devices, or appliances, the use, mention, or depiction of any service, product, device, or appliance during this webinar should not be interpreted as an endorsement, recommendation, or preference by the AADSM. Any opinions expressed or communicated regarding any product, device, or appliance during the webinar is solely the opinion of the individual expressing or communicating that opinion and not of the AADSM. And now I'll turn it over to Drs. Movahead and Dr. Feltz. Thank you, Dr. Ely. I have no conflicts to disclose. And I'm going to start with just a list of goals of orthodontics in orthognathic surgery include the improvement in aesthetics, masculatory function, TMJ health function, and airway function. And I broke that into pharyngeal airway and nasal airway. So I'm going to show you a case that was strictly aesthetics. This is a long time ago, almost 20 years ago, one of my first, she probably was my first surgical case. At age 14, she came to the office, to the orthodontic practice, asking for jaw surgery because she did not like her profile. And that's pretty unusual, especially at that age. You can see the malocclusion, the excess overjet, the class two molar relationship, the narrow maxilla. So she said, I don't like my profile. And what I asked her to do, I said, Samantha, why don't you do this for me? We have your natural resting photograph that you see here on the left. I said, why don't you just posture your jaw forward? I was watching her teeth. And I had her posture forward until the teeth were just about an ideal overjet relationship and took another photograph. So I put these side by side for her. And I said, is this what you're looking for? And she said, yes, that's exactly what I want. And again, that's rare for a young patient to come in with that kind of awareness about facial aesthetics. Okay, so there's her x-ray. This was 2003. We were sending an x-ray lab. Now we're all 3D imaging, cone beam CT. But in the CEPH, you can see the excess overjet, pretty big gap between the lower incisors and the upper incisors. And you can see the lower jaw, the hard tissue chin, soft tissue chin back. And you can also see the lip curl. That's very common with a retrographic mandible. So here's the tracing. I use two different analysis. I use what's called a Sassoonian analysis, which is an arc field analysis, this red arc in the front. And then the typical Steiner analysis. And based on Steiner, her maxilla is in a pretty good position. And her mandible is set back quite a bit. Okay, so there is the initial photograph on the left. That's her posturing forward, which is our surgical prediction. And how does she turn out? Well, first I just showed her what a surgery looks like. I said, this is what we plan on doing for you. Now, this is a video that I could show. I'll show you a similar one later. Here, I just showed the screenshot. But it shows where the osteotomy takes place. And the advancement shows the braces in place. And with orthognathic cases, we typically will put bands around the molars, just so there's more stability during surgery when Dr. Mobehead is tying the arches together that we don't have brackets breaking off. And that's the final result. So look how close we got from the prediction to the final result. She was happy. We were happy. And just an example of a patient that came in wanting a facial aesthetic change. Okay, so there's the final photographs. We left space for the lateral incisors because they were narrow. So we left space for restorations. There's the final x-ray. Now, again, we weren't looking at airway issues back then. So we were oblivious. Unless the patient came in and said, oh, I got diagnosed with sleep apnea, we really weren't screening and looking for airway issues. So what I want to show you in these x-rays, I'll get to in a minute, is how we can look at the airway on a cephalometric x-ray. And there's a final panoramic x-ray. A little bit of root resorption on the upper incisors. So what I've done is traced out the posterior pharyngeal wall and base of tongue, back of tongue, to show you what the airway looks like in the AP dimension on a lateral ceph. Again, this isn't really diagnostic, but just to give you an idea. Now, what I'm going to do is transition to the final ceph. So watch as that transitions over. Okay. So I left the original and I overlaid on the posterior wall of the pharynx. And now I can highlight for you where the base of tongue went. So you can see there was quite a bit of change in airway dimension from an anterior-posterior position. But now with 3D imaging, we can actually measure the volume, which is much more diagnostic. Okay. The next case is aesthetics and what I would say is masticatory function, because she had such a significant underbite. And these cases are really challenging because the lower incisors, they typically tip back until they hit something. So this is a Class III skeletal relationship. You can see the lack of upper lip support. And again, this is way back when we were only in 2D. And you can see at the time we saw her, she was still in the mixed dentition, but a significant skeletal discrepancy with a retrographic maxilla and a prognathic mandible. So there's the tracing. And what I want to highlight in red down there, I circled 75. So I'm going to trace with my arrow. I'm going to trace this line going through the long axis of the lower central incisor. So that becomes one line of the angle measurement for this 38 degrees. I'm sorry, for this 75 degree angle. So the other line is the border of the mandible. So this arc traces this angle from the lower incisor to the mandibular plane. And that is typically around 95 degrees. So the lower incisors are upright by 20 degrees. And then based on the Sassoonian analysis, this frontal arc usually goes through the front of the maxilla, which we call anterior nasal spine. So you can see the retrographic maxilla based on this Sassoonian analysis, an archial analysis, and the chin point, the hard tissue chin is typically on that arc also. So this is like an evenly matched retrographic maxilla and prognathic mandible with retrocline lower incisors to compensate. So I'm going to show you now a simulation. We use Dolphin imaging and management software. So this is their aquarium software that can show simulations. So I'll just let you watch this. So there's the pre-surgical orthodontic treatment, so that the upper and lower arches fit together like a puzzle when you advance and bring the lower jaw back. So this is a two jaw surgery, bringing the lower jaw back and the upper jaw forward. I think we're a little more wary these days about moving the lower jaw back given our understanding of airway function. But this is what the surgery that was provided for this patient. So now they're going to show on the simulation a before and after from the simulation. So I think my next slide shows the patient. So let's focus on this side-by-side and we'll jump to the patient. Here we have pre-surgical dental position. As the lower incisors come forward, you have the excess underbite, which we want to exaggerate so we have more room to move the skeletal bases. And there's a pre-surgical CEPH and then the pre-surgical lateral photograph. And then there's before and after. So I'm going to jump back to that. Oh, I can't do that. But there you can see the upper lip support now. As the upper jaw came forward, now you have some curvature to the upper lip where before it was vertical. And then you have this curl, this lower lip curl, where before it was vertical because the lower lip was stuck back against the upright lower incisors. That's what it looks like, the post-surgical X-ray. And you can see the hardware for the advancement of the maxilla and the titanium plates to stabilize the mandible while it heals. And we get this question a lot. Do I need that hardware in there forever? And the answer is no, because the bone fills in and it becomes stable. Surgeons that we work with tell their patients, you know, six months. That's why we don't want patients playing football and contact sports for six months. But there's really no benefit into taking them out. It's just another surgery. So they're typically left in. We've had them removed in maybe two patients. We had an adult female. We joked that she had a screw loose because one of the screws came loose. So we had to take it out. And I did have one teenage patient, a good friend of my daughter's had a mandibular advancement, and she had a post-op infection. And then once you have an infection where the bacteria may line the metal plate, then they take that out just for safety reasons. Okay. So here's her final x-ray. Remember her lower incisors were upright at an angle of 75 degrees. And now that angle is 98, more normalized. And then here are the final photographs. And then as an orthodontist, you know, we nitpick things. This is such a life-changing treatment for her, but I'm looking at this, her upper right canine. I'm wishing that it were more upright. And you can see it at the beginning and the end. But you can see how proclined that canine started. But look at the transverse. We did a lot of work to broaden the arch. And I think that was just with Damon braces and just arch development, but a big difference. And you can see even the hygiene improves once you get teeth in the right spot and it's easier to access things. All right. So that's before and after. I've gotten through two cases. I have two more and I've got about 12 minutes. Those before and after. Look at the difference when you get the maxilla forward in the face where it should be. And then you can see the upper teeth really makes a difference. You can't really get that just by orthodontics and tooth movement. Okay. The next one is a case with TMJ health function, airway function with the pharyngeal airway. A friend of mine, a severe apneic. He wanted an alternative to CPAP. And you can see the retrognathic mandible covered by facial hair, which is very common with patients. In the panel, you can see a flattening of the left condyle, a very short condylar length on both sides. So over time, some of these patients will have so much airway obstruction and muscle parafunction of the massers. They'll compress their jaw joints, get microtrauma and then get displacement and just gradually get breakdown of the bone. And as that happens, they lose vertical and the jaw drops down and back and you end up with the chin for the back. So this anagonial notching that we call it, in my opinion, a lot of this is masseter parafunction, pulling up to the zygomatic arch combined with a digastric parafunction pulling back on the chin. And then you get this rotation and you get some notching where the, in my belief, the mandible actually changes shape over time. Here's his staph and you can see now he's the opposite. His lower incisors are proclined by 20 degrees in compensation. So what happens is this patient is apneic. The jaw is dropping back over time and the tongue is blocking the airway. So the tongue is constantly pushing forward, and I believe it drives the lower dentition forward on the mandible on the mandibular base. There's his airway volume. We use minimal cross-sectional area as a risk assessment. We don't diagnose off of that, but this is a high-risk patient, and we already know from sleep study that he's a severe apneic. And then you can see in this view, he's just so tiny. Okay, so there's a screenshot from the sleep study. This is just showing apneas, and his index of events per hour of just apneas is 30, which would be considered severe. This is the surgical workup that he did with the surgeon, just showing what the plan was. Oftentimes we have to take both jaws and rotate them in order to get the chin further forward, so that's part of the plan. You can see the gap in the posterior maxilla dropping down. And then the mandible was advanced, just like I showed you for the first patient, and then he had a genioplasty where the chin was advanced. Here is a pre-surgical workup, and what I want to point out on this is I have anchors, temporary anchor devices or tabs, placed in the posterior mandible, and I use those to pull the lower dentition back. I mentioned the tongue has been driving the dentition forward over the years, and this section you can see a nitrite coil spring pulling back the dentition, and it's tied to that anchor, which won't move. And there's space opening. I just did it to a segment so I could make sure that it was working, and then pre-surgical now I have four or five millimeters of overjet. That allows the surgeon to advance the mandible even more because now there's room without him going into an underbite. Okay, so there's the post-surgical photos. There's a post-surgical x-ray, and you can see the difference in the airway volume. So his volume increased by five-fold. One thing I'd like to point out in looking at the treatment is studying where the genioplasty, where that cut was made. He had some extra calcification, I'll point to. That's the insertion of the genioglossus tendons, and those start to calcify when the tongue's in parafunction because the tongue is constantly working during the night to clear the airway. Well, you can see that the osteotomy was made below the geniotubercle where that tendon inserts. I believe we'll hear what if Dr. Mobeha has something to add to that, but if that osteotomy were made above the geniotubercle, we may have had more tongue advancement. Okay, so Dr. Mobeha will cover the DICE procedure, drug-induced sleep endoscopy, but this patient had one, so I'm just going to briefly review his in preparation for Dr. Mobeha. So you can see down here on the scoring boat, must be just an acronym, 2 concentric, 2 lateral, 1 AP, and then for the epiglottis, 0. So 1 is less than 50% obstruction, 2 is between 50 and 99% obstruction, and then those are the locations. So I'm just going to show you his airway volume, his rendering. At the velopharynx, that was the V in vote, he had concentric, meaning it's collapsing from the sides and anterior and posterior, and it was significant, 50 to 100% collapse. At the oral pharynx, he had significant collapse, 50 to 100%, and that was from the lateral aspect. And then down near the tongue base, he had anterior-posterior collapse, and they said it was 0 to 50% collapse, and down at the epiglottis, there was no collapse. Okay, so then what I want to show you is based on the DICE procedure, the surgeon can determine what anatomy do we need to change. We really need to get the posterior nasal spine, I'll point to it here, forward to get the soft palate forward because you had significant collapse, a level 2 collapse, concentric in that region. And what I show here is that from basion, base of skull, front of foramen magnum, to posterior nasal spine, we advanced about 4 millimeters. And with the combination of the counterclockwise rotation of both maxilla and mandible, the bilateral sagittal split osteotomy advancement of the mandible and the genioplasty, the chin point, or pogonion, came forward 14 millimeters, which is significant. And what I found in these cases is when you get that kind of advancement, it brings the hyoid bone forward. Now, the hyoid is suspended with 22 muscles, uh, stylohyoid ligaments, but I think that that position of the hyoid is critical in airway function, so it's good to see that advancement. We're not taught this, we just study cases, and we try to learn from the results, right? And giving presence, I really appreciate the invitation to present because this is how we learn. Okay, so there's the before, uh, his apnea index was 30 per hour, and then the apnea index post-surgery, now he's down to 4.4, which is great. He's off the CPAP, and he just came in today by chance, and I submitted his case for the American Board of Dental Cranious Sleep Medicine when I took my board exam, and I learned a lot from his case. So there he is, doing great. We closed this molar space, he was missing number 14, and is opening a little bit, so we're trying to help him with that. So the last case, uh, is a little bit of everything, uh, TMJ health function, airway function, and pharyngeal airway and nasal airway. Um, I'm going to talk a little bit about nasal breathing. I'm a 49er fan, we had a rough weekend, especially with some Chicago people on this call, but you see that he's wearing a Breathe Right strip, right? Well, so many of our patients have nasal breathing issues. So I have sleep apnea. I had a DVAS and I got fixed. When I get on a treadmill, I try to jog with my mouth shut, and my nose, my nasal valve collapses, because I have a narrow maxilla, and I had impacted canines as a kid, snored as a kid, right? So if I wear a Breathe Right strip, I can jog for 30 minutes at six miles per hour. So I'm learning about function through myself. And we have rhinomanometry equipment to measure nasal breathing. So here is my rhinomanometry, um, baseline blocking one nostril, breathing through the other, measuring flow versus pressure. And then I put in a dilator one notch at a time. And you can see with nasal dilators, I'm up in this 600, 700, which was really good, right? And because I had my septum fixed. So my obstruction is the nasal valve. I just point that out because when we expand the maxilla and we do it skeletally, and we're able to have those forces translate to the whole nasal maxillary complex, we can improve nasal breathing. So here's a young man, uh, I helped him, family, get him diagnosed with sleep apnea. He came in and said he had headaches. We didn't catch it in phase one. I didn't know this stuff then. So we treated for a year and a half, not knowing he was in severe apnea. By the time he got to me, he was really in trouble. His age, I was 15. There's his excess overjet. There's the tracing. A lot of these cases, they have a retrognathic mannibal, but they also have a retrognathic maxilla, at least based on Sassoonian. This is where it gets confusing. Based on this archeal analysis, you would think that the upper jaw is back because anterior nasal spine should be on that arc. But based on Steiner, it says is that maxilla is forward. So he's a severe apneic. So in this case, I'd lean towards the archeal analysis. Okay. And there's his airway 25. He's breathing through a straw. And here's a sleep study came back. His age, I was 13.4, which would be considered moderate to severe apnea for his age group. I think he was 12 at the time. So it's going to take me a couple of years to get him through the second phase of treatment, maybe three years, because we're going to advance his maxilla broad and broad as maxilla. So I've got him on a CPAP so that he's covered. And then there is a skeletal expander. This is the Wan Moon design. This is one of my very first ones. And you can see now we do this all digitally through a lab in Spain. But you see the tabs in the anterior, they were probably reversed. We don't need more length in the front, but they're both extra long. Doesn't hurt anything, but they're long. But then you can see the occlusal photograph. The expansion takes place between this bar and that bar. Here's a hex screw. That's the turning mechanism. And with the expansion, you can see the gap here and here. Now you see the space opening up between the right and left sides of the maxilla. And the tabs are staying parallel. So that's fantastic. That's really good. Okay. When you are able to get skeletal expansion like this, you get improvement in the nasal width. So just want to share with you, Wan Moon taught me, he designed this expander. He taught me that when you have good skeletal expansion, the two halves of the maxilla, they rotate around the frontal zygomatic suture. So we're not doing this. We're doing this. So you're going to see nasal expansion near the inferior turbinates, but maybe not so much up at the middle turbinates. But look at this. I expanded almost six millimeters and the nasal patches at the inferior turbinates went about four. And that's what I'm seeing. I'm seeing about a ratio of 66, you know, two thirds with good skeletal expansion between the nasal width of the inferior turbinates and the maxillary width of the first smallish. And he has a great mandible, nice mandibular width. So there he is after expansion. And then getting ready for surgery, you can see the skeletal, really by maxillary retrusive, then you can see the molar relationship. And here he is after surgery. And now we have a normalized skeletal and normalized dentition. And his airway, again, these can be, these can vary. See how he has low tongue posture? He hasn't been trained to have proper tongue posture yet. He still has nasal obstruction. I don't have time to get into that. But look at the airway. Look at before and after. And before and after. Okay, so now his AHI is down to two. And this is before and after. So what I want to share with you is you learn a lot from parents. It's not just studying images. Because when I talked to his parents in 2018, he had anxiety, depression, headaches. Headaches in kids 10 to 14 times more likely to have apnea. So if the prevalence of apnea in a child is 3 to 5 percent, then it becomes about 50 percent if there's headaches. He was skipping school due to lack of focus and inability to keep up. So here's a kid that was so frustrated. When you go to school, he couldn't remember anything. He couldn't take tests well. He sees his friends succeeding and he couldn't. And now he's a straight A student. Dad told me that last week. This is success of orthodontics and orthodontic surgery starts with educating patients and parents. Present treatment options. I'm going to share with you some things I say. This is what can be done. You got to get it out there. Because if you don't, and then that patient has a problem, you know, we're treating kids that become adults, right? Like me. Nobody told me about expanding my job when I was snoring as an eight-year-old and had impacted canines. And I also say, let me show you some similar cases. Use past cases. Ask for permission from parents to share them. But that's how you educate parents to the possibilities. Discuss risks and benefits. I refer to the oral surgeon for that. Dr. Movahead. I let the oral surgeon talk about the risks and benefits of those procedures. They do a better job than me. Set expectations. It's going to take two years. There will be a facial change. Some people don't want a facial change, right? So you've got to share that and avoid over-promising. While we will increase mid-phase dimensions, there is no guarantee there will be improvement in airway function. But we're studying cases like crazy and trying to be pretty good at predicting what may happen. Okay, so I think I got done. Good time. I want to give extra time to Dr. Movahead, because I'm really looking forward to hearing what he has to say. Thank you all. Okay, so Okay guys can everybody hear me Yep, we're good. Okay, fantastic. What an awesome lecture by Dr. Phelps and I've been waiting to hear that So with that being said I'm going to do a mini deep dive in considerations for management of dental facial deformities TMD and OSA So we have an office that's being built right now in Walnut Creek area and also office in Chesterfield, Missouri I teach at st. Louis University, which is the birthplace of orthodontics and it's the second largest orthodontic program right now in the country And dr. Phelps. This is what do you preach all day today? The tracing that I love which is a sassooni tracing So this is a painting of mine. I love painting. My second major was our history So my job is a perfect marriage between art and science as you can see in this painting as well So general procedures that we perform for corrective jaw surgery are Laporte one osteotomy in my office as well as sagittal split osteotomy and Genioplasty or genoglossal advancement in addition to total joint replacements So when you combine all these together, it's a powerful tool requires some artistic instinct And let's look at a case here this is very much similar to the case that dr. Phelps showed a class 3 case with a hypoplastic maxilla and And I consider it a hypoplastic mandible as well because we wound it up advancing both upper jaw and lower jaw in this case instead of setting one back and We were able to bring the lips together Take care of the lower third of the face that was longer and get a good well-balanced facial profile for the patient But stability is something we don't talk about often I want to look at a case when a movement is too large for sagittal split osteotomy. We have to consider other means this gentleman presented to me in 2012 and we planned for Advancement of the upper jaw for seven millimeters and 19 millimeters in Pagonia and he did not want a total joint He clearly required one because it was a big movement and his joints were broken down so Here is the advancement of upper jaw and lower jaw lots of plating. I Had a feeling that this ultimately was not going to hold and it didn't I want you to see this After surgery, we were able to get a decent profile. But what was happening as far as the joints are concerned What was what is what was important the patient had an inability to open? You can see the sagittal views of the condyles on the right side that was pre-surgery and the condyles post Surgery within a matter of three years that condyle was broken down above and beyond Patient had pain difficulty opening and the bite was falling apart But we had to do a total joint at this point Well, we also did some major disservice to the patient look at the lower, right? look at the bodies of the mandible the bodies of mandible are thin because of the stretching of the sagittal split and we really could have saved them all the headache that would have happened as a result of this and Initially due to right surgery Now, let's take a look at another case here. This was a case that Dr. Phelps mentioned similar to a patient that presented to us with the prognathic mandible and hypoplastic maxilla so Other oral surgeons wanted to set back the mandible and I was against it. I thought both maxilla mandible had to be advanced and we published papers in AGO for AP and transverse dimensions evaluation for setback cases in Korea and that same cohort we studied the fluid dynamics for and In all of those cases we found out the airway decreased So what we did for this patient was advanced the upper jaw expanded as well as advancing in the lower jaw and We wound up with a better airway than we started with instead of getting the airway to become smaller So this was a final bite post surgery expanded And we were and the patient was happy and the father understood who was very much against it understood why it was Have you had to do a two jaw surgery? Obviously OSA is the topic of the conversation Gold standard still is polysomnography And polysomnography does not identify the site of pharyngeal obstruction So I do a lot of dice in my practice prior to surgery post surgery Diagnostic of how much advancement we can do for patients There's a whole lot of that WDU and let's take a look at a few the case that you see here the patient has AP collapse of the airway at the soft palate and lateral walls are slightly collapsed and What we do in a case like this we? know that MMA is going to work for this patient because we're gonna advance the mandible in just a bit and To see how the airway is gonna open up for us and having that knowledge is very important And this is what you can see right there that is my assistant advancing the airway and the patient has automatically has a much better airway and These changes we can do incrementally as well But in the case that you see about to see here This patient presents a presented to us for a bit apnea papi index of 50 This is a lot more sinister because we have Concentric collapse all the way through you can see the circular motion and constriction Of the muscles around the airway this patient will most definitely need Expansion for angioplasty, so it gives us a lot of information fluid dynamics Fluid dynamics is a branch of fluid mechanics. It helps us understand low characteristics low rate pressure drop and turbulence And as Heard this paper by you CFD simulation could be a useful tool in studying pattern physiology of OSA so we want to make the distinction between laminar flow and Turbulent flow, how do we do that? With turn by turning the airway into a more parametric shape we're able to Basically understand what the Reynolds number would be and in Reynolds numbers of under 2,000 are laminar flow more than 2,000 turbulent flow and On top what you see is the three Patients that we had prior to surgery that we did CFD for all their Reynolds numbers were about 2,000 and below are these patients post MMA and not heavy movements Maximum advancement Maximum advancement was 4.6 and mandibular 8.5 and they all wound up With a lower Reynolds number of under 2,000, which is laminar flow We published a paper in a job. Dr. McCooling and dr. Kim and this was one of the cases that was presented there I show you how we do this analysis the magnitude of displacement for this patient was extensive below the soft balance and Post surgery there was no movement for this patients And we also evaluated the velocity velocity as you can see increases right beneath the soft palate which was the site of obstruction for us and this patient had a uterine P as well prior of years ago and Post surgery the velocity stays very much Stable throughout the airway because it's a laminar flow Let's take a look at another way. We look at this from the side profile view. This is a patient before a surgery MMA and After MMA the velocity stays constant throughout Okay, maximum annual advancements I really like this paper. We read dr. Holtzi Because he tells us exactly what a you know General overall success rate is and talking about success rate is obviously would be a what the success means It's a lecture of its own but And you guys don't want to see too many and regular MMA cases. So what I'm going to do. I'm going to go through some revision cases Here's a patient that presented to us with constricted maxilla airway and Retrognathic maxilla mandible as you can see lips are not coming together naturally I wanted to do a segmental in the upper jaw orthodontist was not in favor of it So we did our movements seven millimeters in the upper jaw and 19 and pogonion Did a nice counterclockwise rotation for the patient genu glossal advancement? the airway improved from 64 millimeter square to 235 and this doesn't was an anatomage So this is a patient two weeks after surgery We did a polysomnography for him About six months post-surgery, but this was his initial polysomnography apnea of happy index of 30 the polysomnography told mentioned showed us that he had apnea hypapnea index of 0.3, but he was still registering up to 12 apnea fat apnea of happy indices and per night So, what do we do so we decided based on his Enthusiasm to solve the problem to expand a maxilla to in transverse wise expand a mandible and do another MMA We use a Rotterdam system to expand a mandible and here it is. We gained about 10 millimeters of transverse for the mandible here's the patient after transverse expansion and Also, you can see that his minimal cross-sectional area increased immensely Ultimately reminded of mounted up doing the MMA segmental maxilla as well as a dice procedure on month for You can see here pre-surgery post MMA one and post MMA to the patient's airway increased extensively and We moved from 63 to 427 and Here's a patient before and his final profile frontal view and This is his dice nothing is collapsing you saw the other dices that we had in the beginning of the lecture and Nothing is collapsing anywhere. So Especially no longer wasn't he were even worse. You have to keep track of things. He was no longer registering anything Okay, let's take a look at take a look at a patient with severe or say of 51 for AHI But the question was that where were we going to move the mandible to? So we wound up doing pre molar extractions and he wanted to get the surgery done So we didn't wait for it to close those spaces and we wound up doing a sub a vehicle osteotomy Seven millimeter for the upper jaw 22 for Pagoni on in terms of advancements here's the before and after of the virtual surgical planning and The segmental osteotomy This is how we set back that segment as you can see some plating here and The airway improved from 169 to 308 So volume improved from 30 cc's to 45 cc's And he no longer had to sleep out the end And if we do didn't do that sub a before osteotomy, we would not have been able to advance his mandible as much as we wanted to Now this is a profile before and after and the front of you So some of the cases would require a little extra work and in this case we wound up doing transoral robotic surgery To do base of tongue resection. It's a patient presented to us with sleep apnea and this was a procedure to fit the bill to Take care of his surgery before he was going to have his MMA we it's practically doing a Video game with these two instruments and be able to access the areas that are otherwise hard to access so when this gentleman presented to my office, he had difficulty breathing during sedation and for me to take out his wisdom teeth and He knew that he had sleep apnea But not as bad as we thought he was in a high 60s. His inner wall width was 28 So we went ahead and did base of tongue resection for him. His MCA improved 216 here but When I sent him to st. Louis University We knew that we had to do expansion of the mandible due to very small intermural width that we had Here's a bolano system we expanded a mandible by 10 millimeters and Here's a post panoramic radiograph And post Distraction of the mandible we went from 116 to 297 millimeter square He had not the best joints and when we wanted to do the MMA we decided to do Total joints in addition to look forward one osteotomy So here's how much the maxilla came forward in the counterclockwise rotation 12 millimeters in Pagoni on and about eight point two and the maxilla Because of the submental fat that he had is not as noticeable how much advancement affected his aesthetics, but Sorry about the poor oral hygiene We really couldn't get him to get any better at that But it shows you the whole journey that he went through to get to the final post-op that he had for the surgery And this was the final I'm ready by this But airway wise we were able to move him from 44 to 254 in terms of the airway And here it is, I mean some my functional therapy would definitely help him out All right, so it actually there's a present case that I'm working on this is expansion of the maxilla mandible and transverse deficiency That we have in the mandible as well in or more width of 25 so as you can see here, we did the regular cuts that we do for a Sarpy and Use the use the MSE in the upper marpy in the upper jaw as well as a bologna So there are clay cases that would require both of them and patient is presently actively going through Expansion of the maxilla mandible prior to us planning for a surgery So TMJ is a part of a good part of my practice and Arthrosynthesis is very basic thing that we do or in surgery for patients who have pain as Well as Arthroscopy if I need further diagnostic information arthroscopy is what I get to do in office and Be able to diagnose how does the quality and health of the tissue inside the joint is? One of the things that I was able to incorporate into my practice quite a bit was a digital workflow that I came up with in order to include the virtual world for joint surgery and Orthognathic surgery together and we're getting that accuracy more and more as time is passing by So one of the questions that I get asked is how long will this join last and 20 our follow-up is what we published for. Dr. Mercury and Wolfert There was paper in JMS that be published and that's the longest follow-up and we have to take into account that this joint is not a load-bearing joint okay, a hip and knee is about three and a half to six times the body weight and as far as the Bite is concerned 60 to 35 pounds 8 to 18 minutes out of the day So, let's take a look at a case here's a patient Who had presented to us with OSA post total joint and the fourth one osteotomy The joint on the left side was bone-on-bone and the discs were both anterior displaced and she was on splint therapy for quite some time pre and post of the bite As you can see here and here's a profile view of the airway improving The airway improved extensively for her and she did some myofunctional therapy improved her MCA from 51 to 203 Her initial apnea apnea index was 33 and ultimately we got her to 2.1 Now let's take a look at another case here this patient had trauma and OSA 38 year old male apnea apnea index of 38. He presented to us from Chicago, and the joint on the right side, you could hear every single time he would open up because it was quite, the crevice was quite loud. So we had some generous movements for him, a 10 millimeter in upper jaw, 25 in pogonion, and his counterclockwise rotation for him, and expansion of the airway that we were able to get before and after. And we were able to improve that from 64 to 215. Frontal view and profile view. And this is his apnea and apnea index post-surgery, which is two. Here's another patient that presented to us, 24 year old, 27 year old female with sleep apnea. And she always went by her Fitbit that she had a REM sleep time of one hour maximum every night, you know, and also she had extensive amount of joint pain and facial asymmetry. So it was a maxilla 41 osteotomy and total joint replacement for her. Here's the patient before and after surgery, lips are coming together naturally, and her airway is improved and asymmetry is taken care of. Profile view. Before and after, and we got some nice, decent expansion of the maxilla with segmental osteotomy. Her minimal cross-sectional area improved from 83 to 186 millimeters square, and she can open up to 42 and function without pain. Now, this is one last case that we're going to go over. Here's a patient with ICR that presented to us after joint, after discectomy and application of fat to the joints, something that gets done in Florida. You can see the upper jaw, lower jaw and back. She had multiple surgeries. Ultimately the anterior open bite that happened, they wanted to close with a posterior impaction and the joints were just destroyed. Fat graft cannot be a substitute for a disc. So you can see the remnants of the hardware and also the loss of root roots that has happened here, the root resorption. We couldn't use regular braces in this case, so it actually made things very hard for us. Here's a frontal view. You can see profile view of anterior open bite, and we did a very generous counter-clockwise rotation here and advancement of the maxilla along with genoglossal advancements. 25 millimeters in begonion and nine millimeter in the midline of the upper incisor. So this case was done with Invisalign, so it really kind of made things a little bit harder for us, but the place, way less pressure for the patient. You can see the resorbed joints here. Before, after, airway before and after, and here's a counter-clockwise rotation in advancement of the maxilla mandible along with prosthetic joint and the fourth one osteotomy. So lips are coming together naturally. You can see a whole lot more life has been injected into this patient, and here's the smiling and profile view. And she sleeps so much better and functions, and she said she actually can eat a steak, which is what she wanted for quite some time. One last case to go over with you. This is a case with alloplastic TMJ that was applied for this patient with sleep apnea as per this paper by Dr. Perez. We know that alloplastic temporal mandible joint reconstruction for patients with JIA is efficacious and safe. So this is one of the largest advancements that I've done for a patient who had JIA, and these patients really stand to benefit from this. As you can see, there is no joints remaining, and that's the pannus that causes the destruction. Occlusive plane was at 24 degrees. So we had planned on advancement of Pagonion at 32 and midline of the upper incisor at 7 millimeters. Nice counterclockwise rotation in addition to three-piece maxilla. The holes that you see on the bottom is where we reattached the masseter, bite before and after, and improving the airway to AHI of 2.5 from 21 and MCA from 29 to 204. As you can see, the lower third of the face is restored and profile view for the patient is restored. Okay, I think we got to the end of the presentation, guys. That was wonderful. Thank you, Drs. Movahed and Dr. Phelps. If any of the audience members have a question for our speakers, if you are using the full screen mode, you'll need to exit the full screen mode to access the ask button to submit a question. So I'll be asking the questions from the top down, so please make sure to use the upvote feature to move your favorite questions up the list. Also, in some instances, your question may be answered by a moderator in writing, in which case you'll see a notice under your question with the phrase tap to see moderator's answer. All right, so the first question, and this is a question for Dr. Phelps, could case number one who had mandibular surgery to improve for a profile be treated non-surgically? Would you treat her differently today? No, I treat her the same, but for all patients that I'm considering surgery, I like to screen with a sleep study, and so we collaborate with sleep physicians for that. But if you try to do this with a functional appliance, like a Herpes appliance, that's my best, in my hands, my best non-surgical class two correction, but you're going to be putting forces posteriorly on the upper dentition to the maxilla. So if, I wish, it's unethical to take twins and treat them two different ways, but that's the only way that you could be able to tell the difference. But if you did that, if you had identical twins, one you did a mandibular advancement, one you did a Herpes appliance, I bet you that A point and B point would be further back in the final result on the functional appliance. I just don't see any other way to around that. In my hands, that's my experience. Thank you. And Dr. Phelps, I think this is for you as well. Do you believe that you can expand the palate in adult patients? Yes, and so with skeletal expanders, what we're using now, Juan Moon, I met him at UCLA, he would teach there when I was a resident, and he's a great friend. And so I was having challenges with one of my MSC cases. And he stopped by, he happened to be in the Bay Area. And he told me about an orthodontist that he collaborates with who's in the services. So imagine being an orthodontist in the Army, I think it's the Army, and treating young 20 males, and not having the benefit of Dr. Mobehead down the street to collaborate with. So he started using tandem MSC, so two expanders back to back with six or eight tabs. And I'm getting good expansion with that without surgical assist. But we prep the patient, right, we don't over promise. And we set expectations. If the skeletal expander does not work, if the anchors tip, and if we don't get skeletal expansion, then we could do surgical assist. And then it's just like going, in my opinion, this might sound silly, but it's like going to Chipotle, I'll have chicken and black beans, white rice, it's all do buttress cuts, I'll do a midline split, maybe pterygomax, a suture release, and try to figure out what works best in your hands with your clients. Thank you. Next question, is it true that everyone will get better with palatal expansion? Or is it prudent to always check with PSG, or CBCT, or rhinometry? And which way of checking is best? Do you want to take that one, Reza, and then maybe I'll add something maybe at the end? Um, so I think it's one piece of the puzzle, and not everyone's going to get better. And that's the reason why doing a drug induced sleep endoscopy is very important. Because if, as I mentioned to you, as I showed you, you have a patient that has a concentric collapse, you know, those patients don't respond as well to a palatal expansion. And we don't honestly, we don't have exactly enough data to see what group of patients are going to, you know, benefit from only maxillary expansion, because it cannot be the panacea to the problems that we deal with in terms of sleep apnea. It's, there's, there's a lot more to the picture, and it has to be tailored to everybody. And from the orthodont perspective, when I presented in Dallas, the ADSM, I showed some research where different schools were saying, okay, we expand the maxilla until we get a little bit of buccal overjet. We expand until the buccal cusps, tips on the lower tusks, the lingual cusps on the upper. Everybody is expanding to a different degree. I like to use the mandibular base as a reference for how broad the maxilla should be. And then what are we trying to do? Are we trying to get an excellent occlusion with vertical forces to the dentition? Are we trying to get tongue space? Are we trying to improve the nasal airway that might be obstructed? So there's a whole different, there's all kinds of reasons to expand, but to expand just to reduce an AHI score, yeah, I think that there's going to be a lot of cases where you don't have much improvement with that, but there's some that you're going to have incredible improvement. And so what we're trying to do, I'm so impressed with your research, Dr. Mobilehead, and your presentation was awesome. I'm going to watch it over and over again. I'd like to talk about that last case again. I got one just now that we're treating, but we have to, as practitioners, study our cases, study what happened with our patients. And Conebeam's great for that. I love the dyes before and after. He was the first doctor I've heard talk about that. We use rhinomanometry. We're going to start using rhinometry to measure the nasal airway volume and pharyngometry, as well as the minimal cross-sectional area and the airway volume off of Conebeams. And one last thing to add to that, we can't just, in a lot of ways, indiscriminately expand a maxilla when there is no transverse issue. What if you expand a maxilla and your mandible is still constricted? Everyone's forgetting the mandible because the mandible is the last piece of it. And no one wants to really approach that. Besides approaching that by uprighting teeth on basal bone and not pushing them out of the bone, there is nothing else that we can do. And the only thing is distraction osteogenesis. And we have to face the music. If we were really going down this pathway of expanding arches, we cannot forget about the half of it, which is the mandible, which is the home to the tongue. So that is a really important part of it that hopefully over the next number of years, we're going to be able to get as far forward as maxillary expansion is right now. Thank you. Dr. Movahead, how do we find a surgeon who does the kind of surgeries that you do with sensitivity to airway that you have? It's, I mean, you have to talk to your surgeon, you have to feel comfortable with your surgeon. I've gone through the surgery at prosthetic joints on both sides. I've had an upper jaw, lower jaw advancement. I had two double jaw surgeries that didn't work out. And ultimately, I needed to have a total joint, you know, and upper jaw surgery, because everything fell apart for me. So I am very sensitive to it, because that is a surgery that I needed for my sleep apnea. So I can't really pinpoint for you who that person would be. But I think my experience kind of puts me in a very unique position. Absolutely, absolutely. And next question, how do you access how much expansion is needed, or can be achieved for a patient, whether that's maxillary or mandibular? Is that for me, or Dr. Phelps? Whoever wants to take it. Dr. Phelps, go ahead. Well, Dr. Ely, are you are you asking how do you determine what's the appropriate amount of expansion in the maxilla or mandible? Yeah, how do you how do you access how much is needed? Well, I have a technique. I named it after our son, who passed Dane's analysis where I measure the width of the mandible in a coronal section through the mesial root apex of the first molar, and I measured down at the mandibular base. And you know, you have to account for orientation and this agile plane, I do Frankfurt horizontal, but some patients will have a steep mandibular plane because they've had condor loss and degeneration. So you have to be careful how you do it. But I learned this from Dr. Dwight Damon, just about everybody has the same mandibular except for true prognathics, or patients that have significant mandibular deficiency. And if I can measure the mandibular base, then I create a ratio is usually eight to nine millimeters greater than that with at the buccal CJ of the first molar, and that's what I use as a baseline. And I'll see patients that come in and they need 15 millimeters of expansion. Well, if they're six, seven, eight years old, that might be three expanders, because sometimes expansion screwed max is out at six millimeters or seven millimeters, right? So that's how I do it on adults and kids. And it doesn't matter whether you're five years old, or 30 years old, that mandibular width of the first molar is set very young in age. So you can determine the width on a four year old and it's going to be that's the width that is going to be in adulthood. Thank you. And then Dr. Movahed, is there an age limit, young or old for replacement of the joints? The youngest patient that I've done total joints on is was a seven year old, and the oldest 78. So the youngest one was a young lady from Haiti, that basically had the through because of the earthquake, you know, it shattered her jaws, and she wound up having ankylosis. And so we had to do total joints for her, and she was emaciated. We actually had to put a PEG tube for her to, you know, be able to gain some weight before getting to the next phase of it. And she couldn't open her mouth. It was a very sad situation. So the way that I that we did that in the growing patient, we advanced the lower jaw with a total joint to create a class three, based on the prediction that we got from Rocky Mountain orthodontics, and then she's going to be coming back at age 14 for me to match the maxilla to it. But otherwise, without that kind of situation that we were in 14 years old, for young for a young lady of 15 was fine with me, because the way to think about this is that if they're suffering so much from sleep apnea, you don't want any time pass by and they're going through that period of life without a proper airway. And you can see these patients blossom after this, these surgeries. So you don't want them to go through good portion of their life without that for us to fully wait for the growth. And besides this thing about one more thing here. Once you move the lower jaw forward with a total joint, things are exactly where they're going to be. And also with a Laporte 1 osteotomy, once you detach the septal bumerian junction, AP growth of the maxilla stops. As per Barron studies, we know that the only thing that changes is about two to three millimeters of vertical growth can happen, which is not a bad thing. I take that any day, because the age will take care of the rest of it for us. So I would say girls, 14 boys, 17. That's, that's pretty much the case. Maybe you can obviously view serial steps also to assess the growth. Thank you. And this is the one final question. Do long term cases of severe OSA become terminal? Who can you not help? For example, if a patient has developed significant comorbidities, are they candidate for ortho or surgery? So from a surgical point, for a portion, I'll talk and leave there, leave the other part to Dr. Phelps. Yes, listen, I have patients that have, right now we're waiting for a patient to get her A1C from 11 to under seven. Impossible. You know, I think that case is not going to happen because the patient also doesn't have the will. She knows she needs it, but she doesn't have the will. So patients with number of, because during the surgery, we're going to put these patients through controls, hypertension, and this is a lot to ask of someone's body. And OSA already has done so much damage. So these are the patients that I ultimately mentioned that a shorter procedure would make sense for them, something like Inspire, or otherwise, you know, they have to just stay with CPAP or mandibular advancing devices and everything that likely Dr. Phelps can do. Dr. Phelps, what would you say? Well, when you get to those ages and they've had long-standing airway obstruction, a lot of them have troubled jaw joints and they have recession of fracturing bone loss, tooth loss, multiple restorations, multiple root canals. I see that every day. So the challenge orthodontically is, are they appropriate patient to move teeth around? But I just was listening to Dr. Gimeno again in the presentation he gave to the AO in 2019, and he says survival is more important than the bite, right? So at that point, who cares about the teeth and occlusion, just get them breathing better.

severe obstructive sleep apnea

long-term cases

health consequences

orthodontic interventions

surgical interventions

symptoms improvement

individual factors

comorbidities

treatment success

suitable candidates