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Episode 112 - Dr. Kevin Coppelson - The M.I.N.D. Technique and MMA Surgery

1:07

It's Emma Cooksey here and I'm your host, so I'm excited for today's episode with Dr. Kevin Coppelson of the Breathe Institute.

I would just say that it's difficult sometimes to put together these episodes where I know that there's a lot of different people at different stages of their journey listening.

1:27

So there are people I hear from all the time who are, you know, have figured out that they've got some issues with having a narrow, high arch palette and they're looking at surgical options to try and address that.

1:45

And so for those people you're already going to know, you know a lot of the terms we're using and you know, you'll just, you know, there's no advanced knowledge needed for you.

But for some other people, you know, if you just got diagnosed and you've never heard of the kind of either the main technique or generally surgical pallet expansion or MMA surgery, you might just want to kind of familiarize yourself.

2:14

I've done a link in the show notes and there's a lot of different links, but one of them is through a webinar that Doctor Koppelson did fairly recently.

And in that webinar, he's explaining techniques that have traditionally been used for surgically assisted PAL expansion and how this new mind technique that he's pioneered differs from those other ways of doing it.

2:43

And so if you you're, you know, you have questions about that, it might help to go and watch that webinar and see what he's talking about with an actual 3D, you know, like image of of what's happening.

So to introduce Dr. Koppelson, there's an awful lot of me having to say maxillofacial, so we'll see if I manage it because that's not my favorite word to say.

3:13

So Doctor Kevin Koppelson is a board certified and fellowship trained oral and maxillofacial surgeon practicing at the Breathe Institute in Los Angeles, CA.

He practices a broad range of oral and maxillofacial surgery with a focus on skeletal augmentation for the treatment of maxillofacial deformities and sleep related breathing disorders.

3:40

Dr. Cobbleson has published and active in clinical research on topics involving corrective jaw surgery, sleep disorder, breathing and TMJ disorders.

He graduated from both the Herman Ostrow School of Dentistry of USC with a DDS and the University of Maryland School of Medicine with an MD, so he's trained as both a dentist and a doctor.

4:06

He completed a residency in oral and maxillofacial surgery at the University of Maryland and R Adams Kylie Shock Trauma Center, serving as chief resident in his final year.

He then completed a fellowship in advanced Maxillofacial Surgery at Houston Methodist Hospital, where he focused on the expansion and augmentation of the facial skeleton for conditions like obstructive sleep apnea.

4:31

So without further ado, here's my conversation with Doctor Kevin Koppelson.

So, Dr. Cobbleson, thank you so much for joining me.

It's my pleasure.

I'm excited to be here.

I want you to just start by explaining a bit about your background and your training, because I think you trained as a dentist and as a medical doctor.

4:56

Is that right?

That's correct.

So, so maybe just explain to people a little bit about how you ended up where you are.

So I'm an oral and maxillofacial surgeon that is actually a subspecialty of dentistry.

So I first went to dental school.

5:12

When I was at dental school, I kind of fell in love with oral and maxillofacial surgery.

I thought, you know, going to the operating was cool.

I saw the stuff that they were doing and I was like, this is exciting.

This is what I want to do.

So I applied, got into oral surgery, I went to the University of Maryland Medical Center.

5:28

Now when you go into oral and maxillofacial surgery, they're actually two different tracks that you can go on.

There's like a four year track which is a non medical degree track.

You just do four years of surgical training and then you come out and you can theoretically those people start in dentists, like they start doing the dental thing and then they do another four years.

5:49

Correct.

Yeah.

It's a four year residency training.

There's also an MD track where it's actually a six year training where you actually also go to medical school, get a medical degree and then do your surgical training.

So I'm a sucker for education.

6:04

I kind of still miss school for this day sometimes.

So for me it was a no brainer.

It was a no brainer to do the the longer track and get my medical degree.

I also felt like it would make me a better doctor overall, you know?

So for me it was like a pretty clear choice between the two different tracks.

6:23

When I was in oral surgery training, I fell in love with corrective jaw surgery.

So corrective jaw surgery, also known as orthognethic surgery for sleep apnea, we call it maximum and dibulo advancement or MMA surgery.

That surgery to me was like the coolest thing in the world.

It was.

6:40

Immediate.

It was profound.

It had huge impacts on people's self esteem, their quality of life, the way they could breathe, sleep, chew, speak, all kinds of different things, right?

And it was like immediate, they would wake up, they would look better, they would feel better, they would function better.

6:56

So for me like.

You know, out of all the different surgeries we do, we trained on temporary mandibular joint surgery, trauma surgery, cancer and reconstruction, You know, obviously the dental oviola stuff like wisdom teeth and dental implants and things like that.

The corrective jaw surgery was the one that I was instantly attracted to.

7:14

So I knew that, you know, one way or another, that's kind of what I wanted to do.

I actually, in residency, fell in love.

More so with treating people with sleep related breathing disorders.

I met Doctor Zogy.

7:31

Well, we actually kind of knew of each other, but we actually met up while I was still in my training and we both discussed our love for for people that don't know.

Doctor Zogy is my partner here at the Breathing Institute in Los Angeles.

He's a I think most people listening, no, at this time.

7:49

But I mean, you never know so.

Yeah, So, so we actually.

We had a meeting while I was still in my training.

We talked about her joint love for treating sleep apnea and you know, UARS and things like that.

And I told him like, listen, I this is what I want to do with my life, like it's my calling.

8:10

And he was obviously still in his training.

He was on the same path and we're like, he's an ENT surgeon.

Right.

Is it your nose and throat?

I'm an oral and maxillofacial surgeon.

You can think of it kind of roughly as.

Anything soft tissue goes to him, anything hard to Hugh comes to me.

8:28

So I'm like a orthopedic surgeon for the face I guess is a is a good way of thinking about what I do.

And we're like okay when we're both done with our training like let's link up and and and try to really help people and do research and you know try to stay on the cutting edge.

8:46

And you know, I'm proud to say I think we've done a pretty good job of that so far and you're working collaboratively, right, which I think is a really you know, it's happening some places, but it's that it's pretty rare really.

9:03

It's a lot of people that.

Are mainly rare, right?

So they're not working on cases together.

Yeah.

So in like academic institutions, you're going to have ear, nose and throats and oral and maxilla facial descriptions within the same roof.

But really, how collaboratively are they working, right?

9:20

It's like, OK, this goes to you.

This comes to me.

So me and Dr. Zaghi are literally in the same office under the same roof, you know, running stuff by each other and discussing really complex cases and you know, what can you do for them, What can I do for them?

9:37

And you know I think because of that really unique collaborative structure that we have here we're we're we're helping a lot of people that I think otherwise might not have had the best outcomes because you know one of the things that I.

Unfortunately, get to see.

9:54

One of the things I'll see is people that have failed treatment, they've been through 10 years of therapy doing XYZ name it and it's I talk to those people day in and day out also.

Yeah, yeah.

And then they Cuz there's a lot of us.

10:11

We tell them something that they've heard for the first time in 10 years and.

You know, it's a blessing to be able to help them, but it's also sad to to see someone that's been strung along for so long, given false hope, spending a lot of money and then kind of being sometimes even worse off than they were before due to certain complications that can happen.

10:31

So you know, I'm pretty open minded I.

It's not like I anyone who walks through my door gets offered surgery, right?

There's people that that I'm like, hey, maybe you should go try this less invasive thing.

But at the end of the day, there are certain people that surgery is going to be the best thing for them and give them the highest chance of cure.

10:54

And yeah, and so those people for everybody listening.

So we're going to have like a really broad range of people listening and we're trying to hit everything for all the people.

And so some of the people listening, this is a brand new concept to them that they've they've never heard of double, like MMA surgery, they don't really know anything about this.

11:15

For other people, they're all the way at the point of like they know about all the different procedures and they've heard about this mind procedure that you're not doing and they want to know all the nitty gritty about that.

But maybe just to kind of set the scene, do you want to talk about what's which kind of patients are going to be the ones that benefit from the mind technique that you're going to talk about, but also from MMA surgery, like there's a specific type of sleep apnea patient we're talking about.

11:45

So maybe you can explain about like you know, how their face and jaws developed and a little bit about which kind of people they are.

Yeah, that's a great question.

It's obviously like, super.

Intricate in terms of like actually like you know, doing a full clinical exam, radio graphic exam, but in general they're treating different jaw deformities, right.

12:09

And I guess deformity is a harsh word, it's just the medical word that we use.

But you know, people that grow and develop and develop abnormalities in their jaw, it can happen.

You know, the jaws are actually like very complex 3 dimensional objects, right?

12:27

So.

It's not like you can have just one issue, it can be multiplicity of issues, 3 dimensional growth.

So Long story short, what's the, and I know there's such a huge broad range of patients that all have their individual things.

12:44

So I know that we're talking in generality.

Yeah, yeah.

Yeah.

So I'll speak in generalities.

In general, the mind technique is a surgery that treats what we call maxillary transverse deficiency or maxillary transverse hypoplasia.

For Long story short, that's a upper jaw that did not grow wide enough.

13:03

OK.

So the upper jaw is actually the largest bone in your face, you know where as even as the oral healthcare provider you get kind of coaxed into thinking that the upper jaw is kind of what you see in the mouth?

The bone that houses the upper teeth, your palate and things like that, but it's actually the largest bone in your face.

13:20

It's going to dictate how wide your nasal cavity is, how wide your nasal floor is, and that actually has a huge impact on a couple things that can really affect your sleeping and your breathing.

OK.

So for example, if your nasal cavity is too narrow, it can obviously be very difficult to breathe through your nose.

13:36

Those patients will often be mouth breathers.

You're supposed to breathe through your nose about 98% of the time and so, which is why when I do a lot of these interviews, I like almost pass out because I'm like so much.

13:53

I'm nasal breathing.

Well, me too.

A Long story short, I need that surgery as well, so I actually just did it on Dr. Zaghi.

I know.

I can't wait to ask you about that.

I saw the the.

Video of him.

Yeah, yeah.

So let's definitely talk about that in a bit.

14:12

So patients that have a maxillary transverse hypoplasia or maxillary transverse deficiency, they'll often be mouth breathers, they'll have some nasal obstruction.

The way it can also affect your sleep is a couple reasons.

Number one, your tongue is supposed to sit along your palate forward upward, filling up the roof of your mouth.

14:32

If your palate is too narrow, you will lose space for your tongue, so you'll have inefficient space for your tongue.

The tongue will usually go in one place and that is backwards.

It'll narrow your oral fringe.

You'll airway, make your airway smaller, thereby proning you that get a collapsible airway.

14:48

Because now you're working with a smaller airway.

It doesn't take as much for it to collapse, cause obstructions, right?

The other way it affects your airway is when you're breathing through a narrow nasal cavity and you have.

Increased airway resistance.

It actually leads to more collapsibility of your airway.

15:06

You're breathing with more turbulence.

Explain this.

Because when I when I watched your webinar, I thought that you explained that better than I've heard anybody explain it.

So there's a few people out there who were talking about nasal resistance and how important it is with sleep apnea because so many of us, nobody's even looking at your nose, right?

15:30

So people are getting a diagnosis, Nobody's examined their nose.

They don't know whether there's a lot of resistance or a little resistance.

And so kind of explain about how that can add to this whole collapsing your airway thing.

15:46

Yeah, for sure.

So anytime you take a breath in, right, there's going to be a pressure to the air, right?

And in general.

What you don't want is a big drop in pressure when you're breathing.

And if you have a big drop in pressure, you can think of it as increased negative pressure because it takes a negative pressure to get a breath in, right?

16:05

So you're always going to have some negative pressure, but if that drop is too severe, that's going to cause the entire airway to collapse, right?

It's like, I know this is a very like crude thing, but you can imagine if I'm breathing with a lot of turbulence things, things collapse, right?

16:21

You can look at your external nasal valve.

It's a, it's a.

Easy and cheap way to show it to a patient, but the same thing can be happening throughout the entire airway, not just on your external nasal lot.

So what we do with the mind technique is achieve 3 dimensional expansion of the entire nasal cavity volume.

16:39

Thereby like you're breathing.

It's like breathing from cocktail straw to breathing through a fire hose, right?

So if you're trying to breathe, take a breath through a cocktail straw.

The only way you can get that breath in is with.

High velocity air, lots of turbulence and what that turbulent fast breath of air causes is a big drop in pressure and thereby causing your airway to be more collapsible, right?

17:05

So the airway, in an ideal world, is going to be big.

And not collapsible, right.

So we're treating different things right.

So like when I talked about increasing space for the tongue, well, that's going to be treating airway size, right.

As the tongue comes forward, the airway widens.

17:22

So now you have a bigger airway.

When I'm talking about, you know, threedimensional expansion of the nasal cavity volume there.

We're trying to decrease airway collapsibility.

So we're targeting.

Obstruction through different ways, right?

There's different modalities that you can go about to treat airway collapsibility.

17:41

One of them is make the airway bigger.

The other one is change the dynamics of air movement within the airway to make it less collapsible.

And so the mind technique kind of treats both of those.

We're gaining some tank space.

17:56

We're also changing the dynamics of air movement, thereby making their way less collapsible.

That's why it's so effective.

Yeah.

So we're coming on to it, but I think a lot of people are a little bit confused by there's so much terminology around this, right.

18:14

So maybe if you could explain like kind of where we were before you develop this newer technique of people are like Sarpi and Marpi and Doom and they they get really confused about the terminology.

So can you just kind of explain to us like what kind of options there were for surgitly assisted pal expansion and then why you decided to come up with something of a bit different and how it differs?

18:45

For sure that's such an impossible question.

You can talk about for two hours, probably, no.

Yeah, these are like hour long lectures.

Yeah, they are.

But it's doing really well though it's oh thank you.

It's easy to summarize.

Traditional techniques were based on a surgery called a two piece Lafort 1 osteotomy.

19:04

So Lafort 1 osteotomy is you know I guess we'll talk about MMA surgery in a bit.

That's my other passion, but that's the basically the surgery we do to.

Break it up or jaw and move it around.

In MMA surgery, it's a pretty low cut, so you can think of it as not addressing the entire maxillary bone, but just the palate and the alveolar process.

19:30

So it's like, you know, you can think of it as just this part of the maxillary bone, ignoring the entire bone, that's going to dictate how wide the nose will be, OK?

And when I talk about nose, I'm not talking about external nose, I'm talking about internal nasal cavity wall.

Okay, cuz that's a question patients often ask is like, is my nose gonna look wider?

19:50

And the answer is no.

This is gonna be different inside, right?

It's all internal, yeah.

So traditional surgeries were based on the Lafort 1 osteotomy.

You can Google the image for the people watching at Homeless to see where the cut is, but it's basically a cut that's done almost at the level of the nasal floor.

20:09

And so we're doing that like nasal floor level cut.

We're splitting the palette down the midline.

So now you have like a two piece Laport 1 osteotomy.

Yep, we widen at that level, Okay.

Now, the difference between a Sarpy and a Dome is the type of expander that you're using.

20:26

So in a SARP, you're using a toothborne expander.

So just a orthodontic expander attaches to the teeth, the most common ones a high racks.

And so you do this surgery and now you're pushing on the teeth to get the bone to expand, all right.

So there's some downsides to that.

20:43

Obviously as you push on the teeth, you will get some, some Osteo, some bone expansion, but you're going to get a lot of dental tipping and there's side effects from that are not very beneficial, right.

So the Dome surgery is the same surgery.

It's basically a two piece Lifort 1 osteotomy, except it's with the utilization of a bone borne expander.

21:03

So it's an expander where you actually have skeletal anchorage, so there's some kind of anchorage into the bone.

Little mini screws or or some sort of, yeah, there's there's so many different kinds out there.

There's ones that utilize mini screws.

21:19

There are kinds that just kind of expand that, excuse me, attach into the pallet transversely and just like press that way, whatever it is, you're basically trying to not push on the teeth as much those.

Are attached to bone, right?

21:34

Yes, in some way it's going to be attached to the bone.

And so you're going to have a lot less of those dental alveolars side effects that you don't want to have.

So I started doing, you know, well in my training, we did a lot of start peas.

21:50

I came out, I started doing domes and then I learned about this procedure called ease which stands for.

That's also on my list, so go ahead and talk about that.

So which is a, which is a great surgery and I started reading papers by Cantorella and things like that and I I got Privy to the concept of true nasal maxillary expansion.

22:13

So.

So can you explain what you, so I've written down endoscopically assisted surgical expansion.

How is that different from like Dome or?

Yeah, so it's first of all, it's a lot more minimally invasive than the traditional surgery.

22:32

So to do a Lefort surgery like a Sarpy or a Dome, you're talking an incision that goes from one first molar to the other huge dissection degloving the entire bone.

And what that's going to lead to obviously, is more pain, more swelling, more bleeding.

22:51

And again, because you know what I'm going to be alluding to, you get worse expansion than what would be ideal, right?

Because you're cutting at the level of the nasal floor, you're widening really low, you're getting some airway benefits, but it's not perfect, right?

23:08

And it's a pretty big operation, Okay.

So I wanted you know one of my big things is is minimally invasive, right.

But I don't want to do minimally invasive and minimally effective, right.

So at the end of the day, I'll choose a bigger operation if I get a better result.

23:23

But in an ideal world if you can have minimally invasive and maximally effective, that is like.

The dream, The best of both worlds, right?

So that became kind of like my focus.

I was like, can there be a minimally invasive technique that is also maximally effective?

23:41

It's more effective than the traditional surgery and it's much more minimally invasive.

The recovery is 20 times better.

It's something that can be done in office as opposed to in a hospital and operating room.

And that's kind of where my focus became and that's how the mind technique became developed.

24:01

The way I kind of like led into it was I started doing the yeast procedure.

I was having good results with it, but in my hands, I just felt like I could do it a little bit different.

And basically a lot of the yeast procedure is done transnasally.

24:20

So you'll actually go through the nose to cut the palate.

You know to me a lot of the cuts I made I I wanted to do them through the mouth.

So I changed the technique up.

I utilize different expanders than you would use in ease and you know I'm happy to say it's it's it's going amazing.

24:43

I mean we're we are getting phenomenal results from these procedures.

The recoveries are amazing.

I mean, most of my patients never take any narcotic pain medication.

That part's incredible minimal swelling.

24:59

I I did the procedure on Doctor Zagi on a Saturday and he was working Monday.

So I mean that kind of you can't get that kind of recovery from a Lafore procedure.

And not to mention, you know, the airway results we're getting are are you know, 10X you know, just subjectively I can tell you just from when I used to do Sarpy's and domes compared to what we're getting now with just a few millimeters of expansion, the differences that patients are feeling in their nasal breathing and their sleep is exponential so.

25:33

So MIND stands for minimally invasive nasal maxillary distraction, yes, so, so is it.

So a big difference is in the the way that you're cutting, you're not doing the Lafor thing that you talked about, correct.

25:51

So all those words are in there on purpose, right.

It's definitely a minimally invasive technique, all right.

And we're doing it through three incisions that are about half inch each.

We operate through those little ports.

26:09

And this is on the roof of people's mouths, not through their nose, correct.

Everything's through the mouth.

There's no scars, nothing.

It's all done through these three little ports.

So operating through those ports means, you know, obviously minimal, minimal amount of swelling and pain and and discomfort afterwards.

26:27

And nasal maxillary refers to the type of expansion you get.

So instead of having that low one level expansion where you're only expanding at the level of the nasal floor, we're getting true 3 dimensional expansion of the entire nasal maxillary column, Yeah.

26:45

So it's going not only outward side to side, it's going some forward or so, yes, but you know that is just a byproduct of the expansion.

27:01

So you know we've had at this point multiple patients who had Class 3 occlusion that's like that typical under byte occlusion and when they were done expanding, they were almost in class one and you're talking about a couple millimeters.

27:17

We're not getting like 6-7 millimeters of lower growth, but as the bone expands, you kind of bump into the plates in the back and the jaw comes forward a couple millimeters.

I also have patients now experimenting with reverse pull face masks.

27:34

These are what we can do is add hooks to the expander and the patient can wear a face mask that is pulled forward.

So I've had one patient quit and I have a patient now who's a Doctor Who I feel like it's going to be very compliant.

27:49

So I'm excited to see.

I've read research on it.

Theoretically, in an adult, you can get maybe 2 to 3 millimeters of forward growth using a reversible face matter, you know, So we'll see.

But, but yeah, so maybe 1 to 2 millimeter forward movement, maybe not growth, but just movement as as you're expanding as things bump into each other and things get pushed forward and maybe we can push it another 2 to 3 millimeters with really strict compliance use of a reverse pull face.

28:21

Interesting.

So you said it's an in office procedure.

So somebody comes in and you do the initial procedure and they have like some sort of metal implanted into the roof of their mouth and then they go home and do the expanding it.

28:39

Yeah, exactly.

So, so it can be.

So I I'd say I do about 5060% of them in office.

There's some people that are like listen like I want to be like I I want to anesthesia.

I can't blame those people.

28:54

Me out and that's fine.

Yeah, that's how I do it for Dr. Zaghi.

Hopefully I'm not violating his HIPAA, but he's been sharing his story on.

Yeah, I think he's shared like with the whole world this morning.

So but yeah the the in office ones we're doing under IV sedation.

29:12

I'm as a normal maxillofacial surgeon.

We we have a general anesthesia permit so I can do procedures in office by myself and start an IV, get patients sedated, do the procedure in office.

I've had some patients that I guess we can call them Brave Souls that did it totally just under local anesthesia and those went great.

29:35

So it can be an office either under local anesthesia, under IV sedation or under general anesthesia at a surgery center at a hospital.

So.

So and so then after that, so what's happening in the roof of their mind?

So there's their pallets not cut.

29:52

So there's.

The pallets not cut with this?

No.

So you won't have any cuts on the pallet itself.

You will have an expander that is called on the roof of the mouth and then obviously 3 incisions spread out through the mouth.

So does it get to a point where that.

30:14

So I had somebody else on that did a sarathy thing like I think it was MSE was the the type of thing and she was explaining like she didn't have an incision along the panel to suit you either.

But when she got to a certain point, it kind of like almost like.

30:31

Cracks like overnight or something.

So is that kind of what happens?

No, no.

So with my surgery you're already split.

So there's no question of like turning hoping things crack, more importantly hoping they crack and split in the right way symmetric.

30:51

You know, I guess you know, I the type of patients I see, I see the worst of everything.

I see patients come in that have done things in a way that have led to outcomes.

So that's kind of what led me to modify things in a certain way.

There's certain complications that can happen in adults, obviously not super often, but they can happen when you don't have surgical assisting.

31:16

I think surgical assist for these type of procedures, they just lead to a lot smoother of a expansion, more symmetric, less chance of having your nasal septum kind of get super deviated by following 1/2 of the upper jaw, yes.

31:34

No.

So with my surgery you're already split.

So by the time the surgery is done, you have a get a diastima like this, right?

And then I close you back up.

After the surgery, we wait a week and then we start turning again.

But you're already split.

Everything is symmetric.

31:50

OK, OK.

That's what I wasn't understanding.

OK, so that's already done and you're already split, yeah?

And then the person goes home and they are turning.

So we wait.

We wait.

32:06

We wait a week, around a week.

The reason is, you know, for the last letter of mine is distraction.

It stands for distraction autogenesis, which is a phenomenon where we take advantage of the bone healing properties that humans have, Okay.

32:22

So let's say you get a fracture in your arm, right?

You wear a cast.

After a week, you're going to develop something called the callus between the two halves of the fracture.

And then over time, that callus will, you know, turn into hard bone and you can remove your cast.

Yeah.

32:37

So what we do we're we're basically creating a fracture in the palate, right.

So the reason we wait a week is we close everything back up and we allow those two halves of the fracture to create a callus and then we take advantage of one of the properties of that callus, which is its ability to stretch.

32:57

So we wait a week, then the patient will start turning at home every day.

And so they slowly expand, expand, expand, they're stretching the callus out.

And then when we get to our gold expansion, we stop expanding and now that stretch callus is going to turn into bone.

33:14

So that's.

So I was I got a ton of different questions from people and so that was one of the things that somebody asked was how do you, you know, know how far they should?

Expand or like how do you know when to stop?

33:30

And my answer would be, cuz it's not your first time doing this.

And like, you know, you kind of would be an expert and then would know, but I don't know, is there a particular range and, you know, for certain people, Yeah, yeah.

33:46

So obviously it's, it's patient by patient there.

There's some limiting factors, right.

So like, let's say my goal for every dollar is 38 to 42 millimeter intermolar with, OK Now you may be limited to getting to there by orthodontic reasons.

34:03

For example, let's say your lower jaw is also kind of narrow, right.

And so the orthodontist won't have room to upright the lower molars enough to get you in a good final occlusion.

That can be a limiting factor to how much we can expand, right?

So in cases like that, we will sometimes do an additional procedure on the lower jaw called SFOT.

34:25

It stands for Surgically Facilitated Orthodontic Therapy.

And that's a procedure where we'll actually create osteotomies.

We'll cut between the roots of all the lower teeth.

We can add bone on the outside and that'll give the orthodontist more space to translate the lower molars out so that so that the bike.

34:44

Can work.

Yeah.

So my, you know, at the end of the day, I'm not just treating someone's airway, right.

I want to make sure that they are happy, you know, all the way around.

They have a good bite.

They look good.

They feel good.

They sleep good.

They breathe good.

34:59

It's not like I don't want to just like expand someone, OK.

You're at 40 millimeters and now they, they don't have a functioning bite.

Right.

So.

So at the end of the day, like our goal is to make everything match up the way they look the way they feel because and and so we'll sometimes have to do additional procedures on the lower judge.

35:20

And that's not often Most people that we see that have maxillary transverse hypoplasia, they have buckily inclined maxillary molars, lingually inclined mandibular molars.

So there's lots of space to like, upright those lower molars, and plenty of space to widen the upper jaw.

35:37

Or so.

What we're doing in those cases is orthopedically or skeletally expanding the upper jaw and then orthodonically expanding the lower jaw.

Got.

It And so the person finishes doing however much.

An expansion, like adjustments to their device at home and then do they come?

35:58

I'm assuming they're coming for checkups the whole time, but then do they come back and have that removed?

Is that kind of like okay?

Yeah.

So it takes about six months for not just bone to fill in, but for the bone to become strong enough not to relapse.

36:14

Yeah.

Yeah.

So it would be a shame to go through all that, move the appliance too soon and then have relapse.

So it's about a six month wait.

But during that time, you're doing ortho, closing up the diastoma.

36:29

So it's not like six months of like doing nothing.

It's six months of during ortho, your bites looking better, functioning better.

But we're just keeping those, those, those, those mini implants in place to to, you know, cast the bone, you know, like a cast in the mouth holding the bone where we moved it to enough for bone to fill in.

38:21

I know that you said you're looking at the entire patient and everything going on with them.

But for people who are primarily doing this because they want to see improvements in their sleep and how quickly do do patients kind of notice those changes in nasal breathing and that they're able to sleep better?

38:40

Yeah, great question.

I am even surprised by this.

But night one, OK, so basically everybody I do mind on, you know, I check on them that that night or you know, the next day I'll, I'll give them a call.

38:57

How you doing?

Did you get all your medications and, you know, all that stuff and everyone's like doc, like is this normal?

I'm already breathing a little bit better through my nose and I'm like, yeah, I mean I used to say like, no, maybe it's like placebo or something.

But enough people tell you that you're like, OK, there's something going on here.

39:17

So what I think it is, like I told you, during the surgery, we expand them and then close them back up.

So what I'm thinking is just that stretching from the surgery gets things to start moving, removes cranial strain and gets people breathing better.

39:34

But you know, like for full effect, let's say it takes like, you know, it's obviously like, it's exponential, right?

So each day it's going to get better and better, but it's not like something where you have to wait the six months to have the improvement.

Like as you're expanding, you're going to progressively breathe better and better and progressively sleep better and better.

39:55

So it's, you know, week one you're having some improvements, week two even more, week three even more, week four even more and then you know, then we wait six months, so.

Can you talk me through a little bit about how how did that conversation come up with Dr. Zaghi?

40:11

Like did he just say, hey, I think I want to try this out or like cuz I would imagine that's like a whole bunch of pressure.

Yeah, yeah, so couple reasons.

So he's failed expansion multiple times.

40:27

He's had the MSE, you know, and it didn't work.

It didn't it didn't work out for him.

Had to get it removed.

He tried orthodontic expansion.

Where?

You know, you just use Invisalign or braces just to widen out the dental arch.

Again, that's not really treating an underlying issue.

40:47

It's just kind of masking it orthodonically can think of it as camouflaging and we're in the same office.

So you know day after day he's seeing patients come in like you know talking about their experience and how the mind surgery like.

41:04

Drastically change the way they sleep, the way they feel.

I mean, the stuff that you hear from patients is really, really awesome.

Like I have the best job.

Like getting to hear patients that have been suffering for so long say like I'm sleeping normal for the first time in 20 years.

41:19

I'm off my ADD medication, I'm on my anxiety medication, I'm on my depression medication.

My postures change.

That's a Long story short, like he was just seeing patients come in every day, you know, with.

You know, massive improvements and in their quality of life.

41:35

And he's like, hey man, I need you to do this on me.

Hey, why don't you get on board?

Yeah.

Yeah.

So I was like, it be my honor and privilege.

And there's definitely a little bit of anxiety.

Yeah, I bet you ate your wings that morning.

Yeah, yeah.

41:51

But you know, thank God it it went well.

And actually, you know, I felt like I was repaying him a favor.

He did a septoplasty on me.

All of November, so are the previous November.

So now we're we both operated on each other.

42:06

So it's a big sign of trust.

So another one of the questions somebody asked was, are you planning any future improvements to the procedure like they were saying, such as a new expander or you or you're just going to stick with what you're doing?

42:24

Yeah, No, I'm always open minded, right if.

There's a a better tool out there.

Something.

I mean.

I'm obviously more than happy to use it.

I have been constantly tweaking the procedure.

It's not like I'm doing it the same today as I was 2-3 years ago.

42:42

Very different.

In fact, the way it is right now, it's working.

Amazing.

So as of right now I'm not actively looking to tweak anything.

I haven't had anyone fail.

Big burly man.

42:59

You know any female like within the last two years?

No.

No one's not split.

So in that regard, not actively looking to change anything.

But that being said, you're open.

To yeah, my fingers on the pulse, right.

43:15

So I'm always, I'm always thinking, I'm always looking and you know, brainstorming and if I see something I'm like ooh, that could.

Maybe tweak for people listening.

You're the only one offering this specific.

Yeah, right.

So procedure.

43:31

So are you planning on teaching other surgeons so there can be other people around the country and the world doing it?

That is my plan.

We're working on research right now to show.

We we know how effective it is just seeing patients come in day in, day out.

43:49

Now we need to put numbers to it, right.

So once I publish on it and I get that, you know that first paper out that talks about it in in a scientific journal right now, I lecture on it quite a bit.

But at that point, then, I think it's appropriate to start teaching it right now.

44:09

To teach something that I'm just doing myself that hasn't been published yet is probably not.

Appropriate.

So what kind of time frame are you looking at for that like do you have?

Probably like 12 months.

Yeah.

Okay.

All right.

So we just started.

44:25

We're doing pre and post op sleep studies.

Also pre and post op or not pre and post up but we're doing pain Diaries because again, I told you like no one's some people take narcotics but.

A lot of people are not like, they're just like, it's like a four.

44:43

I mean, I've got to tell you, like that just seems astonishing to me.

Like it just seems like it would be really painful.

But no.

It's like literally, like patients are like, I didn't take anything.

Is that OK?

Do I have to take it?

44:58

My no, you don't have to take pain medication.

You take antibiotics, but you don't have to take pain.

But yeah, I mean, obviously pain is the, you know, subjective thing, you know?

11 Man's four is another man's 10 but in general pretty remarkable.

45:17

Low pain scores and big chunk of people take nothing or take very little pain medication.

So I could like seriously talk to you for three hours, but we're going to move on to I want you to talk a little bit about MMA surgery.

Which patients, you know, do you kind of do the mind procedure?

45:36

And some people still need MMA.

What You know, like what are the reasons that somebody might need that surgery versus the mind technique?

Absolutely.

Great question.

So MMA surgery is stands for maximum Mendibula advancement surgery.

45:52

It's a surgery where we're operating on both the upper and the lower jaw and moving things forward, doing stuff with orientation.

So you can think of it as not just forward, but we can basically we have.

46:08

Total complete threedimensional control of both jaws, right.

So we can think of movements as translational, right forward, side, side, up, down and then orientational pitch rolling Yaw, okay.

And with that control, we can do really remarkable things for patients that have sleep apnea, that have bad bites, they have, you know, crooked jaws, You name the issue, we can treat it with extreme 3D precision.

46:38

So for sleep apnea for example, we're generally going to be advancing the jaw.

So the jaws will be coming forward.

So you can think of that as treating patients that have had they have retrognatic or retruded jaws, right.

So as the jaws grow forward, the jaws are basically the gateway to the airway.

46:57

They affect how big the airway is going to be.

It also affects collapsibility.

But as the jaws get stunted in their forward growth, all those soft tissue structures that are going to dictate how big your airway is going to be, the palate, the tongue, are going to also fall back, thereby narrowing your airway.

47:13

And is that something?

So I've heard like a couple of sleep specialists talking and saying just from like looking at a person's face, well you don't need double jaw surgery because look, you're chin isn't really far back or whatever.

47:31

But this is something that you would really need to have a scan of your airway to determine, right?

Not just a scan of your airway, but a CT or a CBCT scan of your entire maxillofacial structures.

Off of that right when I when I see a patient for console for jaw surgery or MMA surgery, I am taking dozens of clinical measurements.

47:57

Okay.

So if you see my consultation summaries, there's literally dozens of physical measurements that I'm taking with like a boldy gauge.

And then dozens of measurements were taking on a CT scan.

Angles from the skull to the upper jaw.

Angles from the jaws to each other.

48:14

So slight tangent, but it's relevant.

So tell us a little bit about, you did a paper on CBCT scans and because I think a lot of people were having a tough time because that, you know, depending on the height of person standing or there wasn't a lot of uniformity between CBCT scans.

48:37

But you were like, I didn't really understand it, but you came up with an angle that is the same between no matter, you know, which scan you look at.

Can you explain it a little bit?

Yeah, absolutely.

So Dr. Zag and I just published a paper, I think it got published in the June issue of the Journal and Oral, the Journal of Oral and Maxillofacial Surgery, which is the big journal in my field.

49:03

Basically just like I said, we take measurements to to understand jaw growth and things like that.

One of the things we know as.

Sleep apnea doctors, right?

People that treat airway issues is that forward head posture is a common compensation for a small airway, right?

49:22

Subconscious will always choose airway and breathing over long term durability of the body, right?

That's why people clench and grind at night.

That's why people have forward head posture.

These are little compensation.

Yeah.

Yeah.

49:38

You name it, right, you'll, you'll come up with these, whatever compensation to make the airway a little bit better.

So we knew that that was a thing, all right.

But that was not something that people were looking at when evaluating CBCT scans.

Okay.

Because if we know that having a forward head posture is a common compensation, first of all.

49:59

How big of an effect does it have?

And that's one of the things we were able to show with each with the the angle we come we came up with is called the NBC3 angle.

It stands for Nasion to basion which are supple metric points to the upper anterior point of your third cervical vertebrae.

So based on this angle we're able to detect cranial cervical extension inflection.

50:19

OK.

And what we were able to do is first of all come up with a number that.

What?

What is a normal MB C3 angle, What is considered extended or flexed from that angle?

And then how big of a change each five degree change off of the ideal MB C3 angle can have on your airway.

50:41

And it is, it is profound.

So each five degree change has a 25% effect on your airway size.

Each five degree you can have either a 25% increase or decrease in the size of your airway just by a five degree shift.

So that's why patients do it.

50:57

And why is that important?

Well, number one, we're proving something that we all know now we're able to quantify it.

And also as providers, we can use it to reliably compare 2CBC T scans.

So if in one scan the patient has an NBC3 angle of 110 and the other one they have one of 130, then you're not comparing apples to apples, right?

51:22

You're like, look, I made their airway better with this appliance, but in the second scan they're they have forward head posture, right?

Then it's, it's a false falsely positive result, right.

So, so that's, that's what the paper shows.

51:38

Okay.

We're gonna link to that paper.

So people wanna go down that rabbit hole.

They can, but so the back to the MMA surgery, so people come and you, what is it?

Is it just going to be more extremely compromised Airways?

51:58

You're going to recommend MMA versus Mind or?

I like to, I like to think of myself as a sniper.

So I think there there's some people that anyone walks in the door, they get MMA surgery, right?

Totally.

It's the whole light.

52:14

You have the hammer, so everything's a nail, right?

I mean, I feel like with sleep apnea, that's absolutely every specialty and everybody's trying to do their best for patients, but they only have one thing they do.

Yes, that goes with other things as well.

52:32

Yeah, my goal is my consultations are like an hour long.

I'm spending a lot of time trying to really evaluate the patient deeply, get an understanding of them clinically, their history.

You learn a lot from a good history.

You learn a lot from really studying ACBCT in detail and a really good clinical exam.

52:53

So what I'm hoping to do is provide the surgery that I think is going to have the highest likelihood of curing a patient.

My goal is always cure.

OK.

So, so what's the definition of cure, right, Because I spend all this time talking to people about like this shirt thing where they say if we manage to reduce the HI by half, then that's a great result.

53:21

But you have all these patients who are going from 70 to 30 something and they're really disappointed because they're still on CPAP and they still have severe sleep apnea.

So what do you mean by cure?

You mean no other intervention necessary?

53:39

Right.

So in the literature what you're talking about is referred to as success.

So success is 50% drop in the score.

Cure is getting them to not have sleep apnea anymore or not have UARS anymore.

53:57

So.

In general, that's the standard you're going in with that you're trying.

To get That's my goal.

So everything I'm doing in my career is trying to find ways to get people to cure more predictably and more often.

All right?

54:12

And the ways I'm doing that is number one.

First of all, the mind technique was one of those things.

How I'm going about doing MMA surgery, doing things fully fully customized 3D printed titanium plates for the patient, getting more predictable, better results.

54:34

I've developed interdisciplinary care protocol and the first one to do that where we're getting not just me and an orthodontist, but we're having my a functional therapist, speech language pathologist that are all kind of getting together and and.

54:50

All contributing something different, right?

Because maybe, you know, after the surgery there's still going to be tongue tone issues, breathing concern issues, postural issues.

Like the next thing I'm going to be doing is maybe trying to get in deeper into my postural understanding of things and learning how to work with postural therapists.

55:08

But you know, surgery is is one piece, right?

So all I all I'm trying to do is get.

As good of a results as I can by optimizing surgical outcomes and that's trying to do doing MMA surgeries and most state-of-the-art best way I can which which we're doing here.

55:29

And then having a team of providers that are all specialists and different things that all come together and you know that's how you get from success rate, that's how you go from success rates to cure rates, right?

55:45

Or how you get cure rates to equal success rates is not just doing the surgery.

Bye bye.

It's like, OK, let's get, let's get a team of really competent people together now.

And I think sometimes laying out realistic like expectations for patients on what's involved, right?

56:04

Like, I think that sometimes people have this mindset of like, I just want to do a surgery as though it's just that one thing.

So I think a lot of it is patient education around, well, you know, this is what's possible with the surgery for the best outcome.

56:22

You're also going to have to invest your own time in my functional therapy and nutrition and all that.

You know, like all these other things.

That you need into it, yeah.

Yeah.

So, so my, my multidisciplinary care team and now I call it an interdisciplinary care team because we're just working together.

56:39

It's not just multi around each.

Other it's right.

It's me.

It's obviously the Myofunctional therapist speech language pathologist.

We have a nutritionist, we have a pharmacist, we have the patients like the orthodontist, if we have an orthodontist on the case.

56:59

And then their their dentist, right.

Because their dentist is going to be their quarterback.

Good dentist is going to be the one that actually like diagnoses them first, like looks at their mouth and goes, hey, do you have sleeping issues?

I think, you know like sometimes a good dentist that's well educated will be the first person that that that screens and finds these people.

57:19

So but yeah.

And again postural therapy is I think where I'm going next with that the team that we're building.

But but yeah, so I I think I I skipped.

Worked over your question so you asked about when mind when MMA so so and maybe it's completely like you know your judgment and all of that but just.

57:41

For people listening that are trying to figure out.

Yeah, So obviously if if I notice someone has like beautiful forward growth and just a super narrow maxila, we're gonna go mind, right?

There are some patients that have a beautiful, broad Maxima palette, but they have stunted forward growth, right?

58:03

Narrow, small airway.

You're thinking MMA, right?

There's a lot of patients that have both, and the question becomes, well, do we want to do 2 operations or should we just do MMA?

Because MMA is probably the most potent surgery to treating sleep apnea.

58:23

It is the most potent surgery.

But again, my philosophy is if you have both issues going on, then treating the transverse the best way that I know how, which is through the mind technique first and then doing MMA is going to get you those cure rates that go way higher.

58:43

So we have about four or five patients now that have gone through both.

And all of them are cured so far.

So that's kind of one of the things I'm really excited about in the future is publishing data on that first doing mind getting that threedimensional, nasal, nasal, maxillary expansion that you cannot get an MMA surgery, doing MMA surgery, so purposefully doing both right.

59:11

So in some patients we May 1st do mind.

And be like, hey, this may get you to cure, it may not.

If not, we're going to do MMA that'll get you there.

For some patients we purposefully going like we're going to do mine first, get all the amazing benefits we get from that that we could never get from MMA surgery and then we'll do MMA surgery, you know in a year.

59:33

And so the MMA surgery, that's more of a recovery, right, that that's more major surgery than the mines?

Yeah, it's, it's not minimally invasive, right.

It's, it's.

It's.

Kind.

It's not.

It's it's definitely more invasive than than mind surgery.

59:50

Yeah.

I think it gets a bad reputation because of the way it's traditionally been been done.

Yes.

And through the way, it's maybe still being done and patients sharing their photos on, you know, blog posts and they look like pumpkins with, yeah, coming out of so much.

1:00:09

Swelling.

I mean, like for example, I did one on Thursday, so today's Saturday, right?

So I did one on Thursday.

I think it took a hour, 45 minutes.

The patient.

The whole MMA surgery took an iron 45 minutes.

Yeah, the patient's not wired shut.

1:00:26

They're not rubber banded shut.

They could open and close right away.

Minimal swelling.

The patient doesn't look like they had their face smashed.

They don't have things coming out of their nose.

They went home the next day.

Which is, you know, it's like a 23 hour stay in a hospital.

1:00:44

It's great.

And yeah, the recovery is just not that bad.

That being said, I'm using, you know, first of all, I've done a lot of them.

I'm fellowship trained in doing corrective jaw surgery.

So it's kind of my specialty, you know, I'm, I'm good at it.

1:01:03

I'm fast at it.

I get great results.

I'm also using the most state-of-the-art technology.

Like I said, it's not just so you can plan it out in 3D models where you can show people yeah an idea of what it'll look like after.

1:01:19

Something like that.

But it's not just virtual surgical planning, which is what everybody does, right?

Everybody hopefully is doing virtual surgery at the very least is planning the surgery on a virtual rendering of the patient.

1:01:37

But what we're also doing is fully custom surgery, which means 3D printed titanium plates for all the jaws, for the chin, everything.

Why that is advantageous?

First of all it means that.

I'm recreating that virtual surgical plan down to the 10th of a millimeter, down to the 10th of a degree.

1:01:59

It's a perfect, otherwise nothing fits.

OK, so you're getting exact like, I want to move this jaw 4 millimeters this way.

I want to change this by 6 degrees.

I want to move that over half a millimeter.

Here, we're recreating that.

So the aesthetic results are amazing.

1:02:16

The airway results are amazing because I'm recreating the airway movements that I want by moving the jaws.

And the surgery is a lot faster, like I said.

So, you know, that's pretty crazy speeds.

Again, we're not doing it for speed, right?

1:02:33

We're.

I won't leave till it's perfect.

If it takes 45 hours, I'll be in door for 45 hours.

No food, no drink, no bathroom, right.

But at the end of the day, like, we're getting it done that fast.

That just means less pain and swelling.

The less time you're dissected and you know things are being stretched out to do the operation, the less swollen you're going to get.

1:02:52

It's like getting you know, so and then these plates are very strong, they're a lot stronger than what we traditionally use when you're hand bending them in the OR.

So you know you don't need to wire people shut, you don't need to rubber band people shut as long as you're you know what you're doing.

1:03:08

So there's art to getting the patient on a work up to virtual surgical plan, to getting everything to also be recreated in the OR the same way.

Right.

Not everybody can do that.

1:03:25

There's definitely other surgeons in the country that can, but there's definitely a handful of us that have that ability.

So maybe if you wanna speak to, like, is this ever covered by insurance?

Like, yeah, yeah, it is.

So absolutely MMA.

1:03:42

We almost always get covered by insurance.

It sometimes takes a fight, yeah.

I'd hate to tell you, probably the best part of my job is talking to patients after they've recovered and hearing the changes that they've had and having that.

1:04:02

Worst part is.

Having that connection with them.

The worst part of my job is dealing with insurance company.

Yeah, it's just terrible.

You know, obviously some patients we don't have an issue.

There's no fight.

We submit things.

It gets improved.

It gets approved right away.

1:04:17

For some patients we have to send appeals.

I have to do peer to peers.

We, you know, you name it, but you know, we take great pride.

I think we have.

Probably the highest acceptance rates I would imagine about as high as it gets because I have a team of people working to do that and then and then I'm a fighter.

1:04:39

So I feel like once I I write a letter and speak to someone over the phone through a peer-to-peer or something, it's pretty hard rare that they still say no.

I think that making a compelling argument as to why this surgery is beneficial for the patient.

And so with mind it's not as often covered, right?

1:05:03

It's but the overall expense I'm thinking is lower just because you can sometimes do it in office.

And yeah, so it's a lot more affordable again, cuz we can do it in office.

So if people are interested in working with you like you work with people, but you don't necessarily have to be in California, right?

1:05:22

So people can fly in from different places in different countries and.

Yes.

So I'm lucky that or you know that most of my practice, most of my patients come from out of town.

1:05:39

So we have a great infrastructure in place.

To deal with patients today that, yeah, this week we did someone from Japan, which is probably the farthest Japan, it's pretty far, yeah.

Pretty far.

So we have the whole infrastructure in place we so for somebody coming from Japan are they doing sort of discussion and diagnosis and plan of what you're gonna do are you doing that remotely and then they actually come for the surgery or do they have to come and.

1:06:13

So for most out of town patients.

We can definitely start the conversation with the Easy Zoom, right?

So as long as I have a CBCT scan and I have good intraoral photos or what we call intraoral scan, which is what you would get when you're getting Invisalign like a 3D key.

1:06:33

I can get a pretty good idea of what's going on right What their bone is look like, what their bone look, what their jaws are shaped like, how big they are, the health of their gums, the health of their teeth.

Like you can get a pretty good idea.

So a lot of the time we can kind of.

1:06:52

Especially for mind surgery, we can do enough of the work up away where I can meet them here almost right before their surgery.

For MMA patients that are coming from out of town, at the very least I'll need to see them about one month before the operation in person.

1:07:11

And that's because again.

Because I'm doing everything fully custom and I wanna make sure I can't trust anyone else to take the CBCT scan in the specific protocol and job position that I like it in, to make sure that when we go to sleep everything fits like a puzzle piece, right So.

1:07:32

For those patients, they have to come at least a month before and then they usually come and stay for a couple weeks after right on.

So I'm going to link everything in the show notes, but do you want to just tell people where they can find you and where they can find more information?

Yes, so, so my practice is called Breathe Max.

1:07:50

We're at the Breathe Institute in Los Angeles, CA.

We are a multispecialty practice that really focuses on people with sleep related breathing disorders.

You know, from anything from mouth breathing to insomnia to UARS to sleep apnea, our, you know, we're we're a heavy research institution.

1:08:13

We are constantly.

Working on research, which is pretty unusual for private practice, but that's that's our passion, our goal and trying to keep things super state-of-the-art, minimally invasive and maximally effective, right.

If you guys want to find me, I am on Instagram at Doctor Coppelson, so that's DRCOPPELSON.

1:08:35

My website is also drcoppelson.com and thank you all for listening.

I'd love to chat again one day, maybe the next.

Time.

We have the paper out.

You can invite me again and we can keep the comments.

That's really good.

Thank you so much.

I really appreciate it.

Thank you, Amma.

1:08:51

Nice to meet you.


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