Questions about my sarpe surgery (breathing problems) and MSDO

[Femto]

Hello,

I had a sarpe surgery 3 months ago to improve my breathing, at first I wanted MSE but the orthodontist told me it would be a mess with my tooth implant (1-2) as it couldn't go back in place.
He sent me to a surgeon who did Lefort 1 on me, cutting everything (nasal cavity dissection, he did a pterygomaxillary disjunction and it is useless for sure https://pubmed.ncbi.nlm.nih.gov/27524385/ etc..)

My maxillary expander is a two parts device, I’m only turning the back part to keep my front teeth closed. But the front teeth are still opening anyway every time I turn the device, so the movement are very limited.

To this day I feel like nothing changed at all, my breathing is more or less the same.
Is it possible that, with all the cut he made, only the maxilla did expand but nothing happened to my nasal cavity?

"Unlike Surgically Assisted Rapid Palatal Expansion (SARPE), due to the absence of LeFort 1 osteotomy significant expansion of not only the maxilla but also the pharynx and nasal cavity can be achieved, which can be very effective in treating obstructive sleep apnea." https://en.wikipedia.org/wiki/List_of_palatal_expanders#Bone-borne_expander


Edit: Aesthetically, it seems like my face got really narrow below my ears and it is not a weight loss. It is like my mandible body and my gonions went inward, I have a sort of posterior hollowness. I also had a MSDO and I think it is the cause of my facial width decrease but I don't really know.
I am scared the surgeon removed some bones with the disjunction is it possible?
I found this https://academic.oup.com/ejo/article/27/5/512/473595 so I turned the device backwards but my mid and lower face are still really narrower
What can I do about it?

[tyler93245]

Is it possible that, with all the cut he made, only the maxilla did expand but nothing happened to my nasal cavity?

Are you done with expansion yet? SARPE isn't highly regarded but you should feel something, atleast.

Edit: Aesthetically, it seems like my face got really narrow below my ears and it is not a weight loss. It is like my mandible body and my gonions went inward, I have a sort of posterior hollowness. I also had a MSDO and I think it is the cause of my facial width decrease but I don't really know.
I am scared the surgeon removed some bones with the disjunction is it possible?
I found this https://academic.oup.com/ejo/article/27/5/512/473595 so I turned the device backwards but my mid and lower face are still really narrower
What can I do about it?

If you don't trust your surgeon or can't ask him questions, you should find a new one. I have EASE and I'm really liking my expansion process (I'm about halfway through now). I'm having none of the issues you're having so you should begin speaking to other doctors if you can. A consult with a really skilled surgeon should only cost $300 and they might be able to give you advice on if you should keep expanding with SARPE or not.

[kavan]

Hello,

I had a sarpe surgery 3 months ago to improve my breathing, at first I wanted MSE but the orthodontist told me it would be a mess with my tooth implant (1-2) as it couldn't go back in place.
He sent me to a surgeon who did Lefort 1 on me, cutting everything (nasal cavity dissection, he did a pterygomaxillary disjunction and it is useless for sure https://pubmed.ncbi.nlm.nih.gov/27524385/ etc..)

My maxillary expander is a two parts device, I’m only turning the back part to keep my front teeth closed. But the front teeth are still opening anyway every time I turn the device, so the movement are very limited.

To this day I feel like nothing changed at all, my breathing is more or less the same.
Is it possible that, with all the cut he made, only the maxilla did expand but nothing happened to my nasal cavity?

"Unlike Surgically Assisted Rapid Palatal Expansion (SARPE), due to the absence of LeFort 1 osteotomy significant expansion of not only the maxilla but also the pharynx and nasal cavity can be achieved, which can be very effective in treating obstructive sleep apnea." https://en.wikipedia.org/wiki/List_of_palatal_expanders#Bone-borne_expander


Edit: Aesthetically, it seems like my face got really narrow below my ears and it is not a weight loss. It is like my mandible body and my gonions went inward, I have a sort of posterior hollowness. I also had a MSDO and I think it is the cause of my facial width decrease but I don't really know.
I am scared the surgeon removed some bones with the disjunction is it possible?
I found this https://academic.oup.com/ejo/article/27/5/512/473595 so I turned the device backwards but my mid and lower face are still really narrower
What can I do about it?

SARPE is for transverse maxillary deficiencies (when the maxilla is too narrow and needs to be expanded). Usually, the ortho puts in the device before a surgery and the surgery involves making some cuts aimed at getting at the palatial suture so that the 2 sides of the maxilla can move away from each other via the DEVICE aimed at that. The maxilla (or maxillae as the case may be) is 2 maxilla bones fused by the palatial suture. So, the doctor needs to cut into that a little for the expansion device to be used (by the patient turning the key to it).

The part that's concerning is the part where you say he sent you to a surgeon who did a full blown surgical dissection just to put the device in. To the best of my knowledge as it applies to minimally invasive techniques (yet no expert on all these devices), that type of extensive dissection isn't needed to put the device in and any extensive dissection should be reserved for doing the lefort which comes LATER in a SEPARATE surgery after the device has expanded the maxilla.
The article you cite bears that out, although a better title for it would be 'The NON necessity of.....' Yet both the extensive dissection and non extensive dissection achieve the expansion.

To the best of my knowledge, SARPE expands in sort of a V like way where the back of the palate (posterior) expands more than the front of it. Has to do with the palate (transverse discrepancy) being narrow closer to the back of it. But still the front of the palate (anterior) has some expansion which is why it's normal to get a SPACE between the front central incisors. Also, the 'roof' of the mouth (the palate) is also the 'floor' of the nose (nasal cavity). So, the nasal cavity is basically located above where the front of your palate is. OK.

What's really concerning here is that you say you are ONLY turning the back part to keep your front teeth closed. It's NORMAL and expected for the device to kick up a space between the 2 front teeth. After all, THAT'S the area closer to the (front) NASAL CAVITY. So, if your instructions were to turn BOTH parts of the device and you're not turning the front part of it because you don't want the front teeth to separate too much, THAT would be the most likely problem associated with the device not kicking up expansion closer to the front of the palate to expand more of the nasal cavity.

Not sure what to make of the wikipedia article you cite that says:

"Unlike Surgically Assisted Rapid Palatal Expansion (SARPE), due to the absence of LeFort 1 osteotomy significant expansion of not only the maxilla but also the pharynx and nasal cavity can be achieved, which can be very effective in treating obstructive sleep apnea." Not sure what to make of that because SARPE surgery is aimed at putting the device in doesn't really require a full blown Lefort to place it. Minimally invasive techniques can be used and later can come the full lefort.

What it sounds like here, sorry to say, is that you're reading med journals, have little to no med background to make the correct interpretations from them and making decisions on YOUR OWN as to WHICH way and which PART of the device to turn. Ya, that's what it sounds like. So, you should go back to the doctor, tell him how you're turning the device to MAKE SURE you are FOLLOWING the DIRECTIONS.

End of story.

[Femto]

Are you done with expansion yet? SARPE isn't highly regarded but you should feel something, atleast.
If you don't trust your surgeon or can't ask him questions, you should find a new one. I have EASE and I'm really liking my expansion process (I'm about halfway through now). I'm having none of the issues you're having so you should begin speaking to other doctors if you can. A consult with a really skilled surgeon should only cost $300 and they might be able to give you advice on if you should keep expanding with SARPE or not.

Yes my ortho told me to stop but I still have large black corridors, the expansion seems really minor
Unfortunately in my country there is not a lot of surgeon who does it at all

SARPE is for transverse maxillary deficiencies (when the maxilla is too narrow and needs to be expanded). Usually, the ortho puts in the device before a surgery and the surgery involves making some cuts aimed at getting at the palatial suture so that the 2 sides of the maxilla can move away from each other via the DEVICE aimed at that. The maxilla (or maxillae as the case may be) is 2 maxilla bones fused by the palatial suture. So, the doctor needs to cut into that a little for the expansion device to be used (by the patient turning the key to it).

The part that's concerning is the part where you say he sent you to a surgeon who did a full blown surgical dissection just to put the device in. To the best of my knowledge as it applies to minimally invasive techniques (yet no expert on all these devices), that type of extensive dissection isn't needed to put the device in and any extensive dissection should be reserved for doing the lefort which comes LATER in a SEPARATE surgery after the device has expanded the maxilla.
The article you cite bears that out, although a better title for it would be 'The NON necessity of.....' Yet both the extensive dissection and non extensive dissection achieve the expansion.

To the best of my knowledge, SARPE expands in sort of a V like way where the back of the palate (posterior) expands more than the front of it. Has to do with the palate (transverse discrepancy) being narrow closer to the back of it. But still the front of the palate (anterior) has some expansion which is why it's normal to get a SPACE between the front central incisors. Also, the 'roof' of the mouth (the palate) is also the 'floor' of the nose (nasal cavity). So, the nasal cavity is basically located above where the front of your palate is. OK.

What's really concerning here is that you say you are ONLY turning the back part to keep your front teeth closed. It's NORMAL and expected for the device to kick up a space between the 2 front teeth. After all, THAT'S the area closer to the (front) NASAL CAVITY. So, if your instructions were to turn BOTH parts of the device and you're not turning the front part of it because you don't want the front teeth to separate too much, THAT would be the most likely problem associated with the device not kicking up expansion closer to the front of the palate to expand more of the nasal cavity.

Not sure what to make of the wikipedia article you cite that says:

"Unlike Surgically Assisted Rapid Palatal Expansion (SARPE), due to the absence of LeFort 1 osteotomy significant expansion of not only the maxilla but also the pharynx and nasal cavity can be achieved, which can be very effective in treating obstructive sleep apnea." Not sure what to make of that because SARPE surgery is aimed at putting the device in doesn't really require a full blown Lefort to place it. Minimally invasive techniques can be used and later can come the full lefort.

What it sounds like here, sorry to say, is that you're reading med journals, have little to no med background to make the correct interpretations from them and making decisions on YOUR OWN as to WHICH way and which PART of the device to turn. Ya, that's what it sounds like. So, you should go back to the doctor, tell him how you're turning the device to MAKE SURE you are FOLLOWING the DIRECTIONS.

End of story.

"the nasal cavity is basically located above where the front of your palate is"
So, it doesn't make a lot of sense that, in the beginning of the process after I started to expand the back only as my ortho told me to do so and my front teeth started to open, I had to come at his office so he could close the gap by turning the front of the device

I didn't wanted this surgery, but my ortho told me it was the only solution with my tooth implant to not create a gap and I would breathe a lot better after it. Now I wasted money on that, I have a gap and I don't breathe better. I wonder if the best solution would be to expand anyway (with the front) and to remove my tooth implant later replace it. I don't know if it's worth it as this really invasive surgery would be a complete waste and maybe it will not change anything

For wikipedia, I wanted to point out that, as I understand (for sure I can be wrong because English isn't my native language so maybe I'm saying bs), the Lefort 1 osteotomy prevent nasal cavity expansion. And he made this cut on me


Here is pictures of my bone structure and what I think is air flow or something like that, maybe there is something that prevent me to breathe well 
http://imgur.com/a/qEw2hsn

[kavan]

OK, perhaps there was a language barrier when it sounded like you were deciding on your own as to turning the devices. So, I can assume you were doing in accordance with what the ortho told you to do.

In terms of mechanical distribution of forces, I have no reason to believe that the forces transferred to the front of the palate would be '0'/ZERO with a 2 part device where the front part of it was with aim to limit the transfer of forces because they wanted to limit the WIDTH of the GAP between the front teeth. So, it sounds like the 2 part device was with aim to limit width of gap between front teeth (which would also limit expansion to front palate and in turn limit expansion of nasal cavity). Such a limitation would be due to having a tooth implant. The 'roots' of a tooth implant don't respond to being moved via BRACES which are needed after an expansion. So, if the BREATHING you needed was related to the posterior part of the palate being too narrow, it could/would have been improved. However, if the breathing you needed was related to the front part of the palate being expanded (in which case you would be left with a WIDE GAP to be closed by braces), that would tend to explain the LIMITATION behind how they could expand with the device when the limitation was due to a tooth implant and subsequent inability for braces to close the gap between the teeth subsequent to more of an expansion to the front of the palate.

The front part of palate would still get some indirect forces transferred from the direct forces applied to the back. That relates to the type of 'V' shape pattern they see from coronal perspective and also the gap between the frontal incisors. Basically, the opening is MORE in the back where direct force of device is applied and less in the front which has to do with the forces in the back being more 'direct' and those transferred to the front getting less and less direct (indirect) on a continuum that goes from back to front. So, even if it's a 2 part device, there will still be some indirect transfer of forces to the front whether or not you turn the front part of it. But the force transfer to front would be LESS than it would be if it were a one part device. That's because not turning the front part of the device would be to resist SOME of the transfer of forces from the back. So, having somewhat of a gap between the central incisors would tend to occur.

Now, it's normal for the device to kick up a gap between the upper central incisors and for the gap to be WIDE. However, that's in situations where they can expect to close the gap via BRACES as to move the front teeth medially to close the gap. So, it's sounding like in your situation, they would need to limit the width of the gap between the front teeth. Hence the 2 part device where the front part of it helps limit the transfer of forces applied to the posterior palate. Such a limitation would most likely be due to having a tooth IMPLANT in FRONT because dental implants don't move as do natural teeth do when it comes to braces aimed at moving the teeth back into place.

All that said, since you relay you can't breath better, it sounds like that is so due to the the limitations that precluded more expansion to the front part of palate where as those limitations resolved to the inability to close a gap (caused by the expansion) because braces to do so don't move tooth implants. It also sounds like they did not choose a type of device where direct forces are applied to open up more of the front of the palate which would have kicked up MORE expansion to the front of naval cavity YET left MORE of a GAP between the teeth to close with braces whereas a tooth implant would have LIMITED that. Also any mechanical action aimed at LIMITING the transfer of forces to the front of the palate that the device exerted on the posterior part of the palate would therefore limit the expansion to the front of the nasal cavity.

I would not suggest any further (palate and/or Lefort) surgery at this point. Perhaps consult with an ENT to see if what you have can be addressed via something they could do for breathing.

By the way, your bone structure and aesthetic soft tissue profile looks EXCELLENT and well balanced.

[Femto]

OK, perhaps there was a language barrier when it sounded like you were deciding on your own as to turning the devices. So, I can assume you were doing in accordance with what the ortho told you to do.

In terms of mechanical distribution of forces, I have no reason to believe that the forces transferred to the front of the palate would be '0'/ZERO with a 2 part device where the front part of it was with aim to limit the transfer of forces because they wanted to limit the WIDTH of the GAP between the front teeth. So, it sounds like the 2 part device was with aim to limit width of gap between front teeth (which would also limit expansion to front palate and in turn limit expansion of nasal cavity). Such a limitation would be due to having a tooth implant. The 'roots' of a tooth implant don't respond to being moved via BRACES which are needed after an expansion. So, if the BREATHING you needed was related to the posterior part of the palate being too narrow, it could/would have been improved. However, if the breathing you needed was related to the front part of the palate being expanded (in which case you would be left with a WIDE GAP to be closed by braces), that would tend to explain the LIMITATION behind how they could expand with the device when the limitation was due to a tooth implant and subsequent inability for braces to close the gap between the teeth subsequent to more of an expansion to the front of the palate.

The front part of palate would still get some indirect forces transferred from the direct forces applied to the back. That relates to the type of 'V' shape pattern they see from coronal perspective and also the gap between the frontal incisors. Basically, the opening is MORE in the back where direct force of device is applied and less in the front which has to do with the forces in the back being more 'direct' and those transferred to the front getting less and less direct (indirect) on a continuum that goes from back to front. So, even if it's a 2 part device, there will still be some indirect transfer of forces to the front whether or not you turn the front part of it. But the force transfer to front would be LESS than it would be if it were a one part device. That's because not turning the front part of the device would be to resist SOME of the transfer of forces from the back. So, having somewhat of a gap between the central incisors would tend to occur.

Now, it's normal for the device to kick up a gap between the upper central incisors and for the gap to be WIDE. However, that's in situations where they can expect to close the gap via BRACES as to move the front teeth medially to close the gap. So, it's sounding like in your situation, they would need to limit the width of the gap between the front teeth. Hence the 2 part device where the front part of it helps limit the transfer of forces applied to the posterior palate. Such a limitation would most likely be due to having a tooth IMPLANT in FRONT because dental implants don't move as do natural teeth do when it comes to braces aimed at moving the teeth back into place.

All that said, since you relay you can't breath better, it sounds like that is so due to the the limitations that precluded more expansion to the front part of palate where as those limitations resolved to the inability to close a gap (caused by the expansion) because braces to do so don't move tooth implants. It also sounds like they did not choose a type of device where direct forces are applied to open up more of the front of the palate which would have kicked up MORE expansion to the front of naval cavity YET left MORE of a GAP between the teeth to close with braces whereas a tooth implant would have LIMITED that. Also any mechanical action aimed at LIMITING the transfer of forces to the front of the palate that the device exerted on the posterior part of the palate would therefore limit the expansion to the front of the nasal cavity.

I would not suggest any further (palate and/or Lefort) surgery at this point. Perhaps consult with an ENT to see if what you have can be addressed via something they could do for breathing.

By the way, your bone structure and aesthetic soft tissue profile looks EXCELLENT and well balanced.

Thank you for your answer, I don't know exactly what prevent me from breathing well (front/back/my nose/..) but I have a "hypotonia of the palatal veil"
Thank you for your advices I think I'll try to do something like balloon sinuplasty and see
Actually I have some aesthetic concerns that I will post but it is more on the front side..

[kavan]

Thank you for your answer, I don't know exactly what prevent me from breathing well (front/back/my nose/..) but I have a "hypotonia of the palatal veil"
Thank you for your advices I think I'll try to do something like balloon sinuplasty and see
Actually I have some aesthetic concerns that I will post but it is more on the front side..

Just to let you know in advance, I have no idea what that is to advise further on which medical procedures to look into or whether or not it would preclude surgery for aesthetic procedures.