Maxillary Expansion Before and After 1 Year in the Crozat Appliance

How sleep is impacted after one year of palate expansion

I was tired of waking up tired. So I decided to do something about it. 

It’s now been one year since I’ve begun working with Dr. Brian Hockel on expanding my palate with the Crozat appliance. And the results so far have been pretty solid.

Let’s dive into all the changes that have happened within the last year!

Check out the video, podcast, and blog below to learn about it!

Treatments I’ve had this past year

I must confess…

I’m the worst scientist ever.

Instead of isolating treatment variables, I’ve done a bunch of different interventions. Some of these treatments happen in concert with the Crozat appliance, others do not.

The different treatments that I’ve done included:

  • Crozat appliance
  • Myofunctional therapy
  • Lip taping
  • Vivaer procedure

The first three interventions are generally performed together, but the Vivaer procedure was something extra I did to improve nasal breathing. 

Let’s learn a bit more about each.

Crozat appliance

The Crozat is a tooth-borne appliance that pushes the teeth out in the alveolar bone, making more room for the tongue to sit against the roof of the mouth. 

Maxillary on the left, mandibular on the right. And yes fam, those are impressions of my teeth. Impressive…right? RIGHT? OKAY WHATEVER FAM MOVING ON!

A common misconception surrounding this appliance and those similar is that it makes the palate bigger. Nothing changes in terms of palate bone structure with this device. Instead, teeth are moved as far out as possible in the alveolar bone, hence why the Crozat is considered tooth-borne. This appliance type is different from a bone-borne appliance, which is often screwed into the bone, changing the palatal structure itself. 

Myofunctional therapy

Myofunctional therapy is essentially tongue physical therapy. Although this was my second bout (I did some before and after my tongue-tie release), I did work on a few new skills that I hadn’t previously.

Perhaps the biggest area we worked on was improving the ability to differentiate my tongue from my jaw, neck, and facial muscles. Although my tongue range of motion was good, I had a difficult time moving my tongue independently. We therefore practice really isolating tongue movement.

The hardest skill for me to master was gathering food and swallowing. My tendency was to drop food on the sides of my mouth while chewing and then thrust my tongue during the swallow.

For those who don’t know, a tongue thrust is when you push your tongue forward or sideways into the teeth, instead of keeping it on the roof of your mouth.

Lip taping with myotape

It’s easy to keep your tongue on the roof of the mouth during the day, but what about while you sleep fam? Are you gonna be mouth breathing and snoring and all that?

HELL TO THE NO.

To mitigate this tendency, Dr. Hockel recommended that I lip tape, and my myofunctional therapist suggested Myotape as what to use. 

And that’s the story of why Zac never gets matches on Tinder.

Myotape is essentially kinesiotape that goes around your lips. The tape’s positioning encourages an active lip seal, necessary for good nasal breathing posture.

Vivaer

Despite all these treatments, nasal breathing was still a struggle, especially with physical activity. Maximizing tongue posture didn’t seem to do the trick.

After having great success with the Mute Nasal Dilator, I wanted a more permanent fix. 

I consulted with Dr. Soroush Zaghi, the ENT who did my tongue tie surgery, on what to do. He recommended I do the Vivaer procedure, which changes the shape of the nasal cartilage to better promote nasal breathing. I had that procedure about 10 weeks ago from this time of writing. 

I’ll be doing a separate post on all this procedure, so stay tuned 😉 

Key Performance Indicators

What doesn’t get measured, doesn’t get managed. So I looked at several key performance indicators (KPIs) to determine efficacy thus far.

Thse are my most important subjective and objective measures:

  1. Subjective sleep quality
  2. Neck pain
  3. Tongue posture
  4. Nasal breathing capability
  5. Sleep study

Results 1 year into Palatal Expansion Treatment

In just one year’s time, my teeth moved like CRAZY.

Here’s a comparison of what my teeth looked like in January 2020 vs June 2021.

As you can see, there is quite a bit more space both sagittally and laterally. The side to side width change is between 5-7mm, which is pretty significant. Typically, a 5mm difference is considered good for a surgical outcome, so to achieve this amount with mere tooth movement was pretty cool.

But this increased space came at a cost. 

The downside about tooth-borne appliances is that the increased risk of gum recession. If the gums recede enough, I could either lose teeth or get some gnarly cavities.

Sadly, I did get a bit of recession on two of my molars:

You can only push the teeth so far, fam

Dr. Hockel didn’t seem to think the recession was bad enough that I’d lose the teeth, but I may need to finish treatment with some gum grafts, which unfortunately are not cheap. I’ll have to do some research on what would be the best course of action. 

So now that you’ve seen what’s changed about my mouth, you might be wondering what results happened from all this crazy stuff I’ve done. Was the chance of sleeping better worth receding gum?

Let’s re-evaluate my KPIs.

Subjective sleep quality

Though far from perfect, my sleep quality has improved drastically over this time period. I was experiencing quite a few afternoon lulls, days of waking up unrefreshed, and no dreaming whatsoever.

Now, the afternoon lulls are rare. I may experience a handful every month as opposed to every weekday, which has allowed me to be that much more productive. I also wake up refreshed over 50% more than what I normally did, though I still wake up a couple hours earlier than expected from time to time.

Dreaming has been the most interesting change. In the last six months, I’ve dreamt more than I have in the last six years. I now have weeks at a time where I dream daily. To me, this indicates some improvements in REM sleep, which as you’ll see later, is where most of my sleep disturbances live.

Some of the biggest limiters here for me are environmental. I’m still consuming a fair amount of caffeine and stay up late when deadlines hit for work. I need to keep improving on both of these fronts.

Neck pain

Neck pain is something I’ve dealt with on and off over the years. The times I noticed my neck bothering me the most is with intense physical activity, computer work, and sitting at a restaurant. 

With all these treatments (and vision therapy, stay tuned), there has been some improvement in this area. The largest change has been with physical activity. I am now able to play spikeball with my neck feeling pretty solid!

Computer work is slightly better, but the since the pandemic, my computer work has increased drastically. I can’t expect miracles here.

Lastly, going out to eat still leads to problems. If you are sitting on my left side, game over, I’m pretty sore at the end.

Tongue posture

I’ve pretty much aced myofunctional therapy. I’m able to put my tongue into all the desired postures and can perform chewing and swallowing to standard.

The only thing I have difficulty with is consistently nailing the swallow. I notice I go back into old habits if I am rushed and not paying attention while I eat. That’s on me, yo!

Nasal breathing

I was not seeing any real improvements here until I used the Mute and then had the Vivaer procedure. With the latter intervention, it’s much easier to maintain nasal breathing during intense physical activity, especially hiking. When I used to hike, I’d get congested as all hell. That’s all gone now!

What’s also pretty cool is my nostrils actually expand when I breathe in now, as before they used to collapse. 

Despite these treatments, I still feel a bit of resistance with nasal breathing at times, and I have to nasal saline rinse WAY more, as my nose must still be healing from the procedure.

The time I notice I have to work the hardest nasal breathing is actually in the morning right before I wake up for good. I’ll catch myself breathing fairly loud, so I still need to look 

Sleep study

Sure, my feelings are important, but let’s check the data!

Let’s first look at my initial sleep study results. Here, we will look at the apnea-hypopnea index (AHI), which details the number of events I go sans breathing for 10 seconds or more; and the respiratory disturbance index (RDI), which totals any sleep arousals whatsoever.

Initial sleep study results

Here are my initial results, using the Watchpatone, an at-home sleep study:

Initial sleep study (1/22/20)

IndexREMNon-REMTotal
AHI8.03.04.2
RDI14.74.97.2

The total numbers aren’t too bad. An AHI of 4.2 is considered normal, meaning I do not have sleep apnea (YAY!). An RDI of 7.2 is considered mild, indicating slight upper airway resistance syndrome (UARS).

But the devil is in the details.

You’ll notice that both of these numbers elevate during REM sleep. The AHI of 8.0 indicates mild sleep apnea, and the 14.7 RDI indicates moderate airway resistance. 

These values seem to correspond subjectively with what I feel, namely the minimal dreaming, grogginess, and even waking up around that portion of sleep.

As for other findings:

  • Oxygen levels stayed within normal range throughout the study
  • I slept mostly on my left side
  • My sleep disturbances occurred mostly when I was on my back (worst) or my right side
  • REM sleep occurred 23.71% of the night, and deep sleep was 20.74% of the night (both decent)

Now that we have a baseline, the moment of truth. 

Did my sleep study improve?

Follow-up sleep study results

Let’s look at our objective indices first:

Follow-up Sleep Study (9/2/2021)

IndexREMNon-REMTotal
AHI5.43.54.0
RDI12.28.29.4

As you can see, the total numbers are fairly comparable and within the same ranges mentioned above; still in the mild to moderate range for most, which was an underwhelming finding. Is this because the treatment hasn’t been completed or not fully working? It’s still too early to tell.

Other notable findings include:

  • I slept in more positions and more spread out timewise in these positions
  • Sleep scores were better when I was on my right side
  • 28.29% of the night was spent in REM, and 24.59% of the night was spent in deep sleep, an improvement.

What’s next in the treatment process

I still have about a year to go in the process. Next up, I’ll be getting braces (lame) and we will still be expanding the teeth out a bit more.

I’m uncertain as to what else I will do regarding nasal breathing. I will likely chat with Dr. Zaghi again to see if there is anything else worth trying to improve upon this even further, aside from giving my nose time to heal. 

Aside from these treatments, I personally need to continue improving my sleep hygiene. I could definitely benefit from less caffeine, and limit how late I work on screens. These two changes alone will no doubt help improve my sleep. 

Sum up

Overall, I’ve been pleased with the symptom improvements thus far, though I know I still have a ways to go. I’m eager to get through the orthodontic process to see what happens.

To summarize:

  • I’ve undergone palatal expansion for a little over a year, along with other procedures
  • My teeth have moved significantly, making more room for my tongue
  • Subjective measures have improved, but objective test results remain minimally changed

Do you have difficulty sleeping? What have you tried? Comment below!

11 comments

  1. Great post as always fam! Looking forward to your progress on this one, hope it gets better!

    Your post about the Upper airway obstruction convinced me get a sleep study done. Im still looking to find a good one who score RERA’s.
    Got an appointment on 21st of this month at an university hospital.

    My sleep is pretty bad, i have to take a pill just to knock me out. Wake up too many times, 2-3 times just to urimate. Also have to sleep a good 10 hours and i dont even feel that awake. Also have ADHD.

    Have you ever checked out EASE procedure?
    Its done by Dr.Li at san fransisco. Its not invasive at all and seems to produce around %60 remisson of sleep apnea , compared to %80-90 MMA. Sounds too good to be true, maybe it is lol

    Also is Daddy o Pops wearing braces for airway reasons too?

    1. Awesome to hear! I hope you get some help! Definitely, symptoms that would warrant getting checked out.

      I have not done the EASE, soemthing I may look into.

      And yes, he had a different appliance.

  2. Zac, Hi! This is Lesley Bludworth, PT from AZ. I work with Veronika Campbell, PT. Regarding your tongue tie release and breathing, The best improvements I have seen in breathing and nasal congestion have been with the upper lip tie release. If you have not had your lip tie released then it would be worth your time, effort and pain to get it done! This is on an n of 3 patients of my own. But 2 were instantaneous fascial releases of the palate. I have watched lip tied babies nurse and the lip and tissue between the lip and nose goes white so I can only imagine what occurs further into the hard and soft pallet.

    1. Thank you for suggesting that! I’ve had the tongue-tie release, but not gone that route. May consider it!

  3. Damn it’s only a matter of time before this guy realises he needs MMA surgery, and that he probably should’ve gotten EASE or DOME. You can see he expects results but doesn’t get any after 1yr so he tries to explain it away and says he needs to stop drinking caffeine etc. etc. sounds very much like somebody with sleep disordered breathing. Please mate these tooth-borne expanders have poor evidence and basically just ruin your oral hygiene permanently without sleep benefits. I hope you see the light soon.

    1. I appreciate your comment and was offered MMA, but surgery wasn’t financially in the cards at this point in time nor didn’t seem to match up for the symptoms I was experiencing.

      Also, to say I didn’t get any results is not true. As I stated in the post and the video, I’ve had quite a few subjective improvements in sleep. Actually dreaming, waking up refreshed more frequently, minimal afternoon lulls. Perhaps this did not result in objective changes per the sleep study, but an improvement nonetheless.

      As for those procedures you’ve mentioned, there aren’t guarantees with those procedures as of yet. My colleagues have seen quite a few failed cases with those procedures as well This buys me time for things to further advance in the profession if I need something at that point in time.

  4. I only wish you had researched the difference between bone-borne and tooth-borne appliances a little more and not bought Dr Zaghi’s words straightaway. There are plenty of airway-focused orthodontists like Dr Ting, Dr Evans etc. I know you mention the invasive nature of these appliances, but trust me the only thing that’s painful is the infections they give you to numb the palate. MSE/MARPE is pretty easy to bear, trust me. It’s less invasive and painful than a tonsillctomy. And, also for your age you would have needed surgical-assistance to loosen the maxllary sutures so yes, there would have been anadditional cost involved. However, the outcome and the results would definitely outweigh the monetary investment and little pain we experience in almost every medical procedure. I don’t mean to make you feel bad or sorry regarding the decision you took, as I’m sure you thought this would work best for you. Lastly, I would like to ask what you and Dr Hockel decided as to what a successful outcome would be at the end of your journey. Is it reduction in symptoms or just plain palatal expansion?

    Wishing you well for the rest of your journey. Keep us posted on the updates, and I’ll be following your journey.

    1. Thank you for your thoughtful comment.

      I had chatted with a couple different folks on the best way to go, including one of my colleagues who has worked with several patients who have had different bone-borne procedures with mixed results and complications (which also included grafting, perio, and more).

      Overall, I’m happy with my decision for now, as it’s led to some improvements in symptoms (that was our main KPI), and worst-case scenario is if I have to do something more aggressive later on in my life then I will.

      I’ll definitely keep you posted and will be documenting this. Appreciate having you as one of the fam!

  5. Thank you for your video! Fascinating stuff also appreciate the humor. I haven’t dreamt in a long time until I started taking magnesium. Im also doing Myofunctional therapy but had been practicing for months.

    1. Hey Abby,

      Thank you for reaching out and the kind words!

      Magnesium is also something I use a lot. It’s good stuff!

      Keep up with the myo. Looking to do any expansion or anything?

      Zac

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