Why I Am Expanding My Maxilla at 33 Years Old

When getting a tongue tie release isn’t enough

Placing your tongue on the roof of your mouth is important for increasing upper airway space, promoting nasal breathing, and positively affecting neck dynamics.

These were a few reasons why I pursued a tongue tie release surgery. Increasing my tongue range of motion would allow me to more easily attain this posture, and hopefully feel a litany of positive effects.

But that’s assuming one critical piece…

Is there enough room for your tongue to sit on the roof of the mouth?

That, folks, was the issue I had, and why the surgery was not enough.

So I had to recruit the big dogs

Here were my next steps.

Working with an airway dentist

“You have all this tongue motion, but no place to put it.” ~Dr. Brian Hockel

There I was, my first dental appointment with Dr. Brian Hockel, reviewing the findings of my imaging and sleep study.

Do you remember that picture I shared of my airway on part one? If not, here’s a refresher.

Psh. And they say it’s what’s on the inside that counts.

What you are looking at are my tongue and dental arch. You can see that my tongue is pushing straight into the front of my teeth. Do you see that dark gap above the tongue? That’s the roof of my mouth.

My tongue cannot get up there because my dental arch is too small laterally and sagittally. 

So what? Who cares?? BREATHE HOWEVER YOU WANT TO cry the physical therapy nihilists!

But how many of those haterz are checking sleep studies?

Sleep study results

One of the best objective tests you can do to see upper airway functionality is a sleep study. I did an at-home one called the WatchPAT One; single-use and FDA approved.

Your beard is weird

Though it was uncomfortable to wear on my precious finger, it was pretty easy to use. It transmits all the information via Bluetooth. WAY better than doing one in a lab. 

Dr. Hockel went over the results with me in his office. I was negative for obstructive sleep apnea (YAY), but my sleep wasn’t perfect by any means (BOO).

Sleep apnea is measured via the Apnea-Hypopnea Index (AHI). In order for a sleep disturbance to count as apnea, there must be a 10 second or more period without breathing.  

What if you had apneic events shorter than 10 seconds? That’s where the Respiratory Disturbance Index (RDI) comes into play. This measure is a catch-all for any apneic events, airflow reduction, desaturation, or arousal from sleep. The goal of this number is to have less than 5 per hour.

Ya boi was sitting at 7.2 per hour, with 14.7 per hour during REM, both considered mild. My AHI was also at its highest during REM. 

I wake up A LOT during REM stages of sleep, which may explain why I get so sleepy during the day and barely remember my dreams. 

The diagnosis? Upper Airway Resistance Syndrome (UARS), which believe it or not is a worse condition to have than sleep apnea from a sleep/breathing health perspective.

So what the hell does my tongue have to do with a sleep disorder? 

I’m glad you asked!

The inability to attain a palatal tongue posture causes the tongue to sit further back in the throat. This position reduces airway space and makes nasal breathing difficult. Hence, the resistance I am getting during sleep.

In order to mitigate negative effects from this syndrome, we needed to do all possible to help me attain a better tongue posture. To determine how to do that, we have to deep dive into my mouth structure.

My upper airway and mouth structure

Once we dove into the sleep study, we then looked at oral structural findings that could be contributing to my mediocre sleep quality:

The Good The Bad/Ugly
My nasal septum looks good Front teeth (incisors) are tipped backward
I have a pretty girthy…airway Have gunk in my sinuses
Tonsils are slightly enlarged
Turbinates are slightly enlarged
TMJ sits too posterior in the joint, has a void, and is hook-shaped. 
Jaw is shifted to the left
Gunk is circled in red

All of the factors on the right can contribute or are symptoms of limited upper airway space, and would be areas we can address.  

Upper airway resistance syndrome treatments

Dr. Hockel showed me a comprehensive chart of options to improve my symptoms, ranging from symptom management to structural fixes.

First, symptom management choices. The two major options here are CPAP or oral appliance. Both are effective at reducing UARS symptoms, but neither is perfect:

  • CPAP: Compliance and comfort with this device is low. Most people cease use after 6 months.
  • Oral Appliance: Easier to use, has cardioprotective effects compared to CPAP, but will negatively affect your bite and teeth.

The major roadblock for me with these two options was that neither fixes the problem

To fix the issue, we had two potential treatment options:

  1. Airway orthodontics
  2. Maxillomandibular advancement surgery

Let’s look at what each entails.

Airway orthodontics

Airway orthodontics change teeth position to make more room for the tongue on the mouth roof. Dr. Hockel would use a Crozat Appliance and braces to achieve this goal.

What’s nice about the Crozat compared to others is that it has the capability of moving the teeth both sagittally AND laterally. Most appliances either do one or the other. The ones that do both do not have the adjustability this appliance has. It also moves teeth faster than a similar appliance, the ALF.

With my teeth expanding in all directions, this change may help advance the mandible forward, increasing my airway space and preserving the health of my TMJs. I’d also have more room for my tongue to press against the palate, potentially increasing airway space even further.

Once the Crozat has done its thing, I’ll be in braces. We are looking at a 2-3 year process.  

The only issue with this route is the uncertainty of my TMJ health, or what changes my airway will actually have. Effects are potential, not definitive.

Maxillomandibular advancement surgery (MMA)

The MMA procedure (cool name, equally as violent) is a surgery that cuts the bones in your skull to bring the maxilla and mandible forward, maximally increasing airway space. 

If I went this route, I’d also likely need a TMJ replacement bilaterally, which would make up for the joint degeneration but eliminate mandibular lateral trusion. 

You can see how the bone is hook-shaped and has a space in it. That’s not supposed to be there. Oops.

THE GUY for this procedure is Dr. Movahed (how perfect of a name, right?). What makes his approach different is he advances the face AND rotates it counterclockwise, mimicking “normal” facial dimensions. Most surgeons do not do this latter piece. 

If you think of increased vertical facial growth (a long lower face = ya boi), this is essentially an anteriorly tilted face. The counterclockwise rotation helps posteriorly tilt the face, improving airway size and dynamics.

Comparing orthodontics to surgery

I knew I wanted more of a “fix” than symptom management, so the CPAP and oral appliance were out of the race. It came down to airway orthodontics vs the MMA surgery.

Here is my pro and con list for each treatment:

Airway orthodontics

Pros Cons
Less expensive than the MMA Less definitive in terms of airway efficacy
Could promote good tongue posture and change TMJ health/positioning if not too arthritic  Won’t change facial dimensions as much as MMA
Minimally invasive 
Maintain TMJ motion

MMA surgery plus bilateral TMJ replacement

Pros Cons
Will get the best airway changes Uhh, going to cost ya boi like 60k!
Facial dimensions would change to where I’d make Brad Pitt look hideous I’d have two total joints at age 33!
Recovery is like 6 months and would be out of work for 6 weeks.
Then I’d DEFINITELY quit being a PT and go Hollywood

Given that my symptoms weren’t that drastic, the thought of having total joints at my age seemed unnecessary, and I didn’t want to start a Gofundme to cut my face, trialing the airway orthodontics seemed like the no-brainer choice. Dr. Hockel also thought I’d get a decent outcome with it.

In my mind, if this manages symptoms now and my TMJs end up worsening as I get older, I can always get the surgery when technology and procedures will be infinitely better. Worst case scenario? Nothing happens and I could still get the surgery.

I was set to get the appliance next time I visited Dr. Hockel, but I had a few other treatments in the bag to help my symptoms.

Reducing nasal airway inflammation

Because of the gunk in my sinuses, as well as the tonsil and turbinate enlargement, Dr. Hockel shot a quick text to Zaghi, the ENT who did my tongue surgery, to see what we could do.

He recommended I do a couple of months of steroid rinse in my nostrils.

Let me tell you, after I did the first dose, WHOA!

This ‘roid is all the rage

Although ya boi is predominantly a nose breather, I’m loud as hell. 

After one dose, the volume knob drastically dropped, and I could tell an immediate difference in how easy breathing became. The people around me also noticed a difference. It was wild.

My sleep and exercise performance seemed to be a bit better as well. 

Sleep hygiene updates

Dr. Hockel recommended that I start lip taping while I sleep. I’m unsure if this has made a difference in terms of sleep quality, but it’s something I still do.

What likely made the biggest difference though, has been moving into my own apartment. Finally, after years of being on the road and sleeping in questionable beds.

I got a nice new comfy bed, installed blackout curtains, humidifier, cooled my room to 68 degrees, the whole shebang.

Honestly, I think finally having a place to call my home has been the biggest positive change to my sleep quality. Those early morning wakeups have drastically reduced to maybe once every couple weeks, I’m sleeping later, and feeling refreshed. I also now have a job that I don’t start until the afternoon, so for the first time EVER I’m allowed to wake up without an alarm (YAY!).

The Crozat Appliance – Month 1

I was going to get my Crozat appliance as soon as I moved to Vegas, then COVID happened 🙁 

But after several months, I finally got my Crozat. Here’s what it looks like:

Cool cast of my teeth too, right?

And here is what it looks like in my mouth

The bottoms
The top

The Crozat has two sets of wires. You have some that will push the teeth laterally, and some that will push anteriorly. 

Once he fit the appliance, he activated it by pushing the wires a bit beyond the intermolar width. This action applies force into my teeth, pushing them laterally. There was no anterior adjustment as of yet. 

The first few days in the appliance were interesting. The initial favorable changes were in my neck. My range of motion improved a fair amount. 

This change was most noticeable when I went out to eat a couple of times that weekend. Normally, sitting and having to look left during dinner is a problem, but the pain seemed to be dampened this time around. As time went on, symptoms seemed to be hit or miss with sitting.  

Perhaps neck pain wasn’t so bad because the first few days eating with this thing in my mouth, GOOD LORD. It felt like I was constantly chewing on metal, food gets stuck in the appliance, and my teeth hurt when they contact. However, after about two weeks eating became much more comfortable. 

With all this in mind, you might be wondering how my sleep has been. After one month, I’ve noticed a drastic difference in sleep. 

I used to get lulls midday and wake up tired, but these dips have significantly dropped. 4-5 days per week has dropped down to one or two at the most! Those couple of days are normally because I stay up way too late. Getting on a better schedule is on my list of things to take care of.

Myofunctional therapy

I also started working with a SUPER LEGIT myofunctional therapist in Vegas. Her name is Melissa Mugno, and her specialty is designing myofunctional programs to complement orofacial appliances like my Crozat.

Most of the exercises have been focusing on getting me to move my tongue without compensating through my neck or jaw, my go-to.

Below is an example of one of the moves I’ve been doing.

Sum up

Overall, I’d say going this treatment route has been quite successful, and I’m eager to see how things change over the course of treatment.

To summarize:

  • Tongue motion and palate space are needed to improve tongue posture.
  • Moving teeth and surgery are potential treatments to improve airway dynamics
  • Symptom changes can sometimes occur very quickly.

Struggle with sleep? Have you tried dental treatments to improve sleep? Comment below and let the fam know!


10 comments

  1. Very informative Zac. I was prescribed a night guard to basically reposition my trachea(grinding) from a biological dentist. I can’t say it helped with my sleep disturbances however my O2 improved.

    1. Hey Patty,

      That’s cool that the O2 improved. Have you had a sleep study done? May be worth looking into.

      Zac

  2. Well said Zac! You have a great team and that makes the difference. Thanks for getting the word out about these life and face changing treatments / therapies. You are looking good!

  3. Hey Zac,

    I’m glad to hear you’ve experienced benefits with the Crozat (and getting a new place to live!). I haven’t heard much about the Crozat, and I’m more familiar with the ALF and DNA appliances, so I’ve got a series of questions: How often is it adjusted? Are you supposed to work with an osteopath concurrently, or just a myofunctional therapist? I’m also curious about the cost, though no worries if you don’t want to share.

    And one last question: What was your molar-to-molar width before starting the appliance? Your airway indeed looks girthy, which I would generally associate with a wide (or at least wide enough) palate. Maybe your tongue is just that huge. Funny enough, I remember Ron cracking a joke about your too-big tongue desperately looking for a home during the TMCC course we took in Arizona in 2014.

    I’m also wondering if there might be any allergies contributing to the enlarged tonsils and effectiveness of the steroids. It’s not something I know a whole lot about, though I have heard a dentist talk about the relationships between diet, tonsil size, airway structure, and sleep quality. Maybe you’ve already been down that rabbit hole, though it may be worth keeping in mind. I don’t have enough personal or clinical experience to say anything of substance on the matter, however.

    Anyway, best of luck with everything, and I hope you keep sharing updates.

    1. Hey Rob,

      Awesome questions. Here’s the rundown of your q’s

      1. For me (because I live far away) every 6-8 weeks. I think normally it’s 4-6.
      2. He actually didn’t recommend anyone because I’m a bit in the know (PT and myofunctional therapist), but I networked with a MFT. I would probably do both if I had someone going through it.
      3. Cost for me was a bit under 10k. I think this is different for everyone.
      4. I think it was 34mm. Normally you want to shoot for 40 or so.

      Regarding the airway dimensions and wide palate, I am likely compensating through my neck to make it that big. Forward head posture will increase airway space, which I have in spades.

      Allergies are entirely possible, though uncertain. I did some allergy testing and hormesis treatment with an ENT way back in the day, but didn’t seem to have much of an impact. Then again, I live in a different place now, so it’s hard to say.

      1. Hey Zac,

        I appreciate the thorough response! One other question that came to mind: Did you ever try any manual palate expanding exercises (e.g., the “fishhook” technique)? And if so, then how did you respond? I haven’t used such techniques on a large enough sample size over a long enough period of time to get a confident sense of how to interpret the results of such an intervention. For example, if the fishhook technique dramatically improves someones neck and shoulder ROM and/or relevant symptoms (at least transiently), then I suspect it’s a strong indicator that palate expansion with an ALF, Crozat, etc. would be beneficial, though I don’t have the data to support or refute that hypothesis. Do you have any thoughts?

        Anyway, best of luck with the treatment, and I’m curious to see how things unfold.

        Rob

        1. Hey Rob,

          More awesome q’s

          1. I am uncertain if I’m familiar with the fishhook technique. Is that just manually pulling the palate apart laterally? Haven’t had it done myself, but have done to others. Most of the stuff I’ve done is myofunctional therapy to get some expansion, but we didn’t matter.

          2. I would think it’s a potential indicator, but I haven’t tested enough. A sleep study + imaging is likely a better test to use to determine if someone should go this route. People believe/care about sleep studies, shoulder motion??? Guys like us maybe LOL.

          1. Hey Zac,

            The description you gave matches the “fishhook” technique–or whatever other people call it.

            As for sleep studies and imaging, I agree that the typical client gives more value to those tests–I just have a lot to learn about which tests to order and when, how to interpret, and how to use the findings to guide treatment. On that point, I hadn’t heard of WatchPAT before, and I intend to check it out. I also saw that you linked to a presentation Dr. Zaghi gave, and I intend to give it a watch. Thanks for sharing it.

          2. WP-1 seems to provide the most comprehensive data out of all the at-home sleep studies. Most of the one’s I’ve seen just check to see if you have sleep apnea. Won’t pick up other stuff.

            That and airway imaging can tell you a lot

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