Ep 333: Transforming airway health & smiles with MARPE featuring Dr. Svitlana Koval, DMD, MSc, BDS

What we have noticed is that the bone which is right under the nose, this ans part and the bone which is in the back where this maroon bone is, so that bone fuses the first while the bone which is in the very middle, just because there is a lot of forces that concentrate in this part of the palate and that is one of the counter forces of this call.

Welcome to the Untethered Podcast. I am your host, Holly Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway tether, dural tissue and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thank for being a loyal listener as we jump into today's episode. Remember to listen with correct oral rest posture, tongue up, lips closed, teeth apart, breathe through your nose. Let's get started. Quick disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Hi and welcome to episode 333 of the Untethered podcast. Today we have Dr. Kopal rejoining us. Dr. Copal is a leader in airway orthodontic treatment, being the top Marpi MSc provider in Florida. She's a researcher with more than 30 published articles and a book chapter on T scan, digital analysis and orthodontics. She graduated from Boston University GSCM in 2020 with magna cum laude and she's received her Master of Science degree in orthodontic specialty in 2010. Vitlana, welcome back to the podcast.

Oh, thank you, Heather for having me here. It's the second time where we're here together.

Yes, I'm excited. And, and now at this point, because the first time we recorded you were not seeing the girls yet. Right. And so now you've actually had my girls in appliances with you and they' having phenomenal results. I'm so excited.

So yes, yes, I enjoy working with them and I love the results that we got. We did auxiliary expansion for both of them and then we got around 5 millimeters of bone separation. That's cool. That's a lot.

Yeah, yeah. And a lot of people know it's like, not the first time they've had expansion too. And so I've had a lot of people comment lately, though, on their, like, photos online. They're like, wow, Their. Their smiles are so wide. And I'm like, I know. So exciting.

That's the best. That's my favorite part.

Yeah, it looks so good. So, so good. And then they've been really, really diligent about, like, wearing their Invisalign. They're so good about it. We've only had one end up in a trash next door, but we just jumped to the next tray. It was fine. So, no, they've been really good. And they even are really good at this point, being like, oh, like, it's Tuesday. I have to change my appliance. And I'm like, I'm so glad you guys remembered because I'm jet lagged and totally forgot it was Tuesday.

Underestimate how diligent they can be. Yes.

Yeah. Seven and almost ten. It's. It's incredible. So I'm very proud of them. Um, and it's. Yeah, it's definitely very cool too. Now that we're like, a little further along in their Invisalign journey for their, their lower arch, I'm seeing like, the shape of the Invisalign and I'm like, wow, it's so much wider already. And like, we're on trace 17 maybe out of like 27 at this point. And it's very, very cool to see, like, the growth and the expansion that they're having just from the Invisalign trace.

Exactly. So we, we also there. There's like a common notion that Invisalign is just for moving teeth and you cannot really develop the bone. So it, it. It really matters how you plan and design your appliance. And, and you can actually promote this bone growth by remodeling on the bottom arch, depending on how you activate. It's just like using the canvas and the paint in different ways, right?

Yeah, yeah, no, it's very cool. And like I said, they've had other expansion. We've had some results in the past expansion, but nothing like to this degree. And it's very. It's just very exciting. So I'm like, I know their airways are open. And also very interesting. Lilly had developed this chronic cough, and we were just in Italy for three weeks and the cough went away. So now I'm like, I don't think this is airway related. I think this might be, like, we need to test the house for mold. We need to look and see what the allergens are in the environment, you know, other things that could be causing it. Because for a cough that she had for like five months to just go away a week into being in Italy, I was like, oh, something else is going on here. But also I think I was able to be more not aware, but like more sure, if you will, about that. Like this is something more external because of all of the internal work that we've done and knowing that we've grown in the airway and knowing that, you know, they're pretty healthy all around. So anyways, next step on our journey.

This change in an environment just to. For us to understand that these things are related and when combined together, that gives the huge result. Huge change for a child, for a grown up.

Absolutely. And so now everyone's like, okay, Holly, like we keep hearing you talk about Murphy and I'm like, I know it's my turn. And I, you know, I. As a kid I had your regular palatal expander, your RPE followed by braces. And then I had permanent retainers upper and lower that I was told would fall out by the time I was 20. And at age 30, I asked my dentist to take them out because I was having a really hard time cleaning, especially below, like below my lower central incisors. And so they did, they removed it and immediately my teeth started to shift and I was like, oh no. And so then, you know, fast forward to getting into the myo space and realizing why that was happening and treating myself. And you know, then I went into DNA vivos, which I feel like got me some space. But what I've noticed, you know, because I had the nasal surgery I had in April of 2022, so I had the septoplasty and nasal swabody and turbinate reduction. Ever since then I've had this like post nasal trip. And it happens more in like recycled air environments, like if I'm in the car, if I'm on an airplane. But it can really happen anytime. There's other triggers too, but it's been chronic and you know, I can kind of manage it with like clear nasal spray. And it's not perfect. If I don't use it, it comes back. So, you know, I'm like, okay, this is something that's more of a band aid fix at this point. So I'm like, I don't know if something shifted with the structure of the nasal surgery that's like triggering something. I don't know. So part of me is curious to See if that changes going into marpi. But one of my big reasons for the MARPI was, you know, as you and I discussed, was, like, the spatial asymmetry that I have. Left side of my maxilla is turned, like, inward, which has been the case for a very long time, like, pre, you know, DNA vivos expansion. And honestly, I don't think I've gone back enough to even look to see, like, how long has it actually been there? Has it been there my whole life? Did it start at a certain point? I really don't know. But I do know that our goal with the vivo CNA was to try and, you know, unlock that bone. And I was working with, like, a PT who is trained in postural restoration and manual counter strain and all this other stuff. And, you know, we just kept talking about, like, how locked up everything was, and it just wasn't budging. And so part of me is excited to actually, like, split the suture line and get that. That part of my facial structure hopefully in the right place, because my lower jaw looks like it deviates a lot when I speak. And we started to notice that my, like, lower jaw was actually not off midline. It was because of the maxilla that my lower jaw is now having issues. And so in the tempo. Well, the temporomandibular joint. So now that I've woken up a couple times and had these, like, painful moments where I'm tense and I can't really open my jaw, and it hurts to chew, I'm like, all I needed was two times of that happening. Even though it resolved very quickly to be like, okay, this is the beginning of something. I'm not gonna want to continue. Like, it is time. The time is now to do something about this. And here we are, excited to go.

In for this procedure. Yeah.

So now everybody has all these questions, and I. I shared a little bit about the journey, the backstory, because while people kind of know me, I was like, let me give a little brief backstory to anybody who doesn't. But everyone's like, why are you doing this? Why are you doing marpi?

It's.

It seems invasive, and you've done other adult expansion, and you want more expansion. And I'm like, it's not even so much about that. Like, I feel like my tongue fits for the most part at rest, but I do wake up with a scalloped tongue, which tells me that I do need some more space. And clearly my airway is not where it needs to be when sleeping because of waking up with a scalloped tongue. Right. So, you know, I don't have to tell you. So will you share with everybody a little bit about like Marpy, what is it? I know we're going to do the pieza. I forget the whole name of it. Procedure to split the suture. People are asking, do you split it all the way? Do you only split it partially? And then, you know, because I have friends who have gone into Marpi and they don't have that done, they just have the appliance put in and then it splits on its own. So indulge us, tell us all the things.

I have a companion here, easier to do to explain all that. So what Mark P. Does and because we are, we're diving so deep into this in our practice, we deal with this every single day from nine to five. And we have initiated research and published one article, another one is coming. And then we do a cohort study just to analyze what, what is happening with Marpi. Because Marpi is more of an umbrella term. It's a term that combines lots of different designs. And if somebody mentions Marpi, it's not necessarily that the other person who, who used to have sort of the same treatment, that treatment was done with the exact same appliance. So Marpi could be done with different screws, with different appliance designs, with different combination of a screw and a framework with different. All of that could be. There is this, I would say, variety of appliances with different activations and with different, I would say daily activations and different outcomes. What we dive, what we have dove into is a specific design that was shown to produce a lot of facial changes besides just having the mid palatal split. And if we look at this guy, the yellow zone is the maxilla. So this big yellow bone is connecting to zygomas, to frontal bone, to some bones inside the orbit. And these, all of those connections, all those sutures that we see here, they exist in our skulls. They haven't fully fused and they are being disconnected during the course of treatment. Also because the hard palate has several bones to that. What we anticipate is that with the mypi, what needs to, what needs to happen is, you see, this yellow bone is the maxilla, is the same bone that we're expanding. But there's also another bone which is a palatine bone. So this area behind will be the vertical part of the airway, while the nasal passages are so called horizontal part of the airwave. Then it just proceeds into this vertical part which is located here in our throat. So we have to the whole purpose of what we're doing in the context of sleep apnea and breathing and sleep disordered breathing and recovering that normal breathing in our bodies, is to have the pressure within the system equal and not positive, so that there is no resistance from the atmospheric pressure to go and to access the system. So it has to be some sort of a very, very mild negative pressure that is kind of sucking this air into the system. So that's why the, all of the parts of the airway have to be wide enough with less resistance from the surrounding tissues, like muscles and mucosa that do not restrict this airflow. And that all starts with the nasal passages. So if we expand that by doing marpi, which physically expands the, the midpalatal suture and expands the nasal passages, that was shown in multiple research articles, so that increases the physical size of the nasal cavity and the, the most important part. So as you address this very important question, does it open all the way? The approach that we preach and that we follow is this yellow bone from the very beginning, from where it connects to the teeth, to the very end of it, where the, I would say, maroon part is. So it has to split all the way back. And what we found with this combination of piezo and the marpi is that once this split happens all the way to the back, that drags the side walls of the nasopharynx and the velopharynx. And it increases the size of this pharyngeal airway space because those muscles are connected to that maroon bone and they make up the walls of the pharynx of the nasopharynx and the oropharynx. So that increases the size of the airways sideways. It increases not the anterior posterior size of the airway, but it increases the lateral size of the airway. And again, we have a lot of research showing that in adults, the benefits of so called mandibular advancement. The appliances that are used to treat the sleep apnea, they increase the lateral size of the airways rather than the sagittal. So what we are used to measure as this linear AP dimension is not something that actually that needs to be measured because that doesn't change much. What changes is the cross section and the volume and the lateral size. This is what gives more room for the air to pass through the system.

Okay, that's interesting. So in, in cases where people are left to split on their own, are they splitting usually all the way back, or are they only splitting to like the point of the maroon bone that you showed us on the Skeleton usually.

Again, so that depends on this type of the screw used. In most of the screws used previously. Back in the days, the split was a triangular V shaped split that ended where this connection, the sutured between the yellow and the maroon bone was. And that ends the maroon bone. Never split it. Now when we added this piezo, we make sure that it splits all the way parallel in a nice parallel fashion with even spaces everywhere. From the, from this point, we call it ans under the nose point from pns, which is the most posterior point of the palate. So that's the whole purpose, to have a nice parallel and even expansion.

Got it. Okay. So then with this procedure, people were asking, will there be like, because you're doing the piezo, will there be less pressure in the beginning? I mean, obviously there's discomfort when you put any appliance in like this, you know, and to adjust to and everything. But in terms of that pressure, because you're doing the splitting, is there less pressure?

Because I have this appliance, I can tell it from my own experience. So I have aligners in my mouth and I have marpi in my mouth, have everything. So the appliance, when do you put the appliance in? When you do the piezo that is all covered under the same local anesthesia. So you don't feel the difference whether you do piezo or not. So you're anesthetized, you're numb, you don't feel anything. Yes, you are under some kind of recovery sensation for a day or two. This, when the anesthesia wears off, you feel some soreness, just like when somebody rips their skin on the knee. And this is, this is a healing process. After that, when you proceed with the turns, the turn doesn't feel like pain or any sort of discomfort. It just feels like a little bit of pressure. You feel it in your face, you feel it under the nose, you feel it around the nose. But it's not like, I would say a pain or a discomfort. You just know that something is happening. It presses on the surrounding structures on the bones. And what happens is that this whole mid face, this whole yellow area, it just goes forward and outward. And we get more fullness to our face with this procedure because piezo ensures that it detaches from the, from this red bone, which is right here and right here, the red bone is the bone, which is the sphenoid bone, is the bone of the base of the skull. So if, when that happens with piezo, that detaches this whole thing and this slides a little bit forward, so that is being squeezed slightly forward, and we get more fullness to the face because of that.

Okay, that. And that all makes sense. I feel like with the kids having just gone through their expanders, you know, they actually would say so, and it wasn't all the time, but occasionally I would turn their. Do their turn, and they'd be like, oh, like my nose. Like, they could feel, you know, a little something in their nose, and they'd be like. They'd be like, why does it feel like that? I'm like, well, because, you know, we're. We're changing things and things are shifting and. But they were never, like, in any significant pain or anything or major discomfort. It was just more or less like recognizing that, like, oh, I feel that, you know, here on my face. And that was. It was interesting. So that. That makes sense. Like, what you're saying sounds very similar to what they were experiencing, even. Okay, so I'm trying to think of what else people are asking. So the. The mini screw. I guess one of the biggest differences versus, like, rapid palatal expanders that are out there. Right. Is that this is physically screwed into the palate and helps to split the suture line, which does not typically happen for adults. Maybe without the screws in place. Like, we're not going to get the same results, right?

Yeah, yeah.

You typically, like, tip teeth if you have an expander as an adult without the mini screws.

Correct? Yeah.

Okay. Um, and then at what age do you feel like most kids can still do, like, the traditional rapid paddle expander? Like, not traditional, but like what Lily and Mia have versus needing the screws? Like what. What's that age tipping point?

That's. That's an amazing question. So I usually look at the dental development and the facial development overall, and the teeth retain. So like, an average. On average 10, 11 years old is like a cutoff point when I would rather go with a screw retained appliance rather than the regular expander. Not because the. The suture is fully developed, but the suture starts fusing, and that fusing is still linear. So it's just a tangent. The two halves of the maxilla, they just touch in a linear fashion. The more mature we become, the more interdigitations we develop between the two halves of the maxilla. So that becomes way, way more complicated in an adult. So if I see that a child still retains their baby teeth, the second molars, and even the first molars, which are supposed to be lost by 9, 10 years old, then I feel like we can still try to go with a regular, I would say pediatric type of expander, not screw retained. But again, the point is not the choice of appliance, but the outcome that we want to achieve. The outcome is the bone split. If we can achieve bone split without the screws, that's perfect. And the bone split that we are looking for at this age, that makes a lot of difference is anywhere from 3 to 5 millimeters of bone separation here, where we're just mentioning this nice and parallel split. So along the palatal suture everywhere, that gives a huge difference. And research has shown that with 3 millimeters and up 3, 4, 5 and up millimeters of separation of that midline separation, this is what increases the actual nasal passages volume and the airway, the oropharyngeal nasopharyngeal volume. So we do this not because we want to increase the intermolar width partially, that improves the tongue positioning, but when you, when you stretch the bones, that also lowers the palatal ball down, that makes it more, that puts it down in a closer proximity to the tongue. So when we start developing this lingual palatable suction with the tongue, it's easier to develop if you put less effort. So when we see children who struggle with their lingual palatal suction and we see a high voltage palate. Yes, I know that this child will be, will. Will have difficulties with their nasal breathing and with the lingual palatal suction because the tongue is being collapsed backwards and obstructing this airway. So expansion will go first and then complemented by myofunctional therapy, will, will get. Get us to the best results.

Yeah, absolutely. And with your adults, are you also having them then go through myo after. Absolutely marpy. Yeah. So let's talk a little bit about now that we kind of talked about tongue space and everything. Cause I love that conversation. I think that it's, it's very fascinating because as, even as a myofunctional therapist, you know, sometimes we have to stop and think, is there enough room for the tongue? Is this truly an issue with the lingual palatal suction or can they physically not achieve it because of their structures? And like you said, when you do expand and you bring the palate down, you know, it's easier for the tongue to then get up there and possibly do its job, assuming there isn't like a restriction or something else going on. So I like that conversation because it's more or less, I think in the speech pathology world, even though it's super rare. You hear people go like, well, the tongue's just too big for the mouth. No, the mouth is just too small for the tongue. Right. It's like the car doesn't fit in the garage. Which I always love when people highlight that. So thank you for mentioning that. So, a couple other things. So one thing is then the timeline for an adult. So in my case, you know, using my case as an example, can you share with everybody, like what is the timeline for how long do you typically turn the appliance? And then, I know you mentioned it, at some point we, you remove the, the, what is it? The bands from the teeth, but you keep the appliance in the palate still while I begin invisalign. And I'll have the Invisalign on the bottom as well. And then so that whole timeline and side note, invisalign, because people know I've done it before. When I did do it after my last expansion with DNA DNA vivos, it actually retracted me at the end. So in, in order to close the gaps, you know, there was some retraction. Everyone's like, don't do the last two to three trays. And that was right after I'd finished the last two to three trays. So jokes on me. But, but I know you have like a, a very specific procedure that you use in order to move the teeth forward, like one by one to close those gaps, but also to make sure we don have any retraction. So I'd love for you just kind of share timeline, share the, you know, the procedures so that we don't get retracted and all that fun stuff.

Perfect. So with DNA vivas, just to make it clear, when the appliance works, it produces more of the dental ver tipping and the spaces that develop, they develop in between the teeth more or less evenly, especially where the back teeth are. So we, we got that tipping and then in order to close the spaces, we have to retract that tipping. So that kind of reverses it a little bit. In order to overcome this, it has to be either. So the teeth should be moved or closed in some different fashion. So it also depends on how you activate those aligners and how you request that space closure. So let's go back to the timeline again. We have developed our own timeline. It might be very different from what other providers do, but this is something that we are really proud of because we combine the, the direct printed aligners and with this innovative guided piezocorticotomy, because we know where the nasal septum is. And that helps to avoid the side effects of having the nasal septum being dragged to one side rather than stay in the middle. That is the big part that the guided piece of cardiomy overcomes this asymmetrical opening and ensuring that the nasal septum remains in the middle. As to the timeline overall, we start expanding the bottom from the very beginning. So we don't wait until we get some sort of expansion to start matching it. We know that with Marpi we're aiming at a certain number of millimeters to, to get to those outcomes that we're anticipating. So improvement in nasal breathing, getting rid of this, that post nasal drip and making more room for your tongue while maintaining the nice upright position for the, for the teeth rather than having that, that tipping, buccal tipping of the teeth. So we start expanding the bottom. So big thing is that we have two options. We have either invisalign itself, which is the thermoplastic aligners, or we do have the direct printed aligners that are made of a different material and we print them directly. In our office. I move teeth myself, so I know where the teeth are. We have the CBCT merged over the intraoral scans. And I literally move teeth with my hands and with the mouth. So when we do that, I see where the maxilla is, where the teeth and usually mandibular teeth are inclined inward. And again, I'm exaggerating that, but when you just look at this, this is the trajectory between the two lingual inclined mandibular teeth. And once you upright them, you have the increased space, this trajectory becomes way wider. So the question is how to activate those mandibular teeth in order to get this pure nice uprighting with, with the root being in, in its place. But the crown tipping. So that is. Orthodontists know that this is more of a trickier movement because you have to apply controlled tipping and that is more sophisticated movement rather than the regular tipping. So that is something that we do for the mandibular advancement. Again, we combine this type of movement for mandibular expansion. Sorry. So this is one sort of movement and we also do protrude those molars which drags bone along with them and that remodels the outer plate, the outer surface of the mandible. So that is done in a sequential manner and that drags bone while expanding. It happens at a slower fashion compared to the top because the top is usually takes around on average anywhere eight to maybe 10 weeks of expansion. We start with one turn a day, then we can either keep up with one turn a day, or we can slow down a little bit to a little bit slower rate of expanding. This particular screw that we're using gives only 0.1 millimeters, so 1/10 of a millimeter per turn. So it's very, very slow. There are appliances that are also called MARPI that use an activation screw, the expansion screw itself, that gives 0.2 or 0.25 millimeters of expansion. So that is almost three times more than this one. So that is the least that we can get. We can redistribute that expansion over longer time, or we can just slow down to every other day or once in three days. That brings us to a lower rate of activation. But again, I believe that in your case, we will start with one turn per day, and then once the split happens, then we will slow down. Just because you did have this rhinoplasty and septoplasty, just to be a little bit slower, because we anticipate movement here in this area, and I want to track that and check it a little bit closer so that everything happens in a slower manner. Pattern. And again, when we do expansion with marpi, we anticipate all movements everywhere here, even in the sutures that are not directly connected to the maxilla. So this is the frontal bone, and this is the zygomatic bone. While writing the most recent article, we did some research with superimpositions before and after. So that showed movement even in this area. So movement of the zygomatic bone, this dark purple bone that goes a little bit sideways, and also that affects the suture as well. So everything in the face is being affected in a good way and developed. So the overall treatment duration is about two years. This is what to expect from it. And the mandibular advancement is a huge part of the procedure. So even though it may not appear like someone needs a mandibular advancement, but just because we're developing the mid face and we're moving all the teeth to close the spaces to over to overcome that retraction, we're moving everyone one by one with this direct aligner's approach towards the midline. And we'd redistribute those spaces. When finally we just get rid of those spaces because all the teeth are being moved forward.

Amazing. Thank you. Thank you. And so then at what point is it like right after we complete the turning that you take the bands off the teeth and we go into the direct aligners on the upper?

Correct? Correct. Yeah. The other thing is that Some patients, they just ask for more of a aesthetic option while expanding. They don't want to show off their gaps, and they estimate too much and get questions. So this, for this purpose, we do have aesthetic bondings when we just add composite and make teeth a little bit more, a little bit wider and longer, proportionally looking nice and proportionally and pleasing so that it does not attract that much of attention. While when closing the space, we just gradually remove and reduce that composite and keep closing the spaces. So, you see, I look like I don't have spacing, but I do have. So this is a part of the, of the process also that aligners help to camouflage and to hide those tiny little spaces that remain while moving everything around.

So did you, you did the composite on yourself?

I didn't do composite myself. Yeah, I maintain the gap as it is. But what I do, what I want to show is that I still do have a lot of small spaces between my front teeth. So if, if I remove this and even the most recent videos, you can see me with the, with the gap with the diastema. So it's just a couple days between. I can put my, my aligners. When I put my aligners, it just hides everything. It reflects lighted and doesn't show.

Got it. Okay. That's what I thought you meant. But I was like, I wanted to make sure because I was, it's like I was, I thought I saw diastema. For most of your journey, I didn't think. And I know that, you know, when speaking with your team, they're like, you can do this if it bothers you. And I was like, no, no. Everyone knows what I'm doing, so I really don't have plans to do that. I, you know, I feel like the gap is going to be expected and everyone's going to want to know how long the gap sticks around for. So I, you know, we're going to, we're going to roll with the gap. Okay. Amazing. And so then at what point does the appliance come out of the palette fully?

Okay, so let's say we expanded and that took around eight to ten weeks on average. Then we remove the arms, then this middle part, which is attached with the screws to the palatal bone, that remains for another six to seven months. Again, most of the research says that it takes around six months for the bone to fully fuse. What we have noticed is that the bone, which is right under the nose, this ans part, and the bone which is in the back where this maroon bone is. So that Bone fuses the first, while the bone, which is in the very middle. Just because there is a lot of forces that concentrate in this part of the palate and that is one of the counter forces of this skull. So that remains less fused or it fuses a little bit later down the road. So what I've noticed with our observations is that that part in particular fuses it around maybe 10 to 12 months after we completed the expansion. So we will have most of the palate fused while it. It could be that the, that the X ray just doesn't show this solid and thick bone that we expect there to see, but the bone is there while it's. It' being shaped. Formed. Why? Because the center of the resistance of the maxilla of this whole mid. Face is located in that mid. Mid. The area between the second and the lower. The. The distal third of the, of the. Of the palate. So it's just because of the forces and clenching forces and all of the forces, they keep reshaping this part.

Amazing. Okay, and then the big question, and you already spoke about this a little bit with kind of going a little slower to monitor the nose. So knowing that I had the rhinoplasty, the septoplasty and everything, how many millimeters of expansion did you. Did you say that you think I need? Was it 5 millimeters? Roughly 5. And so we're thinking it won't really change the shape too much. Like it might well widen things a little. Well, like, what are your thoughts? I know you're. Obviously, we don't have a magic ball, so we can't say for sure.

But so while the internal structure of the nose, it changes and it increases so this size between the two walls. But the skin, the outer, the sur. The superficial part, which is covered with the skin, it doesn't show the expansion itself. So you will not tell that you expanded your nose and it, it is 5 millimeters wider than it used to be. Why? Because while expanding the internal nasal structure, this outer surface of the maxilla is also pushed forward. So that brings more skin forward, and that kind of annihilates that expansion result by just the perception of more fullness everywhere. So that squeezes the nose, the layer of the nose, this cartilaginous part of the nose. So you don't look like your nose is expanded too much. You just show more fullness and more defined cheekbones mostly.

Amazing. All right, well, I'm looking forward to that. I know that was like one of our biggest concerns was kind of looking at, you know, my results and what I had done to know if it was even a good idea to proceed with the procedure in the beginning. So. So, yeah, here we are, we're doing the thing. So now with. When it comes to marpa, you've talked about how there are, like, different types of appliances or different approaches and everything. Does your. Does the appliance that you use, like. Or the procedure that you use have, like, a specific name to it that, like, differentiates it from other things out there? If someone's like, oh, I want what you do, other than coming to you, obviously. Like, is there. Do you know what I mean? Like, is there like a procedure process, something that's very specifically different?

So while we. We still call it Marpi, we always add this 3D guided piezo cardiomy. So it's guided. It's different than from maybe other MARPI with piezo, but it's guided. So it's different in this way. And also the protocols that also aims at the facial development. So we have applied for the trademark, which is the MRP face that produces those positive facial changes. And that, that. That shows that MARPI is not only about nasal. Increased nasal congestion improvement, this subjective symptoms, the resistance improvement, which is the objective, obviously. And it. It. It just helps to move the mid phase forward and then to advance the mandible. So that protocol is different because we're not retracting anything backwards. And the biggest part of it, we don't use braces for this. We always do all the orthodontic part of it with aligners, because aligners have more capacity to be designed and planned into development and outside movement rather than keeping everything together and close like braces do.

Interesting, because now that you say that, I've seen other people go through MARPI and then they all go into braces. So I. Yeah, I. I see the difference. Awesome. Well, I'm excited because I know you guys in your office do a really good job of documenting the process. You guys have, like, your photos and all the things, so. And I told everybody I will definitely document on my end as well. And obviously you guys have full reign to share my case and all the things. Everybody should go follow Svetlana so that you guys can make sure you see all the things that we share are there. I'm just trying to think if there's anything else. There was one other question that popped up into my mind, and now I totally lost what the question was. Oh, I don't know. All right, well, I'm sure it'll come to me later. And I can always ask, but anything else that you think people should know about it or, oh, I know what it was. Somebody asked me, they've heard about sometimes, like the mini screws or the tads, like, not succeeding in some people. Is that something that, like, you've run into a bit? Is it not really that big of a concern if we're talking about being.

Mobile or loosening up down the road? It depends on how long the appliance is in place, what we see just because of the remodeling. So if the middle part of the appliance is maintained there for too long just because of the remodeling, some of the screws, 10, 12 months down the road, they can become loose, and that is obvious. We understand why they may become loose in younger patients, teenagers, because of the very fast metabolic processes and active bone growth. So this is more likely. And it happens in teenagers. It very rarely happens in adults, especially because of the solid bone, the bone which is already grown, the screws with adequate length, that. That is enough to engage it. And just the process of treatment planning and the positioning of the screw, so angulation and engaging thick bone. We call it cortical plates. So it's a very rare almost. It does not happen in adult patients.

Good to know. I know everyone's like, are you nervous? I'm like, you know what? I'm not. It's not that I'm nervous. I'm like. It's just more of an unknown. Like, as much as someone can tell you something until you experience it yourself, it's sort of like, I don't know. I mean, I'm not a stranger to appliances or any of these, you know, ideas and concepts and the reasons behind it. And obviously, I signed up for this, but I keep telling everyone, I'm like, I just. I just don't know. I can't really tell you what I haven't experienced until, you know, I experience it. Okay. So a couple other questions did pop into my mind. So, one, you do everything in office, and it's. You guys have, like, a separate room for that. Can you just share a little bit about that?

Yeah. So all the. The procedure itself takes, I would say, maybe 30 minutes. Then we talk for another 10 minutes, and we take records just to document everything. And that our patients are confident that the procedure went well, everything is in place as planned. So that is. Everything is, of course, it's sterilized, disinfected. All the appliances come sterilized, and all the screws come sterilized. So all of this is. And I would not say that this is a surgical. Surgical procedure. It sounds like it is, but it's maybe less invasive or it could be compared to the ear piercing. So something. Something like that. Just because, yes, you have to penetrate normal tissues, soft tissues, the bone, but it. It's very similar. So. So under adequate disinfection and sterilization procedures, it's completely safe. And there are very minimal side effects or almost non side effects to this procedure in terms of the placement of the appliance. Patients have to be careful in terms of not irrigating, not using waterpig too much because the tissues are fragile, so they may bleed a little bit. So we advise against using Waterpik for the first week. We advise using just natural rinses, like warm water, salt rinse, and keeping it. And this helps with shrinking the tissue and healing it. We do not start with turning until the tissue after the PISA cardiotomy fully heals. So that takes us a week away from the procedure. And this is when we start turning so we don't get gap. We don't have a. Like a hole in our mouth that we can feel it with. No, it feels very normal. It feels like always. It's just like we understand that the appliance is there and there's a little bit of discomfort of. On how to maintain the cleaning. Cleanliness of the appliance and how to brush everything around. But that's the. The most.

I would say, like, that's just been the biggest, you know, learning curve. Even for what the kids with their appliances and they didn't have the marpy. They just had, you know, the normal. The regular expander that you do. But yeah, that's. We love. We love our water picks in this house. I actually need to order one for myself because my husband was like, I'm not sharing mine with you. Even if you got your own. He's like, you need to get your own. I'm like, okay, now we will in four. Fine, everybody has their own. But no, those water picks are great because even. Even though the girls are like, like, you know, we haven't turned their appliance in very long time, like, food still gets stuck up there and it doesn't. It bothered them in the beginning, but when we were still turning it because there wasn't a lot of space and so things would get stuck and we couldn't get it out. Now it. It's like they don't even really feel it. And so to think of the stuff that could get stuck up there. Stuck up there. If you're not actually using the water pick and cleaning it out at least once a day, you know, Lily, I know, will clean hers out and she spits, and it's like all this stuff. And I'm like, oh, my gosh. Like, did you feel that up there? She's like, no, didn't feel it at all. And I'm like, that's incredible and gross. I'm so glad it's out now. So funny. So, okay, so that's really helpful to. To understand and to know, because I think also for people to just know it's not this, like, major surgical procedure that you're undergoing. It's, you know, I think, a little settling for the mind. Another thought or question. So going back to, like, the nose and everything, do you ever see, like. And I'm even wondering this because, like, we know my maxilla is turned inwards and it's causing asymmetries. Do you ever see, like, other asymmetries created or asymmetries that just don't improve despite getting all the other benefits just because of the shape of the face or whatever may happen?

That's another great question that is out there. If the asymmetry. So what we've noticed is that when the patient comes with initial asymmetry, so let's say one cheekbone is more prominent than the other, what happens is that expansion tends to even things out. So if one side of the face was not developed enough that by even expansion, by even and reciprocal expansion, because you are not activating one side more than the other, you don't. You just push two sides away from each other. What that does, that brings this side that was underdeveloped more forward just by detaching from the rest of the bones surrounding it. What also matters is that most of the times when one side seems like it's underdeveloped, it's more teeth arrangement and teeth positions inside this vertical part of the bone, the alveolar process, the teeth angulations, their positions relative to the other side would be different. So that looks like it's asymmetrical, or one side is still underdeveloped, or one. One side moved more than the other. But this is where this treatment planning with the direct printed aligners comes in. So I've learned so much by treatment planning myself. I. I have noticed so many patterns in how the jaws split by analyzing every single case, and I've. I have come up with to a conclusion that most of the asymmetries are either related to the nasal septum being dragged to one side or. Second thing is that the teeth are located at different angles and they're pushed in on one side more than the other. So when moving teeth after marpi, you have to tackle that more rather than activating teeth in a similar manner, just like braces do. Because with braces, you put a wire that is supposed to bring the teeth to a certain perimeter, to a certain shape. But the initial and baseline angulation of the teeth, they can be different. One tooth can be angulated more, the other could be straight. Then it will be tipping here and will be tipping this even more, so they will look different at the end and that will not not be corrected. With aligners, we have more control over angulating those teeth. And when you move the root inside the bone, that reshapes the bone and that can bring more of your skin and lip lip forward as well. We've seen asymmetric bites. When one half of the nose was a little bit wider, one of the nose, like this part, the corner of the nose was a little bit wider. And when we put the bite together, the nose became perfectly symmetrical because it was not dragged, it was not pulled by the skin by the bite any longer. So it's a big thing.

Yeah. No, it's fascinating though, and to even hear the difference between like, what you can do with the aligners versus, like braces. You know, I really hadn't even thought about that before, so it's fascinating to hear that because, you know, people know I'm very, very picky and selective and who I let touch my face. And it took me years to do my, to do the nasal surgery because it wasn't until I moved here and you know, the doctor I went to was recommended that she was board certified as a, as a plastic facial surgeon and ent. And I was like, oh. And then I saw her work and I was like, oh, okay. I was like, she can touch my face. And I couldn't find that, like when I lived up in the D.C. metro area, like early, just nobody that I trusted to really do what I was looking for. And so, so, you know, anyways, so I don't, you know, don't take this lightly because I, you know, I'm just kidding. But no, it's like, I don't want to go to anybody who can just do anything or who just does a procedure. I go to people where I'm like, okay, I've observed, I've watched, I've seen the results. You know, obviously you have the cases you've written, the papers you've done, the lectures you're traveling all the time, you're constantly learning. Like, you know, I am and my colleagues and I feel like those are the people that, you know, I trust to work on myself and my kids and that I refer to. So. Okay, so anyways, last question and then if there's anything else you want to share, please do. You started to mention certain things, like some restrictions in that first week. Right. We're not going to turn anything until about a week after the procedure. You know, avoid water pick that first week, do more of like the rinses. I know I was told, I think like no working out for that first week. So like, are there, aside from like, like foods, obviously, are there any other major restrictions or even foods you recommend as people are kind of adjusting to their new appliance?

So you will feel. It will feel some, I would say maybe minor annoyance because you cannot floss in between the teeth. That was my biggest thing. I wanted it to be super clean and I was trying to get in there. Even though I have this framework and that goes behind my teeth from the inside, I managed to floss it somehow, getting from the outside and cleaning it in between. But anyway, that was my biggest thing. And I was so happy when the arms were removed after two months. That was my. The biggest thing. So that would be a challenge for the picky people who monitor their hygiene. Precisely. So I believe that you will be struggling with this for a little while. Yes. At the very beginning, what I would say is that there are some foods that have fibers to that, like pineapple or maybe oranges or something like that that will be a little bit more difficult to clean. What I usually do, I carry those disposable toothbrushes with the pre pasted toothbrushes everywhere. So I have a bunch of them in my bag. So any. Anytime I eat, I just go. And I don't need a water pick at that moment. I just, just use the soft toothbrush, goes lightly over the appliance and in between the teeth. And of course I rinse a lot because that helps the most. You clean, you kind of dislodge those pieces. I'm sorry for these details, but this is how it works. So it's not. And the biggest thing is that I snack way less in between. Right. Which is very good for my overall health. So I caught on snacking.

I just joked, I was like, well, I just ate my way through Italy for three weeks. But it's okay because getting this appliance on August 11th. So the seven pounds that I probably gained will all come off very easily.

I promise that.

Oh, my gosh. But so, like, no other, like, major restrictions, Like, I can go back to Pilates after a week. I can, like, yeah, resume.

Don't get punched in the face. That's the biggest thing.

Yeah, don't get punched in the face. I will do my best. Amazing. Well, is there anything else that you want to share about this or, you know, if not, tell everybody where to find you?

I would say that that was one of the biggest things I did for myself, and I'm super happy. Also, I love the way I can breathe. After all, it was very frustrating to wake up every morning and to feel congested every time I try to breathe. When I'm conscious, and I'm concentrating on that, I don't have this issue anymore. So that's the biggest thing. I still have a long way to go with my mandible, with my asymmetry toothpaste. So I'm moving teeth with aligners. But what I can tell is that all the treatments that we offer in our practice is everything I either did in my kids. They all went through that. So we know how this works, and it's. It's human proof. And I also do it on myself because I need to know how it feels to go through all these treatments before I offer it to my patients.

Yeah. Well, that's incredible. And I'm grateful for it. My kids are grateful for it. So thank you. So tell everybody if they're curious to know how they could do a consult with you or where to find you.

Share.

Share your contact information.

Thank you for this opportunity. So we are located in Boca Raton. We do have consults by appointments, and we do offer CBCT imaging in our office because that's a big part of the procedure. So the consultation is usually an hour long because this is how much time it usually takes to take all the records and then to discuss everything. And we have a separate room where we pull out up all the records and we discuss it together so you know what's going on with. With. With you, inside your body, inside your head. And then we discuss the treatment options as well. The office is located on military trail. It's 3020 North Military Trail in Boca Raton. And our phone number is 954-546-002056. We're very happy to see anyone who is interested in Marpi and developing airway for. For themselves and for their kids as.

Well, and you also offer myofunctional therapy in the office too, for your patients, right?

Yep.

Yes. Well, thank you again for rejoining me, for answering all the questions. I think that everyone's going to be really excited to hear about this and then to track my case and see the results. And obviously they're going to be following for the next two years. So we've got. We've got a journey ahead of us. But in that time frame, I think it'll be cool for them to also see, you know, they can go to your profile on and on Instagram and kind of go back and see where you started and like, kind of follow your journey and just even see facial changes and all the things. So I encourage everybody to go and do that and see some of the other cases you posted as well, because you've got some incredible cases just on your Instagram alone. So. So thank you for all the work that you do and for sharing all of that and for answering all the questions.

Thank you for having me. I appreciate this opportunity. Thank you.

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