July 9, 2024 • 48 mins
My guest today is Dr. Kevin Coppelson. Dr. Kevin Coppelson is a board-certified and fellowship-trained Oral & Maxillofacial Surgeon practicing at The Breathe Institute in Southern California. He practices a broad range of Oral & Maxillofacial Surgery- with a focus on skeletal augmentation for the treatment of maxillofacial deformities and sleep-related breathing disorders.
Dr. Coppelson brings the knowledge and experience necessary to stay on the cutting edge of Oral & Maxillofacial Surgery.
Dr. Coppelson's highly specialized training provides him with expertise on procedures ranging from corrective jaw surgery, minimally invasive jaw expansion, dental implants, and management of wisdom teeth.
You can find out more about Dr. Coppelson at drcoppelson.com.
Show Notes:
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Hi everyone, and welcome to another video.
(00:29):
Hi everyone, and welcome back to Airway First, the podcast from the Children's Airway First Foundation.
I'm your host, Rebecca St. James.
My guest today is Dr. Kevin Coppelsen.
Dr. Coppelsen is a board certified and fellowship trained oral and maxofacial surgeon practicing at the Breed Institute in Southern California.
(00:51):
He practices a broad range of oral and maxofacial surgery with a focus on skeletal augmentation for the treatment of maxofacial deformities and sleep-related breathing disorders.
Dr. Coppelsen brings the knowledge and experience necessary to stay on the cutting edge of oral and maxofacial surgery.
(01:12):
His highly specialized training provides him with the expertise on procedures ranging from corrective jaw surgery, minimally invasive jaw expansion, dental implants, and management of wisdom teeth.
You can find out more about Dr. Coppelsen at drcoppelsen.com and at thebreedinstitute.com.
(01:36):
And now let's jump into today's interview with Dr. Kevin Coppelsen.
Great. Thank you so much for joining us today, Dr. Coppelsen. I truly appreciate it.
My honor to be here. Excited to talk with you and see where the conversation goes.
Yeah, yeah. So we're going to jump in and I'll just warn our audience now. I've already warned you that I will slaughter a couple of the phrases here. I've been practicing all day, but I'm just not so great at them.
(02:07):
So just hang in there with me, everyone. So the first thing I want to talk about, because of your specialty, I want to talk a little bit about jaw positioning and why it's so critical to the overall health of the patient and the way they sleep.
Yeah, really great point. There's, I'd say, an epidemic going around right now with modern humans and our jaws being too small for our mouth.
(02:35):
And the result of which has been pretty detrimental to the way people breathe and sleep.
There's obviously signs of it that we see with crowding, how many people need orthodontics, they need to get their wisdom teeth out, they don't have enough space in their mouth for all their teeth to erupt normally and straight.
You know, on a very mild end, you get some braces, get your wisdom teeth out, and hopefully you're functioning okay.
(03:01):
But unfortunately for a lot of people, when the jaws are small, it can really affect the way you breathe and sleep. You don't get enough space for your tongue.
The nasal airway volume is narrow, so it becomes harder to breathe through your nose and you become a mouth breather, at least partial of the time.
You have increased airway resistance, which can lead to conditions like snoring and UARS and sleep apnea.
(03:27):
So it's a huge epidemic. It's really exciting to see people kind of waking up to it.
I feel like it's becoming vogue, which is a really good thing because people are going to podcasts like this, they're reading books, and they're kind of becoming attuned and aware to maybe something that they've been suffering with for years and years and years.
(03:51):
They're seeing it in their child, like, hey, maybe it's not cute that my little kid's snoring.
And definitely the best time to intervene is when someone is young, and then hopefully they'll never need me when they're older.
But I guess maybe some of the things we'll highlight at some point in this conversation is we are living in a golden age of treating some of these jaw issues,
(04:16):
whether the jaw is not wide enough or hasn't grown far forward enough, or there's other issues in the orientation and jaw development.
We're living in a real golden age of the way we're able to treat those conditions, even in adulthood, but definitely catching them young.
As better.
Treating it, you know, like we say, treat the smoke before it turns into a big fire.
(04:40):
Yeah, no, huge issue.
The jaws are definitely the gateway to the airway, so it can be a big problem.
Yeah, everything starts here.
And you touched on it briefly, and I just kind of want to back up to it because I can't just be all Gen Xers.
(05:01):
I'm sure there were groups before us, but from Gen X down at least, it's kind of a rite of passage to have your wisdom teeth taken out.
I remember when I was young, I was excited to get braces.
I was like, I can't wait.
In that wild, that's so crazy.
And it's so funny.
Mine came in completely straight.
So I missed that late teen, early 20 wisdom tooth pull.
(05:26):
I was one of those, oh, you're in your 30s.
Oh, let's just go ahead and take them out.
Why not?
Right?
Because they're getting in the way.
And it wasn't that I'd never have space.
They, you know, they was bumping into things up here, all the block.
But that still kind of plays into what we're talking about because if my jaw were the way it was supposed to be, those little straight puppies would have stayed in.
(05:48):
Right?
I mean, we don't have to have our wisdom teeth out technically.
Yeah, technically, you should have jaws that are big enough to support 32 teeth, fully straight, fully erupted, fully functional.
You know, yours may have came in straight, but they may have maybe even partially erupted and you couldn't clean well behind your second molars.
(06:09):
And it was becoming a plaque and calculus trap that was leading to periodontal disease or whatever the reason was, your hygienist or dentist recommended to get a mount.
But yeah, I mean, what percentage of people end up needing the other wisdom teeth out?
It's super high.
It's huge, isn't it?
Yeah.
Those common procedures we do in America.
(06:30):
And it's not normal.
I mean, if you look at ancient skulls, I'd say non-modern skulls even 500 years ago, healthy adults had 32 erupted teeth.
They had straight teeth.
They did not have braces back then, you know, and, you know, in a very short period of time, faster than evolution can explain our jaw shrunk.
(06:56):
And we're ripping out wisdom teeth. We're putting people in ortho and really sad cases, you know, people are pulling even pre-molars and retracting everything even tighter.
And, you know, in 10, 20 years, those are the patients we're seeing that are having a lot of airway issues.
(07:18):
I mean, when I was a kid, I had retractive headgear.
You know, I look back and I'm like, oh, fuck it.
Right. I just knew the fifth dimension and go back in time and, you know, fix things.
I think we all have that moment, right?
Even hosting these podcasts, there are so many times I have to follow up with my kids.
I'm so sorry. I didn't know. We didn't know.
(07:39):
We didn't know.
We just didn't know at the time.
Yeah. You know, your parents were doing what they thought was best for you, which isn't getting you kind of your wisdom teeth out.
You know, the orthodontists were doing what they were trained.
I'll tell you like.
Exactly.
You know, now that I'm an airway focused oral and maxillofacial surgeon,
most of my learning happened on my own, right?
(08:03):
Like you're trained to take out wisdom teeth.
You're trained to do jaw surgery, but no one kind of puts the puzzle pieces together for you.
And it's like, oh, why are we taking out so many wisdom teeth?
And, you know, why, you know, I think a lot more people need jaw surgery than get it.
That's a whole nother discussion.
It's a, you know, it's not like a surgery.
(08:26):
It's not like it's not a simple thing.
I was in teeth in any ways, but.
But there's a there's a there's a huge epidemic.
I mean, even if you look at nighttime proxism, right?
How many people clenching grind develop temperamentally joint disorders, you know, pain in their masseters, wearing away of teeth.
That's another crutch.
That's another symptom of not breathing normally and easily in sleep.
(08:50):
So I mean, these things have, you know, people react differently, right?
You have the Bapmia patients.
You have the clenches and grinders.
You have the U. A. R. S. patients who have tons of micro arousals and they don't go into deep normal sleep architecture.
And, you know, everyone kind of reacts differently, but it's all due to the same anatomy.
It all comes back to the same.
(09:11):
Yeah, just not working.
I had read something and I don't know if this is totally accurate or not, but that.
You seem more TMJ cases in women or young women.
Why more?
I mean, it's we're all having the same airway issue.
Why is it presenting that way? Does anyone know?
I don't think no one knows why.
(09:34):
You know, it may be a hormonal.
It tends to be.
Hairy menopausal women, I guess that are the most symptomatic. So there may be like a hormonal component to it.
But that's like symptomatic, right?
If it comes to actually like objective measurements of temperament of their joint dysfunction, I'd say it's pretty even between the sexes.
(10:00):
So you'll see, you know, in terms of like, arthritic changes, remodeling changes to the joint.
Clenching and grinding where articular disc disorders, like people that have clicking, popping, crunchy noises and stuff like that.
I'd say it's pretty evenly distributed between the sexes, but definitely when it comes to, hey, I'm suffering, I'm having symptoms.
(10:23):
How do we intervene? It's more common in women for sure.
Sorry, I didn't mean to just kind of throw that one.
That was like, I remember reading this and it just.
No, it's true.
Always, always wonder.
That's true.
So on your website and I'll put a link to it, you know, for anybody that hasn't seen it, both to your website and to this particular topic, but you talk about the mind technique.
(10:48):
Yeah.
So for those who haven't seen the video, would you explain a little bit about this procedure and what the benefits are?
Yeah, absolutely.
So most of my practice is treating jaws that are too small.
That can happen again, like I said, in three dimensions, right? We can, you can be retreated.
(11:09):
The jaws didn't grow far forward enough. There's also like angulation issues with the angle in which your bite is and you're looking in your jaw jaws grow.
Those things we generally treat with corrective jaw surgery.
There's another very common jaw deformity, which has to do with how wide the upper jaw develop.
We call that maxillary transverse hypoplasia or maxillary transverse deficiency, which just means the upper jaw did not grow wide enough.
(11:34):
That's something that's very commonly been treated in kids, put them in a palatal expander before the sutures fuse, although they don't really fuse.
They, it's more of an ossification where the bone kind of meets at the midline and starts to interweave like puzzle pieces.
So it's not the true like vision.
So in, in young kids, you can just use what we call like a tooth-borne palatal expander, like a high-racks, and they can crank it, push on the teeth.
(12:02):
And because the jaw has no fusion at the midline, everything kind of widens.
Very easily treatable in childhood.
And it's a very common thing and something that should be done much more often in childhood.
In adults, we traditionally did this larger surgery called the SARP, stands for surgically assisted rapid old palatal expansion.
(12:26):
It's a surgery based off of a two-piece Lafort 1 osteotomy.
So it's like a Lafort 1, same type of bone cuts that you would do to do an orthognathic surgery where you can move the jaw forward, except you're just making all those cuts and also splitting the palate down the middle.
So you have two halves of the upper jaw. And traditionally, you'd use, again, a tooth-borne expander, something that pushes on the teeth after you've made those two-piece Lafort 1 level cuts, and then you can widen an adult's jaw.
(12:58):
Also, good surgery. You improve people's airway, but it's a pretty big surgery in the sense that it's usually done under general anesthesia in a hospital.
There's some dental side effects from pushing on the teeth where the teeth start to tip out, so we would have to over expand people.
Let's say we wanted to expand them six millimeters, we might overshoot that by 50%. So we'd like push them to like nine.
(13:22):
And then we'd be like, okay, they're going to relapse back to six.
Oh, okay.
So there was, it was a big operation. There was flaws with it.
It also, because it's a Lafort 1 level cut, you're widening the jaw at a very low level. So you're kind of widening at the level of the nasal floor.
And maybe we can put in a graphic or something at some point, but it's a low cut. You're kind of cutting from like the floor of the nose back.
(13:50):
Do you want me to share media during?
Yeah, if you've got something handy. Yeah, that'd be amazing.
Let me open up the PowerPoint. I definitely have something somewhere.
So this is a Lafort 1 osteotomy. So you can see we're cutting the entire bone all the way across at the level of the floor of the nose.
So when we did surgeries that revolved around this, we do a two piece again, we do a Lafort 1 osteotomy with a midline split with a Sarpie use a tooth borne expand like you would in a child and use the teeth as anchorage to push the bone outwards and get the tipping and the relapse and all that stuff.
(14:26):
But you can see you're kind of widening just the floor of the nose. So patients that have a small airway nasal airway volume, they get marginal improvement in their nasal breathing because all you're doing is winding the floor.
It helps. But it's not treating the entire nasal cavity. You still get how it to widen, which gives you more space for your tongue, which is super important, but you're not actually treating the entire maxillary bone.
(14:53):
The maxillary bone is actually really big. So this is actually the full maxilla. It has a body. It has a frontal process of the other process agamatic process and it dictates how wide the nasal cavity volume is going to be.
So what the mind surgery is long story short is a way to make the surgery more minimally invasive. So it's a surgery I do 95% of the time in my clinic as if you're going to get wisdom teeth out.
(15:26):
Do a little IV sedation. I free up the sutures in a few places. We use a special kind of palatal expander that is not tooth-borne, but is actually what we call bone barn. So there's screws that go into the palatal bone so that when you're activating the expander and widening the jaw, you're actually pulling the bone apart and not using the teeth as your anchorage.
(15:48):
And with that, you get three-dimensional expansion of the entire nasal airway. So I have a picture of that to show you as well.
And while you're pulling that up, I mean, what is the recovery time for something like this?
Yeah, though it's less than wisdom teeth. I guess wisdom teeth will be our barometer for everything today.
(16:11):
Yeah, because everybody knows those.
Yeah, so the surgery is done through three small incisions that are this big. You can think of it as like a laparoscopic procedure. We operate through these little ports, free up the suture, free up two sutures in the back, and then some other technical stuff we do in there to loosen the bone.
And so very little pain or swelling. I mean, mild, maybe, very mild upper lip swelling, very little pain is usually five out of 10. I'd say most of my patients don't even take narcotics.
(16:45):
They can take ibuprofen in Tylenol and handle the pain. So it's like a very minimal surgery compared to a lot of other, I would say, oral surgery procedures.
And the type of expansion that you get is this like 3D expansion. So it's, can you see that slide? No, it's not working.
(17:11):
All right, sorry for all the technical issues.
No, that's all right. So then, and then you said it's a SARP that you use. No, is that the same as like the Marpe or the Alpher some of the others where you have to go in and adjust it periodically?
Or is it it's just in there after the surgery? And that's it.
So, so just can you see, see this line? Yes.
(17:35):
So this is the type of expansion we get. It's almost like a Lafort three level. It's full midface expansion. So the cheekbones come out. The blue is the is the after the yellow is the before.
So you can see what actually ends up.
Your entire nasal cavity airway volume expands three dimensionally. The palate still wide ends, you still grow alveolar bone. So a lot of patients that have crowding and stuff like now you have space for the teeth, you don't have to shave down teeth to get your teeth straight.
(18:03):
We have more bone at the midline.
So palate wide ends nasal cavity volume three dimensionally expands and so all of that has a really big impact on the way you can breathe afterwards. I mean, after just a couple of meters patients are like sleeping deeper. They're breathing easier through their nose.
They're able to exercise with their mouth closed things.
(18:25):
You do not wake up with this gap. So it is a it is a slow expansion. So it's we expand at a rate of about two millimeters a month. Sometimes we go a little faster, but let's say on average about two millimeters a month.
So really slow, steady. And then once you get there, hopefully breathing and sleeping a lot better doing a lot of exciting stuff now where that gap.
(18:54):
That gap that you saw in that post op CBCT scan were actually controlling it during expansion. So, you know, one of the things that it was hard for people was dealing with a space between the two front teeth because that a diastema.
It happens as the bone splits apart at the midline.
Now, I'd tell you that patients that end up coming to me to get this done.
(19:17):
You know, these are patients that have not been breathing well, not been sleeping well. They're happy. They don't care because they're like, it's fine. It's going to close. I'm okay. I'm breathing better. I'm feeling better.
It's Madonna. It's in fashion. Let's just roll with me. Exactly.
But, but, but now we're even we're able to to to control that gap during the expansion phase. So we're even taking that one temporary side effect out of the equation, which I think is making the experience a lot better and making going through the procedure a lot more palatable for a lot of patients.
(19:53):
And then so they have to turn it though periodically is it.
Like one like one turn a day. Yeah, like little one. We call it a swing like one swing a day.
Each swing is a 12th of a millimeter. So it's just real slow. You know, millimeters this big, we're doing a 12th of a millimeter day. So it's just real real real real slow.
And then once you get there, does it come out?
(20:15):
Or is this like it stays in forever?
It stays in for six months afterwards, because you have to wait for bone to fill in. So we expand. And then we wait for bone to fill in. So it's permanent. Otherwise, if you remove the expander too soon, before the bone fills in, everything will relapse back to where they were.
So we expand, we hold, wait for the bone to fill in, then we remove the expander. But they're doing they're doing ortho during that time. So it's not like during that six months, you're just waiting. You're, you're doing ortho with the expander.
(20:46):
Still in the mouth.
And is this one of those kind of things as you're explaining it here, then now this is going to start to follow forward, or do you have to do something separate to the job?
That's a great question. So we are getting forward movement, just with expanding, which is not the movement we are planning to do, right? We're planning to widen.
(21:07):
But what we're seeing with everybody is that their upper jaw as it widens will come forward about a millimeter to millimeters.
With that, we can also couple something called the reverse pull face mask. So we can add hooks to the expander and actually provide forward traction on the upper jaw.
(21:28):
And sometimes even in adults, push that another millimeter to so patients who may have been, let's say four millimeters deficient in the forward growth of the upper jaw, just with the natural widening and coming forward a millimeter to with with the reverse pull face mask, we're bringing adults
upper jaw forward to three, four millimeters, which is amazing for a minimum base of upper.
(21:53):
The lower jaw, we're obviously not treating. So it's going to be more of a orthodontic thing, getting it to match where the upper jaw is.
If the lower jaw is really set back, those are the cases where we're sometimes widening first planning to do orthognathic surgery down the road.
But in a lot of patients, just the forward movement they get from the expansion and possibly with the reversible face mask with the orthodontics to get the lower teeth to match is all that they're going to need.
(22:20):
That's amazing. So who is a good candidate for orthognathic surgery? I knew I was going to kill that.
And is there a minimum age for it?
So great question. So orthognathic surgery is a is a more precision surgery in the sense that we can really control the jaw in three dimensions.
(22:41):
We can plan movements down to the 10th of a millimeter. We can fix orientational things down by the 10th of a degree.
So, you know, we can diagnose people, hey, your upper jaw should be seven or eight millimeters more forward. Your lower jaw needs to be 10 millimeters more forward.
You know, your bite is too steep. We can flatten it out. We call that counterclockwise rotation, which actually opens up the airway some more.
(23:04):
We can even widen the jaw at the time of orthognathic surgery so we can actually segmentalize the lafort and widen the jaw and fix the bite.
And, you know, during that time we're also working on symmetry. So let's say your midline is off by a half a millimeter.
We can strain the midline so that your dental midline and your chin midline match up with your facial midline.
(23:26):
There's a lot of beauty and precision in orthognathic surgery.
Who's a good candidate for it?
Insurance definition is going to be someone that has a functional issue, whether that is like chewing and swallowing issues, speech issues, airway issues like sleep apnea, people that bite their cheek or tongue because of the way their teeth align.
(23:52):
And then you have to meet certain radiographic criteria. So we have, we take measurements on x-rays and we show that the jaw is deficient by this much using this angle and that angle.
And that's who would be a candidate.
So minimum age is a great question.
The textbook answer is skeletally mature, right? So for generally, it's going to be 16 years old for a girl, 18 years old for a boy.
(24:21):
However, in very extreme cases, okay, like I just had a case last month of a 13 year old who had really deficient jaw growth, who had severe sleep apnea, was not thriving, you know, struggling in school because they're so tired and sleepy.
That's a case where, you know, you can make a decision like, okay, let's intervene now.
(24:43):
All right. And understanding that because you're going to continue to grow, there may be a chance we have to redo the surgery when you're skeletally mature.
Right, because you're going to wake up with perfect facial balance, perfect bite. Right. That's, that's how these surgeries are done nowadays in the right hands.
And, and, you know, that's going to potentially change as you grow. So if it does not grow in harmony during the rest of your development, then when you're 18, we may have to do what we call it, just a revision surgery, just to put things back to where they need to go.
(25:32):
Okay.
(25:55):
You are listening to Airway First with today's guest, Dr. Kevin Coppelsen. You can find out more about the Children's Airway First Foundation and our mission to fix before six on our website at children'sairwayfirst.org.
The CAF website offers tons of great resources for both parents and medical professionals.
(26:16):
Visit our parents portal, clinicians corner, resource center and video library to see for yourself.
We also encourage parents to join the Airway Huddle, our Facebook support group, which was created for parents of children with Airway and sleep related issues.
You can access the Airway Huddle support group at facebook.com backslashgroups backslashairwayhuddle.
(26:40):
As a reminder, this podcast and the opinions expressed here are not a medical diagnosis. If you suspect your child might have an airway issue, contact your pediatric airway dentist or pediatrician.
And now let's jump back into today's episode.
(27:21):
This is more invasive, right? This isn't like the mind technique. This is...
This is like a hospital surgery. It's a very precision surgery. We do it all fully custom now. So all the cutting guides where we plan the movements digitally so I can see where all the midlines are.
(27:51):
And then we go straighter to this side to make everything straight. We plan all of that digitally. We get cutting guides, computer princess cutting guides and also 3D princess titanium plates.
So that the surgery is done with computer robotic precision.
So the benefit of these custom orthognathic surgeries is one, the accuracy and the planning. You execute exactly what you plan because otherwise everything doesn't fit.
(28:21):
But also it really speeds up the time of the surgery. So it's done in a fraction of the time that it used to be, which just means less pain, less swelling, less discomfort.
The more time you're dissected, the more time you're in surgery, the harder the recovery is going to be. If you can speed up these surgeries less time you're tractioning on the tissues and doing all your stuff, you're going to wake up, you're not going to swallow up as bad and have as bad of a recovery.
(28:46):
But it is still a hospital surgery. We usually keep patients in the hospital for one to two nights.
There's people that send people home the same night and they're okay with it. It's not my style. I like to keep people a couple nights. I want to make sure that they're walking, they're peeing, their pain's well controlled, they're drinking enough, all that stuff if I send them home.
(29:13):
That usually takes about two nights. It's great. In the old days people go, are you going to wire me shut? What is it going to be like? I'm like, no, you're going to have full mobility, you're not going to have restricted opening.
The only thing is non-true diet for six weeks. You're going to be basically like blenderized smoothies, milkshakes, oatmeal, the stuff like that for six weeks and then get you back to a regular diet.
(29:43):
When you're in there, you're not breaking bones, right? That may be a silly question, but you're cutting, not breaking. Cutting and moving, is that how that works?
It's a precision break. We cut the bone where we want it to break. You create fault lines where you want things to break and then you break the jaw and move it to where you want it to go and then plate it in that new position.
(30:15):
Wow.
It sounds wild, I know.
I know it sounds wild, like fascinatingly wild. That's really cool.
It sounds wild, but it works really, really amazing, especially with that new custom titanium hardware and the precision and the speed in which we can do these surgeries now. It's completely different than it was being done five, six years ago.
(30:37):
Yeah, that's fascinating. In my mind, I'm thinking you're in there and then moving things around and that just, the other sounds really cool.
Yeah, I mean, like even the tools that I use to cut the bone is very different than what I used in my residency training, right?
My residency training was literally kind of what you're thinking of in your head. There was saws and chisels and mallets and this and that.
(31:02):
Now I use something called the piezo surgery unit. It uses ultrasonic vibrations to gently kind of cut the bone very precise, very delicately.
The benefit of that is one of the things that runs through the jaw bones are nerves, right? Particularly nerves that give you sensation to your lower lip and chin.
(31:24):
And one of the biggest side effects from orthognathic surgery is the risk of having permanent numbness to your lower lip and chin.
And when you use saws and chisels, it's a lot more traumatic on the nerve and we would see about 20% of patients have permanent numbness on their lower lip and chin.
And since switching to the piezo, it's so delicate and gentle on soft tissues while still allowing you to cut bone, I have no patients that are really fully numb anymore.
(31:51):
Still, I'd say about 80% of my patients make a full recovery, but the 20% that don't, they all gain something back. So they gain about 50, 60, 70% of the feeling back.
It just may not come back quite to what it was before. So it's very meaningful nerve recovery. Everybody gets meaningful nerve recovery now.
No one has full numbness of their lip anymore. So even that has changed, you know, night and day.
(32:16):
I mean, this is a specialty that if you're not on top of it, you become a dinosaur very quickly. It's changing very, very fast.
Yeah, it sounds like it. And it sounds like it also improved recovery for the patients because it's not as traumatic.
Absolutely. It's a lot less traumatic. It's a lot more delicate. And it's even more precise, you know, just being able to just gently cut bone and it doesn't touch soft tissue, it doesn't cut soft tissues.
(32:48):
It's a game changer.
Wow. That is mind blowing.
Yeah.
So we talked a little bit about how you can move it just, you know, you millimeters here or there. Just kind of to put it in perspective for parents who may not have heard some of our other podcasts.
Maybe this is their first one. How can opening the airway for your child, just a few millimeters really impact their overall health span?
(33:17):
And even just, you know, not just down the road, but, you know, short term as well as long term.
Yeah, I mean, that's a great question. I love the word they use health span, right, which is something I really believe in. It's not just how long someone lives, but with the quality of which they get to live their life.
It's huge.
I have the most rewarding job in the world in the world, like being able to treat people that are not their full self because sleep is such an integral part of brain and heart and overall just function and fix them, you know, not just give them a bandaid but permanently cure them by
(34:01):
adjusting the just to where they should have developed to had they been 100 gather is is pretty cool.
For kids, I mean, I can't tell you how many kids we treat that, you know, ADD anxiety, depression, whatever. And the root cause was actually their poor sleep.
(34:25):
Right. It wasn't it wasn't there just a user they weren't sleeping and this is how their brain was responding to the lack of normal sleep architecture and not struggling to breathe anxiety of not being able to take a normal breath all the time.
It's easy deep breath through your nose like you're supposed to. So, if, if someone does have a child that does not breathe and sleep normally that has any kind of abnormality in their jaws, the earlier you intervene, the better and when they're young, it's so easy with early
(35:00):
intervention or orthodontics, little power expander, other kinds of appliances you can really hopefully stimulate or actually promote the jaw growth to where you want it to go and you can change the whole trajectory of their life.
And then hopefully they won't need ortho-agnetic surgery.
Yeah, there you go.
(35:21):
Yeah.
I can't say it anyway.
Yeah.
I'll put links to some of the other episodes where we talk about some of the signs and symptoms you can look for because they don't always snore.
Right. Some kids don't snore, but maybe they have restless leg or they wake up with headaches or late stage bedwetting.
(35:43):
Yeah. So there's things like that. I know parents and I'll put links to it so that they can review that. But you mentioned, you know, being able to look at them.
What are some of the things, spatially, that parents could look at if they haven't necessarily seen any of the other signs? Just, you know, hey, that's not quite right. That's not an alignment.
(36:05):
Mm-hmm. So jaw retrosion is going to be huge one. If someone looks like their chin is really retroated or set back, that's a big sign.
People that have maxillary transverse hypoplasia, people that mouth breathe, they develop differently. There's very prototypical facial characteristics that you can see.
One of them is going to be a really deep palate. They may show excessive tooth show. So they may show a lot of upper teeth because of the jaws of, you know, as it grows narrow, it can sometimes overgrow vertically.
(36:41):
We call that excessive downward displacement of the upper jaw.
Maybe like gummy smiles. Is that what you're talking about?
A gummy smile. If you see any kind of open bite, so if the front is open or the sides are open, that's a big thing. Cross bites are a big thing.
So if you see that, you know, I don't know if you can see it on me guys, but my upper teeth sit slightly wider than my lower teeth.
(37:06):
A lot of people that have narrow upper jaws that have something called a cross bite where the lower teeth will actually sit wider than the upper teeth.
That could be a sign that the upper jaw didn't grow wide enough.
Also just looking at the palate. The palate should be shallow and broad and flat.
If someone has a deep, high vaulted palate, slam down case. Easy.
(37:29):
So just look at your palate. Does it look really deep?
And, you know, worse comes to worse. You just bring them into someone that's used to looking at those patients all day and, you know, between a really good clinical exam, a good history and a CBCT scan.
We can diagnose people pretty clearly and see what's going on.
(37:50):
And I know I hadn't really prepped you for this and this is an opinion. I'm just curious. What do you tell parents when they're presented with, oh, let's just pull a couple of teeth and put on.
Some braces and they'll be fine.
Well, even I've even heard let's pull a couple of teeth and put on an expander.
I mean, to me, I know the alarm works there, but how does that hit you?
(38:11):
You're ignoring the big puff of smoke that's coming out of your house.
To me, it's if the kid doesn't have enough space in their mouth for their teeth, that's a red flag. And, you know, I'm not saying you're going to make them worse by pulling the teeth and making their teeth straight, but you're not making them better.
(38:37):
So make them better. Make the jaws bigger and make the teeth fit.
And they're going to be in a much, much better position. You know, is it a little bit more work to get a powder look spander as opposed to pulling teeth and straining the teeth off?
Yes, but you're functionally going to change the kid's life forever as opposed to just covering your eyes and all their teeth look straight.
(39:01):
Okay, but are they going to breathe in 20 years? Are they going to breathe in 30 years?
Are they going to, you know, you're just kind of ignoring the problem and you have this beautiful clue and use it and treat it. You know, that's how I'd like to explain it to the parents.
I've actually never heard anybody explain it as a beautiful clue, but it really is. It really is kind of here. It really is. We can set your child up for a much healthier life.
(39:31):
Yeah.
For something so simple.
Like life changing.
It's like life changing.
It is.
I use that word a lot and I don't try to use it loosely, but it really is life changing. Like doing these little procedures where you widen the jaw or orthognathic surgery.
It's life changing for people. Like you really completely change the way they breathe. You change the way they sleep and thus they become better versions of themselves.
(39:57):
And if you can do that in a kid, right, that's 30 years extra of enjoying that.
Yeah.
Right. And I know there's there's some, then I can put some links to some of the things we've got in our resource center of linking airway and sleep dysfunction to things like dementia and Alzheimer's.
(40:19):
And they're starting to form connections. And like you said to me, that's a no brainer.
Yeah, neurodegenerative diseases. Just like those cardiac, like heart attack, strokes, cardiac arrhythmias.
Sleep is huge. Breathing is huge.
Right. It's one of the pillars you can't do without it.
(40:41):
It's like the first thing that'll kill you.
Right. Right.
Yeah.
So one of the other things that we talk a lot about is this whole multi-disciplinary approach.
Just to medicine in general, I mean, not just kids, but just overall, that it's it's not something that is taught in medical school or dental school.
(41:04):
I know it's here. Let's silo. Let's do our own thing. Let's become the kings of our area.
But you actually do advocate for this approach.
So what was your journey? What brought you to this kind of paradigm shift in your mindset?
I'd say I'm like, I'm a pretty obsessive person in trying to improve, you know, whether it was coming up with the mind surgery or trying to stay state of the art with the or the genetic surgery.
(41:33):
I'm always trying to figure out ways to improve outcomes for procedures that I do.
And obviously, one of the ways is utilizing the technologies like 3D printed titanium blades, right.
But there's more to it. Right. And one of the things that I got exposed to when joining the Breathe Institute in Los Angeles was their multi-disciplinary approach to tongue-tie surgery.
(41:58):
You know, people that had tongue ties, they would couple it with myofunctional therapy and they improve the results of doing a frenioplasty.
So people that get tongue-tie surgeries, instead of getting their surgery feeling good for a day and then scarring back down to where they were because they didn't have the proper tongue function and mobility and strength and range of motion and all that stuff,
(42:20):
they coupled it with that kind of therapy and improved the results. And I was like, okay, I think that would be very beneficial for orthognathic surgery as well.
I was like, all of these patients have oral myofacial dysfunction.
These patients, they're generally adults who have not been sleeping well for 20 years. Their mind-body connection is all out of whack.
(42:45):
I'm like, I want to bring in a yoga, knee-draw mindfulness meditation counselor to work with them before the surgery.
So they come into it with the right mindset. I mean, you're about to heal. You're about to experience all these changes.
You wake up from these surgeries breathing better. It's not like, hey, we'll see you in six months. Give it six months. It's like you wake up breathing better.
So I want to get their mind ready for all these changes that are about to happen.
(43:09):
So myofunctional therapy as well, working on their breathing patterns, working on their tongue-tie and their tongue posture, they're going to have more tongue space.
When I lengthen the jaws, I want them to use that tongue space to the max. What's the point of having a giant mansion if you only sleep in one of the beds?
I want them to use the whole house. So I have them work with a myofunctional therapist to get the most out of the space that we're creating to work on their breathing patterns.
(43:37):
Because these patients were using their accessory muscles to breathe for 30 years and they don't know how to breathe through their nose well.
So working with a breath worker and a myofunctional therapist, mindfulness and meditation.
And then again, we talked about the diet six weeks, not being able to chew food.
(43:58):
So I want to make sure your nutrition is up to par because you're healing.
You're going to be like an anabolic growing kid. You need more protein than usual because you have to heal all these tissues.
Everyone has their own diet. Some people don't eat gluten, don't eat dairy, so you want to make sure that we're finding nutritious diets where they're getting all their macro-micronutrients.
(44:23):
But it's also interesting. So you have some meal plans where I like these kind of flavors.
OK, let's come up with a blended thing that will be interesting to you so you don't get bored after three weeks and you're just like, oh, I can't eat anymore.
Three weeks of oatmeal, right?
Yeah. And then just, you know, these cases are multidisciplinary by nature.
There's me. There's going to be an orthodontist usually that's going to be finalizing the inclusion, making sure everything fits beautiful.
(44:51):
We don't want you just to have a beautiful face and a beautiful airway, but we want your bite to be really beautiful and functional as well.
So the orthodontist is a big part of that. The general dentist, having them as part of the team so they can quarterback any restorative stuff that may need to be done.
And then I just have a pharmacist on board as well. You know, obviously we have a big opioid epidemic in the country.
(45:12):
The last thing I want to do is just shove narcotics down patients' throats.
So we work on multimodal pain management where we're not just giving them narcotics, but we're maybe adding some CBD and other things that can help lessen the pain burden.
So we're not just relying on opioids to control patients' pain.
And together, this team has really like taken the surgery, which on its own is life changing, like I said.
(45:36):
And now we're getting way more out of it and the experience is way, way, way more positive.
Yeah. That's amazing because it really is. It's a lifestyle change as well.
Mm hmm. Yeah. Right. Absolutely. Yeah.
So at the end of every episode, I always hand the floor back over to the guest as the expert for the final thought for our parent audience.
(46:03):
So I give you this option for this opportunity now.
I'll keep it short and sweet. So I think to summarize, interviewing young.
If you see signs of abnormal breathing, abnormally, orthodontist tells you, hey, let's pull a couple of premolars out and strain their teeth.
Anything like that. The jaws are too small. Intervene while they're young. It's super easy. It's going to change their life forever.
(46:32):
If you're a parent yourself that is having these issues or some adult just know that we live in the golden age of treating these things now.
And it's really safe. It's very predictable. Things are much more minimally invasive, much more precise.
And it's a good time to get it done if you need to.
And yeah, that kind of summarizes my gist in life right now.
(46:56):
I love it. Well, thank you so much for coming on today for sharing all this. I really appreciate it.
Thank you for having me. It was great speaking with you.
Thanks again to today's guests, Dr. Kevin Coppelsen for sharing his expertise and each of you for listening to today's episode.
(47:17):
You can stay connected with Children's Airway First Foundation by following us on Instagram, Facebook, X, LinkedIn, and YouTube.
Don't forget to subscribe to the Airway First podcast on your favorite podcasting platform so you won't miss an upcoming episode.
If you'd like to be a guest or have an idea for an upcoming show, shoot us a note via the contacts page on our website,
(47:41):
or send us an email directly at infoatchildrensairwayfirst.org.
Today's episode was written and directed by Rebecca St. James, video editing and promotion by Ryan Draughan, and guest outreach by Kristy Bochinkian.
And finally, thanks to all the parents and medical professionals out there that are working hard to help make the lives of kids around the globe just a little bit better.
(48:07):
Take care, stay safe, and happy breathing everyone.
Hi everyone, and welcome to another video.
(00:29):
Hi everyone, and welcome back to Airway First, the podcast from the Children's Airway First Foundation.
I'm your host, Rebecca St. James.
My guest today is Dr. Kevin Coppelsen.
Dr. Coppelsen is a board certified and fellowship trained oral and maxofacial surgeon practicing at the Breed Institute in Southern California.
(00:51):
He practices a broad range of oral and maxofacial surgery with a focus on skeletal augmentation for the treatment of maxofacial deformities and sleep-related breathing disorders.
Dr. Coppelsen brings the knowledge and experience necessary to stay on the cutting edge of oral and maxofacial surgery.
(01:12):
His highly specialized training provides him with the expertise on procedures ranging from corrective jaw surgery, minimally invasive jaw expansion, dental implants, and management of wisdom teeth.
You can find out more about Dr. Coppelsen at drcoppelsen.com and at thebreedinstitute.com.
(01:36):
And now let's jump into today's interview with Dr. Kevin Coppelsen.
Great. Thank you so much for joining us today, Dr. Coppelsen. I truly appreciate it.
My honor to be here. Excited to talk with you and see where the conversation goes.
Yeah, yeah. So we're going to jump in and I'll just warn our audience now. I've already warned you that I will slaughter a couple of the phrases here. I've been practicing all day, but I'm just not so great at them.
(02:07):
So just hang in there with me, everyone. So the first thing I want to talk about, because of your specialty, I want to talk a little bit about jaw positioning and why it's so critical to the overall health of the patient and the way they sleep.
Yeah, really great point. There's, I'd say, an epidemic going around right now with modern humans and our jaws being too small for our mouth.
(02:35):
And the result of which has been pretty detrimental to the way people breathe and sleep.
There's obviously signs of it that we see with crowding, how many people need orthodontics, they need to get their wisdom teeth out, they don't have enough space in their mouth for all their teeth to erupt normally and straight.
You know, on a very mild end, you get some braces, get your wisdom teeth out, and hopefully you're functioning okay.
(03:01):
But unfortunately for a lot of people, when the jaws are small, it can really affect the way you breathe and sleep. You don't get enough space for your tongue.
The nasal airway volume is narrow, so it becomes harder to breathe through your nose and you become a mouth breather, at least partial of the time.
You have increased airway resistance, which can lead to conditions like snoring and UARS and sleep apnea.
(03:27):
So it's a huge epidemic. It's really exciting to see people kind of waking up to it.
I feel like it's becoming vogue, which is a really good thing because people are going to podcasts like this, they're reading books, and they're kind of becoming attuned and aware to maybe something that they've been suffering with for years and years and years.
(03:51):
They're seeing it in their child, like, hey, maybe it's not cute that my little kid's snoring.
And definitely the best time to intervene is when someone is young, and then hopefully they'll never need me when they're older.
But I guess maybe some of the things we'll highlight at some point in this conversation is we are living in a golden age of treating some of these jaw issues,
(04:16):
whether the jaw is not wide enough or hasn't grown far forward enough, or there's other issues in the orientation and jaw development.
We're living in a real golden age of the way we're able to treat those conditions, even in adulthood, but definitely catching them young.
As better.
Treating it, you know, like we say, treat the smoke before it turns into a big fire.
(04:40):
Yeah, no, huge issue.
The jaws are definitely the gateway to the airway, so it can be a big problem.
Yeah, everything starts here.
And you touched on it briefly, and I just kind of want to back up to it because I can't just be all Gen Xers.
(05:01):
I'm sure there were groups before us, but from Gen X down at least, it's kind of a rite of passage to have your wisdom teeth taken out.
I remember when I was young, I was excited to get braces.
I was like, I can't wait.
In that wild, that's so crazy.
And it's so funny.
Mine came in completely straight.
So I missed that late teen, early 20 wisdom tooth pull.
(05:26):
I was one of those, oh, you're in your 30s.
Oh, let's just go ahead and take them out.
Why not?
Right?
Because they're getting in the way.
And it wasn't that I'd never have space.
They, you know, they was bumping into things up here, all the block.
But that still kind of plays into what we're talking about because if my jaw were the way it was supposed to be, those little straight puppies would have stayed in.
(05:48):
Right?
I mean, we don't have to have our wisdom teeth out technically.
Yeah, technically, you should have jaws that are big enough to support 32 teeth, fully straight, fully erupted, fully functional.
You know, yours may have came in straight, but they may have maybe even partially erupted and you couldn't clean well behind your second molars.
(06:09):
And it was becoming a plaque and calculus trap that was leading to periodontal disease or whatever the reason was, your hygienist or dentist recommended to get a mount.
But yeah, I mean, what percentage of people end up needing the other wisdom teeth out?
It's super high.
It's huge, isn't it?
Yeah.
Those common procedures we do in America.
(06:30):
And it's not normal.
I mean, if you look at ancient skulls, I'd say non-modern skulls even 500 years ago, healthy adults had 32 erupted teeth.
They had straight teeth.
They did not have braces back then, you know, and, you know, in a very short period of time, faster than evolution can explain our jaw shrunk.
(06:56):
And we're ripping out wisdom teeth. We're putting people in ortho and really sad cases, you know, people are pulling even pre-molars and retracting everything even tighter.
And, you know, in 10, 20 years, those are the patients we're seeing that are having a lot of airway issues.
(07:18):
I mean, when I was a kid, I had retractive headgear.
You know, I look back and I'm like, oh, fuck it.
Right. I just knew the fifth dimension and go back in time and, you know, fix things.
I think we all have that moment, right?
Even hosting these podcasts, there are so many times I have to follow up with my kids.
I'm so sorry. I didn't know. We didn't know.
(07:39):
We didn't know.
We just didn't know at the time.
Yeah. You know, your parents were doing what they thought was best for you, which isn't getting you kind of your wisdom teeth out.
You know, the orthodontists were doing what they were trained.
I'll tell you like.
Exactly.
You know, now that I'm an airway focused oral and maxillofacial surgeon,
most of my learning happened on my own, right?
(08:03):
Like you're trained to take out wisdom teeth.
You're trained to do jaw surgery, but no one kind of puts the puzzle pieces together for you.
And it's like, oh, why are we taking out so many wisdom teeth?
And, you know, why, you know, I think a lot more people need jaw surgery than get it.
That's a whole nother discussion.
It's a, you know, it's not like a surgery.
(08:26):
It's not like it's not a simple thing.
I was in teeth in any ways, but.
But there's a there's a there's a huge epidemic.
I mean, even if you look at nighttime proxism, right?
How many people clenching grind develop temperamentally joint disorders, you know, pain in their masseters, wearing away of teeth.
That's another crutch.
That's another symptom of not breathing normally and easily in sleep.
(08:50):
So I mean, these things have, you know, people react differently, right?
You have the Bapmia patients.
You have the clenches and grinders.
You have the U. A. R. S. patients who have tons of micro arousals and they don't go into deep normal sleep architecture.
And, you know, everyone kind of reacts differently, but it's all due to the same anatomy.
It all comes back to the same.
(09:11):
Yeah, just not working.
I had read something and I don't know if this is totally accurate or not, but that.
You seem more TMJ cases in women or young women.
Why more?
I mean, it's we're all having the same airway issue.
Why is it presenting that way? Does anyone know?
I don't think no one knows why.
(09:34):
You know, it may be a hormonal.
It tends to be.
Hairy menopausal women, I guess that are the most symptomatic. So there may be like a hormonal component to it.
But that's like symptomatic, right?
If it comes to actually like objective measurements of temperament of their joint dysfunction, I'd say it's pretty even between the sexes.
(10:00):
So you'll see, you know, in terms of like, arthritic changes, remodeling changes to the joint.
Clenching and grinding where articular disc disorders, like people that have clicking, popping, crunchy noises and stuff like that.
I'd say it's pretty evenly distributed between the sexes, but definitely when it comes to, hey, I'm suffering, I'm having symptoms.
(10:23):
How do we intervene? It's more common in women for sure.
Sorry, I didn't mean to just kind of throw that one.
That was like, I remember reading this and it just.
No, it's true.
Always, always wonder.
That's true.
So on your website and I'll put a link to it, you know, for anybody that hasn't seen it, both to your website and to this particular topic, but you talk about the mind technique.
(10:48):
Yeah.
So for those who haven't seen the video, would you explain a little bit about this procedure and what the benefits are?
Yeah, absolutely.
So most of my practice is treating jaws that are too small.
That can happen again, like I said, in three dimensions, right? We can, you can be retreated.
(11:09):
The jaws didn't grow far forward enough. There's also like angulation issues with the angle in which your bite is and you're looking in your jaw jaws grow.
Those things we generally treat with corrective jaw surgery.
There's another very common jaw deformity, which has to do with how wide the upper jaw develop.
We call that maxillary transverse hypoplasia or maxillary transverse deficiency, which just means the upper jaw did not grow wide enough.
(11:34):
That's something that's very commonly been treated in kids, put them in a palatal expander before the sutures fuse, although they don't really fuse.
They, it's more of an ossification where the bone kind of meets at the midline and starts to interweave like puzzle pieces.
So it's not the true like vision.
So in, in young kids, you can just use what we call like a tooth-borne palatal expander, like a high-racks, and they can crank it, push on the teeth.
(12:02):
And because the jaw has no fusion at the midline, everything kind of widens.
Very easily treatable in childhood.
And it's a very common thing and something that should be done much more often in childhood.
In adults, we traditionally did this larger surgery called the SARP, stands for surgically assisted rapid old palatal expansion.
(12:26):
It's a surgery based off of a two-piece Lafort 1 osteotomy.
So it's like a Lafort 1, same type of bone cuts that you would do to do an orthognathic surgery where you can move the jaw forward, except you're just making all those cuts and also splitting the palate down the middle.
So you have two halves of the upper jaw. And traditionally, you'd use, again, a tooth-borne expander, something that pushes on the teeth after you've made those two-piece Lafort 1 level cuts, and then you can widen an adult's jaw.
(12:58):
Also, good surgery. You improve people's airway, but it's a pretty big surgery in the sense that it's usually done under general anesthesia in a hospital.
There's some dental side effects from pushing on the teeth where the teeth start to tip out, so we would have to over expand people.
Let's say we wanted to expand them six millimeters, we might overshoot that by 50%. So we'd like push them to like nine.
(13:22):
And then we'd be like, okay, they're going to relapse back to six.
Oh, okay.
So there was, it was a big operation. There was flaws with it.
It also, because it's a Lafort 1 level cut, you're widening the jaw at a very low level. So you're kind of widening at the level of the nasal floor.
And maybe we can put in a graphic or something at some point, but it's a low cut. You're kind of cutting from like the floor of the nose back.
(13:50):
Do you want me to share media during?
Yeah, if you've got something handy. Yeah, that'd be amazing.
Let me open up the PowerPoint. I definitely have something somewhere.
So this is a Lafort 1 osteotomy. So you can see we're cutting the entire bone all the way across at the level of the floor of the nose.
So when we did surgeries that revolved around this, we do a two piece again, we do a Lafort 1 osteotomy with a midline split with a Sarpie use a tooth borne expand like you would in a child and use the teeth as anchorage to push the bone outwards and get the tipping and the relapse and all that stuff.
(14:26):
But you can see you're kind of widening just the floor of the nose. So patients that have a small airway nasal airway volume, they get marginal improvement in their nasal breathing because all you're doing is winding the floor.
It helps. But it's not treating the entire nasal cavity. You still get how it to widen, which gives you more space for your tongue, which is super important, but you're not actually treating the entire maxillary bone.
(14:53):
The maxillary bone is actually really big. So this is actually the full maxilla. It has a body. It has a frontal process of the other process agamatic process and it dictates how wide the nasal cavity volume is going to be.
So what the mind surgery is long story short is a way to make the surgery more minimally invasive. So it's a surgery I do 95% of the time in my clinic as if you're going to get wisdom teeth out.
(15:26):
Do a little IV sedation. I free up the sutures in a few places. We use a special kind of palatal expander that is not tooth-borne, but is actually what we call bone barn. So there's screws that go into the palatal bone so that when you're activating the expander and widening the jaw, you're actually pulling the bone apart and not using the teeth as your anchorage.
(15:48):
And with that, you get three-dimensional expansion of the entire nasal airway. So I have a picture of that to show you as well.
And while you're pulling that up, I mean, what is the recovery time for something like this?
Yeah, though it's less than wisdom teeth. I guess wisdom teeth will be our barometer for everything today.
(16:11):
Yeah, because everybody knows those.
Yeah, so the surgery is done through three small incisions that are this big. You can think of it as like a laparoscopic procedure. We operate through these little ports, free up the suture, free up two sutures in the back, and then some other technical stuff we do in there to loosen the bone.
And so very little pain or swelling. I mean, mild, maybe, very mild upper lip swelling, very little pain is usually five out of 10. I'd say most of my patients don't even take narcotics.
(16:45):
They can take ibuprofen in Tylenol and handle the pain. So it's like a very minimal surgery compared to a lot of other, I would say, oral surgery procedures.
And the type of expansion that you get is this like 3D expansion. So it's, can you see that slide? No, it's not working.
(17:11):
All right, sorry for all the technical issues.
No, that's all right. So then, and then you said it's a SARP that you use. No, is that the same as like the Marpe or the Alpher some of the others where you have to go in and adjust it periodically?
Or is it it's just in there after the surgery? And that's it.
So, so just can you see, see this line? Yes.
(17:35):
So this is the type of expansion we get. It's almost like a Lafort three level. It's full midface expansion. So the cheekbones come out. The blue is the is the after the yellow is the before.
So you can see what actually ends up.
Your entire nasal cavity airway volume expands three dimensionally. The palate still wide ends, you still grow alveolar bone. So a lot of patients that have crowding and stuff like now you have space for the teeth, you don't have to shave down teeth to get your teeth straight.
(18:03):
We have more bone at the midline.
So palate wide ends nasal cavity volume three dimensionally expands and so all of that has a really big impact on the way you can breathe afterwards. I mean, after just a couple of meters patients are like sleeping deeper. They're breathing easier through their nose.
They're able to exercise with their mouth closed things.
(18:25):
You do not wake up with this gap. So it is a it is a slow expansion. So it's we expand at a rate of about two millimeters a month. Sometimes we go a little faster, but let's say on average about two millimeters a month.
So really slow, steady. And then once you get there, hopefully breathing and sleeping a lot better doing a lot of exciting stuff now where that gap.
(18:54):
That gap that you saw in that post op CBCT scan were actually controlling it during expansion. So, you know, one of the things that it was hard for people was dealing with a space between the two front teeth because that a diastema.
It happens as the bone splits apart at the midline.
Now, I'd tell you that patients that end up coming to me to get this done.
(19:17):
You know, these are patients that have not been breathing well, not been sleeping well. They're happy. They don't care because they're like, it's fine. It's going to close. I'm okay. I'm breathing better. I'm feeling better.
It's Madonna. It's in fashion. Let's just roll with me. Exactly.
But, but, but now we're even we're able to to to control that gap during the expansion phase. So we're even taking that one temporary side effect out of the equation, which I think is making the experience a lot better and making going through the procedure a lot more palatable for a lot of patients.
(19:53):
And then so they have to turn it though periodically is it.
Like one like one turn a day. Yeah, like little one. We call it a swing like one swing a day.
Each swing is a 12th of a millimeter. So it's just real slow. You know, millimeters this big, we're doing a 12th of a millimeter day. So it's just real real real real slow.
And then once you get there, does it come out?
(20:15):
Or is this like it stays in forever?
It stays in for six months afterwards, because you have to wait for bone to fill in. So we expand. And then we wait for bone to fill in. So it's permanent. Otherwise, if you remove the expander too soon, before the bone fills in, everything will relapse back to where they were.
So we expand, we hold, wait for the bone to fill in, then we remove the expander. But they're doing they're doing ortho during that time. So it's not like during that six months, you're just waiting. You're, you're doing ortho with the expander.
(20:46):
Still in the mouth.
And is this one of those kind of things as you're explaining it here, then now this is going to start to follow forward, or do you have to do something separate to the job?
That's a great question. So we are getting forward movement, just with expanding, which is not the movement we are planning to do, right? We're planning to widen.
(21:07):
But what we're seeing with everybody is that their upper jaw as it widens will come forward about a millimeter to millimeters.
With that, we can also couple something called the reverse pull face mask. So we can add hooks to the expander and actually provide forward traction on the upper jaw.
(21:28):
And sometimes even in adults, push that another millimeter to so patients who may have been, let's say four millimeters deficient in the forward growth of the upper jaw, just with the natural widening and coming forward a millimeter to with with the reverse pull face mask, we're bringing adults
upper jaw forward to three, four millimeters, which is amazing for a minimum base of upper.
(21:53):
The lower jaw, we're obviously not treating. So it's going to be more of a orthodontic thing, getting it to match where the upper jaw is.
If the lower jaw is really set back, those are the cases where we're sometimes widening first planning to do orthognathic surgery down the road.
But in a lot of patients, just the forward movement they get from the expansion and possibly with the reversible face mask with the orthodontics to get the lower teeth to match is all that they're going to need.
(22:20):
That's amazing. So who is a good candidate for orthognathic surgery? I knew I was going to kill that.
And is there a minimum age for it?
So great question. So orthognathic surgery is a is a more precision surgery in the sense that we can really control the jaw in three dimensions.
(22:41):
We can plan movements down to the 10th of a millimeter. We can fix orientational things down by the 10th of a degree.
So, you know, we can diagnose people, hey, your upper jaw should be seven or eight millimeters more forward. Your lower jaw needs to be 10 millimeters more forward.
You know, your bite is too steep. We can flatten it out. We call that counterclockwise rotation, which actually opens up the airway some more.
(23:04):
We can even widen the jaw at the time of orthognathic surgery so we can actually segmentalize the lafort and widen the jaw and fix the bite.
And, you know, during that time we're also working on symmetry. So let's say your midline is off by a half a millimeter.
We can strain the midline so that your dental midline and your chin midline match up with your facial midline.
(23:26):
There's a lot of beauty and precision in orthognathic surgery.
Who's a good candidate for it?
Insurance definition is going to be someone that has a functional issue, whether that is like chewing and swallowing issues, speech issues, airway issues like sleep apnea, people that bite their cheek or tongue because of the way their teeth align.
(23:52):
And then you have to meet certain radiographic criteria. So we have, we take measurements on x-rays and we show that the jaw is deficient by this much using this angle and that angle.
And that's who would be a candidate.
So minimum age is a great question.
The textbook answer is skeletally mature, right? So for generally, it's going to be 16 years old for a girl, 18 years old for a boy.
(24:21):
However, in very extreme cases, okay, like I just had a case last month of a 13 year old who had really deficient jaw growth, who had severe sleep apnea, was not thriving, you know, struggling in school because they're so tired and sleepy.
That's a case where, you know, you can make a decision like, okay, let's intervene now.
(24:43):
All right. And understanding that because you're going to continue to grow, there may be a chance we have to redo the surgery when you're skeletally mature.
Right, because you're going to wake up with perfect facial balance, perfect bite. Right. That's, that's how these surgeries are done nowadays in the right hands.
And, and, you know, that's going to potentially change as you grow. So if it does not grow in harmony during the rest of your development, then when you're 18, we may have to do what we call it, just a revision surgery, just to put things back to where they need to go.
(25:32):
Okay.
(25:55):
You are listening to Airway First with today's guest, Dr. Kevin Coppelsen. You can find out more about the Children's Airway First Foundation and our mission to fix before six on our website at children'sairwayfirst.org.
The CAF website offers tons of great resources for both parents and medical professionals.
(26:16):
Visit our parents portal, clinicians corner, resource center and video library to see for yourself.
We also encourage parents to join the Airway Huddle, our Facebook support group, which was created for parents of children with Airway and sleep related issues.
You can access the Airway Huddle support group at facebook.com backslashgroups backslashairwayhuddle.
(26:40):
As a reminder, this podcast and the opinions expressed here are not a medical diagnosis. If you suspect your child might have an airway issue, contact your pediatric airway dentist or pediatrician.
And now let's jump back into today's episode.
(27:21):
This is more invasive, right? This isn't like the mind technique. This is...
This is like a hospital surgery. It's a very precision surgery. We do it all fully custom now. So all the cutting guides where we plan the movements digitally so I can see where all the midlines are.
(27:51):
And then we go straighter to this side to make everything straight. We plan all of that digitally. We get cutting guides, computer princess cutting guides and also 3D princess titanium plates.
So that the surgery is done with computer robotic precision.
So the benefit of these custom orthognathic surgeries is one, the accuracy and the planning. You execute exactly what you plan because otherwise everything doesn't fit.
(28:21):
But also it really speeds up the time of the surgery. So it's done in a fraction of the time that it used to be, which just means less pain, less swelling, less discomfort.
The more time you're dissected, the more time you're in surgery, the harder the recovery is going to be. If you can speed up these surgeries less time you're tractioning on the tissues and doing all your stuff, you're going to wake up, you're not going to swallow up as bad and have as bad of a recovery.
(28:46):
But it is still a hospital surgery. We usually keep patients in the hospital for one to two nights.
There's people that send people home the same night and they're okay with it. It's not my style. I like to keep people a couple nights. I want to make sure that they're walking, they're peeing, their pain's well controlled, they're drinking enough, all that stuff if I send them home.
(29:13):
That usually takes about two nights. It's great. In the old days people go, are you going to wire me shut? What is it going to be like? I'm like, no, you're going to have full mobility, you're not going to have restricted opening.
The only thing is non-true diet for six weeks. You're going to be basically like blenderized smoothies, milkshakes, oatmeal, the stuff like that for six weeks and then get you back to a regular diet.
(29:43):
When you're in there, you're not breaking bones, right? That may be a silly question, but you're cutting, not breaking. Cutting and moving, is that how that works?
It's a precision break. We cut the bone where we want it to break. You create fault lines where you want things to break and then you break the jaw and move it to where you want it to go and then plate it in that new position.
(30:15):
Wow.
It sounds wild, I know.
I know it sounds wild, like fascinatingly wild. That's really cool.
It sounds wild, but it works really, really amazing, especially with that new custom titanium hardware and the precision and the speed in which we can do these surgeries now. It's completely different than it was being done five, six years ago.
(30:37):
Yeah, that's fascinating. In my mind, I'm thinking you're in there and then moving things around and that just, the other sounds really cool.
Yeah, I mean, like even the tools that I use to cut the bone is very different than what I used in my residency training, right?
My residency training was literally kind of what you're thinking of in your head. There was saws and chisels and mallets and this and that.
(31:02):
Now I use something called the piezo surgery unit. It uses ultrasonic vibrations to gently kind of cut the bone very precise, very delicately.
The benefit of that is one of the things that runs through the jaw bones are nerves, right? Particularly nerves that give you sensation to your lower lip and chin.
(31:24):
And one of the biggest side effects from orthognathic surgery is the risk of having permanent numbness to your lower lip and chin.
And when you use saws and chisels, it's a lot more traumatic on the nerve and we would see about 20% of patients have permanent numbness on their lower lip and chin.
And since switching to the piezo, it's so delicate and gentle on soft tissues while still allowing you to cut bone, I have no patients that are really fully numb anymore.
(31:51):
Still, I'd say about 80% of my patients make a full recovery, but the 20% that don't, they all gain something back. So they gain about 50, 60, 70% of the feeling back.
It just may not come back quite to what it was before. So it's very meaningful nerve recovery. Everybody gets meaningful nerve recovery now.
No one has full numbness of their lip anymore. So even that has changed, you know, night and day.
(32:16):
I mean, this is a specialty that if you're not on top of it, you become a dinosaur very quickly. It's changing very, very fast.
Yeah, it sounds like it. And it sounds like it also improved recovery for the patients because it's not as traumatic.
Absolutely. It's a lot less traumatic. It's a lot more delicate. And it's even more precise, you know, just being able to just gently cut bone and it doesn't touch soft tissue, it doesn't cut soft tissues.
(32:48):
It's a game changer.
Wow. That is mind blowing.
Yeah.
So we talked a little bit about how you can move it just, you know, you millimeters here or there. Just kind of to put it in perspective for parents who may not have heard some of our other podcasts.
Maybe this is their first one. How can opening the airway for your child, just a few millimeters really impact their overall health span?
(33:17):
And even just, you know, not just down the road, but, you know, short term as well as long term.
Yeah, I mean, that's a great question. I love the word they use health span, right, which is something I really believe in. It's not just how long someone lives, but with the quality of which they get to live their life.
It's huge.
I have the most rewarding job in the world in the world, like being able to treat people that are not their full self because sleep is such an integral part of brain and heart and overall just function and fix them, you know, not just give them a bandaid but permanently cure them by
(34:01):
adjusting the just to where they should have developed to had they been 100 gather is is pretty cool.
For kids, I mean, I can't tell you how many kids we treat that, you know, ADD anxiety, depression, whatever. And the root cause was actually their poor sleep.
(34:25):
Right. It wasn't it wasn't there just a user they weren't sleeping and this is how their brain was responding to the lack of normal sleep architecture and not struggling to breathe anxiety of not being able to take a normal breath all the time.
It's easy deep breath through your nose like you're supposed to. So, if, if someone does have a child that does not breathe and sleep normally that has any kind of abnormality in their jaws, the earlier you intervene, the better and when they're young, it's so easy with early
(35:00):
intervention or orthodontics, little power expander, other kinds of appliances you can really hopefully stimulate or actually promote the jaw growth to where you want it to go and you can change the whole trajectory of their life.
And then hopefully they won't need ortho-agnetic surgery.
Yeah, there you go.
(35:21):
Yeah.
I can't say it anyway.
Yeah.
I'll put links to some of the other episodes where we talk about some of the signs and symptoms you can look for because they don't always snore.
Right. Some kids don't snore, but maybe they have restless leg or they wake up with headaches or late stage bedwetting.
(35:43):
Yeah. So there's things like that. I know parents and I'll put links to it so that they can review that. But you mentioned, you know, being able to look at them.
What are some of the things, spatially, that parents could look at if they haven't necessarily seen any of the other signs? Just, you know, hey, that's not quite right. That's not an alignment.
(36:05):
Mm-hmm. So jaw retrosion is going to be huge one. If someone looks like their chin is really retroated or set back, that's a big sign.
People that have maxillary transverse hypoplasia, people that mouth breathe, they develop differently. There's very prototypical facial characteristics that you can see.
One of them is going to be a really deep palate. They may show excessive tooth show. So they may show a lot of upper teeth because of the jaws of, you know, as it grows narrow, it can sometimes overgrow vertically.
(36:41):
We call that excessive downward displacement of the upper jaw.
Maybe like gummy smiles. Is that what you're talking about?
A gummy smile. If you see any kind of open bite, so if the front is open or the sides are open, that's a big thing. Cross bites are a big thing.
So if you see that, you know, I don't know if you can see it on me guys, but my upper teeth sit slightly wider than my lower teeth.
(37:06):
A lot of people that have narrow upper jaws that have something called a cross bite where the lower teeth will actually sit wider than the upper teeth.
That could be a sign that the upper jaw didn't grow wide enough.
Also just looking at the palate. The palate should be shallow and broad and flat.
If someone has a deep, high vaulted palate, slam down case. Easy.
(37:29):
So just look at your palate. Does it look really deep?
And, you know, worse comes to worse. You just bring them into someone that's used to looking at those patients all day and, you know, between a really good clinical exam, a good history and a CBCT scan.
We can diagnose people pretty clearly and see what's going on.
(37:50):
And I know I hadn't really prepped you for this and this is an opinion. I'm just curious. What do you tell parents when they're presented with, oh, let's just pull a couple of teeth and put on.
Some braces and they'll be fine.
Well, even I've even heard let's pull a couple of teeth and put on an expander.
I mean, to me, I know the alarm works there, but how does that hit you?
(38:11):
You're ignoring the big puff of smoke that's coming out of your house.
To me, it's if the kid doesn't have enough space in their mouth for their teeth, that's a red flag. And, you know, I'm not saying you're going to make them worse by pulling the teeth and making their teeth straight, but you're not making them better.
(38:37):
So make them better. Make the jaws bigger and make the teeth fit.
And they're going to be in a much, much better position. You know, is it a little bit more work to get a powder look spander as opposed to pulling teeth and straining the teeth off?
Yes, but you're functionally going to change the kid's life forever as opposed to just covering your eyes and all their teeth look straight.
(39:01):
Okay, but are they going to breathe in 20 years? Are they going to breathe in 30 years?
Are they going to, you know, you're just kind of ignoring the problem and you have this beautiful clue and use it and treat it. You know, that's how I'd like to explain it to the parents.
I've actually never heard anybody explain it as a beautiful clue, but it really is. It really is kind of here. It really is. We can set your child up for a much healthier life.
(39:31):
Yeah.
For something so simple.
Like life changing.
It's like life changing.
It is.
I use that word a lot and I don't try to use it loosely, but it really is life changing. Like doing these little procedures where you widen the jaw or orthognathic surgery.
It's life changing for people. Like you really completely change the way they breathe. You change the way they sleep and thus they become better versions of themselves.
(39:57):
And if you can do that in a kid, right, that's 30 years extra of enjoying that.
Yeah.
Right. And I know there's there's some, then I can put some links to some of the things we've got in our resource center of linking airway and sleep dysfunction to things like dementia and Alzheimer's.
(40:19):
And they're starting to form connections. And like you said to me, that's a no brainer.
Yeah, neurodegenerative diseases. Just like those cardiac, like heart attack, strokes, cardiac arrhythmias.
Sleep is huge. Breathing is huge.
Right. It's one of the pillars you can't do without it.
(40:41):
It's like the first thing that'll kill you.
Right. Right.
Yeah.
So one of the other things that we talk a lot about is this whole multi-disciplinary approach.
Just to medicine in general, I mean, not just kids, but just overall, that it's it's not something that is taught in medical school or dental school.
(41:04):
I know it's here. Let's silo. Let's do our own thing. Let's become the kings of our area.
But you actually do advocate for this approach.
So what was your journey? What brought you to this kind of paradigm shift in your mindset?
I'd say I'm like, I'm a pretty obsessive person in trying to improve, you know, whether it was coming up with the mind surgery or trying to stay state of the art with the or the genetic surgery.
(41:33):
I'm always trying to figure out ways to improve outcomes for procedures that I do.
And obviously, one of the ways is utilizing the technologies like 3D printed titanium blades, right.
But there's more to it. Right. And one of the things that I got exposed to when joining the Breathe Institute in Los Angeles was their multi-disciplinary approach to tongue-tie surgery.
(41:58):
You know, people that had tongue ties, they would couple it with myofunctional therapy and they improve the results of doing a frenioplasty.
So people that get tongue-tie surgeries, instead of getting their surgery feeling good for a day and then scarring back down to where they were because they didn't have the proper tongue function and mobility and strength and range of motion and all that stuff,
(42:20):
they coupled it with that kind of therapy and improved the results. And I was like, okay, I think that would be very beneficial for orthognathic surgery as well.
I was like, all of these patients have oral myofacial dysfunction.
These patients, they're generally adults who have not been sleeping well for 20 years. Their mind-body connection is all out of whack.
(42:45):
I'm like, I want to bring in a yoga, knee-draw mindfulness meditation counselor to work with them before the surgery.
So they come into it with the right mindset. I mean, you're about to heal. You're about to experience all these changes.
You wake up from these surgeries breathing better. It's not like, hey, we'll see you in six months. Give it six months. It's like you wake up breathing better.
So I want to get their mind ready for all these changes that are about to happen.
(43:09):
So myofunctional therapy as well, working on their breathing patterns, working on their tongue-tie and their tongue posture, they're going to have more tongue space.
When I lengthen the jaws, I want them to use that tongue space to the max. What's the point of having a giant mansion if you only sleep in one of the beds?
I want them to use the whole house. So I have them work with a myofunctional therapist to get the most out of the space that we're creating to work on their breathing patterns.
(43:37):
Because these patients were using their accessory muscles to breathe for 30 years and they don't know how to breathe through their nose well.
So working with a breath worker and a myofunctional therapist, mindfulness and meditation.
And then again, we talked about the diet six weeks, not being able to chew food.
(43:58):
So I want to make sure your nutrition is up to par because you're healing.
You're going to be like an anabolic growing kid. You need more protein than usual because you have to heal all these tissues.
Everyone has their own diet. Some people don't eat gluten, don't eat dairy, so you want to make sure that we're finding nutritious diets where they're getting all their macro-micronutrients.
(44:23):
But it's also interesting. So you have some meal plans where I like these kind of flavors.
OK, let's come up with a blended thing that will be interesting to you so you don't get bored after three weeks and you're just like, oh, I can't eat anymore.
Three weeks of oatmeal, right?
Yeah. And then just, you know, these cases are multidisciplinary by nature.
There's me. There's going to be an orthodontist usually that's going to be finalizing the inclusion, making sure everything fits beautiful.
(44:51):
We don't want you just to have a beautiful face and a beautiful airway, but we want your bite to be really beautiful and functional as well.
So the orthodontist is a big part of that. The general dentist, having them as part of the team so they can quarterback any restorative stuff that may need to be done.
And then I just have a pharmacist on board as well. You know, obviously we have a big opioid epidemic in the country.
(45:12):
The last thing I want to do is just shove narcotics down patients' throats.
So we work on multimodal pain management where we're not just giving them narcotics, but we're maybe adding some CBD and other things that can help lessen the pain burden.
So we're not just relying on opioids to control patients' pain.
And together, this team has really like taken the surgery, which on its own is life changing, like I said.
(45:36):
And now we're getting way more out of it and the experience is way, way, way more positive.
Yeah. That's amazing because it really is. It's a lifestyle change as well.
Mm hmm. Yeah. Right. Absolutely. Yeah.
So at the end of every episode, I always hand the floor back over to the guest as the expert for the final thought for our parent audience.
(46:03):
So I give you this option for this opportunity now.
I'll keep it short and sweet. So I think to summarize, interviewing young.
If you see signs of abnormal breathing, abnormally, orthodontist tells you, hey, let's pull a couple of premolars out and strain their teeth.
Anything like that. The jaws are too small. Intervene while they're young. It's super easy. It's going to change their life forever.
(46:32):
If you're a parent yourself that is having these issues or some adult just know that we live in the golden age of treating these things now.
And it's really safe. It's very predictable. Things are much more minimally invasive, much more precise.
And it's a good time to get it done if you need to.
And yeah, that kind of summarizes my gist in life right now.
(46:56):
I love it. Well, thank you so much for coming on today for sharing all this. I really appreciate it.
Thank you for having me. It was great speaking with you.
Thanks again to today's guests, Dr. Kevin Coppelsen for sharing his expertise and each of you for listening to today's episode.
(47:17):
You can stay connected with Children's Airway First Foundation by following us on Instagram, Facebook, X, LinkedIn, and YouTube.
Don't forget to subscribe to the Airway First podcast on your favorite podcasting platform so you won't miss an upcoming episode.
If you'd like to be a guest or have an idea for an upcoming show, shoot us a note via the contacts page on our website,
(47:41):
or send us an email directly at infoatchildrensairwayfirst.org.
Today's episode was written and directed by Rebecca St. James, video editing and promotion by Ryan Draughan, and guest outreach by Kristy Bochinkian.
And finally, thanks to all the parents and medical professionals out there that are working hard to help make the lives of kids around the globe just a little bit better.
(48:07):
Take care, stay safe, and happy breathing everyone.
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