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.

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.

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.

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:

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. 

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

MMA surgery plus bilateral TMJ replacement

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!

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:

And here is what it looks like in my mouth

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!