's had surgery and you have to get used to your brain remapping what their face looks like , it can be a little startling . My brother said no , you're not Brian anymore , we have to give you a new name .

Speaker 1 42:58

Well , actually , how was that for you ? Like looking in the mirror , like , is that how ? How was that for you ?

Speaker 3 43:06

um and I , I got used to it very fast and I was ready for it , so it didn't really bother me . When I was washing my face , you know , in the shower , my , it just felt different . It was that was , I remember it was kind of the strangest feeling was whoa , okay , I guess I walked this way and I just feels different . But going back to myofunctional therapy , I I would put that as number one on my list of things I would do differently if I could turn back the clock and that's due the myofunctional therapy much earlier . I did it , I'm doing it now even , but I would have done it much sooner .

Speaker 1 43:42

Yeah .

Speaker 1 43:42

I mean it's a lot to do and it's hard and we , we let our patients know about these things and it's for ourselves even . It's hard , you know , we know , but there's a lot you know to do , and with ourselves and our kids sometimes it's harder than telling our patients what to do . But yeah , my cath affair . She recommended two years prior to any jaw surgery and I mean , does that happen ? Not in most cases . We just got a young adult who's having jaw surgery in June , so it was like a month prior . We got him a few weeks ago as a new patient , a month before and tongue tie and all these other issues , and we're like , oh , now we have to sequence treatment for him because , yeah , it's just happening so fast . So when you were recovering from the surgery , how was that process ?

Speaker 3 44:29

They went through phases . There were definite phases that people say was it painful , and I really don't remember pain being a big part of this experience at all . You're on the narcotics earlier on and then eventually on just tylenol and ibuprofen to control whatever discomforts there . It was more just the inconvenience of not being able to open wide and having to keep the rubber bands on the teeth in the early days and having to eat softer foods it's liquids only for a few weeks and then you can start in with softer foods like oh , we went out for breakfast and I thought , oh , I'll probably be able to handle some grits and some pancakes or something like that .

Experience of Orthognathic Surgery and Recovery

Speaker 3 45:11

But getting the food in your mouth it's a completely different experience . Because , number one for me the splint was in the way on the palate and number two , the muscles just aren't really used to moving yet . You can't open and close as much as you used to early on and moving food around is just really hard . Myofunctional therapy probably would have helped that , but it was like when you watch a baby eat for the first time . They put solid food in their mouth and they just kind of get that look on their face and squish their tongue and then it comes back out of the mouth .

Speaker 3 45:45

That was me First time . I tried to eat something that was more solid , but now , sadly , I can eat pretty much whatever I wanted . And there's that process of dealing with liquids and the softer food and then more into the regular foods . And even with the regular foods , not being able to open as wide initially is an inconvenience . You got to kind of squish down on your fork to get it in between the front teeth that can't open as wide . So my memories are all kind of all about the inconvenience of of the eating more than pain or other stuff like that .

Speaker 3 46:24

My marriage , one of the best days of my life was getting that splint out because all of a sudden there was room in my mouth for my tongue that I hadn't experienced before .

Speaker 1 46:33

That's what I was going to say . What did ? What was the splint like ? Exactly ? What did it look like ? Where did it go ?

Speaker 3 46:40

The splint itself . What did it look like ? Well , right here on my drawer , this is it , right here .

Speaker 1 46:47

Wait , can you put it sideways , like it's not that big ?

Speaker 2 46:53

No , it's like a hallway retainer . Yeah .

Speaker 3 46:55

Yeah , for the podcast listeners . It's like a horseshoe-shaped piece of clear plastic that was printed on a 3D printer . It has some little holes in it through which wire will go , and the wire wraps around the premolar so it doesn't cover your teeth . It's just on the total side of the upper teeth and it's smooth .

Speaker 3 47:14

It's not really like probably not much worse than a lot of orthodontic appliances but you can't take it out and you can't use a water pick early on either , so you kind of have to just tolerate this thing there and cleaning it as well as you can . I didn't really realize how much I didn't like it until I got it out , because I saw that that was one of the main reasons why I couldn't move the food around my mouth .

Speaker 1 47:38

So you had elastics connected to that . You said you also had elastics , or are there connected to the braces ?

Speaker 3 47:46

This is another fallacy of well , at least the way we do it . It's a misunderstanding and jaw surgeries people say was your jaw wired shut ? And the answer is we don't wire jaws shut anymore . We just use rubber bands between the brace on the top and the braces on the bottom to help the stabilization of the jaw be in the right place , to help the teeth stay in the right place for the bite . And , frankly , what was really kind of cool is it helped me keep my mouth closed . Having the rubber bands on there made it , so my mouth just stayed closed right away without any effort .

Speaker 1 48:20

You could do that . In my old functional therapy we can rubber band thing an idea . But I have a question . So when you're eating , the rubber bands had to stay in .

Speaker 3 48:29

Oh no , you uh softer foods or liquids . You could keep them in if you want , but no , if you need to open and eat food , you take the rubber bands off , eat your meal and put them back on .

Speaker 1 48:39

The splint was not rubber banded .

Speaker 3 48:41

The splint was wired in so there's a wire going around the premolars that keeps it in position . It's like a cast on a broken arm waiting for that segmental of the upper jaw to heal in the first three months . So it has to stay in typically three or four months .

Speaker 1 48:57

And when you went into the surgery , were the braces off or they were still on .

Speaker 3 49:01

Braces stay on before , during and after . Before , during and after . Yeah , so they they were on me longer than they needed to be because my wisdom teeth had to come out . They were on me longer than they needed to be because my wisdom teeth had to come out and my decision was I saw my airway , bill , can you put my braces on ? Put my braces on . I need to get ready , but in hindsight I probably could have just had my wisdom teeth out that day and waited for a little bit of healing and then put my braces on , and it would have been less time in braces .

Speaker 3 49:33

The wisdom teeth on the lower are right in the area of the lower jaw where the cuts have to be made , and it can weaken the bone in those areas if the wisdom teeth are there . So the surgeon made the recommendation to have the wisdom teeth out . I had all four of them removed . I liked my wisdom teeth . I had all 32 teeth , for you know , I was 60 something years old and , despite what people say , they do help you chew . Having three molars in each quadrant does give you more to chew with and I do miss them even to this day . But you know what it was worth it .

Speaker 3 50:04

I the trade . There was nothing I had to trade off to get where I am now . That would make me regret having done it . I just I might regret the sequence that I did it in and I might regret that I didn't do it 15 years ago . But you know , we got to just do it when we can do it .

Speaker 3 50:21

What happened ? Is it built up in my mind to a priority when I , when I saw that x-ray to me , I told my wife whatever we have , whatever decision has to rotate around this decision . We're going to have to do that because this is going to be the main decision . Every other decision in our life is going to follow from that and that's kind of the attitude you have to have . This is so important that everything else is negotiable , whether it's my time off work , I don't know what's going to happen . I'm going to be gone from the practice for a month and I'm the main person in the office and I have a lot of patients . But I did it . I figured out a way to do it . It just had to be that high in importance to make it happen .

Speaker 2 51:05

I think people need to put it in perspective . I mean , I've said surgery so many times in my life to patients and I can tell the look on their face . I anticipated Even before I get the word surgery out of my mouth . People , their face will change . And some people will instantaneously say , oh , I would never do that or oh , we will never allow that for him or her , their child . And some people will say , oh , my gosh , that's radical .

Speaker 2 51:31

And I had somebody say that to me probably 25 years ago and it was a dental hygienist . And I said to her so let's pretend for a moment . So you think orthodontic surgery is radical ? I said , let's say I'm a cardiologist and we've just done all this testing and we find that your coronary arteries are all blocked 90% . And I tell you the treatment for this and you know what it is is bypass surgery . What are you going to say to me ? The thing you're going to say is when can we schedule it ? You know , can we schedule that tomorrow or next week ? Because you know the consequences . And I mean , I've gone through this , my dad had this done , so I know what they do . And then I told this woman . I said , yeah , so they take your leg and from your crotch down to your ankle they split out and take out veins . They take you from your pubic bone to your sternum , rip your whole chest apart , stop your heart from beating and sew these veins in here . And you're calling orthognathic surgery radical . That's radical to me . Radical to me is not being around to keep my wife miserable and spoil my grandchildren . I want to be around and so you put it in that perspective . And then when you start to understand these health consequences , you know you can ignore your sleep apnea . That's fine . But don't delude yourself in thinking that you're not going to be one of the statistics If we say untreated sleep apnea is good for a 20% reduction in your life expectancy , I mean , women understand that , but men of course don't , because they know better . That will not affect me , but sadly men die just like crazy because of this . Go read the newspaper and see the people who've died of sleep apnea and it happens all the time .

Speaker 2 53:27

The other thing I wanted to mention recovery here , brian's age . It took him a little while but he did really well . The younger you have it done , the easier it is . I've had 15-year-old kids come back literally 10 days post-MMA surgery and say , dr Hank , can I start running again ? From an addicted runner and I'm an addicted runner , so I know that stupid mindset that that kid has I say , chill out , you'll be okay . Or a girl at age 18 coming back from MMA surgery Gee , can I do ballet again ? I want 10 , literally 10 days post-surgery . Can I start doing my ballet again ?

Speaker 2 54:02

And on the other end of that spectrum , I had a gentleman who had had was three weeks short of his 73rd birthday and had MMA surgery . Wow , of course , this guy had ridden the year before , had ridden his bike from Jacksonville , florida , to San Clemente , california , with a bunch of bicycling cronies and he schlepped his CPAP machine along the way and within five weeks post-surgery he was doing 20 miles a day on his bike .

Recovery and Sleep Post-Surgery

Speaker 2 54:34

So you know , I tell people that recovery is what you make it . It'll be as good or as bad as you make it . And to a great degree I think I'm right . There are certain people that are just going to flat out recover slowly . Well , some of them are compromised already and those are the ones that they're already going down that slippery slope . They're increasing their chance of every chronic disease known to man , and particularly heart attack or stroke , which are the big ones which are going to change your life rather dramatically . Yeah .

Speaker 2 55:08

It sounds like it's added in a realistic realistic as one of the options that you don't just reject immediately as soon as it's said to you .

Speaker 1 55:18

Yeah , it's like a temporary inconvenience , temporary discomfort , and I see a lot of people say they don't remember it being painful . It wasn't that painful , exactly .

Speaker 2 55:28

That's never the that's never what they complain about yeah .

Speaker 2 55:32

I mean you're not going to , you're really not even going to believe this , but a lot of times , way early on in my career I would say so . You know you've just had surgery done and tell me what was the worst part of the treatment . And most of them would say , oh , you know , the surgery wasn't really painful , that wasn't all that bad . But you know , those stupid separators you put between my teeth before you put the braces on the back teeth , those things hurt like blah blah , blah , blah , blah , blah . He says that was the worst part of my treatment . And here I am , the orthodontist , thinking that the part I do is kind of peaceful . And you know , everybody goes through this and you think that the surgery is some horrible thing , that you got to survive . And they're telling me that what I did was worse than the surgery . I mean , if I didn't hear this myself , I'd say you're making this up , bill Heng , but it happened to me not infrequently .

Speaker 1 56:23

Yeah , that's funny . So how do you feel now , Dr Hoppel ? Like , do you notice , you said , the breathing change ? You kind of get used to it , but any other changes or things you notice ?

Speaker 3 56:33

Yeah , a lot of changes . I was just remembering how I came back to see patients after a month and they told me you're not going to have your normal energy , you're going to need to really take it easy , and I was skeptical of that . But I let them schedule kind of partial days and I did fine for the morning , but the afternoon would come . I was like I think I need to go just lie down for a little while . I just had to rest . But somewhere around the five to six week mark it was like a light switch going back on and my energy came back and I'm sure that the better sleep had an effect on that .

Speaker 3 57:06

But it's just , it's a big surgery to recover from and your body's doing a lot of healing , and I think that it's . It's really , if somebody is considering doing it , they should be doing it as early in their life as possible , for the for two reasons the easier recovery , having youth on their side . I mean , I did it when I was young , at 61 , but I would have liked doing it when I was even younger , at maybe 41 or 21 , if I needed it . But then the other reason is because you get the time benefit of all those advantages and you don't have those years of whatever the health consequences are , or the poor posture , the myofunctional problems , the orthodontic problems , yeah , so I mean right now it's just it's in the rear view mirror kind of way back there Next month , in a few weeks , I know , but it goes by so fast .

Speaker 3 57:59

Think like raising kids . You think it's going to last forever and then all of a sudden it's like , well what ? They're not that little anymore and it goes by really fast . I can sleep on my back in a way that I couldn't before . For a long time I only slept on my back , but for some reason in the last couple months or so I've kind of gone back to trying other positions and sleeping wherever it's most comfortable . But I don't need this crazy arrangement of pillows . Joy Moeller told me about the neck nest pillow and I tried that out and it's made a big difference in just how I can sleep on my back and be comfortable and I can travel with it . So no matter where I am , it's easy to have with me it's called the neck nest .

Speaker 1 58:43

Is that what it's ? Called neck nest , like a little nest around the neck because I have a pillow like that , what's called the face saver , but the lady who made it's not around anymore , so they don't have that anymore and mine is so gross I bring it every if I travel because it , it kind of like , causes a comfortable hyperextension and supports the neck and that's how I can breathe without that . Um , definitely different sleep quality . So the neck nest , I'm going to look that up .

Speaker 3 59:10

And it's designed by a chiropractor and his whole thing was having your neck and back in the right kind of posture , at least for the few hours right after you fall asleep , that that can be therapeutic . He says that it allows the head to extend backward . You know , like the chin tilt to open the airway . And I'm curious I wonder if I'd gone back five years ago or even two years ago , what it would have been like to sleep with a pillow like that . But I had to be on my back or my stomach . If I wasn't sleeping in a posture where my head was really tipped back , my airway was not going to be open .

Speaker 1 59:43

Now , I just did an interview with Dr Simmons recently and he said pretty well every I don't know for a lot of use the word every , but nearly all stomach sleepers have an airway problem . I know for a lot of Jews , whatever , but nearly all stomach sleepers have an airway problem . So good question to ask your patients If they sleep on their stomach . There's a high likelihood that they have an airway problem . Interesting , right . So you had to sleep with that hyperextended neck on your stomach .

Speaker 3 1:00:05

Yeah , yeah , exactly . I've lip taped for many years over 10 years . I don't remember when I started . I know that when I started it was because of Bill and how he was teaching about it and everybody thought I was crazy . My sister-in-law was I will never put tape on my kids while they're sleeping .

Speaker 1 1:00:22

This guy runs marathons with it . Now it's everywhere .

Speaker 3 1:00:42

So my point is that before the surgery I could just put one little piece of tape from the upper lip to the lower lip and my lips would stay together all night . After the surgery , with the rubber bands on same thing , I could tape and it was no problem at all . But then as time went on and as my muscles and joints adapted and I could open wider and actually eat one of those giant hamburgers that I missed so much , at that point the muscles still slacked like they used to , but the longer lever arm of the jaws stretched lips further apart , so that one piece of tape on my lips wasn't enough . And if I use a two inch piece of paper tape to just like nail it shut , then it was again stretching the skin so with so much pressure that it hurt the skin . So it became a challenge and Steve Carsonson was the one that told me about a thing called a SomnoSeal , and a SomnoSeal is designed for people who use CPAPs and the air goes back out through their mouth .

Speaker 3 1:01:44

It's a little rotary kind of thing going between the lips and the teeth . Now with that in one piece of tape and it's fine , it stays on and I nose breathe all night long . So there are little challenges like that that come up . You've got to just deal with them and figure out what works for you .

Speaker 1 1:02:03

Yeah , and one comment is I never recommend taping the lips shut . I think it kind of got trendy and kind of got taken to another level . But we use lip tape , just half inch , micropore 3M , to support the muscles . The purpose is supporting the muscles to help assist with lip closures . You can still open your mouth , breathe through your mouth if you need , but that's not . You know we don't want that you need if you need , there is no .

Speaker 3 1:02:26

If you need , nobody needs to breathe through their mouth .

Speaker 1 1:02:31

Right , but it gets patients less're when we introduce that and they're like what you're telling me . But so we use the vertical piece of tape . But if patients need more support , we never go across the lips . We do an X position , which provides more support , and then if there's lip incompetence , mentalis strain , we tape in a way where we're supporting the depressor lay-by muscle . So it's almost like kinesio tape concept where it's after certain muscle stretches or exercise that helps support those muscles . But yeah , that's interesting how , with the change in jaw position , you had a harder time with lip closure with just the simple vertical piece of tape and there's so many different types of- .

Speaker 3 1:03:10

Things like the hostage tape . I've tried so many different things that are out there , but I'm a cheater . What would happen is I'd get the tape on even an X , like you're saying , and I would find a hole next to the X to breathe through as I dropped open .

Speaker 1 1:03:24

Yeah so many little things to monitor , to work around to find out why that's happening . To work around to find out why that's happening Very interesting

Importance of Oral Rest Posture

Speaker 1 1:03:36

. And it's interesting also your comment about how it's not just lips and mouth breathing but also tongue position . You mentioned that earlier and I think a lot of us over-exaggerate and over-talk about mouth breathing , open mouth breathing , but there's so many patients with myofunctional issues or poor oral rest posture where it's just tongue Lips might be closed , but their tongue is low forward , spreading out the sides . So it's an important concept that there's a bidirectional relationship between lip and tongue , but some people are not open mouth breathers and still have issues with their oral rest posture .

Speaker 3 1:04:09

I'm still struggling with it big time . I mean , my tongue still drops down during sleep and I don't know . I don't know . I mean I'm doing the therapy , I'm doing the exercises and I suppose if I wanted to all of a sudden bench press 400 pounds , it's going to take me a while to work up to that .

Speaker 1 1:04:27

And I think it's a matter of being persistent persistent , yeah , working the muscles , working them correctly , taking time recovering from such a big procedure . You know you mentioned I had the MSC , which just causes that midline shift and it significantly helped with my airway issues , but it's not necessarily a cure . So I feel like my jaws they just want , they need to be more forward . So Dr Ting's always telling me he's like you just need jaw surgery . I'm like a lot of people told me that .

Speaker 2 1:04:58

Nobody wants to hear it . Nobody wants to hear it . But and you know , I've had people where I've said you need a jaw jaw surgery . If you , if you want to be out of the woods with this and again , no promises , then surgery is really your only answer . And again , no promises , then surgery is really your only answer . But I've never pressured anybody and I've had people go five years , 10 years or more before they come around . I mean , brian knew full well , right early on . But I mean , as he explained , life happens and they got responsibilities .

Speaker 2 1:05:31

But the whole thing of doing it sooner rather than later makes total sense . The last thing you want to do is to get all beat up . I mean , brian and I , we've seen enough people . They come in . Someone comes in at 45 years of age and they're worked over . They could pass for 65 . If you've not been sleeping well and you're immune , compromised , nothing going on well in your life , and you ask them well , how are you ? Well , I sleep horribly , yeah . And then you go through their whole medical history and they're on 20 drugs and everything is horrible . Those people are not the best risks to have the surgery done .

Speaker 2 1:06:12

If you're going to do it , realize that nothing gets better as you get older . Not one thing . I mean I hate to . I'm going to turn 78 in October and I'm I'm still an addicted runner , but , believe me , I don't run as well as I did 40 years ago either , and I'm I'm happy to stay running . But I look at people around and there are very few people now my age that look healthy at all . If they're around , they're looking pretty bad and they're with a walker . You don't want to be that person .

Speaker 2 1:06:46

We talk about health span and lifespan . You want your health span and your lifespan to be one and the same . I don't want my health span to run out and be a burden to my family for another 10 years , and I don't want to sit around drooling on myself and wishing that I had taken better care after I had my stroke . I mean , I have a video that I put together this whole scenario starting at birth , with a child whose mouth is open , going all the way down , doing traditional orthotics , retractive , which makes the airway worse , and faces back . One thing after another , the guy has a heart attack and then he has a stroke and at the end , this person ends up being in a nursing home for 10 years before he decides to stop eating and he starves himself to death . And that's true . I have an uncle . My grandfather's brother , did that very thing . He had a stroke and he would have been the last he was . He was skin and bones . You would have looked at him .

Early Intervention in Sleep Apnea

Speaker 2 1:07:59

There's no way oh , you got to be obese to have sleep apnea . No , you're going to have a 85 year old , pound , 85 pound asian woman with no body fat at all and she can have sleep apnea , and you can have a 400 pound linebacker alignment on the nfl that has apnea . But the fact is , you can have everything in between too . The point being , if you're going to do this , do it early . Don't let yourself go down the tubes until oh my gosh , now , oh , I've had my heart attack . Oh , maybe I should think about this . And then you have the stroke . You know what ? Life is too short . Don't let that happen .

Speaker 1 1:08:34

I'm calling Dr Movahead when we get done .

Speaker 2 1:08:41

If you do the case right , then you wake up . I got to share this one story with you because it's comical . I had a woman this is many years ago come in , she had space between her front teeth and she was a scientist at a pharmaceutical company . Okay , I had a woman this is many years ago come in , she had space between her front teeth and she was a scientist at a pharmaceutical company . Okay , she comes in , she's got space between her front teeth and she wants me to close the space . So I take the medical history and I look at her and I think she's got a PhD . She's no dummy , right , she's a researcher .

Speaker 2 1:09:09

I tell her you know , I think you have sleep apnea , and she looks at me like I'm from another planet and she says well , what do you have to do for that ? I said well , you've not had retractive orthotics . We can't reopen your spaces . That's not going to be on the radar screen . The only way you can have this done is to have double jaw surgery . Well , she did what many people do she voted with her feet and she left and I didn't hear from her and she comes back in about three months and she thought a lot about it . Dr Hang , I thought a lot about this . I think you're right . I'm pretty sure I do have sleep apnea . I said , well , go get a test done to make sure . She got the test done to make sure . And then she says but you know what , dr Heng , I'm scared to death of that surgery . I don't want to hear about it , but I'm going to do the surgery . So this is the way it's going to be You're going to put me in braces , you're going to get me all ready for the surgery , but you're not even going to utter the word surgery until it's time to go for the surgery . I said fine . And so the time came . I got her ready for the surgery . I'm walking her up to the front desk and I say oh , by the way , you're ready for the surgery . And you know her face kind of turns whitish like oh my gosh . And she said okay , okay , okay , fine . So bottom line is she went to have the surgery done and I was on vacation at the time .

Speaker 2 1:10:37

I was back in Vermont where I used to live , and she emails me back . She's like two or three days post surgery she emails me and she's absolutely over the moon . She's so happy and she said sorry for being such a . She said pain in the you know what over this , but I was so scared she says , oh , I feel so wonderful , so glad I did it , can't thank you enough . Then the best thing was when she came .

Speaker 2 1:11:05

When we got back and the first time she comes into the office afterwards she comes up to me and she gives me a hug and I literally I'm not joking I thought she was going to break my ribs . She hugged me like nobody's ever hugged me before . I mean she thanked me . It was that emotional for her because she'd been living . She'd been here in her late forties , early fifties , but she'd been living this life dealing with a lousy airway , and that was her reality . It's like dragging a truck behind you all day , every day , walking down the street and suddenly , when you don't have to drag that truck , you have a life . And those are the kind of stories that I got from my patients . And I'm not here to sell anybody on anything . You got to understand . But do your homework and realize what happens when you ignore these issues . And there's no . You can run , but you can't hide .

Speaker 1 1:12:04

Right , right , and that's the thing . Were you going to say something , dr Hoppel ?

Speaker 3 1:12:08

It's a really important discussion to be talking about this , because I feel like in airway orthodontics and yes , we do an airway oriented practice and we treat sleep apnea , which it seems like in most of our world now it's all about the transverse expansion . Yes , I do MSC . Yes , I do a custom Marpie . Yes , I do custom Marpie . Yes , I do . And we're forgetting that the development of the face has been in a direction down and back , not just narrow , but down and back , and that's not going to be addressed in most of these other ways . For some people it may be enough , but I just think it's important to keep that in mind .

Speaker 2 1:12:51

I came up with a saying for that you can't expand your way out on anterior posterior problem and I have a section in there where I showcases . Some of them have fantastic 45 millimeter intermolar widths and no face and apnea . The point is we must be developing forward , and the earlier the better . And , nicole , you and all the myofunctional therapists , we need to put you all on the front lines in the airway pandemic . You need to be the ones treating the little two and three-year-old kids , getting them to have proper rest or all posture . Even by the time they come to be treated in the primary dentition , some of them , or their faces , are falling back already , which is why I absolutely want to get in and treat at age three , four and five and I honestly I'll put this out there and I know orthodontists will absolutely want to kill me on this one , but I want to put it out there .

Speaker 2 1:13:45

Back in the early 1900s , orthodontists were treating people in the primary dentition and they were treating , talking about health , and they were talking about health and they were talking about trying to prevent mental retardation .

Speaker 2 1:13:58

What we need to do is to recapture what we were doing as a profession more than 100 years ago we need to treat in the primary dentition . It would be a lovely day if indeed we got to the point where kids who got to age six before they even got their first permanent tooth , in that they had ideal rest oral posture and never needed to have orthodontics . Yeah , I think that's the goal , and it has to be , because if we don't do that , the face is already down and back so far . We're so far back from where our ancestors were that even with the best orthodontic surgery and I've had this happen with the most maximum movement of the maxilla , nine and a half millimeters forward in the mandible , who knows how much to fit with the upper you still may fall short and that's sad . When you've played your trump card and you still lose the game , it's no fun and that's where we're at . That's where we're at in this airway pandemic .

Speaker 1 1:14:55

And I'm reading the book Outlive by Peter Attia . Have you both read that ?

Speaker 2 1:15:00

I love that book . What an amazing book .

Speaker 1 1:15:03

I'm just a couple hours into it . So I'm a runner , so as I go writing , I listen , and I have to keep stopping because I want to write down these quotes . So I'm going to say a couple things that fall along the lines of what we're just saying . One medicine's biggest failing is in attempting to treat all these conditions at the wrong end of the timescale , after they are entrenched rather than before they take root . As a result , we ignore important warning signs and missed opportunities to intervene at a point where we still have a chance to beat back these diseases , improve health and potentially extend lifespans . Right , so early intervention , the red flags are there . And then one other thing . I wrote this down , quoting from the book , but I'm going to replace the word type 2 diabetes with sleep apnea , as I read it .

Speaker 1 1:15:51

Sleep apnea belongs to a spectrum that begins long before someone crosses that magical diagnostic threshold . Sleep apnea is merely the last stop in the line . The time to intervene is well before the patient gets anywhere near that zone even pre-sleep apnea . So mouth breathing , snoring , upper airway resistance syndrome is very late in the game . It is absurd and harmful to treat this disease like a cold or a broken bone , where either you have it or you don't . It's not binary . Yet too often the point of clinical diagnosis is where our intervention begins . Why is that okay ? I believe our goal should be to act as early as possible to try to prevent people from developing sleep apnea and all the other horsemen . We should be proactive instead of reactive in our approach . Changing that mindset must be our first step in attacking slow death . We want to delay or prevent these conditions so we can live longer without disease rather than lingering with disease . That means the best time to intervene is before the eggs start falling .

Speaker 2 1:17:00

It's one of the best books that I've ever read and I actually wrote an article based on that . It's appeared in Dental Sleep , steve Carson's magazine after I had read that earlier this year . I think it's an amazing book . I have to credit Peter Attia , because here he was a guy well into his 30s before , maybe even into his 40s , I forget when he realized , you know , he thought he was in good shape but he realized , oh , I'm not in good shape , and so now he's having to play catch up ball .

Speaker 2 1:17:31

One of the most important things I think in that book and I really want to share this with your group is we have people in our profession who are saying well , we don't have evidence-based such and such about this treatment or that treatment , so we can't do anything . Well , that is total garbage in my humble opinion . There is not one dental practice on the face of the earth that is evidence-based Not one , not mine . Nobody has it . There's really no evidence to support most of what is done in traditional orthodontics . The German government stopped even paying for it because they couldn't find any long-term benefit . There's articles in the literature saying one person suspects that there's about 8% of what is done in dentistry is evidence-based . I've just read this .

Focus on Evidence-Informed Healthcare

Speaker 2 1:18:17

What I loved about Peter Atiyah's book was he talked about evidence-informed , evidence-informed and what we have to do . We can't let your kid and every other little kid sit there with his mouth hanging open and stop breathing at night and have brain cells damaged , like you know , like Ron Harper , phd neurobiologist at UCLA , can document with MRIs . We can't allow that . I'm sorry . You've got Phil Cooper , who's written a book called why African American Kids Can't Read and Phil's a good friend of mine in the AAPMD on the board . And it's not the color of the skin , it's the fact that that's a group that's at disadvantage and many of them , by the time they go to school , they've had sleep apnea issues , they've got brain damage . If their skin is green , purple , I don't care , the color , it doesn't matter . We have people of all ethnicities , races that are having these issues . How can we turn our backs on them , looking for the perfect cure and ignore what we've known for centuries ? Then you go back to Eagle Harvold , who did the monkey studies , plugged the nose in the monkeys and produced long faces that we have malinclusions .

Speaker 2 1:19:27

If we don't believe that , why did we do the experiment in the first place ? Why do we think we have to do that on kids ? I'm not going to let my kid have his nose plugged , but I can put two and two together and see it happen , and it's merely an excuse to say , oh , this isn't evidence-based . No , we have to go with what's evidence-informed . We will never , ever , have evidence-based dentistry or evidence-based orthodontics . I make that statement unequivocally . It will never happen because it's impossible . There's no institutional review board . Who's ever going to okay a study that's going to allow certain things to happen that might be very harmful to a child ? Would you like to be in the parachute experiment , where we have the regular parachute and the placebo parachute and you jump out of the plane ? Are you going to let your kid wear the placebo parachute ? I don't think so . Let's be realistic . Peter Atiyah's book was one of the best books ever because he makes a very strong point about evidence informed .

Speaker 1 1:20:34

It's good . Yeah , it's really great .

Speaker 2 1:20:38

Everybody should read that book . Who Cares About Healthcare ? That's one of the best books I ever read .

Speaker 1 1:20:42

It's so good , it's really good . I want to thank you both so much for sharing all your wisdom , your experience , your knowledge . I'm going to do a few little summary points . There was so much good information . One of my summary points is that when we're doing jaw surgery , some of the top key like on the ranking of importance are optimizing facial aesthetics , optimizing airway , optimizing TMJ health . That should be tough right .

Speaker 1 1:21:12

And we should be treating children in the primary dentition Treat early . Number three there is not one jaw surgery patient or one patient who goes to orthodontic surgery who has good oral rest posture , unless they did myofunctional therapy first . Okay , next one , myofunctional therapy should . According to Dr Hing , myofunctional therapy should always be done before surgery . Number one on the list right , this is what we talked about If you can get them to do it .

Speaker 2 1:21:41

many will not do it , as you well know .

Speaker 1 1:21:44

Yeah , that's half the battle right . Half the challenge is that aspect , and I liked what you said that myofunctional therapy should be on the front lines of the airway pandemic . Wow , there's a lot of airway pandemic , like that's what it is .

Speaker 2 1:22:02

I mean when you understand , if you understand the , the facts and figures here , you cannot define it any other way and it's getting worse . You can read , you know , you know I go , I go back with lectures that I heard 25 years ago and I and the everything's just getting worse .

Speaker 1 1:22:18

Yeah , it's crazy . And , dr Huckle , congratulations to you for you know , making the choice , making the dishes decision , stepping up , doing it , getting it done with . Now you're in the point . I'm jealous of you . You're already finished .

Speaker 3 1:22:32

like you , you recovered and I were talking , I said I'm gonna do it . And now way done , done and over . Yeah , I had a very biased point of view because all my patients who I've seen do it kind of gave me courage about the whole thing . And before I did the search I wrote them an email dozens of them and I said just tell me your advice , what would you like to have heard before and after the surgery ? And I collected all that information , only benefited from it myself , but I've tried to pass on the benefit of that to my current patients and I'll use it for my future patients so that they have a better experience with it . There are a lot of different ways to do this and I feel like learning from experience of people who've done it helped me a lot in my journey .

Speaker 1 1:23:20

Well , what , as we just wrap up right now , what kind of words of wisdom or advice would you give somebody now , with your experience before and after One of the patients ? What did they tell you that might have felt really helpful ?

Speaker 3 1:23:34

So many little things , I can't even begin to recount them . It's like a 20-page document and I give that to my patients . I say here read through this , some of it will apply , some of it won't . But go through it , and they apply at different times too . If you do it , you let me know and I'll go over it with you .

Speaker 3 1:23:55

I also put a spreadsheet together of like all the different things you have to keep in mind , like your diet , your oral hygiene , your orthodontics , your physical exercise , your all these different things . When can you start this ? When should you stop it ? When do you start using a straw , stop using a straw ? And I wanted to have it all mapped out , so I did my best version of it and then I sent it to Dr Movahead and his physical , his physician's assistant , and we worked it over , and resources like this can help people avoid having a lot of the having to reinvent the wheel and when they're going through something like this . So if you ever do it , you let me know and we'll talk .

Speaker 1 1:24:35

And maybe you'll write a book or something or put all that information together with all your free time , but like write a book or a pamphlet , like with all those words of wisdom , that would just be really interesting to hear .

Speaker 3 1:24:44

There's so much that is different now from even when I was considering doing it with myself . The skeletal expansion is one example . But how about tooth extraction ? You realize we're doing tooth extractions now , before some surgery . I mean , if somebody asked me , do you ever extract teeth ? I now have to say yes , it's been a long time , but taking out premolars and pulling teeth backward can allow the jaw to be positioned further forward . So there are many people for whom that can be a big help . There are some people you need to reopen their extraction spaces and put teeth back in , so it just

Individualized Sophistication in Medical Treatments

Speaker 3 1:25:20

. There's so much more to it than just oh yeah , I got jaw surgery , I got MMA . What'd you get ? I got MMA . Oh , I got MMA too . That doesn't mean anything .

Speaker 2 1:25:30

It's like I got a car .

Speaker 3 1:25:31

Really , I got a car too . Oh , we're the same .

Speaker 1 1:25:34

It's very individualized yeah .

Speaker 3 1:25:37

Yes . Well , there's a sophistication that can easily be overlooked .

Speaker 1 1:25:43

Yeah , very , very case specific , and I really just want to again thank you both for all of that insight . This is going to help so many people in their own personal journeys or working with patients and colleagues , and I really appreciate all of your time .

Speaker 2 1:25:59

You bet .

Speaker 1 1:25:59

Thank you no problem Happy to help .

Speaker 3 1:26:02

Good to see you . Yeah , take care you .