The Right Bite Sleep and TMJ Pain Care
The gold standard for surgical treatment of obstructive sleep apnoea is still the Maxillo-mandibular advancement surgery (MMA). This procedure has been adopted for patients suffering from an AHI greater than 50. Although the patient can sleep better due to the jaws being advanced, there are facial changes that may occur as a result of this that can give a protruded jaw appearance. And this procedure is maximally invasive.
Also these surgeries do not expand the upper jaw transversely thus the patient suffering from OSA does not get the desired 3D expansion.
Newer and minimally invasive surgeries are available now such as the Maxillary skeletal expansion appliances that bring about transverse expansion as well as forward advancement when used with a face mask. These appliances can easily be used in patients less than 25 years of age without the need of any major surgical procedures. In patients more than 25 to 30 years, the maxillary bone suture is too hard to achieve a physiological split. Therefore we need a surgical assist; by using a piezoelectric saw that cuts through the upper jaw bone with minimally invasive osteotomies. And it has the advantage of not damaging any soft tissues during the process.
Non surgical jaw expansion methods are orthodontic and slow expansion appliances such as Quad helix, Crozat appliance, etc., which have been used for ages but these are limited to certain age groups and cannot work in adults. The newer appliances such as the DNA / mmRNA appliances help us overcome this problem as they work in a non-invasive way to slowly bring about epigenetic changes in the body to expand the maxillary and mandibular bone in a 3D manner. These are the only appliances that can non surgically bring about airway augmentation in adults.
The other novel approach to expansion, albeit slower in adults, is the ALF appliance (Activated lightwire functionals); which is a gentle, sensory, light palatal arch wire which harness the natural forces of the tongue to stimulate the maxillary arch to expand and at the same works on the craniofacial complex to release strains in the sutures. We generally use it in children below 15 years.
Orthodontic expansion in adults is possible using braces but it is limited to the amount of bundle bone available for the teeth to move in the socket and get an expanded arch form. Even with the best possible braces we can only achieve about 1.5 to 2 mm per side in the posterior teeth which may not be sufficient in patients who have a very narrow upper jaw and posteriorly positioned lower jaw. So, in patients who require more expansion, the ideal minimally invasive method to gain 3D expansion is using a DNA appliance to stimulate the epigenetic potential of the body.
In patients who require nasal airway volume to be significantly increased along with maxillary expansion, the only minimally invasive technique is the MARPE (mini impant assisted rapid palatal expansion) such as the MSE appliance (maxillary skeletal expansion) which in conjunction with a piezoelectric saw can split the suture with ease in adults.
Going one step further if this procedure can be done in conjunction with an ENT surgery under general anesthesia, the patient is more comfortable and gets his ENT issues such as DNS, Inflammed turbinates also getting treated at the same along with upper jaw expansion.
In general the orthodontic appliances can augment the growth of the airway in children till the age of around 12 years after which the bones are mature and do not grow further. In adults it is not possible to augment the airway using the traditionally available methods such as fixed braces. They only move the teeth and cannot expand the airway.
Novel appliances such as the DNA appliances and ALF appliances however have proven to bring about airway expansion in adults. A better understanding of these holistic appliances is required to adapt these newer appliances into practice.
Whereas the ALF (Activated Lightwire functionals) is a slow, sensory appliance it is seen to bring about natural expansion in mostly younger children and adolescents, in can be used in adults to release their cranial stresses and enhance the rhythm of the tissues and the bones in the cranio maxillary complex.
The DNA appliance on the other hand is a more sophisticated appliance and more suited for adults as it’s a bit more bulky and requires constant monitoring the activation by the doctor/patient to get long term results. Research has shown increase of upto 250% in volume of the airway post DNA treatment.
Correct use of these novel appliances can bring about airway expansion without the need for surgery in most adult patients who need airway augmentation.
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