I'm a dentist treating myself! CPAP Results... Advice please?

[Kenny878]

Hey nee!

Awesome thread here. I’m also a dentist in the process of treating myself. Sounds like you’ve seen a dentist who’s trained under Dr. Jeff Rouse at Spear (and maybw trained there yourself). Amazing stuff hey!?! I’ve got a similar journey going but I dont want to hijack you’re thread. I am wondering though. What’s your plan with regards to plans for surgey/orthodontics? My belief is that people like yourself (and myself as well) will only get so much out of a cpap and need MMA to get a really good result. I’m guessing you have bimaxillary retrusion as well as VME at least in the anterior (aka a “pitched downward” occlusal plane). Does that sound right? Do you have a maxillary transverse deficiency as well? This would make a proper tongue position resting on the palate impossible, also likely indicates a reduced nasal volume. Did Zaghi take a CBCT while you were there or do you have one in your office that you could take one on? Would be very helpful i think. Feel free to pm me if you’d rather discuss this or more in private. I’m the furthest thing in the world from a cpap expert but I’ve learnt a ton from Jeff Rouse, Rebecca Bockow, Zaghi and others on airway. I think we could learn alot from each other.


Edit: if you feel that your long soft palate is blocking your expiration ask Dr. Zaghi about Provent therapy. It’s essentially the thing you tried making for yourself in a previous post. I personally couldnt adapt to it because i cant stand breathing through my mouth but it may be exactly what you’re looking for

[nee]

Hey nee!

Awesome thread here. I’m also a dentist in the process of treating myself. Sounds like you’ve seen a dentist who’s trained under Dr. Jeff Rouse at Spear (and maybw trained there yourself). Amazing stuff hey!?! I’ve got a similar journey going but I dont want to hijack you’re thread. I am wondering though. What’s your plan with regards to plans for surgey/orthodontics? My belief is that people like yourself (and myself as well) will only get so much out of a cpap and need MMA to get a really good result. I’m guessing you have bimaxillary retrusion as well as VME at least in the anterior (aka a “pitched downward” occlusal plane). Does that sound right? Do you have a maxillary transverse deficiency as well? This would make a proper tongue position resting on the palate impossible, also likely indicates a reduced nasal volume. Did Zaghi take a CBCT while you were there or do you have one in your office that you could take one on? Would be very helpful i think. Feel free to pm me if you’d rather discuss this or more in private. I’m the furthest thing in the world from a cpap expert but I’ve learnt a ton from Jeff Rouse, Rebecca Bockow, Zaghi and others on airway. I think we could learn alot from each other.


Edit: if you feel that your long soft palate is blocking your expiration ask Dr. Zaghi about Provent therapy. It’s essentially the thing you tried making for yourself in a previous post. I personally couldnt adapt to it because i cant stand breathing through my mouth but it may be exactly what you’re looking for

What's up Kenny!

I'm glad to keep all this out in the open in case anyone wants to glean information from our cases, but if you want to PM/exchange info and keep in touch I'm more than happy to do that!!

I haven't trained under Dr. Rouse, but I am on the Spear website and have watched a lot of his videos ... such a smart guy and great source of information. I'm going to look into Rebecca Bockow!

You hit the nail on the head - Bimaxillary retrusion + VME (although it is not very drastic). Maxillary transverse deficiency is present, as is a high arch.

Dr. Zaghi's interpretation of my CBCT was that MMA (with Dr. Relle, an oral surgeon in LA) may not be required. First he wants me to try out SFOT + Invisalign. I'll be doing the surgical portion of SFOT with Dr. Curry, a periodontist out in Arkansas; the Invisalign case was planned by an orthodontist in another state whose name escapes me; and the trays will be delivered and monitored by Dr. Cruz in Dana Point. All of this has been coordinated by Dr. Cruz and he has worked with Dr. Zaghi, Dr. Curry, the orthodontist, and Dr. Relle on many, many cases.

At this point, Dr. Cruz wants me to undergo a DISE with Dr. Zaghi in order to find out exactly where the blockages are occurring, and to have a nice write-up for insurance companies to cover MMA in case it is required. His fear is that SFOT will get me 80% there, and that I'll be "cured" enough for insurance companies not to cover MMA, and so he wants the DISE write-up to occur before I undergo any surgical treatment. Makes sense to me.

As far as Provent goes, I bought myself some Theravent Max and used it a couple of nights ago. Unfortunately the amount of pressure generated wasn't quite enough to prevent the catathrenia and palatal prolapse I suffer from, as evidenced by all the weird noises in my sleep recording app, hahah. I'm going to try Theravent + CPAP to generate even more pressure against breathing and see where that goes.

How about yourself? Mind sharing more about your case?

[Kenny878]

Nee,

Thanks for the info. I agree that maybe others can learn from keeping the conversation out in the open.

Comments about your case:
I’ve heard of Dr. Curry and the rest of the group there doing your SFOT although i haven’t seen any completed cases and therefore can’t comment on it any further. I wonder another thing, do you feel that you have forward head compensation as a result of bimaxillary retrusion? For many people, myself included that forward pitched plane is compensated for by forward head posture which then “masks” the retrusion. A profile shot (and a cbct) makes it seem like your jaws are not too retruded b/c of the forward head compsation. When u fix your neck posture ad take another profile shot, the difference is astounding. I’d be happy to send you a saggital shot from my cbct w/ forward head posture and my lateral ceph (posture fixed) so you can see better what i mean. You may want to try provent, the pressure they generate was too much got me so I feel like it generates a fair amount.

My case:
I’ll try to keep it brief. I’ll start my own thread for more details. I was the classic airway kid when i was young. Think “Jake” that Dr. Rouse talks about. Had all the classic symptoms. When i was in dental school (2019 grad) I watched a lecture Jeff Rouse gave and it blew my mind! I realized that it had just started to change from IFL/UARS to OSA as I gad recently begun to wake up choking. This started me down a path of looking to treat myself, which is still ongoing. It’s gone something like this so far.
Mouth taping to develop nasal breathing habit (still by far the greatest improvement i’ve ever felt)
Myofunctional therapy + sleeping on side. No alcohol. No eating close to bed time.
Mandibular advancement therapy (failed miserably but that makes sense given the fact that I have that pitched occlusal plane.
Cpap (phillips respironics dream station)

I’m sure there’s some things missing there. I’m currently on the waitlist for SARPE —> MMA (that’s generally how surgeons do it here in Canada rather than a segmented lefort) but the sarpe that was scheduled for late April has been postponed due to covid. I’ve done much more research than most and i’m fairly confident that MMA is the gold standard choice. But i find it’s very neat that you’ll get to try SFOT before deciding if you need MMA. Also really good that they’re going to to DISE before that. Very smart. Wish DISE was an option for me even just for curiosity’s sake. Anyway. Sorrry for the long post. Please hmu with any questions at all. Like you (i assume) we are not working due to covid and i have all the time in the world. I’ll start my thread soon so hopefully you guys can help me with my cpap data. That’s the one thing in all this that i’m not very knowledgeable about at all

[nee]

2019 grad! Congrats. What a time to go into dentistry, huh? Haha... I graduated in 2018.

I also do have forward head compensation, but I never understood how that is related to bimaxillary retrusion and a forward pitched plane. Does it have to do with tilting forward in order to be able to breathe better? And yes, please send along the CBCT - I'll send you mine as well.

And why does it make sense for mandibular advancement devices to fail in cases of a pitched occlusal plane? I was wondering why I didn't feel *too* relieved even though I have my jaw protruded a really good amount.

And yes, post the CPAP data! Make sure to read the sticky so you only include what's necessary. It makes it easier for the board members to read it and give you advice.

[Kenny878]

Yes odd time to be alive indeed.

You are right with respect to neck posture effecting airway. This video: https://youtu.be/rsMQmq9160M will give you a better idea. It’s an fMRI that gives you a better picture.

As for the mand advancement and pitched plane or “vertical growth” that one is harder to explain. Essentially if you see a high mandibular plane angle the odds of an advancement device helping are reduced in my understanding. The mCSA (minimum cross sectional area) on a cbct may in fact be posterior to the maxilla and not the mandible and therefore mand advancement helps minimally to relieve the “chokepoint” behind the maxilla. This is common with the “pitched” occlusion. If you’ve ever seen a patient with a normal to low mandibular plane angle, reasonable position of the maxilla in the ap and coronal dimension but a mandible that is waaay far back (very class 2 and very large overjet) those are cases that in my understanding have better prognosis for mand advancement device. Although i dont make mand advancement devices so take everything i say for what its worth. I’ll try to find some more cbct to show you as well to better explain.

[chunkyfrog]

Ah, dentists!
One of my favorite breeds of geek.

[nee]

Wow, great info, thank you.

My brother sleeps with his head tilted back, I'll show him the video.

Here's a shot of me for you to look at, interested in what you see as you know more about this than I do

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And yes, I know I gotta get my third molars out and a crown on that premolar...

[Kenny878]

Thanks for posting that. Your OP is less pitched than i expected. You’ll see what i mean when i send my ceph. Laboomental fold is quite deep, this is usually telling of mandibular retrognathia (to a degree) and/or proclination of the mand anterior teeth. Your maxilla appears retrognathic to me as well but impossible to tell just from this saggital view and not clinical exam and cbct in 3d. Please remember that i’m a new general dentist and not OFMS or orthodontist. Just my .02.

Edit: nasiolabial angle also obtuse. Proclining those ants would help a bit but wouldnt get you all the way in my mind.

[nee]

So I'm going to switch to the ResMed Aircurve 10 S ... found one on Craigslist for $295 with 2890 hours on it.

Worth it?

[Pugsy]

It's fixed pressure bilevel only. Are you okay trying fixed bilevel pressures?

Okay deal since it's the S model....would be a better deal if the VAuto model.

[nee]

So I found a brand spankin' new VAuto and gave it a try the past couple of nights.

Night 1: PS 5.0, EPAP 13.0.

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I woke up after 4 hours feeling really anxious and had to use the restroom. Didn't feel well the whole day so I called night 1 a bad night. I also felt like the machine was starting the exhalation phase too quickly, which has to do with the "cycle" setting having been set too high.

The really low FL's, and the generally rounded inhalation and exhalation curves were encouraging.

[nee]

Last night, I dropped EPAP to 12.0 and bumped PS up to 8.0. I also turned the "Cycle" function to Very Low and, as I was falling asleep, I noted that the machine wasn't "taking my breath away" too quickly which was nice.

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Few things to note: FL's throughout the whole night... I'm going to try using a Breathe Right strip tonight on my nose. Lot's of CA's... I think these are arousal related. And my inhalation curves are dented throughout the whole night. Anyone know why? I thought the increased IPAP would help with inhalation... maybe I took it too far?

Some positives: Slept almost 7 hours without waking up, no restroom usage in the middle of the night. The past couple of nights my mouth hasn't been sore from grinding/clenching with my mandibular advancement device on. AND my leaks are pretty much controlled with a neck brace.

[Pugsy]

PS of 8 can actually trigger centrals so be careful with that much PS.

[nee]

All of mine are preceded by a period of increased ventilation, which leads me to believe they are arousal related?

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Maybe that high of a PS is leading to inhalation intolerance and increased arousals?

[nee]

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Bunch of flattened inspiration curves which would tempt me to bump up PS even higher. These terminated in arousal and a "CA"