Note: This post may contain statements that I no longer consider true.
See: The Vivos mRNA Appliance Didn't Improve My Obstructive Sleep Apnea.
I first came across the idea of a forward-pull face mask on The Great Work Forum in a thread discussing using face mask with MSE for adult expansion. I didn’t end up pursuing MSE, but I thought that if face mask helped MSE users get forward growth, maybe it would help me get more forward growth with Vivos too.
Dr Felix Liao mentions using face mask with DNA appliance patients in his talk at the Vivos Breathing Wellness conference and gives some case reports in his book 6 Foot Tiger, 3 Foot Cage, which I really recommend to anyone with obstructive sleep apnea who is wondering what to do about it. There is a classic line in the talk at 51:51 where Dr Liao presents a patient who said:
“I have a new girlfriend. I’d would rather sleep with her instead of my CPAP.”
Facemask example from 6 Foot Tiger, 3 Foot Cage. Look how comfortable she is!
I had my mRNA fabricated with hooks for the elastics to connect to the facemask after seeing Dr Liao’s talk. Here’s what they look like:
Facemask elastic hooks on my upper DNA appliance
My dentist is great but he has very little experience with Vivos and his advisor said I should wait until my mandible has moved forward before using the face mask, and only do so at the end of treatment. This made no sense to me mechanically since the position of the mandible is set by the way it’s teeth mesh with those of the maxilla, and the longer I’m using the face mask, the more forward growth of the maxilla I’m likely to get.
I really relate to the case S.A. in Chapter 12 of Dr Liao’s book, a 57 year old male with obstructive sleep apnea whose airway increased by 55% on his CBCT scans over a period of 3 years. The timeframe suggests he started face mask at the start of his treatment. I’ve emailed Dr Liao to confirm at what point he usually starts patients in their face mask, but he’s a busy guy so I’m not expecting a quick response.
When I inquired further, my dentist said that the problem was that a face mask like the one in the picture above exerts force backwards on the chin, which pushes the mandible backwards, which is coupled via the interlocking wings on the mRNA to push the maxilla backwards… in the opposite direction to what we want.
This is why I want to use The Bow from Forwardontics which anchors on the chest and forehead instead of the chin specifically for this reason. It should allow the maxilla to grow forward without any extra pressure from the mandible stopping it. In fact, the elastics would be countering the force normally exerted by the weight of the lower jaw resting backwards on the upper appliance via the interlocking wings when jaw muscles are relaxed during sleep. The maxilla will no longer be pulled backwards in the night, which is what my dentist was concerned about with the chin-anchored face mask.
I suspect the advisor may also be following the company line that DNA is so good that face mask is unnecessary anyway. I’ve since heard of other DNA appliance users doing it besides Dr Liao’s patients, and one of them said that it was a lot to get used to learning to sleep with an appliance in your mouth and a facemask all at the same time.
However, I want to ensure I get maximum forward growth from my appliance use so I don’t need MMA surgery down the track. I’m anticipating that I will be wearing my mRNA appliance for two years, and I don’t want to get to the end of that time and think “I wish I’d started face mask sooner.”
There is a recent post on The Great Work Forum from a user about to start DNA appliance treatment using The Bow. If anyone here has used a face mask with an mRNA appliance, I’m curious if you started when you got your appliance, or if you waited?
Update: Read more about my experience with The Bow in my Two Month Update.
6 Comments
Nick · October 29, 2021 at 4:22 AM
Hi Graham. How on earth do you wear this with a CPAP? I got a face mask, and can’t figure it out. It’s just too much stuff and not enough space.
Graham Stoney · October 29, 2021 at 11:03 AM
You need a nasal pillow mask with an inlet at the top of the head such as the Resmed Airfit p30i to make this work if you want to sleep with the BOW on. Putting it all on is quite complex. While I did manage to wear the appliance, BOW face mask, mouth tape and CPAP mask all at the same time I couldn’t sleep with it all, so now I only wear the face mask during the day. It may be easier to sleep with other face masks like The Crane but I haven’t tried them yet.
Jeff M · June 5, 2021 at 6:55 AM
Hi Graham,
I have pretty similar background as you. Extraction and Retraction braces as teenager and now having sleep apnea as adult in my late 40’s. I currently have En Vivos. I have done so much research like yourself, and so glad you have created a website like this to put it all together. It is very beneficial to read through your information and experiences. Also to read the comments of others. I am also interested in the facemask option, and was actually thinking of creating my own which anchroed to the forehead and chest, becuse the chin anchro seemed counter productive.
Graham Stoney · June 5, 2021 at 8:29 AM
Thanks Jeff. Sorry to hear you’ve been going through this too. Let me know how you get on with your custom facemask! Cheers, Graham
Joey · December 14, 2020 at 4:50 AM
Hi Graham. Love your blog. I really appreciate all of the research you have done and your willingness to share. It’s a little spooky how similar our situations are. I’m a guy in my late 50s in the US. I was first diagnosed with severe sleep apnea about 15 years ago. I had several surgeries (mostly soft tissue stuff) that improve my numbers somewhat (into the moderate range), but CPAP never worked for me. Even though doctors could find no signs of allergies, every time I wore a CPAP, within an hour I was sneezing and congested. So, I’ve used Mandibular Advancement appliances (MADs) for years to “get by” but never really entirely got my AHI to less than 5. In recent years, I’ve also noticed that MAD appliances seemed to be less effective as my numbers have gotten worse. I moved back into the lower part of the severe range.
I began Vivos mRNA in mid-May of this year, so I’m at about the 7 month mark now. Just this week, I went for a CT scan to measure progress. So far, I have only been adjusting the upper appliance–once per week adjusting both lateral and forward adjustments. My lateral movement has been good. My forward movement has lagged. At about the 3-4 month mark, my bite went from edge-on-edge on the front teeth to an underbite. About six weeks ago, my provider pointed out the hooks on the upper appliance and mentioned that we would likely need to utilize them to get more forward movement. At that point, I didn’t fully understand how we were going to achieve that goal, but coincidentally you were posting about face masks at nearly the same time. I have since learned that we are going to try the face mask that you show from Dr Liao’s book. I will have more instructions on wear time, etc. on my next office visit when I receive the face mask. I know that I will be wearing it during the day. I’m a little concerned about pulling forward during the day only to then have pushback at night from the MAD feature of the lower appliance. I might inquire about options that you have shared that don’t brace against the mandible. Currently, we don’t have the lower advancement optimized. I’m still snoring heavily, and just last night finished a couple of nights of at-home sleep study to guide additional adjustments. I’m a little torn on the MAD adjustments since it seems like a balancing act between short term benefit (i.e., more forward adjustment on the lower jaw and more backward force placed on the upper) vs. long term gain (i.e., less MAD adjustment and less backward force at night on the upper jaw so as not to compete with daytime forward movement). Also, much like you indicated, in hindsight I wish we had started facemask pulling at least 3 months ago. While I’m willing to be patient as I know this takes time, I don’t want to waste time either because I’ve been tired for too many years. My understanding is that the Vivos team anticipated that I would have this issue, and that is the reason my appliance had the hooks installed whereas many other people do not. I think that the many years of using MAD with the backward force on the maxilla probably is playing a role here.
Thanks again for sharing. Will be interested to compare notes and results going forward.
Graham · December 14, 2020 at 7:02 AM
Hey Joey,
Glad you’re finding the blog helpful. For me it’s a trade-off between feeling well during the day, and ultimately being able to breathe naturally at night. At some point I expect that I will no longer require the mandibular advancement function of the mRNA, but that’s in the future. One advantage I see of wearing the facemask at night is that the forward pull from the elastics counters the backwards pull of the mandible, which is one of the factors that makes the effectiveness of MADs decline over time. My dentist disagrees with this and has suggested that I only wear it during the day, but until I get my head around his reasoning I’m wearing it as much as practical, which is currently about 13 hours/day. It took a little getting used to wearing an mRNA, CPAP mask and Bow app at the same time, but it’s doable. Let me know how you go!
Cheers,
Graham
PS: I took the liberty of editing your comment to clarify that we’re talking about Mandibular Advancement Devices (MAD), not Maxillomandibular Advancement surgery (MMA).