Speaker 1: 0:44

Hello, hello everyone, and welcome to Thursday Night Live with Airway Circle and somebody's calling me exactly at the same time. Make sure I didn't answer. My name is Renata Nami, I'm your host and today with us we have Dr Rebecca Bacol. Thank you so much for being with us today. Thank you for having me. So you've spoken for us before. I'm not going to do a formal intro. I would like for you to share with everybody today who you are, how can they find you and what is your mission today.

Speaker 2: 1:19

Beautiful. Well, thank you so much for having me, renata. I just love what you're doing. I love the information you're putting out in the world, in the community. Your message is so important and this community is really pushing the important message in a positive direction. One of the when we so, renata and I were both at a phenomenal meeting the World Dental Facial Sleep Society. Thank you, dr Yoon, for putting it together. Meeting the World Dental Facial Sleep Society Thank you, dr Yoon, for putting it together. And some of the things that really got me thinking about were some of the conversations that were happening on the side, and I think we have a really unique opportunity today to reframe our understanding about the why behind maxillary expansion and also to really think critically about the why behind early intervention.

Speaker 2: 2:13

So I forgot to say who I am. So I'm Rebecca Bacchia. I'm an orthodontist, dual-trained orthodontist, periodontist. I practice in Seattle and Bellevue, washington, and, yes, I'm an orthodontist. We do aligners, we do braces.

Speaker 2: 2:29

A big passion of mine and a big focus on my teaching is thinking about how to really focusing on health, the health of the patient, and health really is that. It's, yes, it's dental alignment, but it's also periodontal health, it's tongue space, it's joint health and it's a healthy system. How do we encourage growth at a young age to allow for lips to come together, tongue to come up in a passive way so that when a patient is communicating, is eating, is functioning, is, is functioning they, the system is not working. Because when a system is out of balance, that's when we start to see dysfunction, that's where we start to see breakdown. And so how do we do this at an early age? And so historically in orthodontics and of course I'm in in in a lot of the orthodontic circles the main reason to expand in a child historically has been to correct a crossbite. And for sure we want to do that at an early age.

Speaker 2: 3:36

But there's so many more reasons today with new literature coming out all the time about the why behind expansion. So some of the newest research that we're seeing today we talk about expansion to. So the roof of the mouth is the floor of the nose. And so as we expand the upper jaw, if you think about each of the two nasal passages, think of it as two small triangles and so as we widen the palate, not only are we making more space for the teeth but we're making more space for the floor of the nose and that is so critical for these young kids.

Speaker 2: 4:17

If we think about airflow, it's kind of funny to think about, but you almost have to think about physics and you think about these two small holes, the internal nasal valve. And as we reduce resistance to nasal breathing, we improve the entire airway system, we improve this airflow. To think about this in the reverse if there's resistance to nasal breathing on either side of these nasal passages, we create a negative pressure. The negative pressure increases the collapsibility in the back of the throat. So it's not just what it looks like, let's say, on a lateral Ceph, it's how the system functions. And so by doing palatal expansion, we open up these two small triangles and that reduces resistance to nasal breathing, reducing the negative pressure, reducing the collapsibility in the back of the throat, and so oh, go ahead, I don't want to go ahead Go ahead.

Speaker 1: 5:23

Do we have a way to check for this negative uh resistance and negative pressure or the nasal resistance?

Speaker 2: 5:31

Um, uh, probably rhinometry and, and so of course that's not a tool everyone has, but you can even check your patients. So part of my exam I even just have them close their lips and take a breath. You can almost hear it. You can also see the internal nasal valve and the nasal passages when you look at CBCT. Okay, you can take the slice right here and you can see these openings. Now Dr Yoon has two really important publications, one in children and one in adults. Dr Yoon has two really important publications, one in children and one in adults, showing that a diastema in expansion opens the internal nasal valve in kids and in adults.

Speaker 2: 6:14

So maxillary expansion has a huge impact on nasal breathing. Dr Wan Moon and some others have shown that if you'd use a MARPI, for example, the changes in the nose have a downstream impact in the airway to the fourth power, which means a small change in the nose at the nasal floor has a huge impact on function. So MAPSR expansion has been shown to convert patients from mouth breathers to nose breathers. It's been shown to open the internal nasal valve. It's been shown to reduce resistance to nasal breathing. We see a reduction in flow limitations. So all of this has been documented in the literature in flow limitations. So all of this has been documented in the literature Gosh, I don't think I have it in the, in the, some easily accessible. But so the, the, our world is all asking for evidence-based, evidence-based, evidence-based. So I learned something about. So there's a, there's a systematic review and then there's something called an umbrella review. An umbrella review is a review of the systematic reviews.

Speaker 1: 7:33

I did not know about this umbrella review.

Speaker 2: 7:35

That's new to me. I didn't know this either. So there is an umbrella review and, renata, I can send you a copy if you want to post it or share it that shows that maxillary expansion improves nasal breathing in patients and it's an umbrella review, so the highest of high levels of evidence that maxillary expansion helps with nasal breathing.

Speaker 1: 7:58

That is incredible, but is every maxillary expansion made equal?

Speaker 2: 8:04

Good question. No, it depends on sutural development and depends on appliance design, and those two things have an impact because there are some appliances that create more dental tipping and less true sutural change. So if we, as the practitioner, really want to influence nasal breathing, we really need to open the suture. So we think about orthodontic expansion and orthopedic expansion. Orthodontic expansion is dental tipping and there's a number of ways we can do that, a number of appliances to do that, but that's just moving the teeth out. If we really want to open up the nose, we have to open the suture and so, being very, very critical about the age of the patient and the appliance design, there are a lot more tipping appliances than there are true sutural opening appliances.

Speaker 1: 9:01

Wow, it is very difficult as, of course, my functional therapist whenever we send these patients to professionals, other professionals, to work on them and we don't understand. I mean, we're not orthodontists we don't fully understand this. I've had a couple of patients who went to get slow expansion and I do see some tooth tipping and they, you know they didn't get any nasal improvement and they still look like they are restricted, like they still look like they would benefit from a little bit more expansion. What do you do in those cases where the patient has had expansion, there's tooth tipping, do you wait? Is there something that you do for the, you know, can the teeth come back a little bit and then you try again?

Speaker 2: 9:44

Great question, and I might answer this in a few different ways. So we do get a lot of second opinions from patients who've had some sort of orthodontic expansion, but not orthopedic expansion, and so we do have to sometimes undo some of that, so maybe using braces or aligners or even just no retention. At the end of the day, the teeth want to be centered in the bone and so if you take so let's, let's say it was Invisalign or some sort of clear aligner and it just widened everything but we didn't do anything to open the palate. So if the teeth are out here, if you just stop wearing it, it'll come back many times because the teeth want to be in the palate. So if the teeth are out here, if you just stop wearing it, they'll come back many times because the teeth want to be in the bone. There's other appliances I don't want to say trade names, anything like that, but there are a lot of tooth tipping appliances out there and when you take a CBCT you'll see the roots have been pushed out of the bone or you'll see that there's this extreme tipping. For the astute restorative dentist, you'll see things like hanging palatal cusps. You'll see the occlusion isn't quite right, and so you just either tuck them in orthodontically or you just let it relapse and then we can go back in and we do true sutural change.

Speaker 2: 11:04

One other point that I think is really important when we talk about the transverse and this is a little bit of an aside we get so hung up on the width, but the forward back plays a big role too. Sometimes we'll see patients and whether they might have vertical maxillary excess, mandibular retronathia, so they can't quite close their lips, but both jaws are back and so the width might be appropriate, but they have lack of tongue space because the jaws are are backwards or vertical, so so you can't expand your way out of a vertical problem, and that's a big misconception. So expansion is not a panacea, it doesn't solve all the problems and we really need a full diagnosis, a full workup. So, going back to your question, sometimes they'll have lack of tongue space not because of the width but because of, maybe, the retro position of the jaws. That's true for class two and class three patients.

Speaker 1: 12:09

Wow, that is so eye opening. I think that for a myofunctional therapist, the number one referrals that we get are for tongue thrust, and most of this case says the tongue does not have a place to go. It's trying to escape for dear life. I don't believe that the tongue is what causes the open bite. There's always an underlying factor nasal obstruction maxilla, hypoplastic maxilla. However, oh my goodness, we can't push the tongue to go any farther back and get the patient to rest the tongue where it's supposed to be. Because it's not comfortable, they feel like they're choking. That's usually what. Because it's not comfortable. They feel like they're choking. That's usually what I ask them. Do you feel like you're talking if I ask you to put your tongue here and it's like, yes, it doesn't have a place to go. So, for all of these patients who are way too far back in terms of age, is there something? What is that cut off age that you would say it's surgery or there's no other thing we can do?

Speaker 2: 13:05

Yeah, so well, first I may I don't know, maybe you will disagree with me, but I don't like the term tongue thrust because I think it has this connotation of intention and I think you're. You're totally right. It the patient is doing cause they're trying to get their tongue out of their airway Um and or they just volumetrically don't have room for it when they swallow. When I talk to patients, I tell them the tongue it's like a water balloon. It's this fixed entity and it needs space. And so if there's lack of space it could be transverse or it could be AP or it could be a combination of AP and vertical, and so we have to create that space. Many times it's width alone can handle it, but, like you said, sometimes it's an AP issue. A lot of it depends on where the lower jaw is and a lot of it depends on vertical.

Speaker 2: 13:56

If it's just straight protraction of the upper jaw, the research shows that we can do that in a growing child with a great degree of predictability, with a protraction face mask up until about age eight. So for maxillary protraction we really want to catch those kids early. Five, six, seven is much better than eight, nine, 10. Once we get to about age nine or 10, we see a lot of dental tipping and we don't see a lot of true skeletal change unless we use a Marpie. If we do Marpie protraction face mask, we can get that through teenage years and we've been doing anecdotally no studies yet but anecdotally in our practice with Marpie and Dome or Marpie and some surgical release. We've been seeing some success with non-growing adults. How much, I don't know that. We have the literature to support that yet.

Speaker 1: 14:56

Do you only do protraction on class three cases yes, because we can't grow a mandible.

Speaker 2: 15:05

I wish we could, but if you have a patient that's non-growing and bring the maxilla forward, then you've just created an, an overbite that you can't recover from.

Speaker 1: 15:16

That's usually what I hear from my local orthodontist, like what am I going to do with the mandible? I'm like I don't know.

Speaker 2: 15:24

Yeah, so so. And then the other. The other piece to this which is very delicate, renata, is if a patient has crowding, if we, let's say, we take that nine or 10 year old and they already have crowding, if we protract the maxilla and we get any unwanted mesialization of the posterior teeth, we can accidentally impact the canines.

Speaker 1: 15:46

Oh, can you explain that a little bit further?

Speaker 2: 15:48

Yeah, so we can create problems that the patient didn't have. So it's critical to think about timing and dental eruption. So we have the front four teeth they come in around age seven, eight. Then we have the first molars and then the two premolars and the last teeth that often come in are the canines. If you have a patient and the maxilla is small from a young age four, five, six, or one, two, three, four, five, six and those developing tooth buds don't have a lot of space, they are crowded.

Speaker 2: 16:22

And so now when we protract, we're anchoring to the molars our appliances unless you're using a marpie, we're anchoring to the first molars or the primary, second, pre-molar, primary, second molars, and so inevitably you're going to get some forward movement of the back teeth. In a young kid you get less in, in an older kid you get more because the sutures are more developed. So as we come forward, these teeth that are trying to come in around the corner that already don't have a ton of space, if you come forward and the back teeth move forward even a little bit, you just lost arch circumference and so those canines don't have room to come in. Wow. So we created a dental problem that's quite challenging to get out of, wow.

Speaker 1: 17:15

And during this protraction cases, let's say that if they have a mark or if they have a regular extender, in order for you to use the protraction do you have to actively be turning, or can you be done turning and using.

Speaker 2: 17:29

Oh, what a good question. So this is a hot topic in the orthodontic field. The way many of us were taught is that you have to be turning the expander in order for the maxilla to come forward, and in fact, there's some literature that talks about cyclic changes. So turn it forward for a week, then turn it back for a week, then turn it forward for a week, and so that you're constantly changing the sutures.

Speaker 1: 17:56

What is it called the Wigley suture, the Z or the?

Speaker 2: 18:00

Yeah, and so you think like, anecdotally, okay, well, that makes sense. There are some papers, however, that say that when you compare turning to not turning, you get the same amount of protraction, so I don't think we need to be turning. That being said, if we're doing, let's say, a Marpie on an adult, my opinion anecdotally is that we should be turning a little bit. My opinion anecdotally is that we should be turning a little bit because because the turning cause we're we. We want those sutures to be open, to be moving, we want things to be changing. So, um, often, if I'm doing it with a Marpie, even if I might be turning it really, really slowly as we go, so that we're getting that upper jaw to keep coming forward.

Speaker 1: 18:44

Perfect. I have a couple more Marpie questions, but I want to go back a little bit and ask my questions about growth. Yeah, talk a little bit about the difference of vertical growth, horizontal growth and transverse growth. When are those done? When are those expected?

Speaker 2: 19:04

So the Some of the orthodontic textbooks say that the transverse is done by age four, which is kind of crazy. Now if you read those articles critically I think you'll get the width increases a little bit when the first molars come in, because as the first molars erupt you get a little bit of a transverse change. Transverse change. So you could say four or you could say seven, and both would be correct, because that's when the primary second molars come in and that's when the adult molars come in.

Speaker 1: 19:40

And that's maxilla and mandible. It's already different.

Speaker 2: 19:42

So that's maxilla, the mandible, and I've seen studies on this as well. The mandible, it is a fixed width and for the majority of patients the basal bone, the underlying bone, is about the same, but the teeth tip. And so don't think about the teeth, because as orthodontists we can tip the teeth, but the bone, the underlying bone, is a pretty uniform width for most patients, and so we can expand the maxilla and upright the lower teeth pretty predictably in most patients. And so then your next question was about AP. So AP, so forward growth, and so maxilla and mandible are very different. So maxilla, there's a big genetic component. Well, they both have a big genetic component. If you look at the parents and everyone has an underbite, there's a strong genetic component.

Speaker 2: 20:44

There's some literature that talks about tongue ties and kind of hints at it, although I don't know that we have hard evidence about that. But if you think about, we want that tongue pushing up and forward into that pre-maxilla at these early, I'm telling you myofunctional therapy you want the tongue on the spot. There's a reason for that. We think about like this all we all are working on the same thing together. Think about what happens when that tongue is pushing up and forward. In terms of forward growth of the maxilla. It's quite profound. There's a reason for the rugae, there's a reason for all the things that are happening anatomically in our mouths and so that tongue pushing up and forward, we most likely are going to get forward development to the maxilla. If we want to protract that maxilla, we want to do it as young as is reasonable, and so that's the balance. For me as a clinician is when do you intervene with these kids? And for me, a lot of it has to do with maturity, not so much dental age or chronologic age.

Speaker 1: 21:50

That's incredible. How about vertical growth?

Speaker 2: 21:54

Vertical growth is different. Um cause, we will see four or five year olds with gummy smiles already. Early mouth breathing leads to downward backward growth of both jaws. Uh, the earlier we can curve so. So let's talk about what. About what do we? How do we define intervention? Because I think that's an important thing for all of us as clinicians as well. Intervention doesn't have to be orthodontic intervention Intervention. Let's say you have a three or a four-year-old that's chronically mouth breathing. It's asking questions Are you allergic to the family pet? Do you have food allergies? Do you have environmental allergies? Do you have environmental allergies? Are adenoids and tonsils a problem? Can we get them to ENT? Can we get them to the allergist? Can we help retrain that tongue to come up into the palate? Can we encourage lips together? Because the sooner we can get lips together, tongue up, the sooner we see forward growth. If we have an early childhood of open mouth breathing and that lower jaw is spending more time down and back, we're going to get downward backward growth.

Speaker 1: 23:06

So it's, it's directionality, and the tongue and lips together are really the key.

Speaker 2: 23:12

Wow, that's incredible. I have so many questions for you. So another important thing is the condyle. So the condyle is a growth center for the lower jaw and early trauma to the lower jaw can negatively impact growth. And so, really looking for asymmetries, if you see a child and the lower jaw is starting to grow to the side, let's talk about. So I always ask about facial injuries. Did they fall on their face? Did they fall off their bike? Did they fall off a pogo stick? Did they get a blunt fall out of the crib or get a blunt elbow to the chin during basketball or soccer? Because these condyles are quite sensitive to trauma, especially at early ages.

Speaker 2: 24:01

I also think I don't have literature to prove this, but it might make sense if we think about it. Things like digit sucking put a force on that lower jaw during these formative growth years and you think about almost like microtrauma. The other thing that I see a lot of in probably the myofunctional therapists see, is lower lip entrapment. They're constantly biting their lower lip when they swallow, when they're watching TV, when they're at rest, and it prevents that lower jaw from growing forward. So, once again, the sooner we get lips together, tongue up, the sooner we help redirect growth in a positive direction. So thinking about some of these.

Speaker 2: 24:46

So intervention might not be orthodontic but it might be habit correction. It might be reducing the non-nutritive, sucking A pacifier, anything that's holding that tongue low. We see these kids and they come in. They've been using a pacifier to age three, four and it trains the tongue to sit low so that even when the habit is gone, it's the muscle memory, it's the physicality of that tongue. It doesn't know how to come up because it has never rested up. It's always rested low. So do you?

Speaker 1: 25:24

think form follows function or function follows form.

Speaker 2: 25:31

Form follows function. I think that it's the perioral musculature, it's the tongue, it's the lips, it's the cheek muscles that guide the growth of the jaws. Wow, but they go hand in hand, because now, if there isn't, well, and so it's all interconnected.

Speaker 1: 25:52

Every time there's a structural change, there's going to be a function change also.

Speaker 2: 25:56

So so. So, following that, let's talk about asymmetrical growth. Let's say there's no thank you, huge question. So let's say there's no history of well. I mean, we could go as early as torticollis, we could talk about babies and birth, and so really I think body work is important, I think just getting the muscles to work together is important. But let's say the maxilla is so narrow that the child is biting to one or the other side during these formative growth years, and so you have these cross bites and they start to habitually bite to one side. So if we think about condylar growth and development, think about all the muscles. The muscles are being used in one direction and so early expansion can be helpful to avoid any sort of asymmetrical mandibular growth can be helpful to avoid any sort of asymmetrical mandibular growth.

Speaker 1: 26:54

Wow, and I wanted to say again about the tongue thrust patients A lot of this tongue thrust could also be just nasal obstruction, you know, and enlarged tonsils.

Speaker 2: 27:05

I was going to say tonsils.

Speaker 1: 27:06

yeah, If they can't breathe through their nose, their mouth is automatically going to be open, the tongue is automatically going to be down and it could be slightly forward. So that's another thing for us to look at. From your experience after finishing cases, there has been a huge change, I feel like, in orthodontic community, going from permanent retainers to this clear retainers. What have you seen? Why has this change happened and how has this impacted patients?

Speaker 2: 27:39

Retention after early expansion is an area I'm still trying to figure out what's the best route. I think at the end of the day, the tongue is probably our best retainer. Do we give patients retainers? Yes, I'm constantly in conversations with our speech therapists malfunctional therapists. How can we pick an appliance that holds what we've worked on but also allows for that tongue palatal seal? I don't know that I have the best answer. We favor removable so that they can take it out and get that tongue up? There are times when there's orthodontic and dental reasons why we want a fixed retainer, more so to hold the molars back. So it's that. How do we? How do what? What takes priority? And and so it's a constant conversation. I don't know that I have all the answers.

Speaker 1: 28:36

And I'd love for. I don't know if there's any body professionals here, some osteopath or anybody that knows this cranial area really well, but I have heard so many people say no to permanent retainers. I decided to go with a permanent retainer because I don't like the removable ones. I didn't like the fact when I had the clear aligners and my teeth were not touching at night. I feel like they need to if they if they need to touch. They need to be free from each other and there's just something so neurological about your upper teeth and your lower teeth kind of fitting. And plus then, my hygienist mind. I don't want to, all night long, have any leftover bad bacteria be trapped by this you know device that is keeping all the bacteria in there in this moist and dark environment is just going to make things worse, if there's any, of course, gum gum issues. So then I decided to go with a permanent. However, so many people message me on Instagram. I thought you didn't need any retention because you're a myofunctional therapist and everything is supposed to hold.

Speaker 1: 29:44

I feel like our teeth have the ability to always change and move. You know, we're all. All the structures in our body are constantly have this, this rhythmic movement. They can move and they can't change. So, yes, to prevent any relapse, I don't think I would have any relapse. However, to prevent any relapse, I decided to go with it.

Speaker 1: 30:05

However, I got it done on Tuesday, yesterday and today so far, all day long I've had a weird headache and it's on my occipital area. I feel locked and whenever I put my tongue up there, I feel, I feel the retention on my upper teeth. That area can't move at all and it's just interesting now, knowing what I know and and feeling these things. Yeah, you can't move, and I wonder if it's causing my headache. It could be a couple of different things. However, I'm really interested to hear from any body professionals. If you guys are there, message me later and let me know if your patients noted this. Of course, not nobody. Not many people are going to put two and two together, but I am going to keep watching it and if this keeps being a trend, I might consider removing it and not doing anything at all.

Speaker 1: 31:04

But I thought it was interesting that I feel this lock right here. Interesting, yeah, yeah. Another question that I had was about the cranial lock. We talked about the nasal resistance. Oh, marpee expansion, one of the hardest things that I've been noticing with adults. It's trying to find the perfect bite again on the posterior teeth after Marpie expansion. What has your experience been with adults and Marpie and making sure that their bite is correct in the back?

Speaker 2: 31:42

That probably is from secondary tipping and it just needs orthodontic correction. So with any expansion appliance we're gonna get mostly well, we hope, we hope we've chosen the right appliance. We're getting mostly skeletal expansion, but inevitably we'll see some tipping and so if you do that, you get the palatal cusp hang low and then you also need to upright the lower teeth. So we need to upright the lower teeth, tuck the teeth back in, even though we've created this width. So almost think of it as like the movement is like this and then you have to tuck it back in. So I tend to favor braces these days to really get that root to tuck in. It's the second molars that are pretty challenging to tuck in and so trying to get the right type of movement you can probably. We're getting more sophisticated with our aligners. We're getting more sophisticated with slower expansion and trying to hold everything in with aligners. So we can do it with aligners, but I think it's also nice to have the ability to use braces. It might be a root torque issue that you're seeing.

Speaker 1: 33:01

That's very, very interesting. What else did we have on our list? We talked about this function.

Speaker 2: 33:08

Yeah. So there's a few other newer research papers coming out talking about expansion from a health perspective. The two other well. So we talked about function, we talked about nasal breathing, of course, tongue space, but I know this audience knows that the other areas that are quite interesting are eustachian tube dysfunction and nocturnal enuresis.

Speaker 2: 33:35

So if you have a patient that has a history of eustachian tube issues like ear infections, ear tubes, the ear tubes they drain this, the ear canals drain this way, and so in a really little kid it's kind of horizontal because the face, as we age, grows down and forward. Well, that's what we hope. So if the palate is high, vaulted, the ear tubes, it's more horizontal, it tends to. The fluid can get caught. Also, adenoids enlarged adenoids can lead to more ear infection. So it's all interrelated.

Speaker 2: 34:12

And so there's a lot of newer research showing that expansion in kids helps the ears drain better. So really, really interesting. Now Dr Yoon showed that expansion helps reduce the size of the adenoids and tonsils, which is amazing. And then, furthermore, eustachian tube dysfunction gets better with expansion. So as we expand, the ear canals can drain better, the sinuses drain better. Once again, improved nasal breathing. And so our why Renata is expanding, not to be no pun intended, but as we learn more about the power of expansion we can think differently about how it's impacting our patients. The other one that's interesting is nocturnal enuresis, so bedwetting that's otherwise unresponsive to treatment. After the age of five, maxillary expansion in some studies has been shown to improve nocturnal enuresis in children, as has tonsil tonsillectomy. So really interesting how maxillary expansion has a has a big impact on sleep, on breathing and on total body health.

Speaker 1: 35:30

Wow, we share a beautiful patient on a Dome and Marpie expansion case. Can you tell us a little bit about the Dome procedure? How is that performed? Does the patient have to go to a different provider to have that done?

Speaker 2: 35:48

So let's take a step backwards, because because Marpy is a phenomenal tool for expansion on non-growing patients and our understanding of success rates and age of patients is evolving, so what I say today might be different even in six months, and that's how fast this is evolving. When I came out of my residency program, I was doing the design that Dr Evans was really heavily involved in developing, where we had acrylic and the tads underneath, and that was really successful, but really successful, probably in teenagers. Then we started working with the MSC that Wan Moon was involved with and that was very successful, but we saw maybe 17% failure rate and much higher failure rate in adults, especially adult men. So Dr Yoon and Dr Liu were seeing something similar at Stanford and that's where the Dome procedure came about. It was first published in 2017, and it's a MARPI combined with minor Laforte-level cuts. It's very, very helpful for adult patients where we're not going to otherwise see successful expansion with a MARPI. So now we have custom MARPI designs where we can choose our surgical, our TAD placement more efficiently, we can engage more bone, we have custom substructures that are 3D printed 3D designed, 3D printed. We can incorporate more TADs and we have stronger jack screws. So all of those advances are changing the paradigm and so we are seeing less surgery and more true skeletal change, with a lot less unwanted side effects, a lot less failures. So some practitioners do MARPI with corticotomies, some still do it with the dome technique and some do very slow expansion with no surgical intervention at all. So when we use dome, I think is actively evolving and I'm sure that we'll see some papers to this effect pretty soon because it's actively evolving as we speak.

Speaker 2: 38:11

So the patient that we share, really interesting patient because she's maxillary deficient, both AP and transverse. So when I met her she was only touching on her front four teeth, two top, two bottom, with pretty significant posterior open bites. She'd been wearing an oral sleep appliance. She already had recession and pretty significant open bite and therefore tongue issues because the tongue was spilling into the space that she had. And so we did Marpie face mask and we did the dome cuts. And I don't know if you've seen her recently, but as of a few weeks ago she's touching on premolar to premolar. Now we just have to get the molars down. But she now has overbite, overjet. She's sleeping better, she has way more tongue space and then once the MARPI comes out, it'll be even more tongue space, as as we've, because it's AP and it's and it's transverse it is, and she's actually the best myopatient.

Speaker 1: 39:09

She sees how it's improving, so she's super excited about her exercises. This is great. As an orthodontist, it's very difficult, or as a malfunction therapist, it's difficult for us to convince an orthodontist to see these patients young. What is the earliest age, do you see?

Speaker 2: 39:33

Maybe I can add some context to that, just for the audience. So the American Association of Orthodontics says that patients should be seen by age seven, not at age seven. By age seven. So there really is no young age limit. I think that's a big misconception.

Speaker 2: 39:51

I think historically we were waiting as orthodontists for the first molars to come in, because that's historically when our bands would fit on the baby, on the adult teeth. If we're going to design a traditional hyrax expander, we would need to wait until the molars came in. Today, with CAD design and 3D printed appliances, we can design a very nice appliance on baby teeth with a great degree of predictability. So for us in our practice it's more about is the patient emotionally ready to have someone work in their mouth? And you've probably seen this as well. We'll have five year olds that can carry on a conversation like they're teenagers and nine-year-olds that are scared in the chair and crying. And so it's more about are they ready for us to work on them, not so much chronologic age and then also level of dysfunction. Are they symptomatic?

Speaker 2: 40:51

I showed Renata before we started a patient.

Speaker 2: 40:54

She was four years old and her upper jaw was so small that she couldn't figure out where to put her tongue and she couldn't figure out where to bite, so she'd bite to one side, she'd bite to the other side and she had this pretty significant open bite and so her speech was very challenging to understand and she was asked to leave daycare because they couldn't understand her and there was a lot of behavioral issues because she wasn't being understood and it was frustrating for the parents, frustrating for the teachers, and so ultimately she ended up in speech therapy. The speech therapist said I can't help with tongue position because the maxilla is so small, she doesn't have a place to bite or chew, so we had to expand just so that we could get her that tongue space. She did great. She did such a great job. She was four years old and she did a great job in the chair, totally great to work with. The family was so appreciative and she made strides in speech therapy as soon as we corrected the deficient maxilla.

Speaker 1: 41:57

All right, that was wonderful. I had one more question about empty nose syndrome A lot of patients and then I'm going to do something fun right afterwards, so you guys hang in there. Empty nose syndrome A lot of adult patients are super worried because a lot of them need nasal surgery or they've already had, you know, turbinate reduction and all of that. Do you have you seen this at all in your practice? Is this a concern?

Speaker 2: 42:25

I've and this all I can speak about is my experience. I haven't had a patient experience empty nose syndrome from Marpy, if that's the question. From what I've read it's a small risk with nasal surgery, but I haven't heard it happen with expansion.

Speaker 1: 42:48

We have a question from the audience what would be a good timing to intervene with myofunctional therapy at an orthodontic adult patient versus orthodontic pediatric patients, especially in the marpie context? Before doing, after, or all of the above?

Speaker 2: 43:06

all of the above I think proper, proper tongue position, proper nasal breathing and proper lips. Together it's always beneficial. I don't think that you can ever go wrong. It's like when is good posture for sitting? All of the above that being said, I think patients that have very limited resources, if we have a very finite amount of time to work with them, probably after the expander comes out, because we've really maximized space. So if it's in the cards, both financially and time wise, to do it all throughout treatment, before and after, I think that's great. Same goes for jaw surgery cases same goes for jaw surgery cases.

Speaker 1: 43:59

Loves my jaw surgery cases. I've been having so many of them recently and, yes, like you're not going to work on swallowing before the expansion, there's no reason. So you know you have phases of treatment. You have to make sure that you focus on each phase depending on where the patient is and exactly what they need. But please do not push a patient to swallow with the tip of the tongue on the spot. If there's not enough room there, it's not going to work. It's a waste of time.

Speaker 1: 44:21

Great, can we achieve good tongue position with the expander in place? 100% yes, I always ask my patients if you have an expander. I want to make sure that whenever you open your mouth I can see the expander markings on your tongue. That's when I know your, your tongue is up there. I mean, don't we add a bunch of stuff to the spot for them to you know, for the tongue to follow to get up there a hundred percent.

Speaker 1: 44:45

However, if it's a patient who has an overbite, they already have reduced intraoral space. Those patients already have the tongue up because the tongue doesn't have another place to go. Intraoral space those patients already have the tongue up because the tongue doesn't have another place to go. So with those patients, usually you may see an issue with sleep until the expander comes out. So again, there's tons of other things that we can do. We can work on isobreathing, we can work on or a Frank or fairings muscles, we can work on lip strength. I mean all of that stuff before you really focus on tongue position. So you want to add to that.

Speaker 2: 45:17

Yeah, I tell my patients it's like yoga or Pilates it's important and you have to think about it. You have to think about it daily, you have to practice it daily and it's it just like yoga or Pilates. It supports your core. We're supporting this core and it's just key. Supports your core.

Speaker 1: 45:33

we're supporting this core and it's just key for sure, open up the vertical on these patients that are so overbite.

Speaker 2: 45:48

In the front. We use a bite plate a lot, so just putting a platform here in a retainer allows them to come down and forward and that really helps with condylar growth, with mandibular growth as well, to unlock. It helps with lower lip entrapment too.

Speaker 1: 45:58

And I feel like a lot of myofunctional issues solve themselves when you open up the vertical on this. Patients that are just so severely have this over bite. Um, I've seen people do planus tracks in, especially in other countries. Um, I know the myobrace also has an occlusion, you know thing that I don't know the name of it, that they can do, but I didn't know about the bite plate so I can ask my orthodontist to do that.

Speaker 1: 46:22

Yeah, it's very simple yay, all right, you guys are ready. You have already answered many of these questions, but I am going to put you on the airway circle hot seat. I'm going to give you two options and the first one that comes to put you on the Aerie Circle hot seat. I'm going to give you two options and the first one that comes to mind you're going to say Okay. So here we go. Ready, extension, fixed or removable, fixed.

Speaker 2: 46:47

Dome or Marpee Depends on the age.

Speaker 1: 46:52

Fixed or removable. Retention Removable. Fast or slow.

Speaker 2: 46:56

expansion Slow Anti-release before expansion or after After Sweep study in lab or at home Depends on who's reading it, do you?

Speaker 1: 47:08

like class two patients or class three patients, better Class three.

Speaker 2: 47:14

MSD or MARPE Custom MARPE Hab.

Speaker 1: 47:18

MSC or Marpy Custom Marpy Habit correctors or functional appliances.

Speaker 2: 47:22

I guess you could probably say they're pretty. It depends MMA or dome Depends on skeletal pattern.

Speaker 1: 47:34

Ta-da, that was great. Thank you so much. Oh, my goodness, it has been such a wonderful hour with you I knew there were no issues talking. Thank you so much for hanging out with every circle. This is going to go on the video breathing podcast episode because I know so many patients and professionals will benefit from listening to this. So if you're not following our podcast yet, please go to Apple Podcasts, spotify, whatever you like to listen to our podcast. Look for Beauty of Breathing by Aerie Circle. Click on follow.

Speaker 1: 48:08

And here is little Benny who desperately needs some expansion. He is five. If you would like to take on this challenge, please. He doesn't want to be five. He turned five when he's four. Still right, okay, but anyways, thank you so much.

Speaker 1: 48:23

And just a couple announcements. With airway circle, myocircle, which is our advanced myofunctional therapy course, you're going to learn the why behind the exercises. You're going to be able to get results way faster. Because you're going to learn the why behind the exercises, you're going to be able to get results way faster because you're going to step outside of the box and really understand. Look at this patient a little bit differently. Um, january 1st, we only have six squats left and hold on. Okay, let's go give it somebody. And another thing is airway circlereat. April 10th through the 12th Okay, we can go to the neighbor's house. He wants to give the neighbor a gift.

Speaker 1: 49:00

April 10th to the 12th we have Airway Circle Retreat Dr Uma Katwa, who is a Harvard doctor. We are super excited to have him. He is going to be leading an airway talk in this really cozy, fun house where we're going to be able to improve our relationships. We're going to talk about business with Dr Lincoln Harris. Okay, let's put you in your clothes yeah, those are clothes and we're going to talk about business and we're going to talk about personal growth. So super excited to spend some time just recharging and renewing, to be able to leave there transform with new relationships and new businesses, excited to finish our 2025. So if you're interested, you have to apply. Just go on Aerie Circle. You can go on Aerie Circle Professionals page on Facebook and you can apply. I'm going to make sure that I leave the link over there. Thank you guys so much. Any last words, dr Bacal, thank you for all. You can apply. I'm going to make sure that I leave the link over there. Thank you guys so much. Any last words, dr Baco.

Speaker 2: 49:58

No, thank you for all you're doing.

Speaker 1: 50:00

Thank you so much. You guys have a wonderful day. We love y'all. See you later, Thank you.