by Felix Liao
I continue to be very pleased with the decision. My energy level is much improved—no need for a nap in the afternoon, and no tossing around all night with that CPAP machine on. I would never go back to CPAP. Still using the appliance at night just to keep everything in place. If you are considering it, I would suggest looking at it as well.
Robert understands sleep tests are needed down the road to monitor his OSA after oral appliance therapy is over.
Both before and after images were taken without oral appliances in the mouth.
Biomimetic Oral Appliances: Airway Development without Surgery
The whole upper airway benefits from stem-cell activation by using a biomimetic appliance on the maxilla. A 2011 case report in Dentistry Today concluded, “Genetically encoded developmental mechanisms can be modulated by maxillary appliances to enhance the upper airway in adults.”(6)
In my experience, biomimetic oral appliances are an effective solution to open up the airway while correcting the structural causes of crowded teeth, jaw-joint dysfunction (TMD), persistent pain, and chronic fatigue during sleep—provided that the patient actively changes their old habits and unhealthy lifestyle patterns. Robert certainly did.
Holistic Mouth Bites
Biomimetic oral-appliance therapy can provide quick relief from sleep apnea in the short term while remodeling the airway over the long term in mild-moderate OSA cases.
Robert’s case illustrates how a pinched airway can be redeveloped in patients nearing 60 years of age as long as there are sound teeth and healthy gums.
Fuller genetic expression can be achieved in the jaws and face using biomimetic appliances to redevelop both the maxilla and the mandible, as well as the airway.
Chapter Sixteen
Stem Cell Activation: The Natural Way to Airway Upgrades
The mouth reflects general health and well-being.
– Oral Health in America 2000:
A Report of the U.S. Surgeon General(1)
How does a biomimetic oral appliance upgrade an adult’s airway? The short answer is stem cell activation. Here’s a brief look into the science behind craniofacial redevelopment for adults.
Stem cells represent the latent ability to grow, adapt, repair, and regenerate. A baby grows from stem cells; so can underdeveloped jaws and a narrow airway, provided enough stem cells are available.
Sources of stem cells for craniofacial redevelopment include the tooth sockets in both jaws and jaw joints, and in cranial sutures, specialized joints by which the maxilla is connected to the face and head. Age is not a limiting factor, but the number of healthy teeth is.
Stem-cell technology means affected adults are no longer stuck with an impaired mouth structure and a pinched airway. As the maxilla redevelops in size, shape, volume, and position, the mandible is freed from its entrapment. As the three-foot cage between the jaws enlarges in volume, the pinched airway behind them also widens.
All this takes place without pain, simply by wearing a biomimetic oral appliance, and possibly an oral face mask, while you sleep. What a nice treatment!
Craniofacial redevelopment using biomimetic oral appliance more than doubles the airway in a man in his sixties.
Let’s look deeper into the science behind biomimetic oral appliances.
Cranial Sutures: A Resource for Remarkable Results
Cranial sutures are specialized joints in the craniofacial skeleton that allow for the skull’s slight movement which is essential for brain health. Sutures are important during growth and development and in allowing the skull bones to “breathe” in adults. This is called “cranial respiration” in the osteopathic field or “craniosacral rhythm” in the lay press.
The maxilla is connect to the cranium and face by seven sutures, which may not begin to fuse until 68-72 years of age, according to orthodontist Dr. Vincent G. Kokich in 1986, who postulated that adults “retain the capacity to regenerate and remodel bone at the craniofacial sutures.”(2)
This means that the potential for maxilla-facial redevelopment is alive even late in adult life. My patients’ experience agrees: age is not a limiting factor provided that there are enough healthy teeth.
Sutures have the potential to make bone: “Sutures are formed during embryonic development at the sites of approximation of the membranous bones of the craniofacial skeleton,” reports a 2000 study in Developmental Dynamics.“They serve as the major sites of bone expansion during postnatal craniofacial growth.”(3)
In adults, this potential to make bone in the sutures surrounding the maxilla persists, because sutures may not close even late in adult life.(4)
Another study noted that “cells derived from normal and fused sutures displayed characteristics of the osteoblast [bone-forming] phenotype in culture.”(5)
The Surprising Common Feature of Periodontal Ligaments and Cranial Sutures
Periodontal ligaments anchor the teeth to the jaws. Peri- means around, and -odontos means teeth in Greek. Periodontal ligament exist in a 0.25 mm space that contains many interesting cells and sensors, including the ones that inform you of a bone chip in your burger, sand in your salad, or a shred of dental floss wedged between teeth.
Like cranial sutures, periodontal ligaments are both strong and elastic to absorb bite pressure. Dr. G. Dave Singh suggests that periodontal ligament spaces are actually a form of cranial sutures. “The periodontal ligament space is subject to sutural homeostasis, not unlike the sutures of the skull… Recent evidence suggests that this sutural width [of .025 mm] is tightly controlled at the genetic level.”(6) “Most importantly,” he adds, “it has been shown that the mammalian periodontium has a histologic structure that is akin to fetal tissues rather than mature adult tissues.”(7) Fetal tissues are high in stem cells.
This means periodontal ligaments contain stem cells that can make bone to redevelop impaired mouth — another major eye-opener for me and one more great reason to keep up your dental health.
Stem Cells: The New Promise inside Tooth Sockets That’s Blowing Away Old Beliefs
Stem cells in tooth sockets can make bone, gum tissue, fibers, and ligaments to keep the foundation of teeth (below the gums) in good working order. Research has shown, for instance, “periodontal ligament cell progenitors can generate multiple types of more differentiated, specialized cells”, including those that make periodontal ligaments and cementum that covers the root of a tooth and embeds the periodontal ligaments.(8)
“Periodontal ligament fibroblasts after tooth extraction actively proliferate,” notes another study. They “migrate into the coagulum, form dense connective tissue, and differentiate into osteoblasts which form new bone during socket healing.”(9)
A 2004 NIH study similarly found that stem cells in the periodontal ligament expressed stem-cell markers. In other words, science has consistently shown the potential for stem cells in the periodontal ligament to create new bone and connective tissue.(10)
“Deep periodontal ligament cells retain the capability to differentiate into an osteoblast lineage [for making bone].” (11). That means healthy teeth in sound jaw bone are needed for redevelopment.
Stem cells are only a promise. It takes a signal to flip on the switch and turn the promise into reality. The message is delivered in the form of a minimal stretch to the periodontal ligament that’s felt as a a snugger fit of a special type of oral appliance. The message to the stem cells is: “Restart your bone-making assembly line that was once active during your teenage growth spurt that was mediated by your own genes.”
When deficient jaws and a three-foot cage are redeveloped, the airway also widens, and sleep deepens. Growth hormones for repairing daily wear and tear are released only in deep sleep. This is a major outcome of Holistic Mouth Solutions.
From Promise to Reality: Biomimetic Oral Appliances
Biomimetic means to mimic natural biological processes of growth and repair. Biomimetics is a science that studies natural models and then uses these designs and processes to solve human
problems, says Dr. G.D. Singh.
Biomimetic treatments are painless because they mimic (imitate) natural growth during teenage years. Biomimetic appliance is a new type of epigenetic oral appliance that can widen the airway and oral volume within the craniofacial skeleton to result in nonsurgical enhancement of the upper airway to relieve snoring and sleep apnea.
In theory, any maxillary appliance that can redevelop the deficient maxilla in adults and thereby free the mandible and tongue from entrapment has the potential to improve the upper airway. Available evidence shows that biomimetic appliances can remodel and widen an obstructed airway, so we will focus on them based on published evidence, while allowing that other types and approaches may also be effective.
Biomimetic Oral Appliance Therapy (BOAT): Evidence from Activating Stem Cells
Although epigenetic orthopedics is still in its infancy, evidence of biomimetic oral-appliance therapy’s results is starting to come in. One study showed a 22 percent increase in the area behind the soft palate (the nasopharynx), a 16 percent increase in the area behind the tongue (the oropharynx). (12)
In a 2014 study, sleep test marker AHI dropped by 65.9 percent following biomimetic oral-appliance therapy (BOAT). “This preliminary study suggests that ... midfacial [maxillary] redevelopment may provide a potentially useful method of managing adults diagnosed with obstructive sleep apnea, using biomimetic oral appliances.” (13)
A 2016 follow-up study showed a 64 percent drop in the AHI of severe OSA patients before and after BOAT. Conclusion: “BOAT may be a useful method of managing severe cases of OSA in adults, and represents an alternative to CPAP and MAD’s [mandibular advancement devices].” (14) So BOAT has potential to treat severe OSA cases.
Epworth sleepiness scores decreased by 51.4 percent after BOAT, from an average of 8.2 ± 6 to 4.2 ± 3.6, in a 2016 Journal of Dental Sleep Medicine poster report I conducted with Dr. Singh. (15) Recall that the average Epworth sleepiness scale is 4.6 with a range of 0-10 in normal subjects. (16)
Taken all together, there is solid science behind Holistic Mouth Solutions using biomimetic oral-appliance therapy to redevelop the pinched airway inside underdeveloped jaws Now you can be free of that pinched airway and impaired mouth that have been bothering your sleep night after night and undermining your health year after year.
Holistic Mouth Bites
Stem cells represent the latent ability to grow, adapt, repair, and regenerate. A baby grows from stem cells. Stem-cell technology means affected adults are no longer stuck with an impaired mouth structure and a pinched airway.
Biomimetic oral appliances work by signaling and waking up stem cells in the tooth sockets, the sutures around the maxilla, and inside the jaw joints. This turns on the teenage growth spurt that was mediated by your own genes to grow bone in adults and transform an impaired mouth and pinched airway to a Holistic Mouth with a wider airway.
A growing body of studies show that biomimetic oral appliances are effective for increasing oral airway width and volume, as well as alleviating OSA, making it a viable alternative to CPAP.
Chapter Seventeen
Promoting Children’s Holistic Mouth Development and Full Genetic Expression
Pediatric obstructive sleep apnea in non-obese children is a disorder of oral-facial growth.
– Drs. Yu-Shu Huang and Christian Guilleminault(1)
Whole body health depends on a good night’s sleep, which requires an unobstructed airway inside a fully developed face and jaws. A little oxygen deficit night after night adds up to a whole body bankruptcy decades later, as we have seen.
Lessons learned from treating adults with impaired mouths can be applied to keep children from suffering the same medical and dental troubles. This finding from pediatric sleep-apnea research indicates the importance of looking out for that six-foot tiger in a three-foot cage: “Persistent oral-facial problems were always identified as the prominent factor associated with failure to achieve a complete cure of OSA” [emphasis added].(2)
Prevention is in the dental profession’s DNA. A Holistic Mouth checkup can screen for an impaired mouth and steer it in the right direction starting early in childhood.
Epigenetics: Environmental Factors Shaping the Jaws and Face
Two-thirds of the face is framed by the maxilla and the mandible, and the face you now have is the combination of your genes and epigenetics. (Epi- means “on top of”.) “Epigenetics encompasses all processes that lead to heritable changes in gene expression without changes in the DNA sequence itself.”(3)
My translation: epigenetics are non-gene factors that can influence developmental outcomes without changing the genes. Diet and exercise can change your health and body shape, but you’d have the same genes.
So what makes craniofacial development fall short in children to cause crowded teeth and “three-foot cage” in adults? Something else at work besides genes, and that’s where epigenetic comes in.
In my experience, the top four most frequently overlooked epigenetic blockers to normal dental-facial development are tongue-tie, improper weaning, nasal congestion from environmental or dietary sources, and habitual mouth breathing. Others can include pacifiers, processed foods, antibiotics overuse, and “man-made sources like medicines or pesticides” according to the National Human Genome Research Institute.(4)
Epigenetics can be applied just for a positive outcome as well, in my view. That’s the aim of Holistic Mouth solutions. Early recognition and correction of tongue-tie and habitual mouth breathing are critical for Holistic Mouth development.
What Pediatric Sleep-Apnea Research Really Reveals
Pediatric OSA was first reported in 1976 by Dr. Christian Guilleminault, who noted that “subjects had narrowing behind the base of the tongue and oral-facial anatomical abnormalities.”(5)
Historically, taking out enlarged tonsils and adenoids was the first treatment for pediatric OSA. Follow-up research showed that while surgery did improve sleep-test scores, only 27.2 percent had complete resolution of pediatric OSA.(6) In other words, for more than 70 percent of pediatric OSA cases, tonsils and adenoids surgery is not the final answer. So what is missing?
Green arrows point to marked nasal obstruction as seen from the front. The gray is tissue while the black is air. The yellow arrow in the lower right image points to a swollen adenoid, which had closed down the nasopharyngeal airway by over 50 percent.
Fast-forward forty years, and we see that deficient jaw structure is the anatomical origin of OSA in newborns. According to Dr. Huang’s 2015 study of 300 children in Taiwan, “Documentation of a high and narrow hard palate at birth predicts the presence of abnormal oral-facial features existing from birth in most cases [82 percent].” Further, “Only 9 percent of subjects … had a completely normal hard palate, normal breathing during sleep, and normal development.”(7)
Dr. Huang’s finding is strikingly similar to a 1955 osteopathic study by Dr. Viola Fryman who found 88 percent of participants had detectable cranial strains (twisted skull bones) at birth. Only 11.6 percent of newborns come through the birthing process with their soft skull bones holding alignment.(8)
“Considering knowledge accumulated since the 1970s on risk of abnormal maxilla and mandibular growth with abnormal breathing,” concluded a 2013 study by Dr. Guilleminault, “regular follow-up of children with positive history of SDB should be performed particularly during oral–facial growth.”(9)
In summary, deficient maxilla development and weak orofacial muscle tone lead initially to sleep apnea in children, and epigenetic airway redevelopment should pay attention to both hard and soft tissues.
An Ounce of Prevention: Holistic Mouth Checkup from Birth through Teens
A Holistic Mouth checkup starts with tongue-tie on the mouth floor and the airway in the nose and the back of the mouth. Seeing just the smile misses “the whole forest”.
In my opinion, every newborn should be checked for tongue-tie, and a child should have a Holistic Mouth checkup as soo
n as they can cooperate with an evaluation, but no later than age eight. Left undetected, children with tongue-tie can grow into adults with problems stemming from “six-foot tiger inside a three-foot cage” problems.
Lip-tie will keep the front teeth separated, even after braces, if left unrecognized and untreated.
Impaired Mouth Syndrome in children can include such signs and symptoms as habitual mouth breathing, stuffy/runny nose, hyperactivity, tiredness, grumpiness, teeth grinding, crowded teeth, bad bite (malocclusion), and more. Dr. Aelred Fonder found malocclusion to be a source of pains, more sinus infections, and underachievement in school. (10)
Less obvious tongue-ties that do not dramatically affect breast-feeding often lead to abnormal swallowing patterns, bad bite, and facial imbalance. In these borderline cases, a Holistic Mouth checkup can keep many subsequent medical, dental, and mood symptoms at bay.
The earlier the Holistic Mouth checkup, the better. “Every orthodontic case started after age 12 is a compromise,” says Dr. Jay Gerber, longtime director of the Center for Orthodontic Studies. Dr. Gerber emphasized the pediatric airway as a maker of orthodontic success or relapse long before epigenetic studies emerged. My patients and I are beneficiaries of his teaching.
Human jaw and face development takes fourteen to eighteen years. By age twelve, the window of opportunity for fundamental correction is much smaller, especially if dental and facial development has resulted in a long face, a high and narrow palate, an excessive or weak chin, or a flat midface.
Freedom from the Perils of Habitual Mouth Breathing
In addition to tongue-tie, habitual mouth breathing is another serious epigenetic blocker of normal craniofacial-dental development.
“The airway functions, in a real sense, as a keystone for the face. The entire facial complex participates in the growth process. All parts and bony surfaces are involved. … All are necessarily interrelated, and the developmental positioning, shaping, and sizing of any one part affect all others,” notes Dr. Donald Enlow in Handbook of Facial Development. (11)
