52. Adult Palatal Expansion: Everything you need to know

Ever wondered if you can reshape your palate as an adult? Prepare to challenge what you thought you knew about orthodontic treatment as we unlock the truth about adult palatal expansion and the transformative MARPE device. You'll learn about the pioneering work of Dr. Moon and the evolution of expansion appliances, and hear firsthand accounts of how cutting-edge techniques have improved outcomes dramatically. Plus, get answers to burning questions about the latest advancements and less invasive methods in orthodontics.

In this eye-opening episode, we explore the MARPE procedure's potential for children under 10 dealing with craniofacial issues often stemming from habits like thumb sucking. Discover how early palate expansion can significantly impact not just dental health but also tongue placement and overall facial structure. Learn practical tips on how to measure the palate accurately and the benefits of addressing these issues early to avoid complex treatments down the line. We also dive into the role of intrusion techniques for managing high palates and gummy smiles, ensuring you have a comprehensive understanding of these vital procedures.

Lastly, we tackle the complexities of orthodontic jaw surgery and the preparatory role of MARPE. From reducing the invasiveness of double jaw surgeries to addressing sleep apnea holistically, this episode provides a thorough guide to navigating these intricate treatments. You'll get insights into the costs and additional treatments associated with MARPE, along with personal experiences and professional recommendations to help you make informed decisions. Don't miss our deep dive into dental expansion options, swallowing issues, and the crucial role of myofunctional therapy and sleep studies in enhancing oral and airway health.

Chapters

• 0:00 Adult Palatal Expansion and Marpie Devices
• 16:01 Orthodontic Treatment for Children Under 10
• 29:25 Considerations for Orthodontic Jaw Surgery
• 44:01 Dental Expansion Options and Considerations
• 50:09 Swallowing Issues and Treatment Options
• 1:02:04 Sharing the Maya Moves Message

Transcript

Speaker 1: 0:00

Welcome. Welcome to Beauty of Breathing Marpie episode. We are going to be talking about adult palatal expansion. Is this a thing Really? Adults can also get expansion. No way you know. We've always heard for the longest time that around the age 15 or 16 years old, that the suture in between the maxilla fuses and then you can no longer expand. But I am living proof that, yes, you can. So why would you want to expand the palate? This is interactive. You guys are welcome to comment, to let me know what you think, if you have ever heard of this.

Speaker 1: 0:51

So there are orthodontists who have been doing these types of appliances for over 20 years, originally Dr Moon Moon. Oh my gosh, sorry, a filter just turned on on instagram somehow and I don't know how to turn this off because I don't look like that. Sorry about that. Um, so dr wound moon uh, created something called the msc. The mSE was a device that would go in the roof of the mouth and it had four screws two on this side, two on the side. Why do we need to put screws on both sides? Because the maxilla is actually two bones with a suture in the middle, so they have to put, you know, the little tab on one side and the other side and the screws in the middle. So they have to put, you know, the little tab on one side and the other side and the screws in the middle, so whenever you start turning it can apply enough force pulling those, pulling those apart, so it can reopen the suture. So that was the MSD.

Speaker 1: 2:02

Well, dr Ilya Lipkin, my orthodontist, has been doing it for so long. He started realizing that just the MSC, just having four screws, sometimes it was not enough. So he got a welding machine and he started making his own appliances in his office so he would get the MSC. So the MSC is like a custom appliance not a custom appliance, but pretty much everybody. They all look the same. You'd purchase and you'd put the same appliance in everybody's mouths. So the screws had to go always in the same spot. You could not move it around and we all know that the bone up there in your palate some areas are thicker, some areas are weaker. Well, if you're putting those screws in the weaker areas, you're less likely to be able to get in a force to expand. Does that make sense? So when Dr Lipkin started realizing this, he started welding some extra areas in the MSC what's called the MSC1, to be able to add extra screws.

Speaker 1: 3:05

I'm not sure how long after that, dr Moon Moon came out with the MSC2 that had room for six screws, six pads. So of course, time goes by and now they have labs who do custom appliances. Since they're custom appliances they're not called MSCs. Msc is pretty much Dr Moon Moon's brand, so it is called a Marpie, which they are all Marpies because they're a mini assisted assisted implant. Mini assisted implant, rapid fallout, expansion. And the Marppees now are custom. So you take a cbct x-ray, the x-ray goes all the way around you and based on what they see on the x-ray, they are going to custom make this appliance that's going to fit specifically for you where the screws are going to go, in the places where the bone is thicker. Therefore you're way more likely to expand and to get that suture to open.

Speaker 1: 4:19

So I have had a little bit of experience in the last year going through this palatal expansion and I cannot wait to answer all the questions that you guys may have. And I do have my Marfi with me. You guys know Dr Lipkin said he was going to make me a necklace, but I think I'm going to do it. Can you guys see it, I'm going to show on Instagram first and there it is. Look how long the screws are, y'all. I mean it literally goes all the way into your bum, into the nose. So I have some questions coming in and I have a list of questions that you guys have already sent me on Instagram, so I'm going to try to go through all of them. I just wanted to do a little quick intro explaining where does this appliance come from? How long have orthodontists been doing it?

Speaker 1: 5:05

Not every orthodontist does it yet and you know people tend to think that if they did not learn about this in school that it's something crazy and it's. You know a lot of orthodontists or even dentists will talk about this being so barbaric and so aggressive. But now, going through it, you know I barely had any pain. Do some people have pain? Do we still have failures? A hundred percent. However, the more time it goes by, the more training these professionals get by, the more training these professionals get um, and the more we start addressing the whole body as we're going through this thing, the more likely we are to get way more successful cases.

Speaker 1: 5:55

Um, julie ryan is asking do you have a corticotomy on your palate for your marpie did have. So corticotomy. They used to do punctures on the suture to help widen the palate. They don't usually do that anymore. Some people who've been doing it for some time and don't have newer training still do it. However, you know, you guys know that I took Dr Lipkin's course and he is so advanced in terms of experience, how long he's been doing it and how he places them Then not a lot. That's why I always recommend people going to him, because not a lot of professionals still do it like him. Or I will ask a professional have you taken Lipkin's course? Or I will ask a professional have you taken Lipkin's course? Even when I'm sending my patients over to somebody I always ask if they've taken Lipkin's course, because then I know that they have the latest of the latest. So he no longer does the corticotomy and those are little puncture wounds so it's kind of a way to allow the suture to open more easily.

Speaker 1: 7:04

Now they have something called a piezo. The piezo it's a little knife cutting thing and you go into the suture and you do little cuts so it's not puncture anymore. They are little cuts. They actually go in between their front two teeth and they open the maxilla here, first the suture and then they go on the roof of the mouth and open a few more areas. I did not have it done. Usually they recommend like, if it's a female, 38 years old or older, maybe even a little bit younger to always have it done and a male male starting younger because of course, the bone is thicker, it's going to be harder to move. They've never had an issue with somebody not expanding after doing the piezo. Some people call it piezo. I like piezo better. So some people usually so if they do the piezo they're very, very, very, very likely to expand evenly because they made the cut and open the suture without an issue. So I remember Dr Lipkin saying well, why don't we just go ahead and do it right? Almost everybody younger patients, of course don't really need it. I may have a bleeding disorder called von Willebrand's, so I mentioned that to Dr Lipkin and, even though he didn't think it was going to be a problem, we decided not to do the PSO. So, no, I do not have any cuts in my palate whatsoever. It was just the Marpie installed.

Speaker 1: 8:36

I waited. I got installed May 11th of 2023. I waited five days or seven days to start turning and as soon as I started turning, on day three, I did two turns a day. On day three I had a slight headache I believe that that's when the suture opened, but it wasn't bad, because I've had headaches my whole life, so that wasn't bad. And on day five I was like, okay, it's really, it has already split, because I started feeling air in between my two front teeth and I would go like this and I felt air going through. But on day five you could clearly see that there was a space there. So that's when I stopped turning twice a day and I started turning once a day. That's another problem that I see with some of these turns.

Speaker 1: 9:25

So let's talk about the three things that I see done that usually give problems with the MSC or the Marpie. Number one not enough screws. So if it's somebody older, four screws, eight screws or six or eight screws, four screws, very young, you know, children, or all the way to probably around 20 something years old, after 30, really I would already recommend six screws or more to just make sure that you're going to have enough force to split that suture. Unless it's somebody very small, you know, of course the dentist, the orthodontist, is going to decide. It has nothing to do with me, this is just from my experience, y'all um and so one reason people do not put enough screws is one of the reasons why I see things fail.

Speaker 1: 10:25

One reason people do not put enough screws is one of the reasons why I see things fail. Number two reason if they turn too fast. So a lot of people who are trained under Dr Moon, they are taught to turn three to four times a day in the beginning, because there's some research out there that shows that the faster you turn in the beginning, the more likely you are to split. However, I have seen a few cases where the screw will drag into the bone and not split. And then that's when patients have pain and then they have to turn all the way back, get it removed. And then they have to turn all the way back, get it removed, wait a little bit longer until it heals, and that removal is painful, and then they have to put it back in with more screws and that usually works fine. So more screws and less turns. And number three reason why I usually see these things fail. I can't remember what the third one was, but anyways, those are the main two things that I ask my patients or the providers that I'm working with that. Those are very, very important to me.

Speaker 1: 11:43

So back in the day and it's still done in the day, and it's still done mainly like this, where you turn a lot probably you know, once, twice a day and then you end up with this huge diastema. So there's huge space in between your two front teeth and people do that super fast and then you start after you're done turning that's when you start braces or Invisalign usually and then you start closing. If you think about it, there is nothing up here, there is no bone or anything you know yet up there, and then you're going to start trying to close the teeth into that space. It's more likely that the suture when it's mineralizing it will be more unstable and more likely to relapse if you turn too fast and not have a huge gap or other tons of gaps in between our teeth. We kind of want to do this and be done with it, but they are finding out that the faster you turn, the more unstable that bone is in the middle. The suture is in the middle, so more likely for the patient to relapse after because that bone is super thin. Does that make sense. So that's another thing. They're seeing that even one turn a week is enough for adults. Now we have to think about something. A week is enough for adults. Now we have to think about something.

Speaker 1: 13:28

When an expander is put on a child and you use the teeth as anchors, whenever you start turning the key in the middle, the force is applied to the teeth. However, a child is still super malleable. That suture is super malleable. So whenever you start applying pressure to the teeth, it's very likely that the suture is going to open. But as an adult, that suture is fused or a lot harder. So whenever you apply pressure to the teeth, guess what? The teeth move. That's another reason why having a regular expander on an adult or after you're about 18 years old, we're going to get a lot of tooth tipping. A lot of tooth tipping because that force is putting the teeth way out here.

Speaker 1: 14:08

We don't want. We don't want that. That doesn't make any changes to the suture. In order for you to have changes to your nose, for you to be able to breathe better, you have to open the suture. So that's why I like to be a little bit more aggressive in the beginning, even with children. Let's just get an RPE. Crank that open so the patient can breathe better. If we have better airflow, we're going to have more oxygen uptake, we're going to start sleeping better, so let's just go ahead and crank that open.

Speaker 1: 14:37

And if we have to use a functional appliance later to work on symmetries or things like that, then I'm all for it. And yes, we do have to keep in mind that whenever you start turning, we have several sutures right and all of these bones are connected. So whenever you start applying pressure, if it's too much pressure, like those three and four turns a day that some people recommend, it ends up bending the other bones. It's too much pressure, too soon, you know. So every time you go through palatal expansion as a child or as an adult, let's address the whole body. So let's try craniosacral therapy. I just got done with a session with Hilary Zilk because it was amazing. I literally felt my palate moving, like guys. I'm not even joking, I felt everything moving. But I felt my palate contracting and expanding and squeezing my tongue and opening it back up as she was moving some cranial bones. But anyways, a craniosacral therapy, cranio-ost osteopath, all of those things are so important to make sure we address the whole system. It's not just about where your teeth are located, it's not just about the way that you chew and that you close your teeth together. We have to make sure we address everything. Let's see.

Speaker 1: 16:01

We have some more questions here. Sarah Gregory, do you feel like Marpie is too invasive for kids under 10? I have seen some children with those V-shaped palates at 7, 8, 9 years old, when they are that transverse deficient. What is transverse deficiency? When the maxilla, the upper jawbone, is too narrow, that's transverse. If it's too far back, we call it AP deficiency, which stands for anterior, posterior, so front to back, so transverse deficiency. When they're so, so, so deficient, those are usually children who had, you know, thumb sucking, pacifier use or some really difficulty with some oral functions and did not develop correctly at all A lot of craniofacial issues. In those instances the MARPI works really really well, but it's not for everybody 100%. I mean, if it's, you know my children and I can tell that they're already transverse deficient, let's just go ahead and start expanding as early as they do with lettuce. That's another thing. You're not going to be able to start before the kids are ready. So it's not too invasive for kids under 10 if they are the right patients for this procedure. So they have to be very deficient, otherwise I think that one or even two RPEs sometimes they have to do two different appliances.

Speaker 1: 17:51

Let me get one of the questions here how do you know if I have a narrow palate? That's a great question. I like to use a caliper to measure the roof of my mouth so you guys can get this on Amazon the roof of my mouth, so you guys can get this on Amazon. Just type caliper and there's two sides to the caliper. There is a smaller side and there is a bigger side. So to measure in between your molars on the top, I use the small side and I go from first molar to first molar on the top. Those teeth numbers are three and 14. So I measured that.

Speaker 1: 18:33

I, you know, usually I say go, so you go into your mouth with it closed and then you open up until it hits the teeth. However, I don't really want it to hit the teeth. Why? Because sometimes the teeth are tilted right. What we're trying to measure is actually the palate and on the teeth. So the way that I like to do it, I like to go close a little bit more and then I go a little bit higher, where I'm poking the palate and then I open until I can't open anymore. But these have to be touching the palate. That's how I measure because it's a more accurate number according to what they measure on the CBCT, on the 3D x-ray, the cone beam CT.

Speaker 1: 19:16

You know what? I have not measured myself since the MARPI came out. Should we do that right now? And I also have a digital one. So I click on a zero, let's see. Oh, my goodness, I got the same number. Look at that 36.9. I got the same number that Dr Lipkin got measuring my CVCT scan. So I used to be a 30, 30 molar to molar and it's almost a 37 right now. That is incredible the amount of room that I have for my tongue. It's so much easier to sleep, so much easier to swallow.

Speaker 1: 19:58

And, a very interesting thing, when you have a long face which my face is not as long anymore, but whenever you have a patient with a long face you cannot push this patient to keep the tip of the tongue on the spot. Do you guys all know where the spot is? So it's about five millimeters behind your upper front teeth. I have a little X on this model right here. So it's about five millimeters behind the upper front teeth. We are always taught that that's where the tip of your tongue should live all day and all night. However, if you have a very long face and you do that, you feel like you're going to choke. The back of your tongue just gets crunched all the way back there and there's not enough room. Type me right here in the comments if you guys can feel that If the tip of your tongue goes to this spot and you try to suction, you feel like you're choking.

Speaker 1: 20:47

So if you have the face shape that you're a little bit too long, I teach my patients the blade of the tongue, which is slightly behind the tip, it's right here. The blade of the tongue is slightly behind the tip. That part is actually what applies pressure to the spot. The tip of the tongue doesn't do anything, it doesn't have any force, it just rests there. So if you have a long face, it's very likely that it's going to rest on your lower front teeth. So whenever you suction comfortably, however, you're able to suction because we all have different face shapes, right, so not everybody's going to suction the same way and you know you can't make everybody do exactly the same thing because we all look different. You know you can't make everybody do exactly the same thing, because we all look different. So whenever you suction, sometimes you may feel like the tip of your tongue is touching your lower front teeth, and that is totally OK. If you're not applying any pressure, you keep the pressure on the blade of the tongue to the spot, you're fine. But I have noticed that after getting expansion now my tongue comfortably rests a little bit farther back, where we all teach, where the spot should be. So that's something that has changed for me and it's incredible.

Speaker 1: 22:05

I want to know if high palate can be lowered by pulling teeth up. Maybe what you're talking about is intrusion. So I was going to get intrusion done. Intrusion they were going to add the same screws that were called TAD over here and over here. Dr Trevor Nichols I think he's in Arizona he's one of the best in the United States to reduce a gummy smile. Can somebody tag him right here on our Instagram, dr Trevor Nichols? So pads go here and here and they push the teeth into the bone.

Speaker 1: 22:53

So whenever you have a really big smile and you can see somebody's gum, if they push everything up all of a sudden after they do some gingivectomy. There's a couple things that need to be done. Whenever they smile, you can see teeth. So you guys all know you see me when I get super happy I smile really big and have a really big gummy smile. I had some Koi's professionals, koi's trained dentists. Look at me. They do a lot of cosmetic dentistry. Look at me, whenever I was at the penny in New York with Dr Steve Lambert and they made me do this test and I'm going to teach you guys right now.

Speaker 1: 23:32

So if you have a gummy smile, you can do that. You're going to say the M sound and I'm going to teach you guys right now. So if you have a gummy smile, you can do this. You're going to say the M sound and you're going to look in the mirror. So whenever you say M M, as soon as you stop and relax after the M sound, can you see your canines. So look at me. I know that if you're listening to to this, you won't be able to see me, but, ma, you cannot see my canines whatsoever. So think about what would happen if they push those teeth into the bone a little bit more when I talk. You wouldn't be able to see my upper teeth at all. You know what I mean? That would make me look older, uh, so for that reason, it is not the treatment for me. I'm going to get a little bit of gingiv the treatment for me. I'm going to get a little bit of gingivac to me. I think I'm going to get my lip tie released to see if my lip will come down, maybe half a millimeter, one millimeter, and then I may get a little bit of Botox right here to prevent my lip from coming up so much when I smile, and then I may think about veneers in the future. I like the way that my teeth look. However, they are a little bit short, so I don't know if that was the question that you had. Let's see what else we have here. Do you feel like Mar? Oh, I already answered that one.

Speaker 1: 24:49

Which orthodontist offered this in the UK? Can you have the Marpie if you had upper premolar extraction? So yes, you can have a MARPI if you have had your upper or your premolars extracted. Whenever they extract premolars, the problem is that they push everything back A lot of times. Orthodontists will recommend extraction of premolars one if the patient is very, very, very crowded so you have no room for your teeth right, meaning your jaw didn't grow, you know. Another reason is because you have a class 2 bite, meaning the upper teeth are way in front of the lower teeth, or the upper jaw looks like it's way forward and the lower jaw way back. That's called an overjet, when the upper teeth are further out compared to the lower teeth. So when that happens, sometimes they will extract two premolars right here and just push everything back so it matches the lower jaw right. Easy solution to a problem. But you just created a bigger problem because now you diminish the amount of room that you have in the roof of the mouth for the tongue.

Speaker 1: 26:09

Why are we ignoring the tongue everybody? The tongue has such an important role. It needs to live up there, and if it doesn't have enough room up there, what's going to happen to it? It is going to fall back into your airway and it's going to cause an obstruction at night, or it's very likely to. So very, very important for us to find out why.

Speaker 1: 26:28

So most of these patients who have had premolars extracted, they're not necessarily narrow, they are too far back. So they have the AP deficiency I was talking about earlier. There are certain things they can do for AP deficiency. So if you're too far back, they can also do an extender. And they attach something. Even with the MRP, they attach something called a reversible face mask. Sorry, it's an appliance that goes I think it's like maybe elastics or something that goes in the back teeth and then it looks like a bow, an arrow, like a bow that goes from the top of your head to your chin or the top of your head to your chest, and I know that as a child you have to wear for like 16 hours a day. So pretty much you go to school and any other time of the day and all night long you're wearing that. But that is pulling the maxilla forward.

Speaker 1: 27:27

Now, to bring the mandible forward is a lot harder and I am going to get somebody who does that a little bit more to come talk to you guys. So I don't give any wrong information out. It is way harder to bring the mandible forward. Sometimes, when somebody has an overbite meaning the upper teeth are covering the lower teeth we see a lot of times that those patients have the mandible trapped behind the maxilla. So whenever they bring the maxilla forward, the mandible trapped behind the maxilla. So whenever they bring the maxilla forward, the mandible follows.

Speaker 1: 27:56

I believe that my mandible came forward some after my MRP because, as you guys could tell, the MRP does bring it forward a little bit. I usually tell my patients to expect one to two millimeters forward and you guys can tell my upper lip got so much prettier after because I did, I had a non-existent upper lip and as soon as this came up a little bit more, it gave my support to my lip. So my lip looks better now and, um, yeah, so marpe does bring it forward a little bit and I do believe that my mandible slightly. It was not a big change, but I do believe I'll be sharing my before and after photos soon on instagram. So, uh, stay tuned. Um, but of course, most people that need ap growth they need to come forward need a lot more than the market can provide. Uh, I was actually recommended double jaw surgery as part of my treatment and I decided not to go through it because I don't have sleep apnea and if I had to tap me I would probably do it, but that's the main reason.

Speaker 1: 29:07

If I had more problems, more symptoms, then I would definitely look into it, but stat, aesthetics-wise, I'm way happier with the way that I look. Could it be better? It can always get better, but I'm very happy. I'm very happy where I am. Let's see next question.

Speaker 1: 29:25

Hi, renata, I'm possibly going to be having double jaw surgery. I had not considered Marpie before. Should I have MRP first? I think the jaw surgery will be necessary to maximally improve sleep. So most of my patients who go through double jaw surgery, most of them will start with the MRP first. Why it takes longer? Yes, however, it will diminish the amount of cuts they have to do. So if they have to open somebody transversely and bring the upper and the lower jaw forward, if they only have to bring them forward, you'll be less invasive. Uh, it will be faster healing and all of that. So, and of course, like I said, you're going to get a little bit of forward with the Marpie. But now, if transversely, you're fine. If you're a woman, a female, and you have 35, 36 millimeters or more, I probably would not do Mar RP before double jaw surgery. If your main issue is AP, then I'll just go ahead and go through surgery.

Speaker 1: 30:41

You have to remember that if somebody is transverse deficient their tongue position as you grow transversely, it doesn't affect your sleep as much as if you're AP deficient. What am I trying to say here? I don't know why I thought about this, but if you need a tongue tie release, we always talk about having enough room in the palate for your tongue, correct? So if you're transverse deficient, if you're too narrow and you get a tongue tie release, I don't think it's as big of a deal as if you're AP deficient and you get a tongue tie release. It is way more dangerous, in my professional opinion. If you get a tongue tie release and you don't have enough room forward, that tongue is way more likely now to go way far back and make your sleep worse. So very important for you to work with a release provider, with a myofunctional therapist, whenever you're deciding for tongue tie releases. So sometimes yes, I would recommend Marpie sometimes straight to surgery.

Speaker 1: 31:44

I know you have apneas and you're overweight. If you know you have apneas and you're overweight, will this help 100%? You have to address everything whenever you have sleep apnea. Sleep apnea is a very complex disease. It is not just the tongue tie, it's not just the transverse deficiency of the maxilla that causes obstruction. It could be the epiglottis, it could be the vocal cord, it could be because you're overweight. It could be so many different things. It's not going to be one reason, okay, that all of a sudden you're going to be cured.

Speaker 1: 32:21

There's no cure to sleep apnea, there's just maintenance. Whenever we have a young child, there are things that we can do to maybe hopefully get the child to grow in the right direction and they won't have apnea anymore. But as an adult, it's just maintenance. So, a hundred percent, let the three pillars right Exercise, diet and sleep for each other healthy life. So let's start taking care of all these things first before you start spending money with all of this treatment. Like I said, we're all adults and we want easy solutions, we want fast solutions and I do have some patients that have tried several different things and they don't find relief with their treatment choices, but it's because we have not addressed those three pillars. So let's, you know, start a workout routine that can just be walking.

Speaker 1: 33:23

I got a walking treadmill y'all and I'm walking at least four miles a day. It has changed my life. It has changed my energy levels, I am sleeping better and there's research with that. Molly Eastman, who is a good friend of mine with Sleep, is a Skill she talks about. She sent me a research on this that walking every day how to improve your sleep. So I understand that if you, you know if somebody is overweight you already don't have enough energy. It is harder to find time, so I just got this walking treadmill. You don't have to run, you don't have to do any of that, but just walking started.

Speaker 1: 34:00

You know, whatever you can do if you can do 10 minutes to 10 minutes, I'm not one of those people that think that if you don't work, work out for one hour a day, it's not worth it. If you have 10 minutes, just do 10 minutes. You're going to get more energy to be able to do a little bit more the next day. So, 100%, we have to work on nutrition and exercise and then, if you're sleeping better, of course it's going to be so much easier for you to make better decisions for your health, but you have to want to. It's not just going through the market that all of a sudden you're going to get better. You're going to have to address all of these areas of your life. You're going to get better. You're going to have to address all of these areas of your life. So could it give you improvement in your sleep if you get expansion A hundred percent, but it's not going to be the only thing. Did you have happiness before you were overweight? Because if you didn't, maybe just losing weight, which is extremely difficult, I get it. But losing weight may be the solution instead of the Marpie, you know. All right, let's see this question.

Speaker 1: 34:57

I have an anterior crossbite which has caused one side of my jaw is more narrow than the other. I have never tried an expander Told from ortho. It might do more damage than help and would have to perform jaw surgery. Sinus issues are my main concern. Wonder why, right Thought? Also, is there an approximate cost for this procedure? So Marpe doesn't come alone.

Speaker 1: 35:27

If you need a Marpe, you usually also need braces or Invisalign afterwards. You do One of the two. From my experience it can cost from $7,000 to $17,000. Depends on where you are in the world. I have seen some people charge $2,600 for Marpy. I have seen some people charge $7,000 just for the Marpy. So it really depends where you are, what providers you have around you, the amount of training that they have. You know some of these providers have over 1,000 hours of training in everything airway and their experience and all of that. So it really depends.

Speaker 1: 36:19

So you have an interior crossbite. An interior crossbite means that the lower teeth are in front of the upper teeth. Naturally, your upper teeth are always supposed to be outside of your lower teeth, so all the way around. Yes, so posterior crossbite is whenever only the lower teeth on one side are outside of the upper teeth. So I had a unilateral meaning one side, only posterior, the back cross bite, meaning my teeth were completely the opposite way. Right, and that's because my upper jawbone did not fully grow sideways on that one specific side.

Speaker 1: 37:17

Why are we asymmetrical? Why do some people grow more on one side versus the other? Many different things, right, many different reasons. One is a tongue position. Is the tongue applying pressure over there? In order for the jawbone to grow, you need light but constant pressure from the tongue. Sometimes you have a tongue tie, sometimes you have torticollis, sometimes you have tightness in your body and you're going to be able to exert more pressure from one side versus the other. So that's one reason Breathing. Do you have a deviated septum? Do you have enlarged turbinates on one side? If there's more airflow coming in on one side, you're more likely to grow asymmetrical. So several reasons what that may happen. Let me go back to the question. It could be more damage than help you. I don't know what you look like exactly. You're telling me anterior cross bite, but I'm thinking maybe you have a posterior cross bite. I'm not really sure, because you're saying that the jaw is more narrow one side than the other.

Speaker 1: 38:19

Always get a second opinion If you guys don't know where to go to. Always look at our directory. I'm so passionate about this that I created a second company called Airway Circle. With the help of my six friends, who are all volunteers for Airway Circle, we created a global directory. We have hundreds of professionals from all over the world world multidisciplinary um, who are learning more about airway, who have more training than other professionals about, uh, everything airway, breathing, malfunctional therapy so they're more likely to give you the right recommendations for treatment.

Speaker 1: 38:57

So if somebody is telling you it's going to be detrimental, it's going to be worse for you, always get a second opinion, but try to go to somebody who actually does MRP. You know, if you go to somebody who only does ALF, guess what they're going to recommend for you. You're never going to walk into an office where all they do is one type of appliance and they're going to recommend something else. No, that's what they don't, that's what they know, that's what their training is, so they're always going to recommend what they trained in right. So if you go to my functional therapist, that's why I always recommend starting with my functional therapy, because we have extensive knowledge in all of these different appliances and all of these different treatment approaches. So, based on skeletal findings, based on muscle restrictions and freedom restrictions, based on what we find with each patient, we may have something else that we're going to recommend. You know, if I have a super sensory kid at three, four years old, I'm not necessarily going to recommend an expander right away For those patients. I love the ALF, you know. So it's going to depend exactly what you look like, what your symptoms are, in order for us to be able to really recommend something else. Yes, I see you guys answering me.

Speaker 1: 40:16

Next question Hi, planning to get double jaw surgery to bring both jaws forward. But my palate is highly vaulted and intermolar width the measurement I just did and showed you guys is 32 millimeters. Should I consider more before surgery or go straight into surgery Concerned? My palate will be narrow after surgery. So I would definitely ask your surgeon what is your plan for the width of my palate? Are you also going to extend me? Do you have a number that you want to go to?

Speaker 1: 40:46

I am going to tell you guys two surgeons in the United States that I highly, highly, highly recommend. One of them is Dr Reza Movahed. He's in St Louis. I've seen his cases. He is wonderful. The second one is Dr Alfie. He's in Houston, but he sees patients in also Miami and New York. He does evaluations there, but the surgery is always in Texas. Usually double jaw surgery can last from four to seven hours, depending on you know their training. What's going on with that case? In Dr Alfie's cases are usually like an hour, an hour and a half. It is insane. So, of course, the amount of time that the patient is under under stress, it is not as long. St Louis is Reza Movahead. If you guys know who I'm talking about, put his name right here on Instagram and on the notes and guys also tag Dr Alfie. So Dr Alfie's cases and you know. If you guys notice, dr Alfie shares almost every one of his cases.

Speaker 1: 41:53

If these doctors are not sharing their cases, if they cannot show you what they have done even with Marpie, I had a patient the other day. Ask a provider, do you have some before and after photos to show me of the patients that you have done? And they go oh no, no, no, that's confidential. Well, whenever you're changing somebody's life and you really make a great impact, a lot of times the patients are going to let you share, at least with other patients, at least for education purposes. You know, once in a blue moon I'll get a patient who doesn't let me share and it drives me crazy because these cases are so good and you know it's going to help so many other people if you let us share the before and after, so please think about it twice. You let us share the before and after, so please think about it twice and let us share your images. But of course, a lot of people are super private. They don't like social media so they'd rather not not have any of their images over there. So always ask before and after photos.

Speaker 1: 42:50

So ask your provider what is his plan for the width of your palate? Also ask him do you usually work with an orthodontist who does Marpie? Have you done any cases of Marpie before double jaw surgery? Ask those questions. Oh my goodness, I want to say so much more about double jaw surgery, but we're going to have to do a podcast just about that. Can a narrow palate prevent you from suctioning properly? 100%, you can still get enough strength, but usually the sides of your tongue are going to spill into the chewing surfaces of your teeth.

Speaker 1: 43:33

Next question I've currently been doing the ALF with mild expansion results, thinking I'd like to switch to the Marpey instead of doing the second Invisalign phase with my ALF provider. However, my ALF provider told me I'm limited on how much expansion I can do because of the narrowness of my lower jaw. Limited on how much expansion I can do because of the narrowness of my lower jaw. Here is how to handle the situation. Thank you so much for all you do. That is a normal question that I get.

Speaker 1: 44:01

What happens to the lower jaw? If you cannot expand the lower jaw, how are you going to expand the top? What's going to happen to the lower? So most times the lower jaw, the teeth are inclined towards the tongue. So if you upright the lower teeth all of a sudden, so if the lower teeth are like that and you upright them all of a sudden, you have way more room to expand on the top. So we're not necessarily expanding the bottom, we are moving the teeth within the alveolar bone. So the alveolar bone is the tooth, the bone that houses the teeth. This right here is the alveolar bone. Okay, so you can move the teeth from here to here within that alveolar bone. Same thing on the top.

Speaker 1: 44:54

If you get Invisalign, if you get braces, if you get all those other appliances, functional appliances, you're moving the teeth within the alveolar bone. But in order to get skeletal changes, in order to get the high cheekbones and the expansion real, true expansion of the palate and opening of the suture, you're going to have to get the tads here and actually open right here. So the whole thing moves. Does that make sense? After that you can get braces, Invisalign or another functional appliance to move the teeth within the alveolar bone. So on the bottom we don't have a suture, so we cannot necessarily do something to open the suture in the middle. So most of these lower teeth and you guys can bite down and look how your teeth are coming together all the way in the back, the posterior portion, and see if it looks like your lower teeth are inclined towards the tongue. So if we move the teeth upright, all of a sudden we're in crossbite, pretty much meaning the lower teeth excuse me are farther out than the top teeth. So that's usually what we do.

Speaker 1: 46:07

However, sometimes people are extremely, extremely, extremely transverse, deficient. What are our other options? So it was also a recommendation, or actually a consideration for my case, to get something called SFOT. What is SFOT? I can't remember what it stands for, but I'll explain exactly what it is. They open the gum all the way around the mandible on the outside. They pack bone, close it up and wait for that bone to harden. What did they just do there? They made the alveolar bone bigger. So now you can move the teeth way farther out. Does that make sense? So you can move the teeth in the alveolar bone, but it's not real expansion. Expansion is only for the palate, because it's the only place where you can actually open that suture. For the lower you can do just upright in the teeth. You can do that with Invisalign or braces or you can do this SFOT.

Speaker 1: 47:15

It was also considered for me, but I decided to just do Marpie and Invisalign and then reevaluate. See where I am. How can I determine when I get the tongue tie release, when I'm going to have more RP done? So I had my release before more RP because I knew I was about to get expansion anyways and I wanted to see what kind of changes I was going to have with the tongue tie release. Of course it was a faster procedure. My functional therapy wise, I was ready and I was not too far back. I'm a little too far back, but it wasn't too much. So I decided to try it out first and see my experience, see if I was really going to reattach. I know everything worked very, very well. I had a great two-tongue tie so I didn't feel like that crazy change a lot of people talk about. But I'm glad I did it before. I waited about a month, I think, before I started my extension, maybe two months.

Speaker 1: 48:19

So it depends on the patient. It depends on how much room you have, it depends what your muscle looks like. So are you doing my functional therapy already? It depends where your symptoms are. If it's somebody who's choking every time they're trying to eat, if they're having tons of feeding issues that are related to the tongue tie, because it could be something totally different that a speech pathologist would be the best to answer. But if it's tongue tie related, then you know I would opt for the tongue tie release first.

Speaker 1: 48:47

In children I usually am okay with the tongue tie release before expansion. With adults we have to take a couple extra looks at everything else. Why would I need lower jaw surgery to bring it forward? If I can just expand it, you cannot expand the lower. How much was your MRP, Renata? Again, it ranges from $7 to $17. I paid somewhere in there closer to the higher end. Love to know a good MSC or MRP provider in the UK. So I have a secret list of MSC and MRP providers. If you guys do a guidance call with me, I will tell you who the closest person is to you and then we also have the director on every circle that you guys can go take a look.

Speaker 1: 49:39

Hello, renata, from the ages of seven to 24, I had braces placed on different teeth Four times Only. All the teeth were treated ages 19 and 23. This entire time no one has ever expanded my super narrow, vaulted palate that my mom thought was abnormal at birth. Despite this, no one ever expanded my maxilla. I also have a tongue tie and a lip tie.

Speaker 1: 50:09

Now, at 33 years old, I am having trouble swallowing. Could this be related? Could Marpie help me? Of course, I would need to do a full evaluation to find out. There are so many swallowing issues that not every dental hygienist myofunctional therapy can help with. We only do oral phase swallowing issues that not every dental hygienist myofunctional therapy can help with. We only do oral phase swallowing. So if the swallowing um, chewing and swallowing inside the mouth is where we take care of, if the issue goes after you swallow, that goes to a speech pathologist or an occupational therapist who's um experienced and trained in feeding and swallowing dysfunction.

Speaker 1: 50:49

So it depends. I mean, did it happen out of the blue? Did something change? Something that people don't talk about enough are the amount of like trauma and emotional trauma, emotional things that happen to us that can cause physical symptoms. I have several patients who have swallowing issues due to emotional and physical trauma. That has happened in the past. So you always have to look at everything. However, if you do have a super narrow palate, you probably would highly benefit from palatal extension Because as soon as you expand the maxilla, guess what also expands?

Speaker 1: 51:33

Because it's the same bone. The maxilla on this side is the palate, on this side is the nose. It's the same bone. So whenever you expand, you open up the nose. All of a sudden, you have more room inside your nose to breathe, and if you can, you open up the nose. All of a sudden, you have more room inside your nose to breathe, and if you can breathe better, guess what you can do better? You can sleep better. And what is sleep? Sleep is healing. You cannot go through your life without sleeping well. You're just not going to survive as long.

Speaker 1: 52:05

I explained to my patients it's as if you went to sleep at night and you plugged your phone in and you pulled it out. You plugged your phone in and you pulled it out. It's not going to have a full charge in the morning. Therefore, it's just not going to last all day long. You have to be able to plug it in all night long to be able to get all of these amazing hormones that are supposed to be released every single time you go to these sleep stages.

Speaker 1: 52:32

Sleep is so important, not because you spend 10 hours in bed. It means you're getting quality of sleep. How many, how much time are you spending in each sleep stage and are you going into every sleep stage? It's very, very important for us to check all of these things. So I had so many more questions on Instagram and I am live on Instagram right now and none of the questions are pulling up. So what I'm going to do? I'm going to go back and answer some of those. However, I think I had some more questions here. Let's see. Have you ever dealt with a child with what is this Illumination syndrome, constant vomiting of food? I have had some patients who every time they ate they would throw up, and when I looked inside their mouth they had the biggest tonsils I have ever seen in my whole life and a tongue tie. So I'm not sure if these things are being checked in children with this syndrome, but I would definitely take them to a feeding therapist who has experience with myofunctional therapy to check these things out. I will call Dr Razumov ahead, but what's your opinion on OSA sleep study?

Speaker 1: 53:53

For a five-year-old, myofascial therapy seems better than a child using a CPAP. So let me also explain the difference. There is myofascial release and myofunctional therapy. They are two different things. Myofascial release is myofunctional therapy. There are two different things. Myofascial release is fascia. They release the fascia. So there are tons of like massages. There are intraoral massages or body massages, but they have to touch and they have to really break down the fascia. That's myofascial release. Myofunctional therapy are exercises that you give the patient. You don't have to touch the patient. You can tell them do this, move your tongue side to side, copy what I'm doing. That's myofunctional therapy. Of course there are several courses out there and the more you practice, the more experience you get into several other things. So we're not just doing the exercises, we're looking at everything, like you guys can tell, that we address when I'm talking over here.

Speaker 1: 54:54

But five-year-old child with OSA, a sleep study is usually necessary to find out how bad. It is right, because if they have moderate or severe sleep apnea, 100% we have to get a CPAP. Because if a child has lack of oxygen going into their brain because they're obstructing at night whenever they are going to sleep, that is hypoxia, that's lack of oxygen to the brain, that is brain damage. So it depends on the case. We have to address it differently depending on the symptoms, depending on the tips that he says.

Speaker 1: 55:38

I had a patient recently this week who, the mom, reached out to me and it's obviously that this child is having sleep apnea and it is bad. He cannot breathe at night, he's wet in the bed every night, his head whenever he goes to sleep. It's the highest I've ever seen. He almost has his head all the way back. He can't breathe, his airway is blocked and he lives in a country where they do not like to take out tonsils and adenoids. That's an emergency situation. That is a severe case.

Speaker 1: 56:10

It's going to take three to six months to get a sleep study. What are we going to do? Sit and wait. You know we're going to ENTs and ENTs don't want to touch this child and he's already like nine, I think nine to 11, something like that. So it's tough. Do we need a sleep study? A lot of times for insurance to pay for things. We need a sleep study, we need a diagnosis. But if we know that this child already has a problem, what are the treatment options? If it's bad enough, a CPAP. But if it's not, if it's mild or maybe not, you know well, apnea of one is already a problem in a child an AHI of one, expansion, myofunctional therapy, all those things can help.

Speaker 1: 56:51

There's a study out there everybody that shows 24 children had OSA. All 24 had tonsils and adenoids out. That's the gold standard for treatment of children OSA. So all of them had tonsils and adenoids out. They grabbed 13 kids and 11 kids and they separated them into groups. One group had myofunctional therapy, the other group didn't. What's important about the study is that they followed these children for up to four years. Four years later they came back. I can't remember what the number was, but I think the 13 that did not have myofunctional therapy, or the group that did not have myofunctional therapy, all relapsed and had an AHI again of at least five. So all of them had sleep apnea again.

Speaker 1: 57:35

This is the most important thing. If you don't address the muscle, they're going to relapse. Just doing surgery, just doing expansion, you're not fixing the habit, you're not fixing the function. You have to work with a myofunctional therapist whenever you do all these other treatment options. It's not going to fix everything. It's a quick fix. But then it comes back. The other children. I'm not sure if it was the 11 or the 13 group, but the other children who had tonsils and anodes out. All of them had myofunctional therapy. Guess what? Almost five years later, ahi of zero. Nobody had apnea. So that's the important right there of working with a team of providers.

Speaker 1: 58:18

Myofunctional therapy by itself is going to get you so far and then you're going to hit a wall. What is that wall? The structure, the size of your upper and your lower jaw, if you have a tongue tie or not. Um, I have another question, hi, how many of my functional session do you recommend before tongue tie release? It depends.

Speaker 1: 58:39

I have some children who were super low tone that it takes me 10 sessions to even teach them how to suction. Is that common? Not at all. That child's going to need probably 18 sessions before we can do a tongue-to-release. If it took them 8 or 10 sessions to be able to how to suction, I have had some adults who can't suction. Y'all Can you do it? Now you guys write on the comments if you can suction and you got to make that clicking sound. Let me know if you can suction in the comment. There are adults who cannot suction. I can't recommend a tongue tie release in three sessions. You know what I mean. That is so much. There's so much low tone there.

Speaker 1: 59:20

We have to work on toning up the tongue. I don't have a number. I don't have because every single person is going to be different. If somebody is super, super, super tight, so that grade four tongue tie where the tip of the tongue doesn't even elevate those people. I don't usually wait very long. I don't usually wait very long. We go ahead and we do the tongue-tie release. But I tell everybody, listen, it's probably going to be two releases. You're going to end up with two releases. So first release to be able to have some mobility to finish my functional therapy, and then we reevaluate. Sometimes it takes a year or two years before we decide to do a second release.

Speaker 1: 1:00:06

I have seen some patients that I've said that to and they did not need a second release because they did my functional therapy beautifully. They kept up with their stretches. They were not people, they did not have types of immune system that you know created scar tissue, and the release provider was fantastic. Most of those cases were done by Dr Samir Jafari in Atlanta, by the way. She is one of the best I've ever seen.

Speaker 1: 1:00:32

And what are your three preferred exercises before tongue tie release for your patient? Make an appointment and I will show you. I'm not going to give exercises y'all. However, I do have a Phrenectomy protocol that you guys can purchase. They're in the link in my bio. I can suction, but my tongue spills out. Is that too large to fit in my palate? Yes, that probably means that when you have low tone, just some tongue exercises sometimes will allow for your tongue to fit up there a little bit better. Or two, you are too narrow.

Speaker 1: 1:01:10

Alrighty, everybody, I will go back and I will address some of the questions that I've gotten on Instagram. Before. I think that was the same question Should I take my five-year-old to a myofascial therapist before getting a sleep study for OSA? Yes, because there are things that we can start right now. Let's start treating right now. I don't know why he keeps changing my, putting a filter on my face. It looks awful. Your opinion on expansion in spite of myobrasis. So I'm not going to mention all the names of these companies. So I'm not going to mention all the names of these companies, but all these companies out there that have habit correctors, they're habit correctors, they are not extenders. The reason why we see teeth movement is because they're doing myofunctional therapy with the habit correctors. That's all I'm going to say about that.

Speaker 1: 1:02:04

All right, thank you everybody, everybody for being here. Thanks for all of the questions. Please share this episode. It comes out next week. Um, share the Maya moves Instagram page with your friends, with your family. You guys know how much this information may help somebody. You know most people walking around do not know they have an airway issue, they do not know that they can be helped and they're tired, they're suffering, and these are simple things. Let's keep your tongue up, let's keep your mouth closed, let's breathe through your nose. That, by itself, will increase your life expectancy and your life quality. So if you can also help somebody else out, I really appreciate you guys helping me share this message. That's part of my purpose. Thank you everybody. Have a wonderful day. I appreciate you being here today. Bye, bye.