Sleep Apnea Surgery: My Perspective

Sleep Apnea Surgery Center
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[@shuikai272]

Great lecture and I will say I agree with 99%. One thing I will say, is that based on discussions I have had with Dr. Kasey Li's patients (20-30+), the consensus was that expanding the nasal aperture past, generally 25 mm or so (average height male) did not yield improved nasal breathing, or if it did, it was very minimal at best, and basically the consensus was that it was more or less unnecessary to expand to 27 mm, 28 mm, etc. It was described as "plateauing". I also recall multiple discussions where patients mentioned in the chat that, they told Kasey Li their breathing was improving, but in actuality it wasn't, but they told him that it was because they are human and so they wanted to essentially tell him what he wanted to hear, and be optimistic, that type of thing, and then later realize, you know what, it actually isn't any better, I probably should have just stopped turning a bit earlier. I also think there are bite and cosmetic implications in regards to intermolar width and nasal aperture width. So... My interviewing patients isn't necessarily like a study, but I do think it might show another perspective. Hopefully didn't ruffle too many feathers but, I thought you should know what I have seen from the other side.

[@shuikai272]

@Denny Yeah I agree the patient bears a lot of responsibility as well, most of the time they are turning themselves after all. With that said, it is the aperture width, not height, and from what I've seen there appears to be quite a lot of normative data out there.

[@notasuperuser]

Can I send you my CBCTs for analysis by any chance?

[@yahyaelmi8435]

You mean the suture has to split to see improvement?

[@CroElectroStile]

can you expand your upper jaw if you already had an MME operation done? and how much can you expand?

[@yahyaelmi8435]

@@CroElectroStile yes you can

[@OrionL7]

At 34:34 he's referring to Dr. Lipkin who uses piezo cuts to the MPS for adult males. It's interesting that Dr. Li doesn't mention the cuts there, which is unique to the standard MSE tx. I'd be curious to know how much is skeletal vs. dentoalveolar for most of those cases. Some dentoalveolar is inevitable but I feel like in most cases it's enough skeletal that it at least improve symptoms.

[@shuikai272]

The way the expanders are designed it seems to be mostly dental. I predicted it like 4 months ago just a tiny split at the MPS and that seems to be exactly what is happening. I know a guy who did expansion with that method (piezo and lipkin's expander) and he didn't even get a split at the MPS just dental tipping and the ortho just says it was a success because the intermolar width changed and so therefore its a success and therefore thanks for the 15K sucker.

[@OrionL7]

@@shuikai272 I think we have to remember adult maxillary expansion is still in its infancy. All these 'experimental' treatments lead the way to the next best thing. Now the hype is with FME and MIND, but there will be pitfalls there too I'm sure. Having said that though, we shouldn't fixate on treating numbers as we don't even know optimal nasal cavity volume numbers. We do know it's very individual. 1-2mm of maxillary expansion means a lot more than 1-2mm of IMW 'expansion' as it is 3d space ie. volume. Even if only 20-30% of the expansion is skeletal, that 2-3mm could be enough to address many issues, and the tipping can be usually fixed orthodontically. Another thing that's never mentioned is cost. EASE is very expensive and its reach limited. I agree with most of Dr. Li's points, but the bias is there.

[@shuikai272]

@@OrionL7 The question we need to know is, what is the most effective treatment plan? How do we transform an unhealthy airway into a healthy one? We may not know all the answers right now but we cannot stop asking the questions and trying to find the answers.

[@dorinabicaku9855]

Me 26 y.o no skeletal expansion no gap ...just one side of my upper palate molars shifted in outside horrible job bad occlusion causing a lot more problem a lot of money throwed away what is this

[@lesptitsoiseaux]

I had a DISE and have CCC L2, ASV at 19, and in the wee hours my nose start blocking enough that it wakes me up. What can I do? Barbed pharyngoplasty? This is killing me, like it did my grandad at my age.

[@ryant6134]

I have mild/moderate sleep apnea, chronic sinusitis, and am a chronic mouth breather. I had 4 adult teeth removed in my teenage years with braces to “make room” and now have 12 teeth on the top and bottom (24 total). I have a high/narrow palate. I believe my sinus, apnea, and breathing issues stem from my upper/lower jaw anatomy. I really want to avoid a septoplasty and turbinoplasty if possible and address the root cause. What are my options here? Can the upper/lower jaw be expanded? And, can dental implants work adding back my 4 adult teeth that were removed? I’m not concerned with cosmetics just function…And I’m desperate to breathe and sleep properly for once in my life! The book “Breath” by James Nestor talks a lot about these issues and references a few studies I believe. This is what led me down this path. Any help is greatly appreciated!

[@teethree141]

upper and lower jaw can be expanded. but it can only help so much. I had an upper expansion 3 months ago. I still have high nasal resistance and still mouth breathe at night. My expansion helped but its only one piece to the puzzle.

[@ryant6134]

@@teethree141 Thank you for your reply. What type of jaw surgery did you have? And are you planning on any other surgeries or expansions?

[@teethree141]

@@ryant6134 I had the MIND procedure. Minimally Invasive NasoMaxillary Distraction. I am going to see a second sleep specialist/neurologist who Is going to do a rhino manometer test to check nasal resistance, etc. Then he'll let me know if I should be referred out to any specialists. But Im anticipating MMA and septoplasty and tongue tie release.

[@teethree141]

@@ryant6134 Nasomaxillary expansion. I am planning to get a surgery to shrink my turbinates

[@lena990]

What about the people like me who I can nasal breathe fine, but my intermolar width is 28mm, meaning my tongue can’t fit up there

[@shuikai272]

Did you check the scan to make sure your tongue isn't fitting up there. I mean if it doesn't fit then why not expand it?

[@saileshjoshi5422]

​@@shuikai272I ask the sane question to my orthodontic but he said if you expand the maxilla we won't be able to expand the mandible

[@flyondonnie9578]

@@saileshjoshi5422There’s usually a few mm worth of expansion to be had just from tipping the lower teeth outward. In many cases they start out tipped inward so there’s no reason for the mandible to be a problem when doing a moderate maxillary expansion.

[@DMCap]

Shukai, did these individuals send their CBCT to you for analysis?

[@shuikai272]

Yeah. I don't always trust other people to measure it themselves as they could do it wrong. You have to ensure that there is no invisible bone that isn't being picked up by the viewer. So basically I'm hearing people say, it didn't make my breathing better, or my breathing stopped improving halfway through, things like that, or my breathing is way better, and then cross referencing what people are saying with the widths. It seems that you want the airway to be adequate the entire way through. So if someone has a 18-19 mm aperture, 28-30 mm IMW, and you don't expand and do an MMA, it may not really matter how far you advance them, the problem is they have this bottleneck in the nose. Vise versa, if they have a 25 mm aperture, but their pharynx is narrow, they are recessed, there is a pharynx problem, it doesn't matter how much you expand them, there isn't any point to lose molar contact so you can get a >28 mm aperture. Which Kasey Li doesn't typically expand that wide, that's an extreme example, but I'm also looking at one case (patient from BC Canada), and personally I think this was likely incorrectly evaluated (truly, we'll never know, maybe he just needed MMA). I don't really blame Kasey Li because this stuff is so new, I feel like before this he was under-prescribing EASE, so I think he might have done the switcheroo and started over-prescribing. But this case, went from 24 mm aperture, to around 28-29 mm aperture. Personally, I'm not sure what was really accomplished, maybe the benefit will be "unlocked" when he does the MMA, but yeah.. Did he really need it? I don't know. I'm really concerned about losing molar contact if the benefit is in question. What I do see is that when people say "I feel so much better, my life is changed, etc.", you know what they also say? "I breathe so much better". So my thinking is, how do we facilitate this effect? How should the overall treatment be planned, so that this happens? In regards to aperture, how wide does this thing really have to be? Another topic is, "who cares about intermolar width?", well I care somewhat, like what if it is so narrow that the patient cannot fit their tongue between their molars? If you look at CT scans, you'll notice in the majority of scans, the tongue fits between the molars and is on the roof of the palate. If you have a width SO NARROW that it physically cannot fit, then that's a problem. That isn't normative. That needs addressing. If the patient is not normative and they are sick, can't breathe, etc. you shouldn't be surprised. The human body is a system, if you disobey the best practices for how it should be configured, you'll have problems.

[@DMCap]

@@shuikai272 Thank you. So people were expanding and told the doc that breathing was improving. At the same time they took CBCT and sent it to you to confirm that they have reached 25 mm width but because they wanted to get better smile so they told the doc that they were still improving so they can keep going even though the CBCT showed normal width?

[@shuikai272]

@@DMCap No, I think it is more that they either, had like a placebo effect of optimism, they want to feel better they want to breathe better, so keep expanding. Other reason could be, they have a narrowing somewhere else in the airway, in the throat for example. Maybe they need an MMA, they need their jaws moved forward, no chin, no jawline. So because the throat is bad, their breathing is bad, and so they keep expanding hoping that will change, but it may not if the problem is elsewhere. And then the ortho sees the teeth and maybe there is no molar contact. So this is like, really the only downside with the expansion I've seen so far. Other than damage to the alveolar bone I guess, which is just a side effect of using the TPD from KLS Martin, and no other 100% skeletal expander works so what else are you going to do. Everything else about his procedure is extremely good, especially in comparison to the competition, which realistically hasn't been doing a great job as shown in the video.

[@DMCap]

@@shuikai272 If you didn't analyze the CBCT when they were expanding and the individuals that you interviewed didn't analyze the CBCT or even know how to analyze it (according to you) or if a CBCT was even taken, how is it possible that "expanding the nasal aperture past, generally 25 mm or so (average height male) did not yield improved nasal breathing, or if it did, it was very minimal at best, and basically the consensus was that it was more or less unnecessary to expand to 27 mm, 28 mm". No one knew the width when people stopped improving. We are all suffering from OSA and trying to learn but so many on the internet are pretending to be experts and have never treated anyone or even set foot into a surgery room but are telling people how surgery should be done or how treatment should be rendered.

[@shuikai272]

@@DMCap If you scroll up and read my reply to your question of "did these individuals send their CBCT to you for analysis?", I replied with "Yeah". So the answer is that yes, I measured and was aware of what the measurements were. I don't know a single person who says they benefited from expanding from 26 mm to 28 mm, or 30 mm, that is just the truth. Maybe someone will, but I have yet to find anyone. This is statistically significant. Another example. I recall a woman from China I believe, who expanded and had it reversed because she "felt too much air", or something to that effect. She started at around 24-25 mm I think, so she was already above average for her height. I would consider that Dr. Kasey Li did explain part of this point in his lecture. The treatment of choice for OSA is CPAP. Consider how wide an aperture of 28-30 mm really is, this is an extremely wide aperture, and few homosapiens will even have one that wide, mostly only the widest apertures for African ethnicity. The purpose of expansion is to reduce the negative pressure.

[@markk7509]

So does this skeletal expansion involve upper jaw surgery?

[@teethree141]

yes

[@goksel7986]

34:33 what a weird human being

[@Sunrise-fr9jb]

Cope