Why I Chose DNA over Homeoblock, MSE, DOME, MMA and AGGA

I did about 18 months research into palate expansion and surgical options for treating my severe obstructive sleep apnea (OSA). I was guided by the idea that the best treatment is likely to be the one that most directly addresses the root cause: Underdeveloped jaws exacerbated by the extraction/retraction orthodontic treatment I had when I was 13, leaving me with an airway which is too small to breathe through during sleep.

Along the way I tried many alternative treatments for OSA with limited success, and the two dominant mainstream treatments: a Mandibular Advancement Device (MAD) and Continuous Positive Air Pressure (CPAP) machine. Aside from the lack of success I had with the MAD, I find both of these unsatisfactory because they only deal with symptoms without addressing the underlying cause, allowing the untreated condition to progressively get worse over time.

I wanted a permanent solution that would cure the condition, not just mitigate the symptoms. All the options I considered either purport to do this or have been used for this purpose.

My decision-making process was not nearly as linear as described here; there were many twists and turns along the way. Nevertheless, I used to be a biomedical engineer before undiagnosed sleep apnea destroyed my career and my health, and this combined requirements analysis and risk assessment illustrates the main factors I considered.

Your situation may be different, and this may mean the treatment I chose isn’t the best one for you. It may not even be the best one for me. If I need to remind you that I’m not a doctor and this isn’t medical advice, you shouldn’t be reading this.

My Requirements

I’m a 52 year old male recovering from 12 years of chronic fatigue and my risk tolerance is low. I’m prepared to wait to get the best outcome possible, provided I can get health benefits from the treatment early in the process. I’m close to the age where the reduction in life expectancy due to obstructive sleep apnea becomes really significant and some options, such as those involving major surgery, may not be available to me very much longer.

Here are the main requirements and considerations I had for the treatment, listed from most important to least important:

• Availability
• Safety
• Effectiveness
• Minimal invasiveness
• Painless
• Low risk of relapse or need for further treatment
• Maxillary expansion: Sideways and Forwards
• Mandibular expansion
• Mandibular advancement to get me off CPAP sooner
• Additional orthodontic treatment during or after treatment?
• Total treatment time
• Need to wear an appliance or retainer for life?
• Cost

Total treatment time includes any post-treatment orthodontics required to align teeth and open my extraction spaces so I can replace my missing bicuspids with dental implants. I assume that the time taken for implants will be a fixed overhead at the end of all these treatments, so I didn’t consider it further in the decision-making process.

I didn’t consider convenience a factor in the decision; this is my life we’re talking about here.

The Shortlist

From all the options I considered, these appealed to me the most fairly on in the process and I ended up doing the most research on them:

• Vivos DNA/mRNA Appliance
• Homeoblock Appliance
• Surgical and Mini-implant Assisted Rapid Palatal Expander (SMARPE) using the Maxillary Skeletal Expander (MSE) with Facemask
• Distraction Osteogenesis Maxillary Expansion (DOME) with Facemask
• Maxillomandibular Advancement (MMA) Surgery with SMARPE/MSE or DOME
• Anterior Growth Guidance Appliance (AGGA) with Controlled Arch Braces (CAB)

The shortlist: DNA, Homeoblock, MSE, DOME, MMA, and AGGA

I am not aware of any long-term studies into the safety and effectiveness of any of these treatment options to help in comparing them. This makes mitigating risk particularly important and is another reason I prioritised less aggressive treatments which are slower, less invasive, and less likely to have unforeseen risks. Consider the risk to my airway that my childhood orthodontist didn’t foresee when he told my parents it would be a good idea to extract my four bicuspids and pull my front teeth back, compromising my vital airway in the process. I’m still pissed off about that because I’m still recovering from it.

Summary

Here’s a summary of my assessment of each of these options, with further explanatory notes below:

Vivos DNA/mRNA

This is the treatment I know the most about, because it looked promising early on so I researched it most intensively and I’m currently experiencing it. The ratings reflect my current understanding, which is a little greater than what I knew when I made the decision to start treatment. I’m very confident in these ratings.

I attended the talk that Dr Singh gave in November 2019 to recruit dentists to become the first Vivos providers in Australia. I met my dentist there and I’m one of the early Vivos DNA recipients here. However, it seems the device has been available in Australia for some time through at least one lab here, or possibly two, who I suspect licensed the design from Dr Singh’s previous venture, Biomodelling Solutions, Inc.

I rated safety high because this is the least aggressive treatment option and I’m not aware of anyone who has been harmed by it. Proponents of other options sometimes say that all that DNA does is tip teeth, but this assumption is based on the historical failure of Rapid Maxillary Expansion in adults and they never cite any evidence or provide case reports of it actually happening with DNA. There is nothing rapid about the DNA appliance and I consider teeth tipping unlikely provided the expansion force does not exceed the threshold at which living bone becomes brittle instead of viscous. The default expansion regimen of one turn per week, which equals 0.25mm of expansion, should prevent this. Other DNA users on the Adult non-surgical palate expansion Facebook group have commented that if it starts to hurt, that indicates I need to slow down even further.

I rated effectiveness medium because although there are several studies published showing that the appliance can cure obstructive sleep apnea, most of the participants cured had mild to moderate cases, and mine is severe. On the other hand, 3 out of 15 patients with severe sleep apnea were cured in one study, so there’s hope. I am a little sceptical of Dr Singh’s claims that the DNA appliance works via epigenetics, but I’m satisfied that the operation of the appliance can be adequately explained by bone biomechanics. The impact of forward-pull facemasks to generate forward growth of the maxilla in adults is questionable, but Dr Felix Liao has used them with Vivos and I intend to do the same. I disregarded the FDA approval of the mRNA in my analysis because it was based purely on the mandibular advancement feature of the appliance, not its expansion capabilities.

I rated risk of relapse medium because relapse is fairly common after rapid palate expansion treatment in children, especially if they don’t wear their retainers. I know I said the DNA appliance isn’t an RME and I’m not aware of any published data on relapse rates in adult DNA patients, so this may be overly pessimistic.

The DNA appliance has expansion screws for both sideways and forwards expansion of the maxilla.

The mRNA appliance does mandibular advancement in addition to expansion.

Some DNA patients require minor orthodontic treatment afterwards to give optimal cosmetic results. I expect clear aligners would suffice. It appears that as the jaws expand, the teeth settle into the natural place they should have been all along, so this may not be necessary.

The biggest downside of this option is that it takes a long time: Around 18 months to 2 years. However, the other options besides Homeoblock usually require further orthodontic treatment which makes their total treatment time comparable.

Dr Belfor has suggested that the Homeoblock should be worn for life as a retainer, and I can’t see any reason why DNA would be any different if I want to prevent relapse.

It’s very expensive for an acrylic expander, even with the fancy springs. I’m not just paying for the appliance though; I’m paying the dentist to keep an eye on my teeth so everything goes smoothly and I don’t have any complications.

Homeoblock

I have read widely on the Homeoblock appliance, watched all the videos available online, sent my CBCT scans to Dr Belfor for analysis, and had a private consultation online with him where he told me he couldn’t cure severe obstructive sleep apnea but could definitely help me. I’m very confident in my ratings for it.

At the time, I couldn’t find a Homeoblock provider in Australia and Dr Belfor wasn’t prepared to either treat me remotely, or provide the appliance to a local dentist whose training wasn’t current. I’ve since seen a post from Dr Derek Mahony saying that he’s been using Homeoblock for almost 20 years, but I don’t recall him mentioning it to me.

Despite only a single published study showing improvements in two obstructive sleep apnea patients, I rated effectiveness medium due to the similarity in its design to DNA, and independent successful case reports like those of James Nestor and Tom Colquitt. I am even more sceptical of some of Dr Belfor’s more extreme claims, but I’m satisfied that its operation can be adequately explained using bone biomechanics.

The Homeoblock and DNA appliances are almost identical, so I generally gave them the same ratings.

There is a version with upper and lower appliances that does mandibular advancement.

Dr Belfor has suggested that the Homeoblock should be worn for life as a retainer.

I don’t know what it will cost if/when it becomes available in Australia, but I hope it provides some serious price competition to Vivos. I would have chosen Homeoblock if it had been available at a lower price than Vivos at the time I made my decision.

Surgically Assisted MSE with Facemask

Everything I know about MSE is based on research papers I have read, YouTube videos, testimonials from users, discussions with other people evaluating treatment options, and postings on online forums; some of which can be highly unreliable. I am reasonably confident in my ratings, but I have never spoken to a provider about MSE and don’t claim to be an expert in it.

For a detailed description of this option, see Dr. Won Moon’s 3 Hour MSE Presentation, particularly the section where he discusses SMARPE. Ronald Ead’s interview with Drs. Stephen Vaughan and Richard Ting on MSE Surgical Assist is also useful, but beware that some of their comments regarding other options are not consistent with the science on bone biomechanics.

I’ve assumed the worst case that I would need surgery to assist with MSE due to my age and gender. It is possible that MSE could also be successful with just corticopuncture depending on the thickness of my palatal bone and zygomaticofrontal sutures, but I haven’t had this assessed.

When I saw Dr Derek Mahony, he referred me to an ENT to for MMA, which I turned out not to be suitable for. I believe he uses MSE with other patients, but I haven’t confirmed this.

I rated medium for safety due to the aggressiveness of the expansion and the lack studies on its long-term impact. I have heard of people having vision problems due to shifts in the other bones of the skull connected to the maxilla, and others having asymmetrical expansion that is difficult to correct if not caught early.

I rated medium for effectiveness because although Miniscrew-assisted Rapid Palatal Expansion (MARPE) has demonstrated reductions in AHI in sleep apnea sufferers, it it won’t do anything to address my narrow mandible. The strength of MSE is rapid and significant sideways expansion of the maxilla. My jaws are too narrow and too far back, and MSE only addresses one of these. Adding a forward-pull facemask may help with this to some degree, but it’s effectiveness is questionable and MSE still wouldn’t address the width of my mandible, nor do any mandibular advancement. However, I may use it in future if I end up needing MMA surgery; see the note below under MMA.

I rated medium for invasiveness because the appliance is screwed into your mouth for months and minimally invasive surgery such as SMARPE, Endoscopically-Assisted Surgical Expansion (EASE) or corticopuncture is required to separate the intermaxillary suture in males over 20. MSE requires the suture to split in order for expansion to occur because the expansion rate is much higher than bone remodelling can accomodate, so it’s essentially doing distraction osteogenesis at the suture.

I rated medium for pain because the appliance screws into the palate with mini-implants, surgery is required, and DO sounds painful to me. I have heard of people having severe tension headaches before the suture splits but this should be reduced with a technique like EASE. Sometimes I get the impression that a surgeon’s idea of how painful their treatments are is rather different to the patient’s.

I rated medium for risk of relapse because the suture fills with fibrous tissue which can shrink over time after the expander is removed. Practitioners typically over-expand to compensate for this, and perhaps it can be avoided by wearing a retainer. Eventually the fibrous tissue calcifies and turns into bone, but this can take between months and decades depending on who you ask. I am not aware of any long-term studies on relapse rates.

A facemask is necessary to get forward expansion.

If all I needed was sideways expansion of my maxilla, MSE is the quickest, most reliable way I know of to get it.

Orthodontics are required to close the diastema in the front teeth.

I rated treatment time medium to factor in the orthodontics required.

I haven’t heard of people using retainers after MSE.

It’s relatively inexpensive compared to other options, but you have to include the cost of the facemask and post-treatment orthodontics.

Distraction Osteogenesis Maxillary Expansion (DOME)

This is essentially identical to Surgically Assisted MSE (SMARPE) with a different expander manufacturer: DOME uses a limited Lefort 1 osteotomy as described in this paper, and Dr Vaughan’s MSE surgical assist technique described in this video looks identical to me and he says it’s the same in this video comparing them. The expanders are also almost identical; here’s MSE above the DOME expander:

MSE above DOME Expander

I’m not aware of anyone in Australia who currently does the DOME surgical procedure.

I’ve never heard of anyone using a facemask with DOME, but I can’t see why you couldn’t if you get the expander fabricated with hooks for the elastics.

MMA with SMARPE/MSE or DOME

MMA is the only surgical technique I found which reliably makes a significant improvement in obstructive sleep apnea. Other techniques like Uvulopalatopharyngoplasty (UPPP) have low success rates and aren’t likely to help me much given that my obstruction is primarily behind the tongue. Any problems with my soft tissue may improve by expanding my palate to the required size so I would only explore this afterwards. People I’ve talked to who have had UPPP surgery all said it didn’t help much; although maybe that’s why they were talking to me.

MMA is available in Sydney, but the first surgeon I saw who assessed me for it said I wasn’t a candidate and suggested laser tongue ablation instead. That yields only marginal results, is painful, takes several sessions, and is unlikely to cure severe sleep apnea. He suggested I learn to tolerate CPAP, so I sought a second opinion. Not about MMA though, because I knew Vivos was about to become available in Australia and I’d prefer not to have my face carved up unless absolutely necessary.

Choice of surgeon is likely to be critical for the success of this option. I’m comfortable using a DNA provider who I know has only recently done the Vivos training and has not yet had a single patient complete treatment; but I wouldn’t want an inexperienced surgeon doing MMA on me. Counter-clockwise rotation of the maxilla is also important to leave the resting position of the mandible as far forwards as possible to open up airway behind the tongue, and this requires an experienced surgeon.

I rated safety low because this involves some pretty major surgery. The risk of numbness due to nerve damage is significant, and in my age group this is often permanent. Some people need to have their surgery revised if the jaw placement isn’t precisely right. I recently heard that a teenage girl had died during surgery, but this fact sheet says no patient deaths have occurred. There are always going to be higher risks from surgical complications and infection than with non-surgical options.

Preceding MMA with MSE or DOME and Mandibular Symphyseal Distraction Osteogenesis (MSDO) is likely to give the best outcome. This combination is the most effective permanent cure currently available for obstructive sleep apnea caused by retruded jaws like mine forcing the tongue into the airway during sleep.

It’s also by far the most painful option. Post-operative recovery is long and unpleasant. I met one person online who has been left in constant pain following MMA surgery which went wrong. It’s also the least practical since I live by myself and would need round the clock support for at least a couple of months.

I rated risk of relapse low because of all the options, MMA with MSE/DOME and MSDO comes closest to leaving the jaws where nature intended, assuming the surgeon does an excellent job. I have heard of people whose OSA returned years after having MMA surgery; I don’t know if they combined their original surgery with MSE/DOME and/or MSDO, but I doubt it because these are relatively new techniques.

Total treatment time is long because it includes MSE or DOME, possibly MSDO, pre-operative orthodontics and post-operative recovery time.

AGGA with CAB

AGGA is the option I know the least about, so my ratings are highly speculative. I was alarmed about the safety of the appliance given reports I read online and focussed my research on the other options that appear to be lower risk. I have never spoken to an AGGA provider or user, read a research paper about it, or actively sought opinions from other users on online forums. Take all this with a grain of salt.

I rated safety low because of the many accounts I’ve heard of people losing or almost losing teeth. It appears to expand too fast for bone growth processes to keep up with, particularly when used by inexperienced practitioners. I’ve heard it’s supposed to work via the same growth hypothesis as DNA and Homeoblock; but if this hypothesis turns out to be wrong, DNA and Homeoblock work anyway because bone acts like a viscous fluid under light pressure over long periods of time; whereas AGGA pushes so hard and fast that you lose your teeth.

I noted Ronald Ead’s bad experience, but suspect part of the problem was being overly-aggressive with the degree of expansion he attempted in such a short time. Other people have got airway improvements with AGGA, but it seems the most controversial of all these treatments. Jeffrey Miller has since declared AGGA unsafe, and Manhattan dentist Martha Cortes is currently being sued for $10 million by a patient who claims AGGA caused irreversible bone loss and may lead to the loss of her front teeth. Cortes is a highly regarded DNA appliance provider, so the fact that she can’t make AGGA work reliably seems like a real problem. If all I wanted to do is open up extraction spaces for implants and didn’t need to fix OSA and was prepared to wear the risk, this may be the way to do it.

I rated effectiveness low because I’m not aware of any published research showing it is a safe and effective treatment of OSA. The fixed version (FAGGA) cannot be removed each day, making it difficult to apply the cyclical intermittent force required for maximum bone growth.

I rated medium for invasiveness because it’s stuck in your mouth for months.

I rated medium for pain because I suspect it’s triggering inflammatory orthodontic rather than orthopaedic processes.

I’m not aware of any published research on relapse.

It pushes mostly forwards.

Controlled Arch Braces (CAB) are needed to stabilised teeth afterwards and achieve sideways expansion.

Treatment time includes the braces required.

I believe the cost is insanely high; like $25k or something ludicrous. Others have said around $10k, so it pays to shop around.

Conclusion

This treatment plan best balances safety, effectiveness, and the other factors that are important to me. My intention is to execute them in order, stopping when my sleep apnea is cured and I’m confident won’t reoccur:

• Vivos mRNA
• SMARPE/MSE or DOME, with Facemask
• MSDO
• MMA

Image Credits

Me (DNA)

Advanced Cosmetic Dentistry (AGGA)

Dr Theodore Belfor (Homeoblock)

Great Lakes Dental Tech (MSE)

Impact of Distraction Osteogenesis Maxillary Expansion (DOME) on the Internal Nasal Valve in Patients with Obstructive Sleep Apnea (OSA) (DOME)

Shutterstock (MMA)