Is MARPE Needed Before MMA? Where the Evidence Stands

Down fracture. Down fracture. Down fracture. Down fracture. Down fracture. We're talking jobs. All opinions expressed in this podcast by the hosts and their guests are solely their own. This podcast is for informational and entertainment purposes only and does not constitute medical advice. All right. Hello again and welcome to another down fracture podcast, a podcast for talking jobs. Down fracture podcast at gmail.com. Sam, what is up? Let's see, it's starting to turn into fall in terms of weather in Seattle. It's pretty nice. Are you coming up to the national meeting by the way? Are you coming to Seattle? I'm not. I have some family obligations that are preventing me from doing that. Yeah. I mean, if I've already talked to a few different people, but if there's anyone listening to this that wants to say hi to the meeting, you know, I'd be glad to say hello. Meet up people for the first time, that sort of thing. National meetings right around the corner, soak up a weeks away. I think people really experience fall in Seattle. It'll be great. It'll be probably 50, 60s. You know, days will be shortening like three minutes a day. It's going to be awesome. I know how much everyone loves to hear me complain, but I think Seattle's a great place to have the meeting. You know, they do try to move it around geographically, but I don't have it in August. I know there's kids going back to school and vacations and that makes it tricky, but no one wants to be in cold, drizzly weather. Well, it's like the OR, right? Like the OR is always sunny in the OR. If you're just staying inside, it's always nice in Seattle. God, one state. Just go outside one in the summer. I mean, like, why do we have our dental implant meeting in Chicago in December? Like, who thought that was a good idea and continues to? Maybe it's like to help you appreciate where you're coming from. It's like, well, at least I don't live in Chicago in the winter. Maybe, I don't know. But yeah, that's what's gone. How are you doing? Good. Good. Had to travel a little bit more. Traveling again this weekend. Kind of a busy month. Yeah, definitely. Kids back to school and all that sort of thing. It's busy. Let's see. Today, what are we talking about? Yeah. Today, I'm going to pose you a question that I know I get near daily and very frequently in my practice. So I know you probably get it even more than I do. And that is the question of should patients get maxillary expansion prior to maximum intubular advancement to maximize airway improvement, I guess is the full question. We've touched on this topic here and there, but it's such a frequent question and there seems to be a lot of conflicting thought out there. But I wanted to just pose this question to you to get your thoughts and hopefully you can put a couple of coherent sentences together and help us out here. So what do you think for most patients? Yeah, I mean, I definitely get that question. I would say that the question of should I do a Marpe if I'm going to have an MMA or should I just do a Marpe or should I just do an MMA? The third part of it does is Marpe influencing your outcome, right? So and you know, I think some variant of those questions are really common these days because a lot of people talk to patients about expansion and I think there's a lot of good information online about maxillary expansion and not topic is honestly a newer thing. So it's kind of like the new shiny intervention for jaw surgery to help out with sleep apnea. And so there's a lot of interest and you know, the acronym changes over time, makes it confusing, but the idea of doing a Marpe which, you know, I'll think of as a dome. That's how I interpret that to be like a dome type procedure. They an expansion of the upper jaw to improve nasal breathing or to improve sleep apnea measures in a patient who otherwise doesn't have any reason to do upper jaw expansion, right? You have to go cross by no crowding. That's present, you know, just like a hey, I want to do an MMA, should I also do a Marpe? So I find this to be hard information to find out because this is, I would say depends. I see people who are clear jaw surgery people and they come in and it's by maxillary retribution. You could advance them for days, easy two centimeter advancement of pagonion, M&A jives with their skeletal anatomy. You know, let's say they have VME or something of that nature. And let's say even if they have any improvement on occlusion that happens because of jaw surgery, those seem like they're jaw surgery patients to me. Look at if I was going to do one thing to manage sleep, it would be that. I think if people are clearly maxillary expansion people, like nasal restriction, relatively mild sleep symptoms, tongue restriction, those sort of symptoms, the maxillary expansion makes a lot of sense. I think framing it on the two extremes, it's just that people oftentimes are in the middle, right? And you know, I think it depends on the person. I think would be my my clinical answer on that one. How do you practice with that? Yeah, I mean, I like what you're throwing at me there. You know, to frame it another way, like I sometimes I know you really like to paint. And so like, I often think of it as when I'm trying to explain it to patients or other practitioners, you know, I can say if I were to paint a picture of who I think needs maxillary expansion in addition to MMA or whatnot, to me, that's I feel like most of them don't need expansion prior to MMA. To me, the expansion patient, if I were to paint them, is the patient who has mild to moderate OSA has evidence of nasal restriction, narrow palate, whatever, whatever transverse dimension you want to use to signify that maybe there's a decrease in nasal airflow. And they're wanting to avoid other measures such as jaw surgery or they don't tolerate an appliance, they don't tolerate CPAP. So the patient who is mild to moderate who's looking for alternatives to jaw surgery or is looking to alternatives to soft tissue surgery or would benefit occlusively from expansion anyways, like you were saying. So like, either I meant a little bit across by it, I would maybe there's some tilting of my teeth that orthodontically if we could, you know, remove those compensations and expand. Maybe that puts my occlusion, my dentition in a better place. I view it in that lens of this is an alternative to try to avoid other treatments such as jaw surgery, not to supplement it. You mentioned a group that I think is important if there is crowding that would benefit from expansion. You know, I think that can make sense. I have, and I'm sure you have as well, had jaw surgery patients, that typically I would treat with segmental of four, but the magnitude of the crowding is such that we, we need it for orthodontic purposes. We're not doing it for the RV versus premolar extraction. Yeah, I mean, like if there's transverse arch discrepancy, you just need arch length that, you know, expansion of the arches are at approach there. Exactly. But I mean, I think it's that. I don't think it's, as you're saying, the average person or the person who doesn't have specific other needs for expansion, I would say no, the answer to the question is no, you do not need expansion prior to your MMA, unless there's another reason to do it, or you're trying to do it as a first line measure to avoid jaw surgery. Is that your, your, your answer the same or am I a little different than you? Yeah, no, I think it's, I think we're likely practicing very similar here. I think it's the middle crew that's tough, right? Like the people that clearly could avoid jaw surgery if you do a maxir expansion, or hopefully you can avoid jaw surgery. And then other people that's like, you know, you're going to have to do jaw surgery if you're going to do any surgical intervention here. It's the middle crew that's tough, right? And so for the middle crew, there's just lots of scenarios that I can come up with that influence whether or not that's a good idea. So I don't know, like jumping into those. One of those is the duration of treatment, right? Like putting someone through a Marpe or, you know, whatever other acronym there is, ease, mind, dome, whatever. That is going to be a year. That might be a little bit longer than year. It wouldn't shock me if I, you know, is a year and a half process where your sleep apnea is not being managed, right? Like if you have no management strategy for your sleep apnea, and it is causing you a lot of symptoms or medical issues, like you can't work because of how sleep you are, you know, say you can't control your hypertension because of how bad your sleep apnea is. Spending a year in orthodontics or doing expansion doesn't make a ton of sense to me, right? So I think fancy orthodontics are doing rather the best option. depends on if you really should just get better right and so I would say that the the current management strategy of the sleep apnea is important whether or not you do that. The cost of Marpe I think is a thing I think the cost is real consideration. I've been kind of looking at that a little bit more these days I think I was surprised by how much those were and so because I hear anything you know the lowens like 10,000 but then I hear up to like 30 oh really for max or expansion to insert the devices and do the the expansion which if you're then planning to do Jocergery after that I mean the cost is substantial right I mean it's also with either one of those to add in both is a lot and it's just hard for me not to think of early days of sleep apnea management right where everyone just tried PAP and if you didn't try PAP you had soft tissue surgery and if you didn't have soft tissue surgery at MMA I feel like we're doing that with max or expansion sometimes where it's like you're the dental version of that like try out an oral appliance but if an oral appliance doesn't work we'll do max their expansion and if max their expansion doesn't work then you can do it in MMA and you know we're not always but I do think a little bit of that goes on. Oh I absolutely do I absolutely think that goes on too. I hadn't heard 30,000 but I've definitely heard around 10 is the low end and I think I've heard close to 20 and you know I think we we've both answered in our opinion the first question was for a patient who otherwise would not benefit from expansion for other reasons you and I both feel that doing expansion prior to MMA is probably not necessary or provides minimal benefit but I think there's other important questions that people want to know and I think one of those is can you obtain more expansion or more nasal airway change with expansions such as Mark PMSE East dome versus segmental of Fort and this is where as I've mentioned to you before if I were to have feathers they sometimes get ruffled. Yeah I mean there's good argument for it right like I mean I'm there's sound reasoning to say that it could I think is how I would phrase it but I don't know that my problem with it is you know similar to a recent episode if people and maybe they are you know a lot of this is second-hand information you know the patient see a provider then they see us and we're getting second-hand information from the patient so it's it's not always direct but I guess my issue with it sometimes is we're proceeding as if it's factual that it does and I and I could be missing something completely like I could They have better outcomes with that yeah that you're getting more nasal expansion with MSC or Marpe than you are with segmental of Fort and that could be proven at some point and it could already be proven and I haven't seen it but I think presenting that as factual is inaccurate and unethical where we currently stand with our amount of information now could that come out in a year or two and I have to eat crow or say I was wrong and I would change my opinion I absolutely would but I don't think we have that firmly established right now so when we tell patients you get more nasal expansion from this compared to doing a segmental of Fort with intention of widening the nasal airway I think that's inaccurate or because I don't know about you I don't do that many segmental of Fortes for the sole reason of breathing better like you do in Emmett May and you just tip the segments you know like you just tip the segments out so you keep the inclusion basically the same you're really just tipping to improve the nasal breathing so you're generally doing a segmental of Fort for other reasons right like leveling the arch you know transverse discrepancy so it's not it's not a true comparison right and before it's also doing a bunch of other things that just from a nasal breathing perspective it isn't a fair comparison I think one of the benefits of Mark B is you can perceive the nasal airway change as it's happening whereas with a Lefort or segmental of Fort maybe you perceive that right when you wake up but then it immediately goes away like you have congestion immediately and then your nose acts funny for like weeks and weeks right and potentially even months and there's just other moving things in that procedure where you're like your day-to-day experience is just totally different than let's say Max or expansion because you're turning the key and turning the key let's say you're doing ease or something and you start noticing a significant improvement in nasal breathing you're kind of titrating the amount of expansion to the symptoms whereas with jaw surgery we basically have to come up with a plan going into it right and so it's a bit unknown what's the right amount of expansion and so you go by based off of the T three go based off of the face or how much lower jaw expansion you can go with and so I mean that I think from the from the view of expanding further for symptoms I think that's probably one of the benefits of that for sure definitely and I think you bring up an extra an interesting point that I think words explaining a little more because I don't know that everyone's gonna pick up on what you just said and and I've had this discussion with many orthodontic friends and colleagues and it's just that like if you told me or you hey you you can do a segmental of four and you can widen the arch beyond the mandibular arch so that I can flare out the mandibular teeth and make it fit that's different right because if you or I do a segmental of four with the intention of widening the arch and we send it back to the orthodontist and it's way over expanded we're never going to get another patient from that orthodontist again right yeah I mean if our plan is yeah terrible you're comparing apples to oranges because they're saying hey I'm gonna expand this beyond the mandibular arch and at the same time I'm gonna start tilting the mandibular teeth out to accommodate that we don't get that same luxury like if we send them back after a segmental of four we have it fit the teeth reasonably together we no longer gonna have a referral so like if you told us hey Mike Sam you can widen the arch to where you want to maximize airway change and then I'm gonna deal with it in the mandible orthodontically afterwards now we're comparing apples to apples but that scenario does it happen I even have a video do you like videos I mean yeah who doesn't like videos I'm sure there's somebody let me share my video I don't see your screen by the way I'm gonna I'm gonna show you okay because here's this is actually oh yeah video a surgical plant yeah so here's a concept that I think again help her this kind of helps conceptually show one of the things that you said so here's a video where if you look at the segmental of four this is not even really expanding we're changing the occlusion this is merely tilting out the buckle segments in a three piece and you can see how the nasal apertures widening here and you can see the occlusions essentially not changing more than just tilting the segments yeah we're just looking at a surgical plan we're not looking at the video you should look at the video well if you're not looking at video because you're in your car it's basically just a segmental of four so three-piecelefort with two three cuts tipping out the the kind of larger segments kind of like buckley torquing them but the overall is palatal torque yeah you increase the nasal floor in the the piriform rim which I often like to show like even even if you just look at it as a still now you know look at the look at the amount of nasal change you've created just by tilting the segments and you haven't even widened them yeah I mean I agree that this can be done but this isn't run-of-the-mill MMA no this isn't what people are asking the question about whether I should do upper jaw expansion before I do on the May because what you're demonstrating is is something you can do during that right like it doesn't just can't widen it which this is good to speak yeah that's what I mean is from the patient perspective if you're trying to say well I do want to increase my nasal aperture or my nasal breathing there are ways to do it with a segmental of fort if your intention is to do so you know if you're not trying to do it you know you're probably not gonna see a ton of change but again this is this is without even trying to change the occlusion like we haven't even widened the actual arch in fact we've probably narrowed the arch because of the tilting yeah to be fair it's the occlusion is changing it's just not I don't think it's a huge change when it comes to this but I mean I think you can get a lot out of a segmental of fort that you're that to somebody standing again out of Marpeys and it's it I think that's a little bit of a different comparison right like I don't think you make the argument let's do a segmental of fort to help out with nasal breathing and no malocclusion as an isolated procedure rather than a Marpeys and I would you're not advocating for that right no yeah okay but I I do think it's an important question that I see all the time and you know you hear that feedback usually from other practitioners and and then now even from patients of, well, the Mark B would allow my nasal airway to change more. And again, I just, I don't know that to be factual. - Yeah, 'cause it's, and again, on the devil's advocate side, I mean, the philosophy of distraction growing soft tissue, right, 'cause distraction isn't just the hard tissue growth, it's the soft tissue growth. - You know, I could believe that you get more soft tissue changes for the positive. You know, when there's segmental effort, the roof of the mouth's tipping down, the nasal mucosa's kind of tipping up, that ultimately heals. And so there's some uncertainty on that final result comparison versus let's say a distraction procedure. But the hard thing to answer right now is, you know, Mark B, hasn't been a solid term for a long time. You know, like the devices that are being created. Like let's say the F and Mube device, that thing keeps, those things keep changing. And so, you know, definitely 10, 15 years ago, upper jaw expansion was kind of a newer thing. And over a 10 and 15 year timeline, we can't learn that level of detail yet, right? And segmental effort has been going on for a long time. I think we'll get more info, but like what you're saying, the knowledge that Mark B does all these things, I don't, I think that's overly simplistic, 'cause the technique is changing. Like just what is getting cut, if you're doing any cuts as a P.A.'s home incision on the roof of the mouth, are we talking about a device with eight tads down the midline? Do we have a two-born and bone-born device? Are you doing a Saarpe cut or dome-cut or, you know, mine-cut? Like these are all things that fall under the umbrella of a Mark B that make the comparison really difficult to answer, but-- - Yeah, really. - I mean, on the side that I do point out to people is if you, is entertaining the idea with people, like you go through an MMA and we're doing it to expand the area. So for sleep apnea, whether we're bringing it forward counterclockwise or widening, combination of all those. And then you still have residual sleep apnea. It's much harder to expand it afterwards, right? So widening arches after the fact, brings up the possibility of another jaw surgery, because one of the downsides of widening is asymmetry can happen or a malaclusion can happen that you can't fix with ortho. In surgery to correct those things. And so the argument goes, well, if you do have a main, you still have residual apnea or not enough room for your tongue. And then you go down the expansion route, we're now talking about another surgery. And so, you know, if that's where people are, then maybe expansion is the right thing, right? - Yeah, that was gonna be one of my points to bring up to you in a little bit different context as the other patient that I do think is indicated for doing that first is the anxious patient or the patient who is maybe prone to catastrophizing or other issues. I've had that conversation a handful of times with patients of, hey, if you really feel like you want expansion and you would be somewhat devastated, maybe it's not the right word, but if you would have a tough time coming to terms with the fact that, hey, I didn't do expansion, I did MMA and I still have residual OSA. If that scenario seems like a Doomsday type scenario for you or that would really kind of linger with you, then yes, I think you should do the expansion first, if for no other reason, then your own anxiety of kind of in the back of your mind feeling like you've done everything possible that you could. And I think that's something that shouldn't be ignored, like it almost sounds like I'm being mean-spirited there, but I generally mean that I'm like, 'cause I mean, it depends on the difficulty. - Really that personality type, let's do it so that you don't have that fear missing out or what ifs after the fact? - Yeah, and I think that's like a real clinical thing, you know what I mean? I think the symptom of I don't have enough space for my tongue, you hear about the tongue falling back with a small lower jaw, but then you hear about the ones where your tongue doesn't have enough width to it. And I just don't think Jossardery does a great job on that one, 'cause it's really hard to know what's the right number to deliver with that. And so using a distraction, using a device to where it starts feeling like you have more space, that being said, it is hard to sort that out too with the Marpe devices, 'cause those devices take up room and you can start getting some crazy occlusions and some crazy aesthetics by the way. But I think it can be helpful doing that first off if it's the right patient for it. - Yeah, the final question that I can think of that I wanna ask you that I think people would wanna know. And I think it's a little bit tougher to phrase is another piece of information that we don't really know is how much the expansion truly helps in the context of MMA. And what I mean is what if we basically comes down to the patient is it worth it. And I think that's the tough question because what I'm getting at is what if you did expansion prior to MMA and you went from an AHI of let's say 40 to six and if you had just done MMA alone, you had gone to an eight. Like is that worth $10,000 to $30,000? An extra year plus of treatment, potential other complications issues. It does make the Lefort a little more challenging in some instances. - Yeah, I mean, that's how it would just be on that one. I think there are influences that of the Marpy that could be negative on MMA, right? Leforts do feel more like a revision Leforts after someone goes through a back-ster expansion. There is scar tissue, the roof of the mouth, blood supplies different, especially with eight tads on the roof of the mouth. I get concerned with things like necrosis, paladal incisions, how much the blood flow goes through those. Who knows, right? Like how could you know that because those procedures are relatively new? And maybe it provides more resistance to the surgical plants. So let's say your surgical plan is a centimeter, 12, 13 millimeters. And because max-ster expansion happens, it's more difficult to get them that far. And so you can't actually achieve the surgical plan because a scar tissue, you know, did it really help you out? It's just, it's looking backwards, it's easy to answer that question, but looking forward's hard. So that's why I would personally, if I was in the camp where I had severe sleep apnea or moderate severe sleep apnea, nothing else was really working for me. Joss surgery, I can get advanced of a long distance and I still look like a reasonably normal person. I would stick to MMA. But if my face was already too far forward or if I had more mild sleep trouble or nasal restriction, then widening makes all the sense in the world. - Yep, I'm with you. I mean, I often do that same exercise in my head of like trying to put myself in the patient's shoes and if it's, hey, I'm mild to moderate, I don't have other reasons to do Joss surgery. I don't tolerate CPAP. Maybe I would personally probably try and apply it. But if I didn't tolerate those things, yeah, I would be in the camp of okay, let's try to expand the, but if I'm in 20 is the number that I always throw around, I don't have any factual basis for that, but that's the number I just use in discussions with patients. I think if you're 20 or above and you're trying to do expansion as your soul means of addressing your sleep apnea, I just don't think you're gonna get there. And if you do, I don't think it's gonna last all that long. Like you're, even if you've got five years, you're gonna, I think, creep back up and need another modality of treatment. So if your goal was to avoid CPAP and you're at 20 or above, I generally tell patients I just don't think you're gonna get there. And again, I wanna be clear, I'm not basing that off of any study or research. That's just kind of the feeling of dealing with these things regularly that I have. So that's kind of how I approach it too. I guess I would say. - Yeah, I mean, I think it's great that, you know, there's alternatives to MMA in the Bony surgery world, right? So for a long time, it is just, let's just pull your jaws forward and you're kind of just stuck with it 'cause there's not too many other alternatives. And so it really is a great thing that Maxar expansion is helpful in the breathing world. And, you know, it's good to ask the questions about what's the right approach. And it's just hard to answer in these clinical ways, right? That's why you see patients for consults and you talk to them. And, you know, like talking to young surgeons about this stuff, it's like, wait, what do these guys even stand at? So yes or no, you know? And it's, you know, there's clear, yes and clear no. But the middle is where you spend all your time practicing. And, you know, you go to one room in the next room, it could be functionally the same X-ray and functionally the same clinical scenario. But the human you're talking to in their situation influences to the best decision are two different decisions. And so that part's tough. And I just, I am a, I'm suspicious that we're a little bit over our skis on the Marpe world right now. - Oh, I couldn't agree with you more. - And again, as I mentioned to you with my feather ruffling comment is just, let's present it the right way. Like if we think it's having a benefit, I think that's how we need to be phrasing it to patients. Like hey, we think this might be a benefit. It's not really well established. We propose it based off this mechanism, but it's not proven. Like I think if you're having your discussions ethically with your patients like that and they choose to go forward with it, it's completely different than being told as a patient. Oh no, you have to do expansion prior to MMA or it's not gonna work or it's not gonna work nearly as well. And I just don't think that's factually accurate at this point in time. Again, two, three, five, 10 years from now, maybe we established that. I'll change my mind with new evidence as always. But I mean, resistance to this sometimes do you from other practitioners and patients, like almost doubting my perspective on it, not that I'm inherently right or wrong, but like when I try to explain the rationale, do you get pushed back? Oh yeah, I mean, I think so. I think in terms of that, pushback's fine. I think it's just more has to do with like how, how could we know our stance, right? Like I think my opinion on this is really just kind of like crafted by looking after patients. You know, I see patients and through it. And I see people through a max expansion. I see them through MMA, you know, revision MMA. You know, you see them after they've done two, three expanders and then maybe, you know, bad situations, a couple of different, two, three different jaw surgeries. And it's like, well, why didn't we just kind of address the main thing here, right? And it's, it's, again, easy looking backwards. It's super hard making decisions looking for it. But either one of these things is a bit, a lot to go through. And I just don't think it's an automatic. Yeah, of course, you have to go through a max expansion before MMA. Yeah, yeah, I'm gonna throw something out there and you can, you can slap me on the wrist if I'm being too much of a jerk. But I've actually come to have to have this discussion with a couple of patients where I remind them, hey, Mr. Miss patient, like, I don't have a dog in this fight really, like, if you go through expansion and then you have MMA, like, my case load, like, I'm not losing a case, I'm still doing your MMA. I get paid the same, like, I'm still doing the MMA. Like, I almost have to break that down from sometimes to get it to resonate of like, hey, I don't, I don't make more or less money if you do it first or not. Like, I don't really care in that regard. I'm truly trying to help you. I'm truly trying to educate you based off of what I know and what I see. And I don't make a dollar or more or less, like, but I find that sometimes that's the final thing I have to say to patients to finally get it to like, resonate of like, oh, he, okay, he really, he's right, he doesn't make more or less money. He's not trying to convince me to go with him versus not do something. And that's where I sometimes feel like it clicks and I hate to do that, like, I hate to talk in those terms, but it seems to somewhat resonate with patients. Have you gone that route? I don't think I've used that same terminology. I mean, I, uh, I do get the pushback. Like, you get the back of like, you're against this and I'm like, not like against it. Like, I'm just truly trying to give you my honest opinion. You know, you, you came to me. I have an ethical obligation to, to tell you what I think and give you my informed opinion and I don't care. What, if you want to do it ahead of time, do it. I'm just trying to help you. Yeah, I mean, it's, it's, I think part of that comes from you recognizing that you don't know, right? And you're like, Hey, I'm not really sure. There's a couple of different solutions here. Um, and it may have been that the previous practitioners they've spoken to had more certainty than you did, right? And so the uncertainty may bring up the idea of, well, maybe they don't know, but, and I need to find more providers that know, um, but I generally think having some like practitioners expressing the uncertainty intervention is, is a sign of a good practitioner. Um, because I agree. There's just, I mean, I think you have to explain it. Like I don't think you can say just, you know, I don't know. I think you can say we don't know, like those studies don't exist. That evidence doesn't exist yet. Yeah, I, I, this might be a little bit of a hot take, but I, I am at least a little bit clinically suspicious that, um, the expansion isn't beneficial. I, I think the, you think it's not, you think you, you're suspicious. It's not beneficial. Yeah. So if we just took the average person who, um, you know, is moderate to severe sleep apnea, uh, or really symptomatic mild and they have small jaws and they go through max our expansion and then an MMA versus just an MMA. I think my current clinical suspicion is that MMA is just better, like in a lot of ways. Huh. Like that. I am open to them wrong. Yeah, I don't feel good enough to start telling people that, but. But if you, if you, if someone asks you like, what do you, what do you really think after seeing patients through this stuff? Yeah, like are you seeing people because they went through max our expansion and just being like, oh, yeah, I'm, like, H.I. Yeah, I think my, my wording in this, this could be semantics more than difference of opinion. I think I wouldn't phrase it that it's inferior. I would phrase it in the sense of, I don't know it to be superior. Like, I don't know that I would say going through expansion first is inferior to MMA alone, but I, I definitely would say I def, I do not know it to be superior from a clinical standpoint only. Yeah, no, I don't tell people I think it's inferior. I just, just talking to you just like, you know, we talk otherwise. No, no, but I would agree, hey, I do not know that doing expansion when you don't need it otherwise, doing that then MMA, I do not know that to be superior to MMA alone. And in fact, and that's just the clinical take. If you took the financial take, the time take, the complication take or rate or increased and problems, if you threw all that out there, then I would be fairly confident saying I, I would lean towards it being inferior. Because even if it's close, coming back to my point of how much money and time is a slight difference, even worth. If you even get that, and I'm not convinced you get it. Yeah. And I'm sure there's there's times where that's helpful. The part that I wonder about is, you know, when we talk about stuff, we talk about a lot of like objective outcomes, like H.I. Reduction or sleepiness scale reduction, nasal breathe, like nose score or something. But you know, I wonder if the subjective experience is worse going through Maxxer expansion first. You know, like, has to be just imagine you as a patient. Like you, you're trying to figure out what's the right thing to do and you find out no one really knows. And we're trying to, you know, talk to different providers. I'm going to try this thing first and it's taken a year, year and a half. You spend whatever 20K on it. And then you go through a May and, you know, you become, I think it would be hard not to focus on a number of subjective outcomes that are really unpredictable with the interventions. You know, things like tongue space or, you know, nasal breathing. Because they're subjective. It's like sleepiness and sleep avenue, a symptom or H.I. and the sleepiness are two different things and outcomes. And I wonder if doing Maxxer expansion first helps like, you know, kind of cause or, you know, it helps facilitate increasing focus on subjective symptoms that the interventions do poorly to fix anyway, right? So like, you know, because there's the doing better on sleep and then doing better in general. And I just wonder if maybe doing a bunch more things ahead of time causes more problems from that standpoint. What do you think? Well, I mean, I think the one avenue that's clear is, let's say I went through expansion in MMA and I still had residual OSA or symptoms. I think that's more devastating to the fate from a patient perspective. Like, hey, I went through all of this and I've still got residual disease or I've still got subjective symptoms or both. I think in that context, yeah. Well, yeah. So, I mean, the overall experience has to be worse. Like it has to be. Is that what you're getting at? Yeah. And to what effect that has on any individual depends. But I don't know. It's from that world is why I'm not sure on the objective measures. It's not like clearly the pattern is emerging in practice where people who go through Maxxer expansion and then have MMA, you know, like our cure rates are now 80 or 90 percent. Like, you don't really see that. It's still, I don't know, I'm suspicious. It's either a wash or and then clinically, it's like, it sets you up for more problems almost. So, yeah, that's where I would agree with you as I think. More cost, more time, more higher complication, rate or likelihood is a given. Like, I feel pretty confident saying that those things are true, right? Like, I don't think anyone would dispute time and cost or more. I would, I don't think anyone would dispute that it makes the, the MMA or the LaFort more difficult. But you do have to infer, because again, I don't think we have the data that shows that complication rates are higher. Like, we don't know that either, right? But I think you can kind of infer a little bit of, It's like a revision. surgery like you said, there's these issues. So cost is for sure higher. Time commitment is for sure more complication rates. We can't prove that they're higher, but you know, I have that discussion with the patients who've had that that is, hey, I think you're at a little more risk for these things. But I think what we can't say definitively is that it's beneficial. And so I think that's that's kind of a good way to put a bow on a lot of this is what we can and can't prove. I have a hot take since you threw out a hot take. You ready for my hot take? What's that? I mean, you don't you don't see him as ready as I was open, you would be. I mean, I'm ready. I'm okay. I'm thinking this one's going to be a little bit off-color, but go for it. It might be. As a surgeon, I have the hot take that many of our colleagues are just rolling with this to appease patients and referrals and decrease turbulence. Yeah, I don't know if that's a hot take. I mean, because there's something you have to kind of pick your battles. In a discussion on MMA, there's so many other things to talk about, right? Like, you know, like magnitude of advancement or risk with numbness or healing issues or tooth injury, or you know, where the location will be surgery first, ortho first, insurance coverage, you know, just like there's so many other things to bring up to then throw in that, well, should I do Max or expansion? You know, like maybe that you don't pick that fight, right? It's like, yeah, I mean, you can't if you want. I mean, that'd be okay. You don't think we as surgeons should be speaking up a little bit more about it? We're doing a whole episode of it. I guess so. I think I'm serious saying that surgeons really aren't, aren't voicing and opposing viewpoint on this whole world. I think that's probably true. Take is not it after all. Because if we talked about this, I mean, if we have that, you know, we talk about the problem. So yeah, there we go. We're part of the solution. But I mean, I see this, you know, you and I do second opinions all the time and I see this more and more of the surgeon agreed or the surgeon said, I do need to do this and I'm like, I get it. We all want referrals. We all want cases. But I think we do have an ethical obligation to speak up. Like, I don't, again, I don't think you have to say no, you shouldn't do it. I think that's wrong too. But I think pumping the brakes a little bit and giving an honest opinion, I think we're we're ethically obligated to do that. Yeah, because one of the hard things of doing the right things sometimes is it's going to make people mad at you. And we're negatively referring to your doctor mad at you. Yeah. Or you know, who knows? Just you wonder your colleagues. That's the hot take is it's easier to go along with this. It's you're probably better for business to go along with this is that's my hot take. And I think it's I think it's really hot. You don't seem to think so. No, no, I think I think that's true. I just I as you're thinking about it, it's like it I don't know how I can weigh in on other people's practice, you know, like because I don't I'm not in their practice. So I guess I would be just coming up with a theory. And you know, in national meetings, I didn't see I don't know how much max or expansion discussion there is. I don't think there's very much actually. And so it doesn't doesn't seem to be a torch that are like the jaw surgery world really taking on. It seems much much more popular in general dentistry, continued education, orthodontic, continued education, maybe even perio. But fine. I think there's probably some components that I like your take. That was awesome. Yeah. I mean, I would let me last question since I think we've covered this. If you're a patient or like do you have anything that you would specifically want a patient, like if you had to create a little snippet to just say in this topic, Mr. Ms. Patient, here's what I think you should know or you should look out for this or be careful in this regard. Do you have anything like that? Or do you think you've already said it? I think we've already said it. I mean, the book ends of the clear yes, no. If you're in the middle, it really depends on what you're most concerned about, right? I think if you are most concerned about avoiding MMA because it's too scary and it just seems like too crazy of a thing, expansion makes a ton of sense. No. If you want to do the one thing that's probably make the biggest impact on your breathing better, MMA is right. Just as long as you can move things far enough in the clinical situation is right, that has to be the better of the two options. So yeah. I would just have to be skeptical. You know, to the extent advocate for yourself as always be a little skeptical. You know, if you're, if it's starting to seem like you're in an assembly line of, you know, hey, you need expansion, then you need surgery or, you know, you need SFOT, you need this specific type of expansion or expanded. Like if it's starting to seem like you're kind of being put along an assembly line of things or people or providers, that's where I would get a little skeptical from what I've seen. You know, hey, you have to go see this person to get this specific orthodontics. You have to go to this person to get this specific right kind of expanded. You have to go to this person to get the exact MMA that you need. Like, yeah, if you get your patient entering the pipeline and that's what's starting to happen, I would say take a breath, pump the brakes, go see Dr. Bobak and Seattle and get an honest opinion. And I think that their, the information should be out there and oral surgeons or just surgeons may not do as good a job that MMA does a good job at the nose. You know, it is a, yeah, marketing for the nose and MMA doesn't do much for the nose. While there are problems with MMA and the nose, there's problems with Marpeo the nose. You know, like your case here of a segmental effort of where, you know, there's, there's huge post-operative nasal volume change. I, I think we kind of discount LaFord osteotomy for nasal breathing. Largely because you don't just do LaFord for nasal breathing. You do other things for nasal breathing, right? So, but that doesn't mean that if you need to LaFord for other reasons that it's also not going to be helpful on the nasal breathing front. So yeah, so for the image, I'll describe it since again, I always forget that people aren't watching us. I don't know why they wouldn't be watching us, but I guess you're ahead. And I need to wash it. I always work out before I do these. Yeah, so we have an image of a patient where we, I did MMA W where we did segmental LaFord and midline medivilar osteotomy. We're just, I, I happened to two for other reasons get a six week post-op image, which kind of shows after a lot of the edema sinusitis and other things have calmed down. And so we went from a intermolar width of 35.7 to 44.1. And we went from a nasal, I guess, what do you want to call a nasal base width of 28, 38.5. So we widen the nasal base by 10 millimeters with a segmental LaFord. There's a huge difference in the nasal aperture there. So again, I, this notion that you can't do it with a LaFord or that Marpe is better. I don't know that we've established this, but again, I completely agree with you in the sense that we don't usually do a lot of LaFords with the intention of widening the nasal airway. But if we did, like an MMA W, I think we're going to get comparable and maybe even better nasal airway changes than Marpe and Messy alone. Yeah, I mean, one off on your case, me that's a great outcome. Exactly. I don't know how our evidence is. I mean, that's kind of where evidence is with MSC and Marpe is it's all case series at this point. Yeah. So that's why I keep harping on. Just say we don't know or we think or we hypothesize or this is the rationale, but to present a dysfunctional for for either way, for or against and whatever scenario I think is just inaccurate, sure. And I'm usually right. So well, good. Well, I'm glad we talked about this. This has been some of us coming up a lot and I think it's an evolving topic. There's definitely one that's if anyone's doing any airway kind of indication for jaw surgery, you're definitely getting these questions. So if you've got some opinions, look forward to hearing from you. Yeah. Well, thanks hopefully we helped some some people with this topic because we do get it all the time and it'll probably be our lowest rated episode and we'll probably get lots of hateful comments. Comments or comments is great. I would say, you know, to extend again, you know, anyone is at AMS, hopefully I can meet some new people. It's a good time to meet up and so that'd be great. Awesome. All right. Well, that was another amazing episode of Downfracture Podcast, a podcast for talking jaws. [email protected]. Thanks again, Sam. I'll see you next time. All right, see you up here.