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Clinical Orthodontics: A Great Future in Plastics by Dr. John Grady

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Header: A Great Future in Plastics
by Dr. John Grady

Myriad published studies show the positive correlation between rapid maxillary expansion (RME) and increased nasal volume and decreased nasal resistance. Implementation of RME treatment for airway management lags behind current studies; however, few practitioners have successfully integrated RME airway management and treatment of pediatric sleep apnea into their practices.

Over the past 20 years, a new industry has blossomed for general dentists: managing and treating obstructive sleep apnea (OSA) through the use of dental sleep appliances. There now exist dedicated dental sleep specialists, a board (the American Academy of Dental Sleep Medicine), board certification and a journal (the Journal of Dental Sleep Medicine).

Managing airway with RME remains relatively rare, even though it can be extremely effective and more permanent. Part of the problem may be a general lack of knowledge and familiarity among those dentists and physicians who treat OSA. Physicians and dentists cannot confidently refer OSA patients to orthodontists if they don't have firsthand experience and understanding of RME treatment.

Our initial attempts to educate physicians (mostly ear, nose and throat specialists) and dentists usually involved the use of before-and-after panoramic radiographs showing increased nasal volume. Although the radiographs are usually impressive, they are limited to two dimensions and offer only a "slice" of the airway (Fig. 1).

Printing a new paradigm
In 2014, we attended a symposium for orthodontic and otolaryngology residents about OSA. It then became clear that despite RME's powerful ability to treat OSA, there was a clear lack of familiarity with, and understanding of, RME and its implications. We decided to use the three-dimensional radiography of CBCT and the three-dimensional printing capabilities of additive manufacturing to explore airway changes in our RME patients.

We began taking before-and-after CBCT imaging on our RME patients and sending the data to 3D Systems in Denver, which specializes in printing 3-D models for a variety of medical and surgical purposes. The results were not only impressive; they also were independently objective, tangible and undeniable (Figs. 2–4).

Through these models, we now have the ability to easily and clearly illustrate and share the airway changes that RME has created in sleep apnea patients.

Communication has greatly improved with patients, parents, general dentists, sleep apnea dentists, sleep physicians and otolaryngologists. Referrals of apnea patients have increased by multiples. And most importantly, many more children are benefitting from a much-needed, and often overlooked, treatment.

I believe we have acquired a new and correct paradigm: Most/many pediatric OSA patients need both adenoidectomy and RME. The ENT surgeon can clear the airway surgically, but the maxilla and nasal cavity may remain hypoplastic. An orthodontist can enlarge the maxilla and airway to normal proportions. And this can make a life-changing difference to our patients.

Fig. 1a

Fig. 1: Because a panorex (tomogram) is a two-dimensional angled slice, it may not always be representative of actual 3-D change. Take note of the intermaxillary suture. These films are typical images of rapid maxillary expansion (RME). 		Fig. 1b
Fig. 2: On this 3-D maxillary model, the clear plastic represents bone and red plastic represents soft tissue.
Fig. 1a

Fig. 3: These 3-D models, which represent a before-and-after case over a six-month time period, were printed to show only bone. 		Fig. 1b
Fig. 4: Note the dramatic airway improvement post-RME on this 3-D model of a patient who had been diagnosed with severe sleep apnea despite two adenoidectomies. The patient's post-RME sleep study (PSG) was normal.
Fig. 5

Fig. 5: Dr. John M. Grady holds a 3-D airway model.




Dr. John Grady John Marshall Grady, DMD, is a residency-trained specialist in orthodontics and dentofacial orthopedics. The practice in Wexford, Pennsylvania, specializes in orthodontic treatment for children and adults through orthopedic appliances, traditional and cosmetic braces, Invisalign and orthognathic surgery. He completed his dental education at University of Pittsburgh School of Dental Medicine. Grady attended the State University of New York at Buffalo for his orthodontic residency. Dr. Grady works with Drs. Dan E. Kastner and Matthew C. Gornick at GKG Othodontics, where they employ awareness of RME to improve their patients' quality of life.



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