Episode 63: Getting Down To The Root Cause With Brian Hockel, DDS

Hi and welcome to episode 63 of the Untethered podcast. Today we have Dr. Brian Hockel joining us. Dr. Brian is a graduate of the UCSF School of Dentistry. After graduating, he practiced with his father for 11 years and has continued the family traditions for the next 20 years. Dr. Bryan's experience has spanned cosmetic, restorative and orthodontic care and he is active in the American Academy of Gnathologic Orthopedics, the American Academy of Cosmetic Dentistry, the North American association of Facial Orthotropics, and the American Academy of dental sleep medicine. Dr. Hockel is one of the only Northern California dentists who practices and teaches airway orthodontics and orthotropics methods to improve airways and the facial growth for young kids. Dr. Hockel and his wife Beth have 11 children aged from 12 to 28, six boys and five girls. 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. Welcome to the Untethered Podcast. Hi, I'm your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist, SLP 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, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Brian, thank you so much for joining me on the Untethered Podcast today. I'm really excited to have you here.

My pleasure. It's great to be here with you, Holly.

So let's jump right on in and talk about the root cause of all things airway, you know, postural issues, orthodontic issues that you see as a dentist and with patients coming to your office.

It's a good question, a good topic, because right now the conventional wisdom is that the way we grow is because of genetics for the most part, and we're just pretty much doomed to grow the way that our genetics tell us to grow. There isn't a lot of research and there isn't a lot of evidence for that being the case. And if you can just think of examples of identical twins where they have the same genes but one of them mouth breathes her whole life and the other doesn't, they can grow to look really, really different. So to me, the best answer for explaining what the root causes are kind of comes back to the causes of what causes of airway issues, myofunctional issues, crooked teeth issues. I mean, if we. I'm gonna go ahead and just show you a picture here of how we can grow either more forward or more downward and backward. Two general directions our face will tend to grow. The better looking faces tend to have more forward horizontal growth, like on the left there. The rest of us tend to have some amount of vertical growth. And it turns out that when you look at some of the things behind that, lip posture, tongue posture and jaw posture are some of the biggest influences. We might think it looks kind of cool to have that lips apart look, but this is a little illustration I did some time ago that it really doesn't look that good. But it also turns out it makes a difference in how the jaws grow. So the open mouth posture is going to tend to promote more downward and backward vertical growth. Lips together, teeth together, and the tongue to the palate. That's really the answer yes and no to your question. Because then the next question will be, okay, well, why aren't the lips together? Why aren't tongues to the palates all the time and why are the jaws apart? That's a more complicated and difficult thing to try and solve. And that's why people like you are never going to run out of patience to be able to treat. Good mouth posture is going to lead to decent growth. But this boy started opening his mouth to breathe at age 10 and his face grew very, very different down the road. Oops, sorry, let me go back to that. Here he is at age 17 having. Hello, here we go. There he is. Look at how the lower half of his face just, it just melted down and backward. That's because he got a pet that he was allergic to at age 17, at age 10 and because of the allergies, started mouth breathing. So the face grows according to the posture it assumes. And this was John Mewes brilliance of what he calls the tropic premise that the direction the jaws grow in is going to be a result of the posture that they assume. So you want lips together, teeth together, and the tongue to the palate in general. And you're going to have more of the growth on the right if you have that. Otherwise you get more vertical growth under the surface. This affects the airway. So if the jaws haven't grown as far forward as they should, in Bill Hang's illustration here, the airway is not going to be as wide behind the soft palate, behind the tongue. John Remmers, the Harvard trained physician who coined the term obstructive sleep apnea, said, it's a structural disease. If our jaws just grew forward to the place where they belong, we wouldn't have the disease. So the way we posture our mouth leads to how we grow and then how we grow leads to the structural dimensions of the airway, among other things. So I think that's kind of the longer answer to your question there. Hopefully that helps.

Yeah, absolutely. And you know, I've seen a lot of these pictures and these descriptors and a lot of the courses I've taken. And so, I mean, you're speaking my language, right. But I think this is information that is not well understood or even readily available to either parents who have no clue why their child's face is changing and they don't even recognize that there even are changes present. I've got families who come in and will say, well, does your child generally have an open mouth posture when they're sitting in front of the tv or when they're reading a book or they're not speaking or eating or when they're sleeping, do you hear them breathing? Are they snoring? And they might know if they snore or not, but they have no clue if their child's mouth is hanging open. And so I go, okay, well, go home and call me tomorrow, let me know what you observed today and tonight. Because it's a real issue that nobody has trained anybody to even be aware of. And it's goes beyond parents, even into professionals. Professionals don't realize this is an issue.

Yeah, it is slowly getting out there and you get the kids putting down each other in the series Stranger Thing by looking at each other, going, mouth breather. It's kind of, it's becoming a little bit more understood. But you're right, parents, unless you tell them and you raise their awareness and then they notice all the kids around them doing the same thing. I think there was one study that said it's something like 88% of the time in industrialized countries, children have their mouths open. So it's a very common thing.

Yeah. And we know when the mouth is open and the tongue is low in the mouth, and there's this orofacial myofunctional disorder going on that, you know, we can train, we can train the tongue to rest up in the palate, to close those lips if we have a patent airway. But let's talk about tongue space because I know that's another topic that you, you discuss. And we always want to increase that tongue space if we can, if it's an issue. So can you talk about that a bit?

Yeah. It becomes a catch 22 because the tongue is. The job of the tongue is to create the home it's going to live in. And if it doesn't do its job, if the tongue is down low, then the palate is going to be narrow and down and back and it can get to a point in life and pretty early on. I mean, even by age 7, 8, 9, 10, if the palate is not developing to its potential, it can get to the point where the tongue can't fit up there. And just doing exercises or just telling a kid to put their tongue up there can be very frustrating because there just isn't room at that point. So then it requires both reshaping of the size of the box that the tong lives in. And I try to caution people, don't use the word palate expansion. It's not just the palate. I mean, the palate's the lid on the box and the lower jaw is the box under the lid. You can't just make the lid bigger and not make the box bigger. It takes both upper and lower expansion. And in the handout that I gave you that we can offer to people, it has a little thing. I sat down one day, I got so frustrated about this, I thought, let's just write. I want to write some thoughts on expansion because people say, I think he needs palate expansion. And. Yeah, but it's not just palate. And also it's probably not just a side to side thing because it's a forward backward thing. And all those pictures I was just showing you horizontal and vertical growth, it's a forward backward thing that the upper jaw is dropping down and back. So just doing expansion in a way is missing the other whole dimension of the anterior posterior position of the jaw.

Yeah, and that makes a lot of sense because I work with a variety of children with a variety of appliances from a variety of providers in the area. And some are airway centric and some are not so much. Some are putting in growth appliances like DNA with, you know, young children and adults and they've got ALS and MRNA and just, you know, all different types of. And they have a whole. Actually the dentist that I work closely with have a whole variety that the two of them use because not one appliance is appropriate for every person, which I love about them. But then I also get the kids who come to me with the tongue cribs and because they figured out a way to get their tongue in of front, front of his tongue crib and continue to push those forward. And you know, and so there's definitely, we're definitely still up against some old school information here.

Well, using anything to increase the size of the box that the tongue lives in is going to be good. And it's almost less important what appliance you use to do it than it is that you do it and do it enough and then try and get it out of there and let the tongue take over. Try to train the tongue. You can hold it with appliances that are really minimal bulk, but getting out and letting the myofunctional element be addressed. And if there's a tethered tongue, obviously that has to be addressed as well. But when you asked the question, I thought about the issue people talk about. They have a really high vaulted palate. Take a look at that high palate. What do you think? Doesn't that high palate look like it's a problem? Well, let me give you the other perspective on high palates, because remember what I said the tongue is supposed to do. It's supposed to make the upper teeth, the upper jaw grow wider and upward and forward. It's when the tongue doesn't do that that everything drops down, that now the palate is relatively high. It's high relative to the teeth because the teeth have dropped down. It's not the palate that got sucked up into the nose and, and make the septum deviate in order to allow that. It's not that. It's the alveolar bone and the teeth dropping down so low that the palate has been left way up high behind. So it's never a goal to get the palate to come down, but it looks like it's come down when you properly expand and advance and develop the size of the maxillary arch.

And that's fascinating for you to say that I'm actually in a DNA myself right now and I'm not wearing it at the moment, obviously. And my four and a half year old has been in an ALS since last August and she's almost done with her top and bottom. You know, we're both doing top and bottom expansion. So, yeah, I mean, we are both experiencing it all firsthand and it's very cool to do that. But there is discussions in a lot of the groups that, you know, your palate is the roof of your mouth, is the floor of your nose, and if you have this high narrow palate, it's going to impact, you know, nasal breathing. So what is your thought on that? It sounds like you disagree with that statement on some level.

Well, I disagree with the image that it conjures up which is that the palate goes up into the nose and that restricts the nose. Yes, of course it's the floor of the nose and the roof of the mouth. But I think it's probably more just the development laterally and forward. If you develop that to get more room for the teeth and more room for the tongue, you're also developing the base of the nose. So insofar as the mouth has ended up the wrong shape because of downward narrowing backward growth, then the floor of the nose is also going to be narrow. So when we use an expander that attaches to the palate and it actually physically opens that suture in a non growing patient, we're getting more room for the mouth, which helps the teeth and tongue, but we're also getting more room in the nasal cavity. It helps the airway as well.

Yeah, yeah. And I've seen all these benefits firsthand, which has been amazing. So. Yeah, thank you, that's very helpful. What about your thoughts on, you know, not. Because I get this a lot from some of our really, we've got some really great orthos, really well known orthos, you know, in the area they refer for myofunctional therapy. But then they also still tell families, well, we should wait until those six year molars grow in to see if we even still need expansion. And these are the kids who have the collapsed palates. You know, they've, you can see that that tongue is not up there and we can try myo, but we're not entirely sure that it's going to do the trick right now. What are your thoughts on that?

I think the earlier the better. I think that it's not too early to have a discussion even before a child is born because there's so much we know now about things that can stack the odds in favor of the child. And this is not a guarantee. A lot of people you listen to make it sound like if you just breastfeed, if you just avoid the bottles and pacifiers and sippy cups and transition to solid foods as soon as you can, everything's going to be fine. Those are all important things to do. But sometimes people do those and then there's still a problem with the growth, there's still issues with oral posture. So we really understand everything we need to know. But what little we do understand is worth conveying to an expectant mother and even to a mother of a newborn looking for tethered tissues and the mother of the one and two year old looking for mode of breathing, looking for mouth posture. There's stuff that we can counsel on at that age. It's not like we're going to put braces on, but if not the orthodontic and facial growth type of practitioner, then who's going to do that? Not everyone sees a lactation consultant, not everyone sees the other professionals who are generally tuned into this. So I think it's good to talk about moms, about the baby they may be having in the future, as early as possible. But for an actual visit to start, actual intervention, maybe somewhere around three or four, it depends on the cooperation level of the child. It's not too early to say, come in around then for more definitive treatment. But how do you know they need definitive treatment? And what about that lost time in the few years before that with things that could have been done differently to be prevented? The future is going to be about prevention. It's not about all these fancy appliances. We have to intervene at a later age when the ship has already sailed. It's really up further upstream that we're going to need to know more about how to intervene.

Yeah, yeah. Well, I'm happy to hear you say that as well because my, my now four and a half year old started right before her fourth birthday last August. And she's a super compliant patient and you know, she definitely is a picky eater. She had that tongue tied. It got, you know, nobody said she had it and I wasn't really fully thrown into this rabbit hole of all things hots, myo and airway at that point. She's really my reason why I got into everything that I'm in now.

She got the tongue tie.

She did it too. Yeah, she was two years old. So we did the release at two with Dr. James Ryan and he's amazing. He's the oral surgeon that we refer to locally. And so he did my tongue tie after my second one was born. He did my second ones at day five of life because I knew what to look for at that point. You know, nobody in the hospital diagnosed it until I said something and then they wanted the hospital surgeon to release it and I said, don't touch my baby's mouth. I'm going to Dr. Ryan. But yeah, you know, if you to see the difference even between my first child and my second child when I treated at age 2 versus 5 days of life. And then myself as an adult, and I've had braces invisalign permanent upper and lower bar retainers behind my teeth until maybe, I don't know, five years ago when I finally was like, well, should we take these out? They were supposed to come out, like, you know, they told me they'd be out by the time I was 20. Well, that clearly hasn't happened. I'm way older than that. So. Yeah. And then everything started to shift as soon as we took that out. So I was like, oh, we have a problem.

Hello. Was it on the. On the upper and the lower. The bonded bars?

Yep, upper and lower bars. And yeah, as soon as they took them out, I even said to my dentist at the time, I said, my lower teeth are shifting. And he said, no, no, no, they're fine, they're fine. And I was like, they are not fine. I can tell they're not fine. Like, look, this one's turned a little bit. And you. Oh, you're fine. And I was like, okay. And sure enough. So I. He retired. And I go now to a friend I actually grew up with who is an airway centric dentist and owns one of the practices who's local to me, doctor. And so it's just been amazing to work with her and her team because they are airway centric and they understand all of this. And so we've been on this journey together. But to be a patient in it obviously opens up your world in a very different way too.

Yeah, yeah. Well, it's good that you got the wire out of the upper, especially because the osteopaths talk to us about how that binds up the motion. The two sides of the maxilla, which aren't fused, they actually move slight amounts. And it turns out when you bond them together with anything crossing the midline with attached to the teeth, that it prevents that kind of cranial movement. There isn't that issue on the lowers, but yeah, it's good. I must have felt good to get that out.

So it's funny you say that because I now have a cross bite, an open bite. You've got like all kinds. I'm in expansion. So now my bite's completely messed up and been almost two years. And I won't let you know. I'm like, we're not stopping yet because I'm working with a manual therapist who is working actually to turn my maxilla on my left side because it wants to collapse inward. And so the fact that you said that he's been getting in there and trying to see, well, what can we do with the cranial motion. He does this modern counterstrain technique along with some other stuff. And I've seen him work wonders on my patients. He's actually in our dentist's office one day a week as well. And so, yeah, it's been amazing. But that was a really fascinating tip that you gave someone. Oh, yeah. That's probably exactly why my maxilla wants to, you know, turn in on one side. It's so used to having been held in place, and now my entire bite is completely messed up, so.

Right. Well, enjoy.

Thank you. Yeah. So, you know, and I love how you also. You mentioned here the first thing that you list is that straight teeth are great, but airway takes the priority. So let's talk a little bit about that.

Okay. Yeah. I mean, we're trained in orthodontics to line up teeth and make them fit in a certain way. There was a group of people, the American Board of Orthodontics, that came up with guidelines for how an ideal bite should fit. And it was through observation of teeth. But there really isn't science behind that. We kind of just have taken for granted for a long time, well over a century, what the natural arrangement of teeth should be. And so the whole study of orthodontics has been about how can we. How can we achieve that goal? Oftentimes on jaws that aren't arranged ideally. So sometimes we have to look for ways to just make the teeth fit when the foundations are off. There's a lot to try and do that. I mean, the mechanics of using braces or Invisalign or any kind of appliances that we use, it's challenging to do that. It becomes this mental game. But we get into a trap with it, thinking that that is the game. And we often miss that. There's a bigger picture going on around the teeth. And so the focus on airway has led people to question, what are different arrangements of teeth? What's the meaning of different arrangements of teeth with regard to the airway? How does it change things with the airway? And there's a study that was done in China, taking people whose teeth stuck out a lot, where bicuspids were extracted and the teeth were brought back into good alignment. And it doesn't take a genius. You can ask any patient or little kid, if I take your teeth and I'm going to bring them from here and bring them back there, do you think your tongue has more room behind your teeth or less room? It's kind of just common sense. You almost don't need a study to think through that kind of common sense. The spinal column isn't going anywhere. And if the teeth are coming back closer to the spinal column, there's a limited amount of space in there. So that the result, the conclusion of the study was that the airway got smaller at different levels behind those teeth that were retracted. So straightening teeth is still always a goal because we like straight teeth, especially in the US as opposed to some other countries, it's not as much of a priority. But when we can straighten teeth and at the same time not make the airway worse or not take a chance of the airway getting worse, then I think we're getting a bonus. And if we can straighten the teeth and make the airway better, that's even better. And if there's already an existing airway problem, it may not be full on sleep apnea. For a lot of women like you, a thin, fit woman is more likely to have upper airway resistance. And that will often get missed, obviously in the diagnosis. But if there's anything we can do that can tip the scale toward helping that, then why not take the chance to do that? It just requires a little bit different thinking. It's like the sun does not go around the earth. There's a different way of thinking about what's fixed and what's movable and what we can do. So, yeah, that moving teeth affects the airway and trying to do it in a way so that it will help. But a lot of the response to that would be, well, but I do this or that kind of treatment and technically it might be pulling teeth backward in the face. And I've never seen a problem from that. In fact, I even have head film X rays showing that the airway didn't get smaller. Whatever. It is true that at times teeth can be pulled backward in the face for various reasons and different types of treatment and maybe not cause an immediate problem with the airway. But here's what I know for sure is that you can't tell me which cases for sure are going to be like that and which cases for sure might actually have an airway problem. So until you figure out a way for you to tell me where the risk is, I'm going to just go with what I know for sure. And that is it's better not to take a risk. And with the uncertainty there, it's better not to retract teeth at all. If you can avoid it. Don't retract teeth at All. Now, obviously, a front tooth sticking out at a tremendous angle a little bit like that is not going to tend to be a problem. And you can't leave teeth at a weird, crazy angulation. But those are exceptions. That's not the norm. What I'm talking about is Class 2 cases where the upper jaw is back too far and the lower jaw is further too far back. I notice. I didn't say the upper jaw is sticking out. The upper jaw is back too far to take that and fix the bite by bringing the upper backward. With any number of different kinds of appliances that we have, some are way more efficient than others. Back in the old days, it was the headgear. Any of those appliances has the writ. The potential to cause a risk to the airway. And like I said, until you can tell me for sure 100% that I'm not going to be causing a risk, then I'm just not going to do it. I'll stay safe.

Yeah. And that's an interesting topic because I do get a lot of kids who come to me after their orthodontics have been complete or right before they're about to get their braces off and that expander out. We're seeing a lot, not a lot, but there are some people who will leave that palatal expander in while the braces are in. I know when I was younger, that's not what they did. They put the palatable expander in for three months. It came out and then they put in the braces. And after the braces came out, I went into either a permanent retainer or whatever, whatever the plan was at that point.

And things relapsed a lot after those three months of expansion because it wasn't held. Number one, it didn't go far enough. Number two, it probably didn't involve the lower as much as it should. And number three, it wasn't held.

Yeah, yeah. So, I mean, whatever they did that then was held by those front bars and lower bars.

It.

I don't know what, maybe it didn't hold, but it made my teeth look straight. Right. So I thought my teeth were great. I thought I had a great bite because, you know, and even my husband says, I married you for your teeth. You had really great straight teeth. He's like, you're a good horse. I'm like, well, now they're all jacked up. Sorry, honey.

Yeah. Good thing we've been married for a while.

Exactly. But we get a lot of kids. You know, it's always that catch 22. We get these kids, these parents who spend a ton of money on orthodontic work. And now they're coming to us because they're going, oops, there's a tongue thrust. We're pushing those teeth forward. And we've already spent all this money in orthodontia. Let's see if we can like stop what's going on and maybe even bring back. And I look in these mouths and I'm like, this child has the most narrow palate, top and bottom. They match beautifully. The bite looks beautiful from the standpoint of the teeth all matching up and sitting nicely together. I'm like, but holy cow, like, where does the tongue fit in its mouth? And I even have, you know, I have a therapist who I just assessed who is going to go into upper and lower expansion. And same as an adult, same situation with a slew of symptoms. So my argument is whether or not they are impacted by airway now. Well, we take those scans and we see, well, you know, you can like your argument before. We don't know which kids it will or will not affect airway wise. I still feel like I'm on. I feel like we're gonna have a lot of issues as adults with other, you know, cranial related. Everything is connected to the tongue. Everything is connected.

Built into that guarantee I want you to give me is not only that I won't be putting the airway at risk right now, but that I won't at any point in the future for that. For that child's life.

Right. Which you can't do.

Yeah. You can't. Yeah. So why take the chance? And here's the flip side to that. Those of us who do this, and we've had the opportunity to increase the tongue space later on in life, bring the front teeth forward later on in life, reopen the spaces where those teeth were removed later on in life. And we've seen what patients go through and we hear what they tell us about the changes that help them with. We know that there's a connection there, or else why would we be able to reverse it in so many people later on?

Yeah. Yeah. So, I mean, I think a lot of parents feel like they're getting started early at six or seven or eight or nine, and, you know, I'm that first crazy person that they hear tell them, oh, no, you have to go see this other dentist because your child's three and a half. But we need to get started, like, you know, like, go talk to them. Maybe we can start now. And they're like, Now, I wasn't budgeting for that. I wasn't budgeting for any of this. So I think we, you know, and that was part of why last summer I literally got on to look for a podcast on this topic to start listening to it. It didn't exist. And I was like, look, man, I have to create this. So here we are. It's working toward. You have your work toward optimal breathing and oral posture. I think everything is interconnected, and I think that's just so important for general health. And so I love these seven tips you have here. And we'll definitely share these guidelines in here.

Yeah. To send a patient to you to train the tongue to fit in arches that are too small later on is a backward way of looking at it. I mean, kudos to them for recognizing the tongue should fit in there. But the whole thing about a tongue thrust, I don't know. I used to emphasize that so much in the late 70s, Bill Zickifoos wrote a chapter in my dad's book that was published in 81 about myofunctional therapy. And at that time, the whole emphasis was on thrusting. And that maybe it's good for someone doing orthodontics to recommend to recognize that that's happened for some kids or to make the connection between a posterior open bite or bilateral posterior open bite or an anterior open bite. And to think that it's the thrusting that's causing that. I don't think it's the thrusting. I think it's the constant, just passive positioning of the tongue in those places. Why? Because the kid's an idiot? No, because it's got nowhere else to go. Because we're an idiot. By thinking the tongue is going to fit into a 29 or 30 millimeter molar width. It's really. I mean, when you look at the skulls, before we started to grow more downward and backward, 42 to 44 millimeters was not an unusual width. And that's still a goal that we'll have when we're widening for a growing child. Try to aim for 42 to 44 millimeters at the gum line of the upper first molars for a width. It's gonna leave extra space for some kids to do that, but there's no law against it. Turned out I checked it and there's no law against having extra space between some of the teeth. So it can be done.

Yeah, well, and I. That's a great point too, because, you know, while I get those referrals for the child who is tongue thrusting, I was actually taught by Sandra Holtzman and Becky who, Becky Ellsworth, when they were. They were still part of the iao and now they're out on their own. But I was taught through them when they were the IA in the iom and part of that course I knew at that point, and I'm sure they still teach this, is that it's not the tongue for us, like you said, it is not the, you know, sure, we swallow thousands of times a day. That's not what we think is actually causing the open bite or, you know, the issue of the tongue. It's the oral rest posture, like you said. Where is the tongue at rest? What is the intensity of the tongue pushing against the teeth or through the teeth? You know, where is it resting? And that's really. That's what's going to change the bite. So I don't really have that argument with my local providers per se. I'm glad that they're just referring because they notice that something is going on. And so I often will use the word like tongue thrust or other terms that I used to school people on and say, no, it's not really that it's a tongue forward rest posture or a tongue forward swallow, but really we think it's the rest posture. So I love when other providers bring these things up because it just. That's what it's like music to my ears.

Yeah, restoral posture. That's what it's all about, the restoral posture. My friend Simon Wong makes the analogy. He said it's like three different pairs. The lips are a pair, the tongue and the palate are a pair, and the upper and lower jaws are a pair. And he said all the pairs need to be together, spend time together, he says, like married couples. If they spend time together pointing in the same direction, they're going to grow in the same direction. They spend time apart, pointed in opposite directions, they're going to grow apart. And it's kind of an image for you of how that works. But that's John Mew's tropic premise. Position the jaws and the mouth commonly assume is going to determine the direction of the growth. So when your lower front teeth started crowding after the wire was debonded, there was something about your mouth posture that wasn't in balance that was working against that. It's not like they had springs on them and they remembered their original position from years ago and they just went right back to that original position. It was the muscles around them creating an environment where the influence was more toward the crowding.

Yeah. And they had even put something on initially, and it may even have had some sort of springs on it, and it wouldn't stay in. And so then they took that off, they put something else on that was just the wire. And as the ends of the wires would start to come off of each tooth, they would just cut it off that one tooth, leave it in off the rest. And I was like, is this really actually helping anything at this point? And they just reassured me and they, you know, now, of course, it's really challenging to keep it, you know, clean and not have buildup back there, because as much as you try to get the glue off the back of your teeth, it definitely changes the back of those upper and lower teeth that the bar was glued to for so long. So I'm like, this is. It's a constant reminder in my brain of all the dent. All the orthodontic and dental work I've been through. But, yeah, we're headed in a good direction now. And it's. I've got great expansion. My tongue fits up there. I was really picky of the dentist. My friend, she said to me, she's like, so, do you think you're done? You can judge is your tongue. I was like, no, you know what? I don't have enough space between my back molars for the posterior portion of my tongue to fit up there. We still need to keep going. Let's keep doing this a little longer.

Good, good.

Yeah.

Well, people will not realize that it's the posture that affects that. And I think that's one of the biggest educational things. It's the difference between treating a symptom and treating the cause, treating the disease. Disease is really the oral posture, and the symptom is the crooked teeth that want to go back to where they are. But since we aren't confident, at least I'll speak for myself. I'm not confident that I'm going to be able to get someone's oral posture corrected 100% and be able to guarantee them. Your mouth posture is now going to be able to take over and be the retainer. Now, in orthotropics and in postural, orthodontics, I mean, that would be the ideal to correct the mouth posture all the way and to just know that from here forward, your mouth posture is going to be perfect the rest of your life. But because I have a hard time saying that, because having the teeth stay straight is a priority, I think having retainers is still a worthwhile strategy. But we have to know that to the degree that a retainer doesn't work, it's, it's that there's an imbalance underlying. And losing the retainer for a week and finding out that things shift, that tells us something. You've got a muscular imbalance there that needs to be dealt with to get that on your side too. The retainer is part of what you need on your side. But good to have all the muscles working with you too.

Yeah. I mean, I've even had kids who say they wear the retainer. Who knows I'm not there, but they say they wear it and their teeth are still shifting and you have to look at where the tongue is resting and you have to wonder, is that tongue stronger than that retainer too?

Oh, yeah. I mean, my daughter, one of my daughters, has perfectly straight, wide upper teeth, perfectly straight, wide lower teeth. But because of her oral posture, the two arches are just slowly moving away from each other, staying nice and straight. So the retainer isn't going to stop everything. That's why myofunctional therapy is still so important.

Yeah, yeah. And, you know, and it's definitely been really, the whole process has been eye opening to me as I went down the rabbit hole of everything. Myotoxin airway. And it's been a fun rabbit hole to go down. I've learned so much and I just, I feel like it's, you know, I've had everything from a adult realtor getting married who just wanted to be able to have enough energy and not feel tired so she could give her wedding speech. And she had such a severe tongue tie that nobody had looked at. And so with a frenectomy and a proper myo course, she didn't need any expansion, really. She actually had beautifully wide upper and lower palate and she'd had previous orthodontia that held for the most part, but she was so tied and her tongue had never existed up in her palate that it wasn't going to hold. Just seeing what you can do, even for an adult has just been absolutely eye opening and incredible. I've had the kids who've been in speech for 13 years that come to you and score at the level of a two year old on a standardized speech test. So of course people are going to keep them in speech and I'm over here like, well, let's, let's do something else. Let's try a different course of treatment and we'll work on a little bit of the speech because we want to make sure that, you know, you sound appropriate going into high school or, you know, through your high school years. But it's just incredible to me that, you know, I know, look, I wasn't taught this in school, and I'm not knocking this there, the therapist that worked with any of these children. But we need to do better. We need to figure out, like you said, it's the root cause, stop looking at the symptoms and figure out the root cause of what is causing this in the first place. And let's work from, from there. But I think critical thinking is even. Not even taught, you know, not even taught in how to address these or get down to the root cause of a lot of these issues. So I'm very grateful for, you know, what I feel is a small world of airway centric providers right now. But it's seems to be quickly growing. And so that's. It's an exciting time.

Right? Right. Definitely. The first slide of my PowerPoint that I didn't show you was a picture of the Wild west, because I feel like that's kind of where we are with airway centric orthodontics right now, is we are just seeing this massive, expansive territory and we're going out there trying to claim as much of it as we can and learn what's there. But there's also the, you know, the Wild west outlaws, you know, people who can just kind of say, yeah, well, this is the way it needs to be done and kind of claim things that, well, we don't know. There is no law there yet. There is no ultimate expert when it comes to airway orthodontics. We're all trying to find our way. It's exciting and we've got to learn from each other, put our heads together and figure out what does work. But it is by no means we're not there. We're still just at the very beginning of this whole thing. And to be pulled back down from people saying, well, there's no connection between orthodontics and how you position teeth and airway, and there's no proof of that. There's no connection. And stop making claims about that. I don't know that it's not productive. We shouldn't make claims that aren't justified. But at the same time, the people who aren't doing what we're doing and seeing the results that we are shouldn't be saying that it doesn't work or won't work when we've seen it working.

So, yeah, it's well on my side of things that whole evidence based practice, ebp. Is there, you know, research to support what you're doing and. Well, sure, there's a lot of research that actually does show that myofunctional therapy is effective. There's not as much research that shows that frenectomies are needed or effective. And that's a whole other discussion for another day. And I know that there's more research coming out that is demonstrating the effectiveness on speech. And so I know Richard Baxter just came out with a study recently And I know Dr. Zaghi and Yoon have come out with the TRMR and that's been really amazing for me to even use in practice in my assessments and continuous therapy to reevaluate tongue space versus tongue tie. And so, I mean, we are, like you said, we're on the forefront of really great things for anybody who is open to it and open to kind of exploring this area. And like you said, I think it still is the wild, wild west. There isn't a ton of things that we know for sure right now, but we, we do know is that we are seeing improvements, especially in cases where they had hit a wall or they were not. You know, sure, but the teeth look beautiful, but they've got all these other symptoms. I've had teenagers who had a, who were insomniacs and couldn't sleep, but then they were getting up at 5am to go swim on the swim team. And you know, I mean, I've just seen so many interesting cases. And the parents then come back and say, you know, they were very hesitant at first because it just seems so outfield to them with this child, seen 15 other specialists and then all of a sudden, you know, they start down our journey and they realize, holy cow, like this is actually benefiting my child. Okay, now I'm, now I'm all ears. Tell me more. So, yeah, we're definitely, you know, I encourage everybody who's in this space just to hold strong and keep doing what you're doing because it works. It works. And I know we're all figuring it out together. And on that front, do you have. I get asked this all the time and my answer is always like, well, it varies and it's really case by case. But do you have a traditional model or Recommendation for expansion vs myofunctional therapy? Like which, which chicken or egg should come first?

Oh, you mean which to start with?

Either which to start with or what you typically see?

Well, sometimes I'll depend on the myofunctional therapist to tell me what kind of results they're getting without expansion. You mean if, you know, expansion's needed and it's just a question of what order to do it in? Yeah, yeah, yeah. I think a lot of the time I'll depend on the myofunctional therapist to help out, but I use an appliance a lot called a crozat. You're probably familiar with it, but the crozat appliance is a wire appliance that holds on to back teeth, and it doesn't take a lot of room. That bottom one there is a maxillary one about to fall off my model here. But if you use an appliance like that, it doesn't take away a lot of the tongue space. Then the myofunctional therapy can be going on even during the course of the arch development, and it can be helping the arch development. So I think that to the degree you can use an appliance like that, you could get started earlier. But I think I find myself a lot of the time saying, let me get a head start with getting some space so that the work you do with the exercises pays off more. Yeah, I do say that a lot, but of course, it depends on the patient and their situation.

Yeah.

Other cases, what if they're going. What if they're going to do orthognathic surgery? Should they be doing it before or after? And the answer is yes, both. They should be getting the ball rolling ahead of time, but it's going to be a very different situation after the surgery.

Right, right. And that's also same goes for, you know, pre and post operenectomy work and myofunctional therapy in that space. And so, yeah, I'm glad to hear you say that too, because I always tell everybody there is no hard pass rule here. It's really what appliance, like you said, like, what appliance is going in. Can we even do mayo with that appliance in there? That's why I love, especially for my little kids, our local providers, a lot of them, not a lot. There's a handful of them that do the ALS appliance. And so you want to have an appliance like that, but in, like, the Prozac that you shared, that allows the tongue to actually rest in the palate and allows you to do the MYO program. You know, I will usually say, well, let's do a few months of expansion first and see what we can get. And then if we feel like we're now gaining some space for the tongue, you know, let's jump full on in and do the mile program while that appliance is in there and graduate them from Mayo before the appliance comes out. So that's always my goal, when possible, but, you know, there's always different scenarios and things that come into play, so.

Yeah, that's a good question.

Yeah, there was. It was. I was thinking of it as. It was, actually. It came up in one of the Mayo groups on Facebook the other day, and I was like, it depends on. There was also another question that we talked about earlier about, do you see the drop in the palate? How much of a drop do you see? And so I was really happy we spoke about that, too, because, again, everybody's responses were different.

I don't care about a drop in the palate. I'll never use the term get the palate to drop. I'm trying to get the palate to reshape and the alveolar bone to develop upward and forward. It's how you think about things.

Yeah, well. And I think you're the. You're the first dentist that I've ever heard say that. To be completely honest with you, I don't think I've ever heard anybody else say that, because people do talk about wanting the palate to drop down, you know, and for me, I'm like. I look at myself as an adult, and I'm like, well, how. How functional or how, you know, what does it matter? My tongue can fit up there and I can breathe through my nose, and it seems to be enough. I mean, I know the deviated septum, but that's a whole different issue, again, to deal with at a separate time, you know, But I have good oral rest, posture at this point, aside from the fact my max was turned, and we're working on that, but the tongue fits up there now, you know, so. And has it dropped down a little bit? Like, have they had to, you know, shave down the top of my DNA appliance as things have lowered a bit? Yes, but the whole palate took a different shape, you know, So I think that it's more about that and the expansion forward and laterally that you talked about. So this is awesome.

Yeah.

Is there anything. Go ahead.

I was just gonna say it's good chatting with you about all this. It's like meeting a family member you didn't know you had. You know, when those of us get together, the rabbit hole is. It's a lonely place in certain circles, but there are a lot of us in it. And we adopted a picture of a rabbit in a rabbit hole as our team Airway study club logo because that's kind of our common experience and we all fall in for different reasons. But it's always great to come across like minded people.

Yes, 100%. And we're gonna have to adopt something like that for our study club too now all the time. Welcome to the rabbit Hole. But that's, that's amazing. So is there anything else that we didn't cover? I know we could talk about this all day. We went through a lot. But any other last tidbits?

Well, I think just for parents, ask questions, get different opinions and do research and trust your gut. And if something doesn't seem right to you, then find out and get questions answered before you proceed. The child has a huge amount of potential, innate potential. And what we're all trying to do is help the child's potential to be realized. And the earlier we can do that, the better. And that's true for any parenting. You know, the sooner we teach a child something. But. So that would be kind of my parting words would be just start early and trust your gut and try and get the child to reach their potential.

Fabulous. Well, thank you so much. I really appreciate your time today, Brian. This was fun chatting and I can't wait to meet you in person someday once we're past this whole pandemic.

You're very welcome, Holly. I'm glad to talk to you.

Yes. All right. Have a good evening.

You too. Bye. Bye.

Thanks for listening to this podcast. If you want to hear more of these Myo Tots, Airway and Feeding related episodes, be sure to leave a review on Apple podcasts or pledge a small amount on patreon.com forward/the untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook. On my Facebook page at Hallie Balkanbing is on Instagram at at Halle Vulcan and you can head over to theuntetheredpodcast.com to grab a copy of the show Notes where you can also subscribe to be kept up to date on the latest podcast episode.