Fourteen Month Vivos mRNA Appliance Update: Mid-treatment CBCT Scan Shows Expansion and Teeth Tipping

This update has been delayed for a few reasons: My mum died in September 2021 and that’s been taking up a lot of my time and emotional energy. I had a mid-treatment CBCT scan and was concerned about the results, so I wanted to talk this over with my provider before posting about it. I also had nasal surgery to improve my daytime breathing and have been recovering from that.

I had been resisting having a mid-treatment CBCT scan that my provider wanted because I’m averse to unnecessary X-rays. The lifetime radiation risk is cumulative and when a patient ends up developing cancer years later, nobody is likely to connect the dots back to the X-ray that broke the camel’s back. Hence, I try to be as conservative as possible and had been declining my provider’s request for a mid-treatment scan.

Meanwhile, my provider suggested I start doing Myofunctional Therapy with Orofacial Myologist Rochelle McPherson to tailor exercises to my personal circumstances. Up until now I’ve been doing the exercises in a general myofunctional therapy for obstructive sleep apnea YouTube video, but seeing an actual myofunctional therapist in person is likely to give better results because they can look at what I’m doing with my facial muscles, tongue posture and swallowing reflex and give tailored exercises to improve it. Rochelle prompted me to have the CBCT scan because it’s important to verify that the treatment is progressing safely, which I had to balance against my concern about X-ray safety.

I’m glad I finally took their advice, although what the scan uncovered disturbed me greatly.

After spending some time looking at the images from multiple angles, the good news is that there is plenty of bone around my teeth and appears to be some skeletal expansion; but the bad news is that my teeth are clearly tipping.

In all the CBCT images shown below, the image on the left is from a scan taken on 7^th July 2020 before treatment, and the image on the right is from 17^th November 2021 after a little over 13 months of wearing my Vivos mRNA Appliance. All the measurements on the scans are in millimetres and were made by me with NNT Viewer. Caution is advised since I don’t necessarily know what I’m doing nor what to look for.

Here is a comparison of the slice through my upper wisdom teeth showing sideways maxillary expansion, with measurements between the inside (lingual) edges of the bone:

My upper jaw (maxilla) appears to have expanded by about 1.5 mm at my wisdom teeth. However, the teeth are also clearly tipped further outwards, which I am disappointed about to say the least.

My upper front teeth have also tipped out forwards, as shown on this slice through my left front teeth (left central incisors):

According to Cephalometric Evaluation of Incisor Position by Ellis and MacNamara, the normal relationship between the maxillary incisors and the maxilla is in the range of 108-112 degrees, so although my incisors have tipped outwards it appears that they were originally tipped inwards significantly, and in fact I’ve still got a couple of degrees to go before I’m in the normal range. I was relieved to discover this, so thanks to Doug Toombs for the reference.

I’m guessing it would start hurting when I chew on hard foods if I went too far, and I shudder to think what happens if I have a catastrophic failure. Tipping teeth outwards probably does give more tongue space, but it freaked me out so much I stopped wearing the appliance for a couple of weeks until I could talk it over with my provider, which had a big impact on my usage this month.

My provider says that we can upright the teeth again later with clear aligners without losing the gains and has taken another interoral scan to send to Vivos for analysis. The other notable thing about the 13 month scan is that my tongue is not on the roof of my mouth, which suggests I need better myofunctional therapy.

On my lower jaw I appear to have a tiny amount of skeletal expansion, although it’s so small that it could be measurement error. Mostly the teeth have just tipped out a little, whereas they tilted inwards before so this is an improvement:

The really bad news is that there appears to have been little if any forward growth despite 2177 hours of facemask use. My provider says I’ve had 2 mm, but I can’t see it on the scan. Forward growth is way harder to measure because there is no obvious reference point and I’m no expert at reading CBCT scans given I’ve only ever analysed my own. I tried measuring perpendicular from a line between the furthest point backwards on my skull to the lowest point at the middle of my front alveolar between my two front teeth, and there appears to be no change at all:

Here’s the full 3D context of the forward growth measurement so you can see how I picked the point on the alveolar to measure to indicated by the blue line on the lower right image:

Without significant forward growth, I doubt the Vivos mRNA Appliance can correct my retrognathia enough to alleviate the obstruction behind my tongue and cure my sleep apnea.

My provider says I should get a millimetre of forward growth a month if I wear the face mask for 12 hours a day, but I’m sceptical. Plus, I’ve only averaged 5.3 hours/day with The Bow and 12 seems impossible unless I do nothing but lie on my bed all day, every day. I’ve never been able to sleep with The Bow because it’s too big and clunky, flipping from one side of my body to the other when I roll over in bed.

I originally chose The Bow because it doesn’t put any reverse force on the mandible which could counteract the forward pull on the maxilla. However, now I’m reconsidering how much that matters considering it’s not much use if I can’t wear it while sleeping.

The lower jaw (mandible) anchors at the Temporomandibular Joint (TMJ) which is behind the upper jaw (maxilla) on the skull, so I’m no longer convinced that pushing backwards on the mandible will counter the forward force exerted on the maxilla much. My provider supplied me with facemask which rests on the chin and forehead like the one used by Dr Felix Liao’s patients in his book 6 Foot Tiger, 3 Foot Cage. It may not be ideal, but it is much lighter so I’m more likely to be able to sleep with it. Sorry to anyone who bought a Bow based on me choosing it, especially if you can’t sleep with it; it probably is better though if you can.

I tried using the new facemask for a few nights and haven’t really gotten used to it. As with The Bow, the elastics cause drool to run out of my mouth so I’ve been sealing around them with Sleep Q+, which means I don’t need to use 3M Micropore Tape and Polident denture adhesive; but Sleep Q+ is a lot more expensive so I’ll see how I go with it.

I appear to have a tiny amount of skeletal expansion on my lower jaw, but it’s so small that it could easily be measurement error:

As far as my airway goes, it looks narrower at 13 months because my spine is more vertical and my head further back:

This highlights the problem with using CBCT scans to evaluate airway dimensions. I understand this is part of the Vivos protocol, but the results vary wildly with head posture and since the scans are typically taken standing up, they don’t reflect what happen when we’re lying down asleep anyway. That’s why Evan Lavizadeh just had a DISE.

The other obvious thing that my myofunctional therapist Rochelle pointed out is that my inferior turbinates were huge and mostly blocking my nasal airway. I had heard stories of Vivos improving nasal breathing and was hoping this would be the case for me but after 13 months I didn’t sense any improvement. I have been binge listening to Dr Steven Park’s excellent Breathe Better, Sleep Better, Live Better podcast where he talks a lot about treating obstructive sleep apnea. He uses the analogy of climbing a treatment ladder starting with simple devices, machines, and working our way up to surgery until we get the result you need. My mum’s death has highlighted the importance of taking responsibility for my life and my own health, so I decided I needed to step up and take some action on this. I’ll talk about this in my next post.

For the sake of completeness, here’s my fourteen months usage graph, and the CPAP pressure trend analysis graphs covering the period up to 30/11/2021: