Author Topic: SARPE while MMA for better breathing  (Read 4173 times)

jawguy14

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SARPE while MMA for better breathing
« on: May 22, 2024, 08:15:37 AM »
Hello everyone, I have a question regarding SARPE + MMA and can't find an answer to it. You would help me a lot if you answered this question. And sorry for my bad english btw.

I'm planning to have MMA surgery this year with CCW and downgrafting to get my sleep disorder under control. I saw that the surgeon im planning to do the surgery with, sometimes does a SARPE in the same surgery as the MMA. The MARPE would be placed on the palate by an orthodontist a few hours before the surgery.

I think that expanding the nasal cavity in addition to enlarging the upper airway through MMA makes sense because, because on the one hand, I am recessed and have an underdeveloped lower jaw, but I also have a narrow palate and have the typical empty gaps on the left and right when I smile.

So for me it's really about breathing better through the nose, thats why i would do SARPE additionally. But according to my understanding, it is impossible to expand the nasal cavity if an MMA surgery was performed at the same time.

Because in MMA with downgrafting and ccw with lefort 1, the maxilla is completely separated from the skull and then repositioned further down and forward, what creates a gap between the skull and the maxilla, which is why everything is held together with plates. Due to the Lefort cut, only the floor and the very lower part of the nasal cavity is still attached to the maxilla, the larger part of the nasal cavity is now just attached to the skull.

As far as i know, during a normal SARPE without MMA, the surgeon simply cuts the palate down the middle to ensure the split, and also makes a few Lefort 1-like incisions to weaken the overlying bone area to facilitate expansion later. Then the Marpe application is turned up little by little in the weeks after the surgery, which expands the palate.

The difference between these lefort 1 cuts in a normal SARPE in comparison to a SARPE with MMA is, that the maxilla is still connected with the skull, because the maxilla isnt repositioned further down and forward, so there is no gap through an mma-advancement. So in a normal SARPE the expansion still impacts the nasalbreathing, because the maxilla is still connected to the skull.

So is it right, that the expansion of the palate doesnt improve the nasal breathing in the scenario with SARPE+MMA at all? Because then, the expansion would only affect the maxilla and not the nasal cavity due to the gap. I would then just do the MMA and see, if my sleep problems get solved through just increasing the upper airway. If its not enough, i would wait, until the bone heals completely and then after maybe 2 years expand my palate with mse+ease or something like that. What do you think of that?

Thank you in advance.

kavan

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Re: SARPE while MMA for better breathing
« Reply #1 on: May 23, 2024, 03:05:40 PM »
I can't answer your question the way you've asked it or with reference to your understanding of things. However, if it helps, I'll go over my understanding as it relates to putting in an expansion device soon before double jaw surgery.


MMA=Maxilla Mandible advancement= DOUBLE JAW surgery

MARPE= mini screw assisted rapid palatal expansion
SARPE= surgically assisted rapid palatal expansion

You use the terms MARPE and SARPE interchangeably. I don't know the fine point difference between them. What they have in common assisted rapid expansion of the palate.

From what you say, you are going to get a device installed before the surgery to ASSIST RAPID EXPANSION OF THE PALATE. Like, it's not as if the surgeon is going to cut your palate in half and separate it during the surgery. Whether, it's a MARPE or SARPE device, it's something he's going to put in BEFORE the surgery to expand the palate later down the line. The device has a turn key that you turn at home over a period of time for the palate expansion. So right before the surgery, they can make some kind of incision to the palate that will allow expansion later down the line (at home).

Perhaps it might help to know that the ROOF of the hard palate (part of the maxilla) is also the FLOOR of the nose.The floor of the nasal cavity is the hard palate, which separates the nasal cavity from the oral cavity. So, your maxillary advancement aspect of the MMA (DJS) is advancing forward your HARD PALATE and with that is the floor of the nasal cavity. So, with the maxillary advancement, the base of the nose along with it will also be advanced. But there will be no width to width expansion of palate and hence no width to width expansion of the nasal cavity. That comes later via the expansion DEVICE put in which will allow you to turn a key to it for palate expansion after the main surgery.

If in addition to the double jaw surgery (lefort, BSSO and all advancements and rotations involved in it), you also need expansion of the hard PALATE, YES, a device can be put in there soon before surgery where you can turn the key attached to it on a daily basis for EXPANSION of the palate at home.

EXPANSION of the PALATE CAN IMPROVE NASAL BREATHING. But to expand safely and not compromise the blood supply by acutally splitting the palate in half and separating it that way, they put in an expander DEVICE which is what you are getting.

Again, the PART of the maxilla being moved is the HARD PALATE which is addition to being the ROOF of the MOUTH is the FLOOR of the nasal cavity. The main surgical procedure is the DJS (or MMA). So, the base of your nose will be ADVANCED with this. The PRE-SURGICAL installation of the rapid expansion device is for the AT HOME part to make your hard palate WIDER via turning the key to it on a gradual basis. Since the hard palate is the floor of nasal cavity, then you will have more room for breathing.

So, NO, you don't have to wait 2 years to get your palate expansion afterwards. You can get the device put in before your surgery as looks to be the plan and basically expand your palate AT HOME after your main surgery.




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jawguy14

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Re: SARPE while MMA for better breathing
« Reply #2 on: May 25, 2024, 06:16:32 AM »
Thank you for your detailed reply and your time. I've looked into the topic again and think I understand it better now.

I know that the Roof of the hard palate is also the floor of the nose. The floor therefore remains connected to the maxilla even after the Lefort 1 cut, which completely separates the upper jaw from the skull in DJS.

The maxilla is then moved forward (like the mandible), because of the DJS. If only that were to happen, it is maybe possible (the odds are higher) that the expansion of the whole nasal cavity after the surgery could be achieved by turning on the turn key of the expansion device (the exact name of the expander my surgeon uses is "GNE").

Because in this case, the maxilla is (simply put) only moved horizontally. It was not moved down in a downgrafting procedure, which would have created a gap that would have had to be filled with material (such as natural bone). The vertical distance between the skull, maxilla, hard palate and everything that goes with it remains the same.

But in my case, the posterior maxilla would be downgrafted by 3-4mm, to achieve a CCW-Rotation. This gap is then filled with material, probably natural bone. This means, that the maxilla and the skull would be "connected" again.

Back to the topic of the hard palate. The hard palate is both, the floor of the nose and the roof of the mouth. For this reason, the floor of the nose would also be expanded with the expander device in the weeks after the surgery, because this area is not affected by the Lefort 1 Cut. The hard palate isn't cut horizontally in the middle or anything weird like that, which would separate the floor of the nose and the roof of the mouth.

In my eyes, the problem is, that the floor of the nose with the area of ​​the nasal passage, which lies under the Lefort Cut, is only a very small part of the nasal passage. I have attached 3 pictures where you can see a skull example showing how my surgeon does the DJS with CCW and downgrafting. In the picture of the front view, I marked in red the area of ​​the nasal passage that I think would be expanded.

In order for the expansion to affect the whole nasal cavity, the expansion would have to involve the bones to the left and right of the large main part of the nose cavity, which lie above the Lefort cut.

I drew the areas in green. I know that good expansion (like EASE+MSE) also has an effect up to the cheekbones (which is why many people have a optically wider face after) and that the lower nasal cavity expands more than the area at the top between the eyes. It's just a rough sketch.

To have an impact on these essential areas in green, the pressure of the expansion would also have to affect the areas where the Lefort cut with the downgrafting took place.

The problem I see is stability. Because the expansion by turning on the turn key (sorry for my bad english, i dont know how to articulate it different) of the expander device happens in the weeks after the surgery. After what I read in the testimonials (but I'll ask him myself also) of the people, who did the expansion with my surgeon the same way i described it (putting in the device shortly before the surgery, then DJS, then expansion in the weeks after), the expander device only remains on the palate for a total of 4 weeks after placing it there on the surgery day.

I know that's a very short timespan for a expansion device to stay in the mouth and I'm not 100 percent sure if my surgeon would actually do it that way. I will clarify it later, but what is clear is that the actual expansion takes place shortly after the surgery.

During this period, the entire jaw is still very unstable due to the DJS. The whole thing is held together with plates, which are removed after 6 months when the bones have grown well together again. This includes the area where the Lefort 1 cut and the downgrafting took place.

In my opinion, it is therefore unlikely that the expansion would affect the areas above the Lefort cut, which would result in the majority of the nose cavity not being expanded (since it lies above the Lefort cut).

Ron from Jawhacks talks in his Youtube-Video "How MSE Works" about the DOME-Procedure (min 5:40). He explains that the sutures that connects the maxilla with the zygoma (cheek bone) are cut on both sides. This is done so that the pressure, which is created by the expansion, isnt transferred to the cheekbones. So the resistance of the cheekbones decreases, which simplifies the expansion.

However, this has the consequence that the optical changes that you get through an expansion like EASE+MSE (in which the suture between the maxilla and zygoma is not cut) cannot be achieved, because these are accomplished by pushing the zygoma/cheek bones outwards (which does not happen in the DOME, because of the cuts).

I have to admit that it is based on Rons Video not entirely clear to me whether the zygomas will be cut completely (which would be quite invasive, which I cannot really imagine) or whether incisions will only be made to weaken the areas, not to cut them completely.

In Rons Interview "Pt 3 - Dr. Vaughan Compares SARPE, DOME and MSE", Dr. Vaughan says (min 5:53), that the cuts, which are made in a normal SARPE (without DJS or something like that of course) are similar to the cuts made in a DOME. The difference is the places where the cuts are made, with SARPE the cuts are made in the area like those of the Lefort 1 cut, while the DOME cuts are like i said in the sutures between the maxilla and the cheekbones. There are also cuts made in the suture of the palate, but thats not the point here.

At min 5:35, Dr Vaughan says that the SARPE cuts are less invasive (and therefore also the DOME ones, because he says they are basically the same), which also overlaps with what I heard about the SARPE cuts in the Lefort 1 area, that they are just incisions and not a complete cut of the bone like the Lefort 1 Cut in a DJS. This complete cut must be made in a DJS in order to be able to advance the Maxilla.

With this background, in my opinion it now appears that even incisions (not complete cuts) as with DOME reduce the chance that the areas after the incisions (with DOME the cheek bones, with SARPE the bones above the Lefort 1 cutting area) get changed/influenced by the palate expansion.

By this logic, SARPE procedures would admittedly reduce the chances of significantly improving nasal breathing. I know that there are still people who have improved nasal breathing after the SARPE procedure and also Dr. Vaughan says in the interview that he and Dr ting use SARPE and DOME to primarily improve nasal breathing, which doesn't make complete sense to me. But I think that it is simply the case with incisions that they reduce the chances of improved nasal breathing through a SARPE, but that its still possible, that the nasal cavity above the Lefort incision areas can be expanded. Correct me if you think different or i get something wrong.

Referring to my case, where not only incisions, but a complete cut is made with Lefort 1 (+ the downgrafting and the added bone material, which makes it even more less likely) I think it is very unlikely that the expansion shortly after the DJS would improve my nasal breathing (in a significant amount).

Sorry for the long article. This is just my perspective and how I see everything, you're welcome to share your perspective.

kavan

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Re: SARPE while MMA for better breathing
« Reply #3 on: May 25, 2024, 03:43:48 PM »
I'm sorry. Your response to my entry is quite excessive. All I wanted to point out was that the roof of the hard palate is the floor of the nose and that an expansion device could be placed during the time of the surgery for palate expansion later down the line and there is no preclusion of adding an expansion device right before the surgery. I added that because it wasn't clear to me from your text that you knew that salient relationship of 'Yes an expansion device can be installed during the main surgery.' I did not expect my entry (which I added 'just in case' you needed clarity that that the hard palate aspect of the maxilla was BOTH the roof of the mouth and floor of nose) would elicit discussions on different types of devices and reference to You Tube videos.

Undoubtedly, there are different types of expansion devices and extents and types of cuts for the type of expansion one is aiming for. As to the floor of nose, some have their increases to the posterior maxilla, others to anterior maxilla and to the best of my knowledge, the MSE expands evenly throughout. However, I don't know all the fine point distinctions between all the different modalities. But ya, if the aim of an MSE was to also expand the cheek bones, a cut in addition to the suture of the palate would be needed for their release.

 Also, I shall add that when we use the term 'maxilla', it is a complex butterfly type bone. The HARD PALATE is part of the maxilla being displaced DJS. If you look at a ceph diagram the hard palate (part of maxilla that is displaced) is referred to as ANS-PNS. (anterior nasal spine to posterior nasal spine). All L1 cuts aimed at disjointing and displacing the hard palate by definition also disjoint from the rest of the maxilla parts of scull that are not the hard palate.

With palate expansion the nasal cavity is going to increase somewhere and palate expansion is associated with increasing the width of the nasal cavity. But the main factor associated with better breathing is the CCW-with posterior downgraft along with the advancement of both jaws because it makes more volume to the airway.

I'm unable to address all the specifics you cite here that resolve to whether or not what ever type of expansion your doctor plans to do will give you better nose breathing other than to suggest that if you actually have a NARROW palate (like buccal corridors--black spaces where the back teeth are in shadow) would tend to be improved.

I think the type of complexities and minutia here that concern you are best put forth to the doctor. I'm a loss to address them all.




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jawguy14

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Re: SARPE while MMA for better breathing
« Reply #4 on: May 28, 2024, 02:51:45 AM »
I made the text that extensive because I tried to convey my thought process in as much detail as possible.

To put it more simple: What are the odds that palate expansion (via a expander device) will impact the nasal cavity if expansion is performed shortly after DJS with CCW and posterior downgraft. Regarding the stability of the area, where the LF1 took place and the skull and the maxilla are now connected to the additional bone of the downgrafting.

GJ

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Re: SARPE while MMA for better breathing
« Reply #5 on: May 29, 2024, 09:53:45 AM »
I made the text that extensive because I tried to convey my thought process in as much detail as possible.

To put it more simple: What are the odds that palate expansion (via a expander device) will impact the nasal cavity if expansion is performed shortly after DJS with CCW and posterior downgraft. Regarding the stability of the area, where the LF1 took place and the skull and the maxilla are now connected to the additional bone of the downgrafting.

I'm not convinced palate expansion is possible with stable results in adults, and might even cause complications to the tissue, etc. How old are you?
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kavan

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Re: SARPE while MMA for better breathing
« Reply #6 on: May 29, 2024, 06:21:22 PM »
I made the text that extensive because I tried to convey my thought process in as much detail as possible.

To put it more simple: What are the odds that palate expansion (via a expander device) will impact the nasal cavity if expansion is performed shortly after DJS with CCW and posterior downgraft. Regarding the stability of the area, where the LF1 took place and the skull and the maxilla are now connected to the additional bone of the downgrafting.

Try thinking in terms of getting the palate expander IF you need a wider palate for say a better smile like if you have buccal corridors hiding the back of your smile. If in addition to  it widening the palate it also helps nasal breathing than great.
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