Aligning Maxillary Expansion with Nasal Breathing

Over 3 consecutive weekends, I spoke, taught, and learned of contemporary updates in naso-maxillary expansion, at the AAOMS, AAO-ISSS, and AHUL. Coincidentally, they all took place in Florida, my new home base. DOME (distraction osteogenesis maxillary expansion) was showcased at the sleep apnea symposium and sleep surgery course at AAOMS. At ISSS, my former fellows and observers to Stanford ENT showcased DOME and modified approaches in lectures and the cadaver lab. At AHUL, key opinion leaders in dental sleep with real-world data gathered to plan research directions for maxillary expansion.

Today, DOME is characterized by functional naso-maxillary expansion with distraction osteogenesis to convert a high-arched palate to a dome-shaped palate. It aims to improve nasal breathing during wakefulness and sleep. The name DOME, in its acronym form, was born organically. In 2014, Dr. Christian Guilleminault (affectionately, C.G.), alerted Dr. Audrey Yoon and I to the unmet need of addressing adults with narrow maxilla and nasal obstruction, particularly during sleep. It truly feels like yesterday when C.G. first drew the TADs (temporary anchorage devices) on the maxilla for us at the Stanford Sleep Center in Redwood City. That set in motion a burgeoning of clinical and research activities surrounding maxillary expansion and sleep-disordered breathing.

The day C.G. drew his maxillary expansion design for us.

Generally, skeletal naso-maxillary expansion in adults [1-5]:

1. Improves nasal breathing, per patient report

2. Lowers the apnea hypopnea index (AHI)

3. Complements other sleep procedures for improved outcome

We owe C.G.’s for his vision, as maxillary expansion became an area of intense academic and clinical endeavor across multiple specialties. Efforts continue across dentistry, oral surgery, and ENT to better understand the mechanisms behind efficacy and failure in maxillary expansion and its contributions to nasal breathing. As we continue to optimize patient experience during treatment, innovative approaches to esthetic considerations are also buzzing with activity. Examples include the “no-gap” (you know what I am talking about if you have ever been expanded), no diastema DOMExD with clear aligner orthodontist, Dr. Claudia Pinter.

Before Naso-Maxillary Expansion

After Naso-Maxillary Expansion

When I started my career as a sleep surgeon, maxillomandibular advancement (MMA) entered the era of virtual surgical planning, and soon-to-be patient specific implants. Maxillary expansion evolved from open approaches to endoscopic, and other minimally-invasive techniques.[6, 7] And, Inspire emerged as the first hypoglossal nerve stimulation implant.

For the field and I, 2014 began a new era that advanced sleep surgery, by expanding our repertoire, and inspiring the pursuit of better breathing during sleep.

A decade later, I am grateful to see how maxillary expansion has become aligned with nasal breathing and wellness.

References

1) Liu, S.Y., et al., Distraction Osteogenesis Maxillary Expansion (DOME) for Adult Obstructive Sleep Apnea Patients with High Arched Palate. Otolaryngol Head Neck Surg, 2017. 157(2): p. 345-348.

2) Liu, S.Y., et al., Feasibility of distraction osteogenesis maxillary expansion in patients with persistent nasal obstruction after septoplasty. Int Forum Allergy Rhinol, 2022. 12(6): p. 868-871.

3) Yoon, A., et al., Distraction Osteogenesis Maxillary Expansion (DOME) for adult obstructive sleep apnea patients with narrow maxilla and nasal floor. Sleep Med, 2020. 65: p. 172-176.

4) Thuler, E., et al., Correlation between the transverse dimension of the maxilla, upper airway obstructive site, and OSA severity. J Clin Sleep Med, 2021. 17(7): p. 1465-1473.

5) Thuler, E.R., et al., Transverse Maxillary Deficiency Predicts Increased Upper Airway Collapsibility During Drug-Induced Sleep Endoscopy. Otolaryngol Head Neck Surg, 2024. 171(1): p. 317-319.

6) Liu, S.Y., et al., A Minimally Invasive Nasal Endoscopic Approach to Distraction Osteogenesis Maxillary Expansion to Restore Nasal Breathing for Adults with Narrow Maxilla. Facial Plast Surg Aesthet Med, 2022. 24(6): p. 417-421.

7) Jara, S.M., et al., Posterior Palatal Expansion via Subnasal Endoscopy (2PENN) for Maxillary Deficiency: A Pilot Study. Laryngoscope, 2024. 134(4): p. 1970-1977.

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