When patients think of palatal expanders, they may think of torture devices. But with recent advancements and technology, they are more sophisticated than ever. In this episode of Clinical Edge Fridays, Kirk Behrendt brings back Dr. Rebecca Bockow, instructor from Spear Education, to share where we are today with MARPEs and why now is the best time to offer it in your practice. To learn how you can “expand” the services you provide, listen to Episode 909 of The Best Practices Show!
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Quotes:
“Historically, we had adolescent expansion. So, five, six, seven, eight, nine, ten, all the way up into early teens. Once we get into the teenage years, if we think about this, we're trying to influence a sutural system. So, the bones in the head are a series of bony plates, and they meet at sutures. A suture is a site that responds to pressure. So, in a young child, seven-year-old, eight-year-old, if we glue something to the upper teeth and we slowly turn, we are widening the maxillary suture as well as some of the surrounding sutures. As we, as humans, age, the sutural system gets more intertwined and more mature. So, if we use a tooth-borne appliance on a skeletally mature patient, we inadvertently push the teeth out of the bone rather than opening the suture. So, historically, we would have tooth-borne expanders, and then we would have to jump to a surgically-assisted expander. Meaning, we have the same appliance glued to the teeth. When the bone no longer can change, we would send the patient to the oral surgeon, and the surgeon would cut the bone, and then we would do our expansion. The big innovation in our world came with TAD-supported expanders, and we've been using them since about 2007, 2008.” (5:24—7:01) -Dr. Bockow
“Once we start seeing the adult dentition and we start thinking about more skeletal maturation, that's around the time when we have to think that a tooth-borne appliance to widen the upper jaw has the possibility of seeing more dental change and less skeletal change. When we think about our final outcome, we want to actually widen the upper jaw. So, the innovation is to use miniscrews and anchor the expander to the bone itself. MARPE stands for Miniscrew-Assisted Rapid Palatal Expander. We use an expander, and we add TADs, Temporary Anchorage Devices, underneath the expander itself so that as we turn it, we're actually widening the upper jaw. We're widening the bone, not moving the teeth through the bone, so we prevent gum recession, we widen the nasal floor, and we're avoiding surgery.” (7:51—8:54) -Dr. Bockow
“This is really exciting because this is where the needle keeps moving as we get better and better at this. So, back to when we first got into this, our TAD expanders used to be most predictable from teenagers to probably in their 20s. It was great, but once we got past let's say age 25, we would have to do a TAD expander and we would combine it with a surgery. So, we'd still add the TAD expander, but we would ask the surgeon to cut the upper jaw and to cut in between the front teeth. Then, as we turn it, we're still getting that widening, but it was an outpatient surgery. Today, what I'm really excited to talk about are some of our advances that have taken away our need for additional surgeries — in many instances.” (9:15—10:09) -Dr. Bockow
“Going back to our evolution, where we've come from, 2014, I think, was the first time I took a course on the MSE, the Maxillary Skeletal Expander. That was really popular — it's still a quite popular TAD expander MARPE brand. It's a brand. It was great, but it had its shortcomings. Dr. Audrey Yoon published an article in 2022 showing that it has a high failure rate on MSE. It fails about 17%, 18% in adult females and 67.7% in adult males over the age of 25. That's a really high failure rate. Adult male bone is dense. As we would turn the appliance, any of the following would happen. The TADs would bend, the jackscrew itself would break, or a combination. So, the appliance would tip, but we would never see the suture open. And I've had failures in my own practice. Of course, you never start your treatment plan thinking that that's going to be the patient that it doesn't work on. So, we started doing more and more surgical interventions in combination with the MARPE — the MSE, specifically — to avoid these failures.” (10:20—11:49) -Dr. Bockow
“A lot of implant surgeons today are doing guided implant placement. They take a CBCT, they have a library of the implant, then they design where the implant is going to go, and the lab designs the guide. Why can't we do that with TAD expanders? So, they developed a software program to custom design where the TADs are going to go for that specific patient. That right there was a game changer. So, they're able to handpick where the TADs are going to go for that patient. Then, they can 3D print and 3D mill a custom substructure. So, not only can we decide where the TADs are going to go, but we can decide how many TADs. So, we're learning that the more TADs we use, the higher the degree of predictability. So, custom design, custom TAD placement, stronger jackscrew, and more TADs.” (15:33—16:40) -Dr. Bockow
“Here is one patient coming in in a few weeks. So, I'll highlight what's unique here. You can see we've custom designed — this can go into a narrow palate. We have four TADs per side. Each TAD is custom chosen where it's going to engage the bone. The jackscrew here is incredibly strong, and everything is 3D printed, very customizable. So, what we've been able to do is dramatically increase our predictability, and we've been able to reduce our complications, and we've been able to reduce the amount of surgery.” (16:42—17:27) -Dr. Bockow
“Our oldest patient to date has been 66 with no surgery. So, age is no longer an impediment to this procedure. Now, if you think about the sutural system, there's a suture here, here, here, and in the roof of the mouth. That's the whole nasal maxillary complex. So, if we can widen, chances are we've opened up all those sutures. Now, we can combine it with a face mask. We've corrected underbites. We've corrected open bites. We can leverage the skeletal anchorage to accomplish movements that historically had to be a more complex surgical intervention. Now, this doesn't take the place of jaw surgery. But it can solve problems for some patients less invasively in a very predictable way, and that's been really exciting.” (19:57—20:53) -Dr. Bockow
“I think the general public is excited about it, and they think it's a panacea. So, we can widen the jaw, we can bring the jaw forward, and we can intrude with a reasonable degree of predictability, widening for sure. Some patients are great candidates for MARPEs. Some, the true diagnosis really is a maxillomandibular problem, and some of them really need jaw surgery. So, we have patients that come to us, and they say, ‘I need a MARPE.’ I say, ‘Well, you actually need double jaw surgery,’ or, ‘You need to see a sleep physician. You need to see an ENT. A MARPE won't fix it.’ I think, as a profession, we need to understand where its place is, what its purpose is, and if we're chasing something like sleep apnea to remember that as dentists, as dental professionals, we're part of an interdisciplinary team and no one person, no one intervention, can guarantee resolution of such a complex medical issue.” (21:33—22:44) -Dr. Bockow
“I think we're getting better and better with our designs. I think those of us that are using it in a high volume, I think the more research we get behind these, I think we'll have a better understanding of predictability, case type. I think we don't have a uniform agreement on where to place the TADs, the angle to place the TADs, the turning regimen. There are some people that do multiple turns forward, multiple turns back, and then the next day they do a few more turns forward, but still the same number back, and then a few more, and then a few more back. So, having a standardization of a turning protocol, having a standardization of number of TADs, where to place the TADs, or just an understanding of where and how they're failing. (23:05—23:55) -Dr. Bockow
“Periodontally, we ultimately want to keep the teeth centered in the bone because the bone is the scaffold for the soft tissue. So, by growing and developing the bone instead of just pushing the teeth out, we have better stability long term. So, helping prevent problems, helping improve stability, improve our outcomes — and I think also, the airway implications are phenomenal. We're seeing improved nasal breathing, we're seeing improved tongue space, and we see a reduction in sleep apnea scores. Once again, we cannot promise resolution of sleep apnea. That's another big piece. We do a lot of education with our patients, talking about what's reasonable to predict, what's a reasonable expectation, rather than promising something like a cure — which, we just can't make that promise.” (25:13—26:09) -Dr. Bockow
“Orthodontics isn't just about straight teeth anymore. We, as a dental profession, have the ability to make patients healthier, and that is a privilege.” (27:04—27:17) -Dr. Bockow
“If you can travel with any of your team to courses together, that becomes really powerful so that you can all speak the same language, you have the same goals, whatever courses you may take to travel with your team . . . I think also, just genuinely taking the time to meet together, have coffee together, invite some of your professionals or colleagues to your office, look at cases together, have some literature, some papers, and say, ‘Hey, this is something I saw. What do you think about this? Can we talk through this?’ so that we're all talking using some of the same language and the same goals.” (28:09—28:53) -Dr. Bockow
“It's an exciting time to be a dentist . . . It is such an exciting time to be in this profession because we really can help these patients get healthier. It's not just about cleanings and fillings and crowns. In orthodontia, it's not just about straightening teeth anymore. We can look at the whole system. We can look at the periodontium. We can look at the tongue. We can look at the nasal breathing. We can work collaboratively with our ENTs and our sleep physicians and talk about sleep. MARPEs provides a tool for us to truly, no pun intended, expand the type of services that we can provide. So, MARPEs has been an absolute game changer for our practice, and to be able to do it with a great degree of predictability and to be able to do it without surgery has transformed our practice in such an exciting way.” (30:11—31:10) -Dr. Bockow
Snippets:
0:00 Introduction.
1:23 Dr. Bockow’s background.
5:22 Why this is an important topic.
7:32 MARPEs, explained.
15:05 Where we are now with MARPEs.
18:35 The recovery process for patients.
19:31 Age is no longer an impediment.
21:04 What people get wrong about MARPEs.
22:45 The future of MARPEs.
25:00 Airway and periodontal implications of MARPEs.
26:10 Now is the perfect time to lean in.
27:19 How to get buy-in.
29:55 Final thoughts.
31:21 Dr. Bockow’s future course.
Dr. Rebecca Bockow Bio:
Dr. Rebecca Bockow is a dual-trained orthodontist and periodontist – the only dual-trained provider in Seattle and one of only a handful in the country.
Dr. Bockow grew up in the Greater Seattle area and attended University Prep for high school. She received a B.S. in Biology with Honors at Haverford College, where she also played soccer, squash, tennis, and ran cross-country and track. She completed her DDS training at the University of Washington Dental School in 2007. Dr. Bockow practiced as a general dentist in Seattle for two years while simultaneously teaching at the UW dental school.
Dr. Bockow completed a highly selective dual-specialty program combining Orthodontics and Periodontics at the University of Pennsylvania. She is a board-certified orthodontist and periodontist. While simultaneously enrolled in two residency programs, she also received a Master of Science in Oral Biology, focusing on intranasal ketorolac for postoperative implant pain management.
Dr. Bockow lectures nationally on periodontics, orthodontics, interdisciplinary orthodontics, airway, and skeletal growth and development. She contributes to multiple professional journals as an author and editor, and she is also a resident faculty member at Spear Education.