Just took final records on this case and wanted to share.

Initial presentation: 58y/o F patient. Presented to my office with a litany of previous consultations and a binder full of various specialty consultations. The initial exam (usually 20-30 min) took 1hr. and 20 minutes. She was formally diagnosted with sleep apnea. She had a nasal surgery recently with the hope of improving but had limited success. She is trying to manage sleep apnea with a CPAP but unsuccessfully. She had had multiple opinions and MMA had been discussed. Here is her presentation at initial exam (I blurred the eyes upon patient request).

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![Screenshot 2023-11-09 at 4.06.01 PM.png](blob:https://community.speareducation.com/bf03db7e-33bb-4e27-85cd-fbdb474d36ca)

![Screenshot 2023-11-09 at 4.01.22 PM.png](blob:https://community.speareducation.com/4070cec7-ad6c-4345-a048-016fe254d3f1)

She has just about every "symptom" of an airway problem we screen for. Forward head posture, forward tongue posture, previous extractions, maxillary constriction, anterior open bite, bimaxillary skeletal retrusion etc. She has a skeletal issue in all 3 planes: a transverse, saggital, and vertical. Our treatment plan included a SARP-E utilizing a TAD-borne expander initially and THEN performing a MMA - max/mandibular skeletal advancement. I wanted to use a TAD-borne expander to prevent excessive dental movements. In these cases, the expander is placed prior to surgery, the maxillary suture opened, and then we began our expansion protocol.

A complication arose. We typically place TADs and then scan and order our appliances. However, one of the TADs became loose and un-usable prior to the surgery. Fortunately, I ordered a "backup" expander that is more of a traditional Hyrax which we ended up using instead (moving a hospital surgery date is extremely challenging). Always have a plan "B" Despite best efforts, this became a more "traditional" SARP-E as opposed to MARP-E. Would still prefer a skeletally anchored expander to minimize the amount of dental movements. Here are progress images after the expansion and SARP-E expansion:

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These are photos prior to MMA Surgery (it looked scary BUT we were able to close all of the anterior space)

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Here are the final photos along with the new and improved airway:

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![Screenshot 2023-11-09 at 4.01.22 PM.png](blob:https://community.speareducation.com/7c55a6a6-5adc-4fab-bc9d-920dd56d17ed)

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In review of her final position: We have gotten almost a doubling of airway volume and per her report - she has not had to use the CPAP and slept all the way through the night for the first time in her life. A huge deal. We got about 5mm of maxillary arch expansion with the SARP-E. Initial airway volume was 7.9cc. Final airway volume was 12.2cc with an over 3x increase in the Min airway volume.

In retrospect, I would have REALLY liked using the skeletal expander because I feel like we have seen more recession on the buccal of the upper first molars due to some of the inevitable dental movement associated with a traditional expander / SARP-E and on #18. The other option would have been to add PAOO to her case to prevent this. I feel like we were probably at the limits of what the patient would accept. I am going to get her in a Hawley retainer to allow some settling of the buccal occlusion.

She was a great patient and had LOTS of questions throughout. A very rewarding case and learned a lot!