Episode 89: Innovations in Maxillary Expansion with Marianna Evans, DMD

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. 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, 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. Welcome to episode 89 of the Untethered podcast. Today we have Dr. Mariana Evans joining us. Dr. Mariana Evans is a board certified dual specialist in orthodontics and Periodontics practicing in the greater Philadelphia area. She received her DMD degree in specialty training at the University of Pennsylvania. Dr. Evans frequently lectures on skeletal expansion, guided facial growth, interdisciplinary care, and periodontal plastic surgery. She co founded Ortho Perio Institute and recently developed 4D morphotrophic orthodontics expansion protocol with a focus on airway and periodontal health. Mariana, thank you so much for joining me today on the show. I'm excited to have you here and to talk about innovations in maxillary expansion.

Thank you so much for having me. It's a great honor to join you today and to share with you some of the exciting things that are happening in orthodontics today.

Yes. Yeah, so we don't actually you might be the first. I think you're maybe the second orthodontist we've had on the podcast. There is an orthodontist in the dentist's office that I work with closely and so she's been on. But you know, we really haven't had trying to think back, I think it's mostly been dentists. So I'm excited to hear, you know, from your experience, your expertise. I know that you're in the research world as well. So you've got so much amazing knowledge to share with us today. So let's, let's dive right on in. Can you share with our listeners just a little bit about your practice just so they understand your background and what you do on a day to day basis?

Sure. So I am dual trained in orthodontics and periodontics. I practice right outside of Philadelphia in Glen Mills and Newtown Square area. On daily basis I see the majority of my patients are orthodontic patients, adults and children. And I still do some of the periodontal procedures for orthodontic patients, such as management of impacted canines or impacted teeth. In general, I treat a lot of children and adults with congenitally missing teeth. I do a lot of soft tissue augmentation, bone grafts, teeth. And the only thing that I had to give up periodontally was dental implants, sinus lifts, and conventional periodontal therapy for periodontal disease. So the majority of my practice is focusing on skeletal development in patients with malocclusion in children. In adults, we do a lot of orthogonal surgeries for patients with sleep apnea or any type of craniofacial growth problem. And we do a lot of protraction, in other words, bringing maxilla forward. This is a very common problem today because the facial structures are just not growing. And our patient pool is getting younger because we realize that we can do so much more in a younger age. And also we are getting more adult patients that have not been skeletally developed as children when they underwent orthodontic treatment many years ago, because what we have today was just not available back then. It's a very exciting time in orthodontics today because we are learning more the connection between facial development and breathing. And I think that myofunctional therapy is going to be a very critical part of it because the majority of patients that have malocclusion, that have any type of skeletal deficiencies and require treatment, have also myofunctional disorder, improper tongue, posture, and they will need some kind of retraining and muscle strengthening exercises to get to the new normal for them. So thank you so much for having me today.

Absolutely. Yeah. You bring up a great point. As a certified orofacial myologist, you know, and speech pathologist, I also specialize in treating pediatric feeding. And it's just so interesting. I started really a long time ago working on pediatric feeding, but at the same time, I was also working with children who had severe speech sound disorders. And it wasn't until I got into the MYO world that I started to look at all of them very differently, because, like you mentioned, you know, getting younger, your patients are getting younger and younger. And we're recognizing that these children have myofunctional disorders at birth. Sometimes, you know, it's not just something that can develop, it can be there at birth. And so that's changed my practice even to look at these babies that come into our practice and moms that I speak with, you know, is your baby's mouth open or closed? Let's start there. Like, can you hear them breathing? You know, just asking some of those questions. And I, I think it's really amazing the work that you're doing because if we, you know, in my opinion, if we can get in there younger and we can treat these patients earlier on, like, how much better will they be, you know, set up for the future when their airway is maximized and, you know, everything is where it should be. So, yeah, so I'm excited to learn about, you know, the appliance work that you do and what would you share with us some of the appliances that you commonly use, whether it be a child versus an adult? You know, what does that look like in your practice?

So a big part of our practice is maxillary development because maxilla is just not growing in modern population today. And I think maxilla sets the tone for the growth of the mandible, for the position of the tongue. And I think as part of orthodontic treatment, we really have to focus on understanding the maxillary deficiency and addressing it. The good news is that maxillary deficiency is reversible in children. And today in adults we have technology where we can expand adults without surgery utilizing temporary implants. So temporary implant expanders like mse, acrylic type of expanders are a very big part of my practice today because without those bone anchors, we cannot get the skeletal correction that these patients really need. Traditional appliances have limitations because with removable expanders or with pure tooth supported expanders in all the patients we achieve mainly tapping of the teeth. So we are not getting the change at the base of the bone. And I will share with you some of the information today on what is happening to maxilla when it's not growing, how it should be growing. In order for us to answer some of these questions, because the research is so limited, we have to go back and study maxillary development in pre industrial skulls. We are very lucky. In Philadelphia, we have at the University of Pennsylvania Anthropology Museum, one of the largest collections of pre industrial human skulls from all over the world. So it's a very diverse collection. And me, Dr. Boyd and Dr. Juliana Zorga, who recently joined me in my practice, Dr. Reem Abdul Rahman, that also joined us recently in the practice, we were able to get access to this collect and take cbcts of the skulls and study them from all possible angles. In terms of the anterior posterior development of the skulls, horizontal and vertical development. Because the norms and the information that we use to diagnose today's faces is based on faces of the past 100 years. And the majority of our faces have shrank over the last 100 years. So we might not be using the right norms today to fully reverse and treat facial deficiencies. So I can either share with you some of this information now, or we can continue talking?

Yeah, I would love for you to share it with us. I think that's absolutely phenomenal that you're so close to the University of Pennsylvania and they have such a wide variety of schools. So I knew you were doing this work, you'd share that with me, but I didn' realize how vast the, you know, different skulls were, how many there were. They were, you know, from all over the world. That's really. That's really fascinating. And I know there is a lot of discussion in the Mayo world about, you know, our faces are shrinking, our jaws are shrinking, everything's collapsing on each other, and there's just not enough research or information out there. And like you said, the norms are based on already collapsed, already shrunk jaws. So already, you know, facial complexes. So that doesn't help us much. So this is very, very interesting, especially to. And so I'm excited to hear about what you have to share with us.

So let me see if you can see my screen. Can you see it?

I can't. Oh, yep, now I can see it. And for anybody who is listening to the podcast, this will be on YouTube as well. So you'll be able to visualize what we are looking at.

So I just want to share with you a few slides based on our research and our findings in our practice. So we are going to talk a few minutes about maxilla. So maxilla is a very important anatomic structure in your face. It's located in the center of your face. It is a critical structure for respiration, mastication, vision, aesthetics, and speech. So the integrity of the maxilla is very critical for function of occlusion and also of respiration. It's very important for periodontal stability. The skull on the left is the treated skull where we develop maxilla. So you can see that the teeth are positioned in the center of the bone. There are no penetrations of the roots through the bone, and they are axially positioned in relationship to the mandibular teeth on the other side. On the right side of the slide, you see the red maxilla, which is very deficient. And you can also find that the maxillary teeth are flat, so they are no longer upright. The patient does not have A posterior crossbite. But the maxillary teeth are flat to properly fit or to allow the best fit with mandibular teeth. So this is a very common finding in patients with maxillary deficiency. So when maxilla doesn't grow, the tongue doesn't have space in the maxilla to rest properly on the palate. And the tongue actually should be growing the maxilla from the very beginning of life. So when maxilla doesn't grow, the tongue has to go somewhere. And the best position for the tongue is going to be the lower jaw, since it's attaching to the lower jaw. And so you can see in the skull with the fissure maxilla, the mandible is significantly bigger, more massive and is broader because of the lower tongue position. So we find that commonly in patients with maxillary hypoplasia. So we wanted to study maxillary development to the very depths of it. We want to understand and answer the question to which dimension we should be expanding maxilla, because today we don't have that answer in orthodontics. We know how maxillary teeth should be relating to the mandibular teeth, but that only answers the posterior portion of the maxilla. It doesn't give us any information on how much to expand maxilla to accommodate the anterior portion of the dentition and also the tongue. So we actually took our project at University of Pennsylvania back to pre industrial humans to the collection, collection of pre industrial skulls that came from all over the world. And what we find based on our research, that today's maxilla is shrinking in three planes of space, horizontally in anterior posterior direction. And it's also getting longer. As it's getting narrower, it's getting longer. So we have a lot of dental alveolar extrusion with vertical growth of the jaw structures. We also have widening of the mandibular base and we also have flattening in the malar area or the cheekbones. That probably explains that we are not breastfeeding our children today, as biologically and genetically is meant for the children to be breastfed. So interesting that all of the skulls in the collection come from different parts of the world. So they are very diverse in terms of ethnicity. But the majority of them have wisdom teeth in occlusion. Wisdom teeth that are worn, there is space for them even if they are not erupted in younger specimens. So it's definitely something that we don't no longer see in today's patients. The majority of my patients that come for orthodontic treatment will never have room for the wisdom teeth. The wisdom Teeth usually get impacted and need to be extracted because our jaw structures are not growing forward and in the horizontal plane. So this is some preliminary data from our study that outlines where we see the shrinkage. So the shrinkage is happening at the red lines on the skull on the right. This is one of my patients with maxillary deficiency versus the pre industrial skull. You can see how much shrinkage you get in the mid face at the level of the maxilla. And you also have a significant change in the mandible. So because most likely the tongue is displaced to the lower jaw position, the lower jaw is going to get wider. And that's what we see when we compare patients to those pre industrial skulls. So we have changes in the proportions between the upper and lower jaw, which we haven't had throughout the whole history until the post industrial changes happen in our environment. Here you have the face of the patient in relationship to the silhouette or the outline in blue of ideal anterior posterior facial development. So in the sagittal plane, maxilla and mandible should always be ahead of the forehead, should always be ahead of what we call Labella line or the most prominent part of the forehead. But today's spaces are just not growing forward. This is one of the reasons why we don't have space for the wisdom teeth. And a lot of my patients won't even have space for the canines or second molars or premolars. So stevia is really deficient. And on the skull on the left is the pre industrial skull. So you can see that there is a very flat occlusion and significant development of the maxilla and mandible. And look at the skull on the right. This is one of my patients. Look how massive the mandible looks in relationship to maxilla. So if I make maxilla of the pre industrial skull the same size as maxilla of my patient and superimposed them in 3D, you can see how much wider the mandible gets as maxilla gets narrower. And we already have some papers in the literature showing that the narrower the maxilla gets, the wider the mandible will get because the tongue still has to go somewhere. So instead of sitting on the palate, it's going to develop the mandible or over develop the mandible. So we also have to remember that today's hypoplastic maxilla is very common. It's a pandemic problem. It accommodates the majority of the skeletal malocclusions. You can see it in open bites in Class 3, Class 2, Class 1 crowded cases. And as I said earlier, it's a 3D problem. It's most commonly under diagnosed problem because we just didn't have CBCT imaging until recent years. So there is no way for us to diagnose it properly without this imaging because clinically there is a lot of compensation at the level of the teeth which kind of masks and hides through skeletal deficiency. And because it's so commonly under diagnosed, it's very commonly undertreated problem. And the most important part that you need to take from today's presentation, that it is reversible. You can reshape maxilla, that maxillary bone in children and today in adults without surgery. So when we look at our study and we try to understand that. So I think it comes down to the tongue. The tongue is the king of the mouth and the king is going to sit in the throne. So instead of sitting on the palate where the tongue no longer does because of the most likely insufficient breastfeeding, when introduction of pacifies introduction, very soft diet from a very young age and eating soft diets throughout life and mouth breathing, you develop this orofacial dysfunction where the tongue just displaces from the very beginning of life into the mandible and doesn't function on the palate, doesn't grow the palate. So what we see on the cbcts of our patients, usually that lower tongue position, collapsed palatal wall, those narrow high palatal arches, as you can see here. This also comes along with very narrow nasal passages. Most of these patients have anatomically narrow passages and also have possibly allergies and significant nasal congestion. What we do in orthodontics is basically we can reshape the palate, we can make it flatter, we can make it broader. And by reshaping it in the horizontal direction after a certain amount like 5 millimeters, we also find that maxilla develops forward so you can have also more space for the tongue in the anterior posterior direction. And in some patients we do see automatic tongue repositioning to the palate, but in the majority of the patients it doesn't happen. And that's when we need to engage myofunctional therapist to retrain that king. After we move the throne to the palate to saline, the throne that is now on the palate, because the habits that develop throughout life are very persistent and are very difficult to break. So just because they expand the palate doesn't mean that the tongue is automatically going to go and sit on the palate. So there is definitely a very significant need in that interdisciplinary treatment. Here you have a pre industrial skull from Morton Collection on the left. And you can see that beautiful palatal development, that beautiful space for the tongue, all the way from the roof of the mouth to the base of the mandible. In the middle is one of my patients. Before expansion, you can see that low tongue posture. This is a child, actually adolescent patient with sleep apnea who was a preemie born in 26 weeks, who was never breastfed and had sleep apnea basically from birth. We know that premature birth is a risk factor for sleep apnea. These children have a lot of myofunctional problems, deficient jaw structures, and this is how much we were able to reverse that skeletal deficiency, open up nasal passages. And now this patient doesn't have a sleep apnea anymore. So we have incredible technology today to be able to do it. So the way we do it, we utilize special bone anchors, as we did in this case, that open mid palatal suture and other circumaxillary sutures that allow midfacial change. And you can see here mid facial change, where we have widening of the nasal cavity. We have nice uprighting of the maxillary dentition in the basal bone of the maxilla, so the teeth are positioned in the bone. We have the change at the level of the cheekbones when you look at the relationship of the cheekbones to the mandibular ramus. So the changes that we can do to the facial skeleton are very dramatic today. And this is the change in the patient's face. So you can see that the teeth spread much better than prior to treatment. You have good occlusion. She has room for wisdom teeth to erupt in occlusion. She has nice projection of the cheekbones and just is so much healthier. And we were able to do it without orthogonal surgery. And this is the patient four years after expansion, two years after they removed the braces. And you can see stability. And she's not really great at wearing hair retainers, but the teeth are indicating that there is stability in the function of the tongue. There is a harmony between the function of the lips and tongue because the teeth are not shifting. So I think the technology today is fascinating. This is the same patient before and after look at the change of the palate. This patient did not undergo any type of face mask therapy. This is the change from expansion alone, utilizing the bone anchor. So you not only see the change in the level of the teeth, look at the change at the floor of the palate, basically the base of the palate. This significantly not Only got wider, but got longer. And this is the child again with sleep apnea, where we had to achieve this result with several rounds of expansion. So the limit of the palatal expansion today is actually not in the palate itself. It's in the ramus of the lower Java. You have the muscular attachment that will limit how much you can expand that maxilla. So it's a three dimensional change. So when you think about growing bone in medicine, in children that have some kind of growth bone deficiency, we are talking about human growth hormone. So in orthodontics today, this can be done without need to use human growth hormone, without need to use any type of surgical intervention. This is what is achieved through destruction, osteogenesis. It's a physical stretching of the facial bones, jaw bones, without drugs and without hormones, with orthodontic, orthopedic skeletal expanders. So there are different types of expansion that is available to our patients today. And surgical expansion, as you see in pain, still is an option for adult males that are older than 25 but have thick bone that probably are not going to respond without surgical intervention. And the best results that we see in the literature right now is confirming that the non surgical expansion, as we see in the center slide outline in blue at the level of the maxillary and circumaxillary sutures, will be the one giving you midfacial change. And that midfacial change will give you significant nasal change and shows that there's going to be improvement in the sleep apnea parameters or breathing parameters in patients. And there is another type of expansion called dental alveolar at the level of the teeth. This is something that we achieve mainly with removable appliances or with purely tooth supported expanders in all the patients, in all the children. So there is definitely a place for any type of expansion in orthodontics. But we have to get to the right diagnosis and get the right expander for the problem that the patient has. If it is a skeletal problem, that means that probably for all the patients we are going to use mini screws to expand without surgery. They are candidates for non surgical expansion. If it is children, we are going to use probably bonded expanders or expanders that are going to give us more skeletal change. And if it is a dental velar problem, then sometimes we can even stretch periodontium with arch wires or we can utilize any type of other dental bowel expanders, such as removable expanders in general. So ideally we find that it's probably best to treat in a younger age, in a younger Age, the bones are more moldable, are softer, the sutures are more patent, and we can achieve much significant, more significant skeletal change. In older patients. It's becoming more challenging. We also have to remember that if somebody underwent orthodontic treatment with expansion, doesn't mean that the skeleton was corrected, because it depends what appliance was used and how the measurements were taken to determine whether expansion was sufficient or not. Here we have two patients under age of 17, between 16 and 17, that went through phase one orthodontic treatment with expansion and then phase two orthodontic treatment with braces. And you can see that the maxilla is corrected in 1, 2. Very nice outcome. And in the patient on the right, that there is definitely persistent maxillary deficiency. So just because somebody was expanded doesn't mean that maxillary deficiency was corrected. We know that skeletal expansion will improve occlusion and also will improve periodontal support. So a lot of our patients that are periodontally very fragile with severe crowding with blockout canines or the premolars, as you can see on the left here, once we expand, position the teeth back in the bone, get those teeth in axial loading, the periodontal tissue, just like the dentition respond and they look healthier, they look stronger, they look more resistant to gingival recession and periodontal breakdown. This is one of the patients with sleep apnea. You can see when they started, they had severe, severe crowding with blocked out canines. And how much we were able to correct this problem. Skeletally, you can see the changes in the pathoscine bone on the buckle of the teeth. You can see the changes in the nasal cavity. So we are very, very fortunate that we are able to offer our patients this treatment today. If you have any more questions, you can always join me on Facebook. I have a group that we share a lot of this information, Orthopedio Global forum. And we are open to myofunctional therapists, not only dental providers. You can also email me with questions and I'm going to just switch back to stop sharing my screen if you have any questions.

No, that was phenomenal. And I know that again, if you guys were listening and you felt a little bit lost, go to YouTube. We'll make sure that you can. You want to visualize what Mariana was sharing, because, I mean, the before and after images, they speak for themselves. They are incredible. And you can really see the maxillary deficiency and all that dental crowding. And it just makes so much sense that, you know, one of the last examples you shared, you said the child had severe sleep apnea and you could see how impacted the bite was. I mean, the malocclusion was severe. There was definitely. Visually, when you can see these images, it just drives it all home. So thank you for sharing that, because to see that and then to see the after and to see that every, you know, the top and bottom jaws, you know, that maxilla and mandible fit together, and that one is not deficient compared to the other. The visualization of that and seeing what it should look like I think is very helpful, especially to people who are not in the dental or ortho space. You know, myofunctional therapists who maybe don't have access to this information all the time, it really makes sense that, well, our symptoms will disappear when we have a face. You know, the orofacial complex actually supports the airway and supports breathing and supports space for the tongue to exist in the palate. So, you know, I don't have a ton of questions, but, you know, I think you covered everything beautifully. And it really goes back to a lot of other conversations that we've had here on the podcast regarding, you know, we have parents sometimes who listen to and they say, well, what can I do for my child? And we know breastfeeding is a great idea if you're able to, you know, obviously we want to feed the baby, so whatever that looks like, that's what's going to happen. But we know there's a big change in that. And there also seems to be a shift back towards breastfeeding because awareness and education is increasing in that space, which is great. But we do still struggle with that soft food diet in our, you know, in the United States of America. And I don't know if that's global. I don't know if you have more information on that, but I know that it's definitely an issue here. Do you have any insight on whether soft food diets are global or is it really contained to certain areas?

It's definitely more of a problem in the developed countries, but I think it's becoming global, especially as the food industries that manufacture snacks and processed like snack foods spread to developing countries. I think it's becoming a problem in those countries too, but I think that there is something that can be done, and obviously we need more research. But I think if we can start eliminating or controlling one factor at a time and see how much by changing that factor, we can change the development of the face, I think it will be interesting to see. For example, I Originally come from Ukraine and I was raised in the last 10 years of the Soviet Union times. So the Soviet Union thing was definitely a bad thing and that's why it just didn't self sustain and fell apart. But there was one thing that was very amazing about the Soviet Union was that every woman had three years of maternity leave, paid maternity leave. So the majority of women had opportunity to stay home for up to three years and nurse the babies, raise the children. And I think at that time.

The.

Skeletal structures were developing much better. When you look at today's literature, any child that is breastfed less than six months has a significant higher rate of maximum deficiency. Not even to mention other systemic health issues that they may have. So I think breastfeeding is very critical. And unfortunately in the United States, instead of supporting maternity leave, the government chose to give, which does not replace the natural physiologic function of breastfeeding and the importance of it. So I think to make a change and support women that are raising young children, problem I think a lot of children are introduced to fermenting, that every parent has full control in not giving their children sugar until after age at least 3. So the culture is the problem. It's all cultural, right? Grandparents bringing candy to young children. So the other thing is pacifier. The pacifier is so easy to eliminate. No baby is born asking for a pacifier. The pacifier is for the pan. You can eliminate pacifier, you can eliminate sugar and soft foods. You can introduce like hardened meat to a child, like meat on the bone, like lamb or lamb chop or veal chop or any type of steak type of meat. If you can introduce like carrots from a very young age, like sucking on a stem of pineapple, it's a very good fruit to kind of develop proprioception, develop proper tongue function and swallowing, rather than to give a child like a pacifier or any type of other, like soft snacks. I'm not a very big proponent of any of those packaged snacks, pureed foods, or any type of those dried fruits that melt in your mouth. They have nothing that they offer for the muscular development and muscular activity. So there are a lot of things that can be revisited in terms of food industry for younger children and also.

What.

You can do at home. And I also think that a lot of the problem is the postural changes in children. All of these devices that we developed, including car seat to hold the child under the age of one, it doesn't really help with the proper development of the head posture and. And as soon as the child can hold something in their hand, they can hold an iPad. And they are no longer exploring the world by looking around. They are exploring the world from the iPad or the iPhone. So I think so many little things that can be done that may change, make a big change in how the face is growing.

Yes, I agree with you. I know a lot of it is convenience and culturally driven. And, you know, we've talked many episodes on here about, you know, a food pouch. Maybe if you're in an absolute dilemma, in an emergency, you have to grab it off the store shelf to feed your child. Something like, on occasion, fine. But for it to be their stable, you know, diet that they're eating every day is just. It's. If you look at the ingredients in those pouches, they're not healthy. They're often applesauce based and completely full of sugar. And so, you know, and this is not to shame any mother. This is just information that we're sharing. But we've talked a lot about this and about other ways that you can achieve, you know, giving your child harder textures early on in safe ways, you know, to develop while also, you know, yes, puree has a place, but it shouldn't. They shouldn't only be eating purees for the first six months of life either. It needs to be a combination. So I think the conversation is getting started out there, and there's a lot of different, you know, moms and therapists on, they've got lots of information that they're sharing. So I'm hoping that we start to make some big changes here. But it would be nice if the government would give mothers time off to breastfeed their children and actually raise their children, versus, you know, causing that additional stress in the mother's life of having to try and figure out how to feed their child and work, because that, again, culturally is a big issue here. And the other thing that you brought up is the pacifier. I actually made a Instagram post like a month or two ago where I wrote, pacifiers are not a milestone. Because I think that parents automatically think, here are the things I have to buy for my baby. And a pacifier is always one of the first things on that list. And I'm here going, babies don't need pacifiers. I know that in the U.S. i think the whole stance on it is that it's supposed to help prevent sudden infant death Syndro. And I'm going, if we're trying to prevent SIDS in babies, maybe we should be looking at their airway. Because I do believe there are some research that's been done in this space that has demonstrated these. And it's not a ton of research, and it's not large groups of babies that have been studied. But I think there was one specifically. I was talking with a colleague the other day who was presenting to us, and something along the lines of this group of babies that were studied after passing, unfortunately, they all had restricted airways. And, you know, that really is the issue here. It's not that they're suddenly passing with no health issues. Nobody's looking at the baby holistically. Nobody's looking at the baby's airway and their orofacial structures. And if we start doing that at birth, we can prevent these issues versus trying to study them after they happen. So, you know, it's an interesting topic. It's a very touchy one. I know parents just want to see sleep, and they think that, you know, it'll pacify the baby so they can sleep. And so, you know, I basically say by six months, if you're using one, you better get that out. And if you're using it, it better not be flat. It needs to be nice and rounded so the tongue can at least cup around it and develop some. Some, you know, skills. But aside from that, you know, we really advise no pacifier. And so I love around the orthodontic pacifier and how, you know, oh, the parents, you know, I've got a lot of parents on my account who have said to me, well, my orthodontist or my dentist, you know, they said that I should use this pacifier because it's not going to mess up the shape of the palate. And I basically go back if the pacifier is. So ideally, no pacifier is better than anything on the market. And there's a reason why there's a major lawsuit against one of the big companies who put out an orthodontic pacifier because they found it's actually very harmful to toddlers who continue to use them. So very interesting discussions that. Surrounding this topic. But, you know, it's definitely a conversation we need to continue because culturally, I think we've, like you said, we've got a lot of big changes to make, and they start. They start as soon as that baby comes out of the womb. So we need to be looking in that mouth day one.

Yeah, well, totally agree.

Yeah. Yeah. Well, this has been amazing. Mariana, is there any last thoughts that you want to share with us before we finish today?

I think I covered everything I wanted to cover today. Thank you so much. For inviting me. If anyone has questions they can always find me on the Infinity Dental Specialist. This is our practice name website or they can email me directly. I will put again the slide as my email.

Perfect. And we will also put in the show notes, your email and the Facebook group as well as your website so that if they have they want to reach out or contact you they can.

Definitely My email is m evansfinityorthtopario.com and let me see here. And they can always text me or contact me through Facebook as well. Thank you so much for having me.

Yes, thanks Mariana. 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 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 halliebulcan biz on Instagram @hallebulcan and you can head over to theuntetheredpodcast.com to grab a copy of the show notes or you can also subscribe to be kept up to date on the latest podcast episodes.