Coffee Break with Coachman: Jaw Revolution with Dr David Alfi

Christian Coachman: What I said is that I saw this lecture yesterday. It's a very dear topic, as you guys know. Even though I'm not an expert on jaw surgery, I'm not an expert on the airway, these topics became very meaningful to me because, for me, it represents the ultimate level of meaningful dentistry—having an impact on quality of life at the highest level possible, the opposite of what we call camouflage dentistry.

And for me, it was amazing to see that jaw surgery is becoming something more controlled, less aggressive, more predictable, faster, and because of all these things, something that we can refer to more and can rely on more. One of the reasons why dentistry never really explored the topic of the airway and quality of sleep that much was because we never really understood what we could do for that, so it's better not to even talk about it. But now, as we see these solutions becoming real and feasible, there's no reason why we shouldn't start helping our patients with something that can change their lives so deeply.

So, David, I think that your topic is amazing, and the techniques that you're using for jaw surgery are amazing. You know that I've been working closely in collaboration with surgeons for many, many years. My father always believed in this—some amazing surgeons. But what you showed yesterday was really groundbreaking, and that's why I think it's so important for the DSD community to see what is possible and start taking advantage of it. So please, delight us with your beautiful content.

Dr. David Alfi: Thank you very much. Thank you for the perfect introduction. That's exactly what I'm going to talk about today, and for me, it's very exciting to share this information. It's something I'm very proud to be a part of and very passionate about. I can talk about dentistry and jaw surgery all day, every day.

I joined DSD as a clinic about two years ago, and the reason I did was that it was very refreshing to see the vision that Christian had. There were a lot of parallel philosophies and thoughts that I thought didn't exist until I met Christian and the DSD team. So what I wanted to do was associate with such an organization and, more importantly, with dentists like you guys who obviously share that same vision.

So, what I'm going to talk about today is... I went to medical school and dental school, and I can tell you that the way the education was for me, I became an expert in treating and managing symptoms and not necessarily curing disease. And now, after spending 12 years taking care of patients and evolving the type of practice that I have and experiencing symptom management versus curing disease, it becomes obvious to me that a lot of the things we were doing were dental insanity or even medical insanity. You can go outside of dentistry into real-world situations to find very parallel but more obvious examples of that.

So, if you have a garden and your plants are dying, a good gardener or botanist is not just going to continue to replace the plants—they're going to check the soil, check the sunlight, check the drainage. If a tree's leaves are dead, they don't try to treat the leaves; they treat the same—the environment, the roots, the soil, the nutrients. It seems so obvious, but in my experience in dentistry, we were doing just that—treating leaves and not the tree.

For example, I learned to treat hypertension with pills, depression with pills, anxiety, insomnia—pills and more pills. ADHD? Pills. OSA? Pills, and even CPAP. Erectile dysfunction? More pills. And then you go to things that are more obvious to us as dentists: TMJ. We learn to replace the joints. Someone has TMJ—we learn to replace the joints or take out the disc or even replace, reposition the disc, open the joint, wash it. But none of those are really addressing why the joint was having problems.

And I think that—I put an emphasis on TMJ because for me, TMJ was a very frustrating anatomy to help patients with. But now that we step outside the box and see what we can do for them and look at the nutrients or the soil for that tree—the cause of the TMJ breakdown—I think that I'll make a point that we had it all wrong all this time.

Gingival recession—we have recession, and then we build back the gums. But why are we having recession? Is it because people are brushing too well? Is that really the reason?

So, I think the point of this topic, and obviously, I'll show cases to go through it, but I want to put an emphasis on things that we really learned to miss and ignore. And a huge part of that has been the airway and function. Us as dentists, like Christian said, we are at the forefront because the mouth is the gateway for the airway, and we are the gatekeepers. We have so much knowledge and expertise in actually recognizing the signs and symptoms of airway disease and now the ability to treat them, but we just have to make it obvious—shed light on it. So that's what this talk is about today.

We see teeth, and we have cavities—we restore them. We have missing teeth—we replace them. This is what our education has been and where our mindset has been. We have recession, like I said—we replace the gums. We have crowding, and we remove teeth. But these things are all just treating the leaves. Why do we have crowding? Why do we have broken-down teeth? Are we really going to replace ground-down teeth with veneers, expecting that those veneers are going to have a different fate than the original teeth did? Or are we going to end up with the consequences of redoing dentistry, frustrated patients, and empty bank accounts?

And the same with orthodontics—there are many, many patients that I see. By the time they get to me, they've gone through two, three, even four rounds of ortho treatment. Why is that happening? The big thing is the airway—we've missed that. We really have. But I hope today that this will become obvious. Once it is, once you see these things, you can’t unsee it, and it'll completely change your practice in so many ways because what will happen to the patient? Transformations are going to be life-changing, and then those patients are going to bring you so much reward in their experiences and then everything that comes down the line, downstream from that—even from a practice, business environment.

So, very simply, we see people all the time with underbites, overbites, asymmetry, open bites. That alone is telling us so much, right? An overbite—small lower jaw. An underbite—small upper jaw, underdeveloped. An open bite—maybe both jaws are small; there's no room for the tongue, the tongue is fighting for space. Those are very obvious once you just say it out loud.

And for years, what we've been doing is camouflaging these things, right? With compensatory ortho, removing teeth. But when we do that, maybe we're even making the problem worse because we're closing that space. And if we're not addressing the space, what happens? When you compensate and close that bite, the tongue is going to fight for space and open that bite. And that's been the experience of many of my patients. By the time they reach me, they've had their bites open right back up, go back to where it was.

If you think about gingival recession, is it more likely that the recession happened from someone being a diligent toothbrusher with good hygiene? Or is it that the lower anterior gingiva that so often recesses, and we treat with gingival grafts, had pressure from mentalis strain and lip incompetence from the front and tongue pressure flaring those teeth from the back? Was that causing bone loss in the anterior buccal aspect of those teeth? And is that causing gingival recession? I think that's actually what the majority of these things are.

So, if the jaws are small, there's no room for the tongue, right? Because the tongue is housed by the jaws. So by definition, if you have an underbite, overbite, asymmetry, open bite, or crowding, you don't have room for those teeth, and you don't have room for the tongue.

So I said this yesterday—dental crowding is such a key sign that tells us, really, that there's no room for the teeth, right? The arches are too small. Unless that person has supernumerary teeth and they have 40 teeth, or 34 teeth, or 38 teeth, then maybe they'll have some crowding appropriately. Or they have macrodontia—their teeth are too large for their arches. But those are very rare situations. 95%, probably, or more of patients with crowding have the appropriate number of teeth—they just don't have the appropriate amount of space.

So what happens is, if you don't have space for the teeth, you don't have space for the tongue. Behind the tongue is the airway. And even not as obvious as that, the upper jaw and lower jaw house the tongue, but the upper jaw also houses the nasal structures, right? So the turbinates, the septum, the nasal airway.

So many patients that have trouble breathing through their nose go first to an ENT for turbinectomy, septoplasty. But very rarely is the septum abnormally large or the turbinate abnormally large. Much more common, probably 99% of the time, the maxilla is too small—either narrow or recessed, or both. And when that happens, you not only have limited tongue space, you have limited space for the internal nasal structures, and you get nasal and mouth breathing restriction.

Christian Coachman: David, just one question here. I think this is, for me, the first learning point here is that when we connect tooth position with the quality of sleeping, we are actually, of course, connecting tooth position with airway management. And when we connect tooth position with the airway, we are actually analyzing two things. First, the fact that we are under-developing the lower third of our faces means that two things—we have crowding and all these issues that result in less tongue space. So that's the first factor: the tongue is going somewhere and usually blocking the airway, right?

Dr. David Alfi: Right.

Christian Coachman: And the other one you mentioned is that lower underdevelopment means that if the mouth is underdeveloped, the bottom of the nose is also underdeveloped.

Dr. David Alfi: Exactly.

Christian Coachman: So it means that it's not just taking space from the mouth, but you need to expand the palate to expand the bottom of the nose. So when we expand transversely the palate, we are actually doing two things—we are opening the nose at the top but also moving the tongue forward at the back.

Dr. David Alfi: Exactly, right. Two things. And I think a lot of people recognize the tongue very obviously but not so much the nose. And in the past, people would say, "Airway, we need to bring the mandible forward," right? But it’s not necessarily that—you need to actually expand the maxilla, and everything will follow.

Christian Coachman: Yeah, and for most patients, it's both.

Dr. David Alfi: Right. And something that's interesting to me, that I recognize, or at least come to the conclusion, is if you look at anthropological studies, and there's a lot of data on this, and you look at 200 years ago, the facial skeletons were much more developed. They had much more forward growth than what we have today.

Christian Coachman: A modern-world thing.

Dr. David Alfi: This is a modern-world thing, and it's a true epidemic, but it's so true that we've normalized our faces, and it's so normal that I think it contributes to what we've been missing, right? But if you zoom out and you look at our faces and faces of a thousand, five thousand, ten thousand years ago, you wouldn't miss it. You would say that this population has a problem.

Christian Coachman: So I think that's one of the important points is that sometimes things are so obvious that they're not obvious, and that's one of the situations that we have here.

Dr. David Alfi: The reason for that is multifactorial. I find it interesting, so I talk about it. You think about diet changes—we probably have way more processed, refined foods than we had a thousand years ago, I'm sure. And that leads to differences in chewing, especially early in development, right? And that may affect the growth of the structures.

The other thing that's interesting is, if you think about what we're seeing, especially in developed countries, there are so many antibiotics given early in life and during pregnancy. Infants are exposed to antibiotics before they're born, but even early in life, if anyone has a fever, the standard of care for a young kid is to start them on antibiotics very early, no matter what the reason for the fever is—crazy.

So what happens is that changes the microbiome very early in development, and the microbiome in development is essential for the development of our immune system. So there's actually a lot of data out there that early exposure to antibiotics makes people hyperallergic. So that's why we have all these peanut allergies. So many kids are running around with EpiPens, way more than there were when I was a child, right?

Christian Coachman: And completely different than some developing countries.

Dr. David Alfi: Exactly.

Christian Coachman: And how does this affect the growth?

Dr. David Alfi: So what happens is that if you have allergies—pets, foods, pollen—that causes congestion in the nose and it causes mouth breathing. Mouth breathing and the loss of nasal breathing during the development of a child's face, we know, causes adenoid faces, narrow maxillas, downward and retrognathic forward growth of the jaws.

So I think what we're seeing is really multivariable and epigenetic. We've really seen a transition to smaller faces, and people are suffering. Now, the examples I put on one of the earlier slides about hypertension, erectile dysfunction, insomnia, TMJ, gingival recession—all those examples, I put them there because those are all associated with sleep apnea, restrictive airway disease.

So now, being on the other side of it, I have so many patients that are able to come off so many of these pills—some of them come off all of these pills. And it's curious to me how many of our adult population who are on hypertension meds, anxiety meds—I mean, we're talking about 80% of the population that's on at least one of these—how many of those are airway-associated? And I think it's very high because of this epidemic.

So it's cool for us just to recognize it, and being at the forefront, what transformations you can make—take these patients off of these meds, make them healthier, and potentially save their life. But even more importantly, give them a better quality of life. And then, when you're doing so, even make them look younger, healthier, give them a brighter, more beautiful smile. It's such an impactful thing, and it's an infectious thing to go to work every day to experience that.

Christian Coachman: I usually say that improving the airway is the perfect and ultimate definition of combining function and aesthetics.

Dr. David Alfi: Yeah, absolutely.

Christian Coachman: There's nothing better that represents this combination than the airway.

Dr. David Alfi: One thing is completely connected to the other—there's nothing more beautiful than somebody that breathes very well.

Christian Coachman: Yeah, absolutely. I think it's so true, and people ask me about having aesthetic results with jaw surgery. And how do you—what's your philosophy on planning for aesthetics? And that's exactly that. My philosophy is you put the patient in the appropriate position, give them the appropriate jaw position, the appropriate smile, the appropriate length, and they're going to be beautiful because they're going to be healthy.

Dr. David Alfi: Right.

Christian Coachman: And health and beauty...

Dr. David Alfi: Space is beauty, basically.

Christian Coachman: That's why intuitively, people say, "I want to show more teeth; I want a wider smile."

Dr. David Alfi: Exactly. And medically speaking, that's the reason why. You know, space is beauty. Airway and aesthetics are completely connected.

Christian Coachman: Yeah, exactly. I mean, you have to have no insight about aesthetics, but you treat function and you're going to be an aesthetician.

Dr. David Alfi: So what happens is, we have these small airways, small jaws, and when people go to sleep, they lay down. That's going to get worse because of gravity. And if they ever actually go to sleep, as you go to deeper stages of sleep, the muscles relax. And if you go to the deepest stages of sleep, the muscles are very relaxed. That's the most restorative sleep—is REM sleep. The muscles have to relax. But if the airway is compromised and you have no room there, and that space closes, that's not compatible with life.

So people are never going to get that deepest stage of sleep. So they'll sleep, the body will constantly wake you up so you don't die.

Christian Coachman: Correct.

Dr. David Alfi: And sometimes you don't even know that you're awake, or you may not be fully awake—you may be in lighter stages of sleep. So you think you're asleep 8, 10, 12, 14 hours, but you ask these patients, "When you sleep 14 hours, do you feel rested?" And the answer is always no. It doesn’t matter how much they sleep because they're never getting restorative, healthy sleep.

So, like Christian said, I think it's so obvious once you say this out loud, what these issues are. But why have we missed it? And I think a big part of that is—I fell in love with jaw surgery when I was in residency, and it became my passion and became what I wanted to do. But when I came out, I fell in love with it because of how transformative it was. But it was transformative...

Christian Coachman: In extreme cases.

Dr. David Alfi: In extreme cases, right. And it was rewarding in extreme cases. But with the traditional tools, and we were doing the best we could with the tools we had at the time, it's a long procedure. People are wired shut. They have to go through braces sometimes a year before to get there. It's expensive. The recovery is difficult.

Christian Coachman: Huge.

Dr. David Alfi: So it was a huge decision. It was a huge decision, and it wasn't an easy sell. And not only that, if even that was true and the results were great, it still would have been an easier decision to make. But the reality is that orthodontists then get these patients back, and they were fighting with what we call relapse. But really, it was limitations of technique and technology. So you had a case that was very difficult to go through and then had unpredictable results. We didn’t really have a solution.

But things have changed. That's what we're talking about today. There's a jaw surgery revolution. So what if I told you that, yes, the jaws are small, but now we can fix it in as little as 45 minutes? I could do a double jaw in as little as 45 minutes. On average, I take about an hour to do a double jaw surgery.

Christian Coachman: This is unbelievable.

Dr. David Alfi: It's fun, yeah. And anybody wants to come see it live, in person, I have students all the time. It's literally bringing something down from four hours, six hours—standard still today, six to eight hours...

Christian Coachman: Six to eight hours is probably the standard—the faster guys, about four to six.

Dr. David Alfi: But I do it in an hour, hour and a half, on average, and we've done it in as little as 45 minutes. So what if I told you that this is possible? There's no wires, scars, or elastics. Everything can be done inside the mouth. We don't need post-op wiring or elastics. Actually, we don't even need braces. We can do it with Invisalign. And with the technology we have, such as DSD, getting on and simulating a case and knowing where the endpoint is, we don't even need pre-surgical orthodontics in a lot of these cases. We can do surgery first and then finish with Invisalign afterward.

So what if it was an outpatient surgery, and the patient goes home in 23 hours or less? Most of my patients I keep overnight just to keep them comfortable. Some I've sent home the same day after surgery, but always the next morning, they're ready to go. And they're ready to go back to work in a week to two weeks, not wired shut, they can talk, and their swelling looks like wisdom tooth swelling. That's the reality of where we're at today.

So what if we can do all that and fix the OSA, fix the airway, give them a beautiful aesthetic result, make them look younger, healthier, give them a quality life, and we don't expect any relapse? We have a predictable outcome and stable outcome. So now the game is completely different.

Christian Coachman: It becomes a real tool in your toolbox.

Dr. David Alfi: It becomes a tool, and it's something that we have access to that's accessible, affordable, and as people get more trained in doing this, it'll be easier to get patients in because I personally do about 200 a year at this time. I could probably go to 300, and the volumes for the busiest guys in the past with traditional were about 30 to 50 a year for the busiest guys. But now we can open up that to many more patients.

Christian Coachman: So the key is to focus not on big facial discrepancies to indicate this but to really master the process of identifying airway issues.

Dr. David Alfi: Yeah, exactly. And that changes the paradigm and changes treatment plans.

Christian Coachman: The GP needs to become an expert on identifying that on the first appointment—raising the yellow flag and further exploring that.

Dr. David Alfi: Yeah, exactly right. You guys are the gatekeepers. The GPs are the gatekeepers—all of us. When I was at Columbia, that's where I trained. I did my surgery residency. When I was there, there was a difference between orthognathic surgery and maxillomandibular advancement. And still, people separate them, but in reality, every single patient I treat is an airway patient. I don't distinguish one versus the other. We're expanding airways for everybody. Everybody that has a jaw discrepancy, bite problem, and because of this epidemic, they're all airway cases. They all need expansion.

Even the ones with perfect class one occlusion—they may have perfect class one occlusion, but their bimaxillary recessed—both their upper and lower jaw are recessed.

Christian Coachman: So these are things that, once you start to recognize them by looking at the patients, you cannot notice that they are retruded, right? But if you ask the right questions and you see that they're not sleeping well, if you give them a little bit more space, even if facially, aesthetically, it doesn't mean that much, right? You give a little bit more space, you change their life.

Dr. David Alfi: You change their life, and I have some examples of that, but that's exactly right. So things have changed, and it shouldn't be a surgery where MMA is one centimeter forward, straightforward. It was very dogmatic—every patient has individual needs.

I like this slide because I trained at Columbia—I went to dental school, med school there, and surgery. And I spent 10 years, and that's the Washington Heights campus in Northern Manhattan. And when I was there, that new virtual-type building that's standing there wasn't there. Instead, it was the size of a tomato garden or a pickleball court, and never in my imagination could I envision an educational building like that going up there in the same space. But that's there now—that's a real picture. And it's a large building that services a lot of educational content for the Columbia University Medical Center.

But I like to parallel that because New York City, when I was there, was a mature, in-my-mind, perfect city. It's gone through everything it can go through, and it's so saturated, it's very hard to envision that things could get better or could get grander or just could change or progress. And most often, we won't be able to envision what changes will be, but there's always going to be changes—that's a constant.

So I like to parallel that because, in dentistry, I think it's very easy to rest on our laurels and think that we're there, that we got there when in reality, we're never there. You know, it's a constant quest to be better. And that's what was very exciting for me, meeting you and hearing you talk about DSD, is that I felt that you had that Mamba mentality vision, and everyone on this call, I know, has that same type of energy and philosophy.

So that took me to Houston—this is my office, and we have a Mamba mentality room, the Kobe room. I grew up in Los Angeles before I moved to New York, so I was a big Kobe fan, obviously, as a kid in terms of basketball. But as an adult, what I really learned to respect and admire from Kobe was that Mamba mentality, and he really lived that. I mean, he worked harder than anybody, and he was on a constant quest to be the best version of himself, and he talked about it all the time.

So for me, that resonates a lot because I identify with that, and I know all of you guys do too. And it's such an inspiration to have that piece in our office and to be reminded about that mission—I think it's an amazing energy.

So that brings us to how we're doing these surgeries today. And like I said, in the traditional sense, we were doing what we could with what we had, but things are different—landscapes have changed, patients are different, we know more, but so do patients. They have information; they may get obsessed about their airway and learn about it more than any one of us will ever know because they may have more time to delve into it. But that's the reality—the dissemination of information is different.

So the environment is different, and we have tools to respond to that and make things better. And I'm talking about these tools today, but hopefully, I'm talking about more tools tomorrow because we're on a constant search. But the reality is that you can't solve today's problems with yesterday's tools, and when you start doing that, you fall behind.

Christian Coachman: So if you go back one slide here, of course, a few years back, 99.9% of the surgeries were not planned digitally, correct?

Dr. David Alfi: Right, that's number one.

Christian Coachman: That's number one—making it a routine, really mastering the process of leveraging, not only showing software once in a while to show off in lectures, but actually...

Dr. David Alfi: Right, absolutely.

Christian Coachman: ...every case—plan the case much better because you're pre-planning everything digitally. And then the second part that I think is even newer is how do you translate this plan into the mouth through these custom devices?

Dr. David Alfi: Right, right.

Christian Coachman: Because I remember planning cases, orthognathic cases, with 3D software five years ago, but I always felt that there were no tools to translate the beautiful design. It was easy to simulate on the software...

Dr. David Alfi: Simulate, but to transfer that—that was a mismatch.

Christian Coachman: Exactly. It didn't really make sense, right? And that falls into the concept that we define as guided dentistry. Guided dentistry is not only simulating 3D but also having the tools to translate the plan into the mouth.

Dr. David Alfi: Right.

Christian Coachman: Creating outcomes that are very similar to the plan.

Dr. David Alfi: Exactly.

Christian Coachman: And you showed all these new tools that, for people that don't know orthognathic surgery that much, we don't realize that this didn't exist.

Dr. David Alfi: It didn't exist, yeah.

Christian Coachman: And it's there now, and most people still are not aware of it, but it'll completely change in the next five years.

Dr. David Alfi: Yeah, I mean, it's such an obvious improvement. And I'm not a—I don't drive fast, walk fast, or talk very fast, but I can do surgeries faster than anybody because I'm using the tools.

Christian Coachman: Yeah.

Dr. David Alfi: So this is a picture about three years ago with a fellow at the time—I have a fellowship where I train a surgeon one year at a time. It's Dr. Hassan. And at that moment, we're fist-bumping because we finished a double jaw surgery from incision to close in 60 minutes. So for me, it was really a tremendous feat because, you know, I started doing this about 12 years ago when it was eight hours when I started. And eventually, with the traditional, I got it down to about four hours routinely. But to go from four to one was really significant. And it's not just speed because we're doing it faster, but more importantly, the outcomes, the movements, the stability, predictability—better.

Christian Coachman: If this is not the world record, it's probably pretty close.

Dr. David Alfi: Yeah, I think so. I actually signed up for the Guinness Book.

Christian Coachman: Okay, we'll see.

Dr. David Alfi: We'll see.

Christian Coachman: That's great—you should.

Dr. David Alfi: We'll see. So this is what I had in residency, and how unfortunately, still, a lot of surgeons are doing this today is in the analog world, right? They're taking a 2D cephalometric tracing on tracing paper like arts and crafts, then making a plan, pouring up stone models using a facebow transfer to an articulator, cutting the models, moving the stone teeth, and then making an acrylic hockey puck to transfer that information—drawing lines and using calipers to try to translate the metrics to the model. And then, as many sources of error in those steps, then you have to go to the operating room and bend the plates and measure in the operating room the vertical distance, so then you introduce even more.

And when you're talking about midlines and vertical dimensions and cant and asymmetries, you're going to get it wrong—it's impossible to get it right.

Christian Coachman: Healing is stability, meaning that you're going to heal and keep that plan.

Dr. David Alfi: Yeah, exactly. So those were the tools. But now we have amazing virtual planning, not only for cool slides but because you can see amazing anatomy and actually see where you're cutting, design the cuts, and if the cut has interferences or doesn't work, you can change the cut. Those are things that we didn't know back then. We would do surgeries and, in the moment, say, "Why isn’t this working?" Now I know because I can see it.

So the future is now, and the world is custom. And I love this slide because, again, I often like to step outside of dentistry into real-world examples to learn because I think sometimes when you get hyper-focused, you miss a lot of things that are out there. So I think it's important to read books that are outside of our field and try to apply it. But if you look at business and marketing—Chipotle, Starbucks—these guys hit it 30 years ago with customizing their product to the individual. And we all get different burrito bowls and different Starbucks drinks, and there's a million variations. But what it did, and what really made them successful, is the ability to cater to individual needs and really customize care, and technology has made that accessible and affordable.

Christian Coachman: So basically here, the revolution happened when you were able to do a simulation in the software—that came first.

Dr. David Alfi: Right, that came first.

Christian Coachman: The simulation is customized, of course. You simulate case by case. But then you were stuck because this translation was not there. Now the key is that you need to customize every single tool that you're going to use.

Dr. David Alfi: Right.

Christian Coachman: So you need to have a company that can manufacture these customized devices—not standardized tools and plates that you then miss the opportunity to copy-paste the plan into the mouth.

Dr. David Alfi: Exactly.

Christian Coachman: Because otherwise, it's impossible to get what you planned.

Dr. David Alfi: Yeah. But now we can. So we went from arts and crafts—the Stone Age—to the digital age, and really, it's Stone Age to the digital age, but that's where we are now.

That takes me to this case—this was about four, maybe five years ago now. And I always start with this case because, for me, this revolutionized my practice, and in a way, it revolutionized jaw surgery because it's led to help me pioneer a lot of these technologies.

She came in, a 16-year-old girl at the time, really vibrant, smart, ambitious student, high school student, volleyball player, you know, as well-adjusted as can be, but struggling with a really bad problem. She has severe retrognathia, microgenia, narrow face, vertical maxillary excess (VME), obviously a bad airway, but also a bad social problem and functional—you know, chewing, everything that comes with the importance of what we do. We're so privileged to be doctors for the most important structures of the face—really breathing, speaking, swallowing, and the way we greet the world with that smile.

So she had a lot of struggles. And when I treatment planned this case, the options at the time—if I were to do a board examination even still today, the answers to treat this case would be either a total jaw replacement or a neck Frankenstein-type incision from ear to ear, big exposure, inverted L-osteotomies, a hip graft for that bone, and that’s a 12-hour procedure with an unsightly scar. Or a total joint with some scars, risk of facial nerve injury, and then, at 16 years old, the very likelihood that those joints would have to be replaced in the future.

And I didn't like those options at all. But being in the med center and on top of virtual planning and reconstruction, I was familiar with some applications that were available to print titanium guides and plates. So when we planned this case, obviously, we did our due diligence to diagnose appropriately. Because when you think about total joint replacement, the reason to do a total joint replacement is very few, but it's overused. You know, a joint should open and close, and if the jaw opens and closes, the joint is doing its job. And that's exactly what you would expect when you put a joint replacement in—you would only want it there so that the jaw can open and close. But if the joint is already doing that, why would we replace it?

And in her case—and I put a lot of TMJ examples—they all have joint resorption to some degree for different reasons. The key is not to really treat that leaf, but to treat the disease. So in our cases, I like to first see why the joint is having the issues she is having. For her, she melted really quickly during development, and we diagnosed her with juvenile rheumatoid arthritis isolated to the TMJs that are now burned out. And we know that because we collaborate with a rheumatologist, we get an MRI, we get blood tests, and we have an actual diagnosis. So now, yes, she resorbed her joint, but it's stable, the disease process is gone, and the joint is functioning and has no pain. So in my mind, joint replacement is out the window. To me, that’s insane. But instead, now I know that I’ve got to fix the problem that she has, which is an airway problem that's going to make the joints worse over time.

So we do orthognathic surgery, and I don't want to do that neck incision, so I'm going to try something different in this case. And that’s what I did. So we did an inverted C-type osteotomy, dowel grafting, counterclockwise rotation of the maxilla, even brought the maxilla forward a little bit, and brought that chin forward some more. A very, very ambitious and aggressive movement, especially if it would have been traditional plates, because that would not have been stable, accurate, or predictable. I was shooting for a 34-millimeter Pogonion movement. Pogonion is the front part of the bony chin—34 millimeters is three and a half centimeters. This is more than even a distractor would achieve. So it's very ambitious, and traditional plates that are bent in the operating room are not going to hold that—it would fail. And to get that type of accuracy would not happen in the old world.

But I know that we can print with a titanium printer guides that give me the information I want to transfer. So that's what this is—these are titanium guides that are just a millimeter thick. I can sneak them in inside the mouth, I can use anatomy like the sigmoid notch, ascending ramus, whatever I want. I can design it.

Christian Coachman: Part of the revolution comes from having a printer that prints titanium.

Dr. David Alfi: Yeah, because look at the fit of these devices to the bone.

Christian Coachman: It’s like a glove.

Dr. David Alfi: It’s like a glove. And the key about titanium for these guides is that we can print on all of our Stratasys 3D printers a plastic guide, but they’re much thicker.

Christian Coachman: Mhm.

Dr. David Alfi: And you don’t have that access to do it in the mouth. So you want them as precise and as delicate as possible to make the whole surgery more delicate.

Christian Coachman: Yeah.

Dr. David Alfi: And minimally invasive. So I do this, fit this all inside the mouth. I can feel it. You don’t even have to see it—you know it's in the right place.

Christian Coachman: So the plate will actually guide the position of the bone?

Dr. David Alfi: Exactly.

Christian Coachman: Retrofit them.

Dr. David Alfi: Exactly. And that’s a very key concept. I like that you said that because what happens is, with these guides, we make the holes and make the cut—you can see it’s all inside the mouth—and I’m going to do exactly what we planned. And then the plate itself acts as the GPS, acts as our navigator because this transfers all that...

Christian Coachman: Like an implant guide.

Dr. David Alfi: Exactly.

Christian Coachman: The guide for the implant.

Dr. David Alfi: Exactly.

Christian Coachman: Not the opposite, because before the surgeon was guessing the bone and then screwing the plate into that guessed position.

Dr. David Alfi: Yeah, exactly. Same concept.

Christian Coachman: Right.

Dr. David Alfi: So from the surgery perspective, what it does is, in the old techniques, the traditional techniques, the surgeon uses the teeth, wires the teeth shut, and then holds the jaw where they think it’s supposed to be, bends the plates to the bone. And when you bend the plate to the bone, for one, there’s no way to know where it is exactly—you’re guessing. And there’s no way to know that you’re not doing it under tension because you’re just fitting it in there. And when you do it unpredictably and with tension, that’s why relapse happens. So relapse is poorly understood, but really, it’s a technique and technology issue.

Christian Coachman: Because initially, everything in the patient’s face will work against this movement, correct?

Dr. David Alfi: Correct.

Christian Coachman: The muscles, tissues…

Dr. David Alfi: Exactly. And if you’re just securing it, you’re fighting against that.

Christian Coachman: And when you have this, this plate is holding the pieces in position against this tendency of going back.

Dr. David Alfi: Correct. So the key difference—instead of putting the plate to the bone, here, I’m moving the bone to the plate. So I know when every hole lines up perfectly and passively that I have a passive and accurate position. Otherwise, there’s no way to know that. So technically, it’s an amazing concept that helps us get the predictable result.

So these are the patient-specific implants for her, and that’s the result. So this became a four-and-a-half-hour surgery—this was the first one of its kind—instead of a 12-hour surgery, with no scars and a crazy movement at the time. And maybe I was crazy for trying it, but it worked. And it’s really changed the way I’ve approached all my cases since because I knew that if something can work on such a profound movement with accuracy, then it should work in every movement, as easy as the case is.

So this is her before and after. This is only six weeks after—you can see no scars on the face, amazing position. And the key is, especially for a movement like this, what is the stability like? Because stability has been an issue for jaw surgeons for so many years. So I talked about her for many years at our national oral surgery meetings to other surgeons. And I resisted putting it on my Instagram because I was saving it for these talks. Eventually, I gave it enough time where I said, “Let’s put it on Instagram.” And her boyfriend DMed me and said, “I would have never known she had surgery—she looks wonderful.” This is four years later, and I asked them if I could share this, and they said yes. But this is then, four years later. This is the follow-up—stable, predictable. She’s actually come into the office since then, and there’s been no change at all in occlusion despite that huge movement. So this, for me, was just, you know, a breakthrough.

I love social media, and I said this—it’s been very good for my business and my practice and, you know, getting access for patients to this information. But I think that just like everything we’re talking about now, it’s an amazing digital tool because when we think about the way we learned traditionally, you know, I was going to the library, the basement, and scanning books with the photocopier, taking quarters to read things. And it was very difficult, one, to get the information you wanted, but it was also not very accessible. The Journal of Oral and Maxillofacial Surgery has a circulation of 6,000, and you know, an article might—the journal may be opened by a hundred people and read by thirty residents. And that’s the reality of how we were—we learned to learn. But now I can post something and get a million views—I have something with 50 million views. But routinely, I’ll get thousands of views for a case. And not only that, all my peers, like you, are able to comment, share, and challenge immediately. And not only my peers but patients too. So I think it’s an amazing tool to share and learn from each other.

I’m actually even involved with a software company that’s trying to figure out, you know, how to make planning for jaw surgeries better. And one of the engineers told me that he uses my Instagram to learn how to test cases. So it’s an amazing tool, so I urge everybody to do the same if you’re not doing it, and you know, message each other. I’m pretty active, so DM me if you have any questions or if you want to come by and visit an operating room.

Christian Coachman: So, next case.

Dr. David Alfi: This is a case, and I selected these TMJ cases on purpose. This is a TMJ case. What does that mean? So she came as a second opinion. I get a lot of second opinions in Texas. In Texas, total joint replacements are pretty popular, so I get second opinions for total joint replacement. And she came as a second opinion, and basically, this is not my note, but a note from another experienced surgeon who—everything is TMJ, right? She has left TMJ; it's been there for 13 years, it’s episodic, the pain is severe, and then you go to the plan, and she has a TMJ problem, so we're going to replace the TMJ.

But this is missing everything we just talked about. I look at her, and I see airway. Why am I going to replace that joint? The joint is doing exactly what it should do—it’s opening and closing. She has pain, but it’s not the joint that’s giving her pain; it’s the muscles around the joint, it’s the teeth that are giving her pain. But she’s miserable—she has a lot of headaches, a lot of discomfort, she has a hard time concentrating at work, and it just takes a very simple questionnaire—are you tired? You know, I don’t use fancy questionnaires for my patients—I just ask them, "Are you tired?" And the answer almost is, "I’m always tired." Do you ever feel rested? Do you get restful sleep? "No, I don’t get restful sleep." That’s it. Do you snore? "I snore," or "Yes, on occasion." Those right there are confirmation that there’s an airway problem, and you’re going to get it every time.

So what do I do? I send her for a sleep study, and then she’s no longer a TMJ patient; she’s a sleep patient. She’s a sleep apnea patient. So I’m not focusing on the joint anymore because the joint is the victim of the error. So why are we going to victimize the victim when we can help? Right? So we’re going to go to the airway instead.

What I do is we plan the jaw surgery—counterclockwise rotation, advancement, forward projection, put her in a better bite, and a place where now my collaborating orthodontist can finish it with Invisalign, and then a restorative dentist can finish her after that with crowns and veneers.

So this is where she comes to, and I tell the patients, "Look, your joints—you have TMJ pain, that’s what you’ve been told. You have jaw pain, but really it’s musculoskeletal, and your joints look funny on an X-ray because you’re wearing and tearing them from chronic bruxism, unhealthy steep bites. So let’s fix what we know the issue is—you have a bad bite and you have a bad airway—and let’s see what happens," right? It’s a very obvious thing. You can always go back to the joint if you need to, but why not fix what we know is an issue and see what happens? So we do, and all her joint problems went away, and she now focuses better at work, she’s much happier, and she has no more headaches or jaw pain.

Here’s another patient. This patient also came as a second opinion. She had surgery 12 years ago. And if you look at the X-rays, this is what her surgeon did—there’s a bicycle chain that reconstructed the condyle. And if you look at that condylar position, it’s not in the joint; it’s anterior to the fossa. So when they did this surgery with a Frankenstein incision, they not only probably took 16 hours to do this, but they put the joint in the wrong place. And unknowingly to her, she’s been dealing with relapse in the bite and anterior open bite—she can open and close, and she doesn’t know the anatomy is not there. So she actually does not have a TMJ. And I like to put that as an example because the joint, whether it’s a real joint or a pseudo joint—because if you replace a joint with a rib, a fibula, or a total joint replacement, it’s a pseudo joint anyway. And what you’re asking for is it to open and close. She’s already doing that.

And she came as a second opinion—somebody wanted to do a total redo on her, which wouldn’t address her real issue, which is an airway issue. You can see that airway there. But it’s also almost impossible to do a joint replacement when the joint anatomy is not there anymore. So it would have been a very difficult, unpredictable procedure, and it would have put her in the same exact position she’s in now—it wouldn’t have fixed her root cause. So instead, I told her, "I’m going to ignore the joint because your joint created one. Over the 10 years, you created a new pseudo joint, and it’s doing what I need it to do. Instead, I’m going to fix your problem." So I plan a double jaw surgery, and these, again, are hour, hour and a half surgeries, all inside the mouth, counterclockwise rotation, forward movement, we open up the airway. And again, 17 millimeters, 16 millimeters at the Pogonion—these are large advancements, but that’s where she needed to be. We closed that bite, and this is her afterward.

If you look at her afterward, yes, her bite is much better than it was. The plane angle is better, but more importantly, she not only looks better, but she feels so much better. All her chief complaints, which weren’t sleep apnea—why weren’t they sleep apnea? Because your patients don’t know what they don’t know. They don’t know that they can’t breathe because that’s the way they’ve been breathing all their life. Her chief complaint was her TMJ. But us as the gatekeepers can now easily recognize that she has an airway problem. So now she says that all those chief complaints, the jaw pain, headaches that she was struggling with, are gone. And not only that, she has way more energy, she feels better, her anxiety is less, and she’s doing better at work.

Here’s another example, and this one is my favorite one from my nerdy orthognathic orthodontic background because this case has every chapter in an orthodontic book. She has VME, asymmetry, retrognathia, sleep apnea, narrow maxilla, cant—she has all of the above. Everything you can think of—it’s every chapter in one patient.

And I like it because in traditional methods, this would be one of the most difficult to get right because if you’re bending something to get that vertical impaction at the correct degree…

Christian Coachman: Very delicate movement.

Dr. David Alfi: Very delicate to get the symmetry right.

Christian Coachman: You can easily make it worse.

Dr. David Alfi: You can easily make it worse, exactly. But with the technology we have, we can do this very, very accurately and hit every single one of those chapters in an hour and a half. So if you look at her, we planned the case for maxillary expansion at the time of advancement. So it’s a three-piece maxilla, we’re bringing that jaw forward, bringing the chin forward, and we’re fixing every single one of those things and also making her healthier. So again, you look at the movements—15 millimeters, a centimeter and a half at the Pogonion. I’m not going one centimeter, or there’s no dogmatic way to treatment plan these—that’s the point. They’re all different, and they’re bigger numbers than the dogmatic plans would prescribe because they’re individual needs.

But this is her afterward. So the retrognathia is gone. You look at her side profile—much healthier. You look at her eyes—much brighter. And I’ll get into that, but look at her from the front—the VME corrected, the cant corrected, the symmetry corrected. But this is a patient that dealt with so much anxiety pre-surgery. She really struggled—she was on SSRIs and still, despite that, severely anxious. And after surgery, she said the biggest thing for her is, yes, she feels rested and healthier, and you can see her eyes are much brighter, but she says she feels complete calm now, like she’s never felt in a long time. That anxiety is completely gone.

Christian Coachman: She’s off completely?

Dr. David Alfi: Yeah, sleeping—qualitative sleeping from sleep.

Christian Coachman: Yeah, exactly.

Dr. David Alfi: She’s getting oxygen and restful sleep. This is just an animation of how we’re utilizing this technology. So you have your 3D plan—it’s important to do it interdisciplinary. That’s what I love about DSD in particular is we can integrate virtual plans and meet, you know, overseas, different offices all at the same time and come up with a collaborative treatment.

Christian Coachman: But what’s happening here—so you basically have two sets of devices, right?

Dr. David Alfi: Correct.

Christian Coachman: First are the guides?

Dr. David Alfi: Yeah.

Christian Coachman: And second are the plates.

Dr. David Alfi: Yes.

Christian Coachman: So we put the guides on, drilled the holes, and made the cuts…

Dr. David Alfi: Like the implant guides.

Christian Coachman: And the implant.

Dr. David Alfi: And the implant itself.

Christian Coachman: Exactly, right.

Dr. David Alfi: That’s exactly what it is. So here’s another case. This is one of my favorite cases because of what an amazing result he got. But a 16-year-old kid, competitive, private school in Houston, very nice, ambitious, again, kid, but really struggling. Why is he struggling? He looks so tired, right? A 16-year-old kid shouldn’t have eyes that look that tired. You know, he’s youthful, but with that retrognathia, it’s no surprise now that we know there’s no tongue space. So how is he sleeping?

So we plan it, and he needs a 22-millimeter movement. And many of our cases are going two centimeters, but the lower was coming forward 22 millimeters—that’s how far recessed he was. And without this technology, again, we never trained—when I trained, we never learned to make these moves. The reason we didn’t is because that’s an unstable, unpredictable move, and we weren’t focusing on the airway. So what we did with orthognathic surgery was really dental position surgery. It wasn’t facial surgery. We were just trying to get the bites right and doing it as easy and predictable as possible, which was wrong. So we weren’t making large movements. If there was an underbite of 10, we would split the difference, bring one jaw forward five, bring the other one back five to make the surgery easier and get predictable results. What we didn’t realize at the time is we weren’t addressing the airway, and that bite would relapse over time because the tongue’s going to fight for space.

But the reason we’re seeing these movements—10, 15, 20 millimeters—is because we can treatment plan accordingly. And I like, for anyone that knows American football, the example is you go for the touchdown and not the field goal when you have a good quarterback, right? If you don’t have the quarterback, you go for the field goal, and you’re compromising. And in reality, that’s what we’ve been doing all this time. We were compromising our results. We’ve been going for that field goal when now we’re…

Christian Coachman: Playing safe.

Dr. David Alfi: We were playing safe, but we weren’t doing the right thing.

Christian Coachman: We weren’t winning.

Dr. David Alfi: Right, we weren’t winning the game. Now we’re going for the touchdown—we’re winning the game because we have the quarterback, or in this case, we have the digital tools and the technology. So here’s his result—a very aesthetic result, obviously, and look how rested he looks now, confident, happy. His life’s completely changed, and it’s been such a pleasure to see this kid.

Christian Coachman: One thing I want to emphasize here because I’ve been in lectures showing the impact of orthognathic surgery, right? And people showing pictures like this and mentioning the impact on life. And life is much better, much more confidence. There’s a big change here because we are focusing on the airway and how this impacts sleep. So looking better is just the consequence here.

Dr. David Alfi: Exactly.

Christian Coachman: And this was not mentioned until recently, you know. People were not focusing on that. As you said, it was a life-changing experience because you were changing the social perception of your face. Now it’s completely different and much deeper and much more meaningful because you get that as well, but you’re changing the quality of living because you’re changing, as you said, the quality of sleeping, amount of oxygen, and everything else.

Dr. David Alfi: And everything else is gone, yeah.

Christian Coachman: And then, for us as providers, no matter if it’s ortho, perio, dentistry, how much more satisfying is it to know that we all put a part into this? So, you know, Todd Shires is an orthodontist in Houston that I work with a lot, and we have a team. He’s not the only one, but we have our team, and we know our roles, and we do the things we do very well. And I don’t say we refer to each other—we collaborate with each other. And what happens from that, not only is it amazing for our practices that we can share these patients, but if Todd can do an SFOT and gingival graft, SFOT to set up orthodontics, gingival graft after we get the right function for the patient, if my restorative dentist can plan the crowns and veneers that are going to last and be completely aesthetic with proper arch form, proper position, and not only that, more importantly, the tongue’s not going to fight them, whatever broke down those teeth is not going to re-break these veneers, so the dentist is happier not only to get a more beautiful result but to get something that’s going to work, right?

So this technology also—and what I like about what you’re doing—is it allows for people to do what they do very well and help the patient in the ultimate way. And as a patient, there’s nothing I would want more for myself than to have a team like that taking care of an issue.

So, a couple more cases. This one I like to put because she’s a class one occlusion. Her profile is not obviously bad, and her sleep study is mild. I sent her for a sleep study, and she has an AHI of six, I believe, which is a mild obstructive sleep apnea. That’s significant. To date, what we’ve been doing is trying to tiptoe around this thing—try an oral appliance, use CPAP, put a nasal strip on your nose, basically putting band-aids for things that are going to get worse over time and never really addressing what her issue is. She has a lack of tongue space that is causing that AHI of six. But her chief complaint, again, is not sleep apnea—she doesn’t know she has a sleeping problem. She has shoulder pain, neck pain, and her posture is never comfortable, and her jaw is never comfortable. And it’s interesting— a lot of these patients will come and just say, “I don’t know where to rest my jaw; I don’t know where to rest my tongue.” How many times have you guys heard that? They don’t know what to do with their mouth. And that’s a very significant thing for someone to say because they’re right. The reason they don’t know is because it’s inappropriate—they don’t have space. So, a patient in a lot of practices would be dismissed as a jaw surgery patient, but now, because of the experience taking care of these cases and knowing I can do it in an hour safely, predictably, I’m seeing things a little differently. And that’s what I hope to transmit in this talk—to see these things that we were not seeing before.

So for her, it’s more obvious to me that she needs more space. So I’m going to bring both her jaws forward, keep her in a good occlusion—we’re going to do it all with Invisalign, surgery first, and it’s a seven-millimeter movement for her. Again, it’s not 10, it’s not 15, it’s not 20—this is what you were talking about before—it’s an individual need. But she needed this to become in an ideal position, and that was probably going to fix her situation. And if you look at the imaging we have—and we have these in our offices, cone beam CT—and you can do volume renders, and you look at the airway, it got a lot better with that forward movement of both jaws because we were giving tongue space, we were pulling the tongue forward with the lower jaw, we were also making more space in the maxilla with the upper jaw and putting her in a really nice profile.

And then what happens afterward—someone asked yesterday, “How much weight did she lose?” She actually lost no weight. Before and after, her face thinned out from just appropriate function and health, and I’ve seen that a lot too in many of these patients. So here she is...

If it plays...

Christian Coachman: Yeah, they just look healthier now.

Dr. David Alfi: Yeah, so she’s describing all the neck pain, shoulder pain, which was her chief complaint, and nobody knew what to do with her. And after surgery, which has been a very easy recovery for her—not wired shut—really went back to work within a week or two, and now all those chief complaints—shoulder pain, neck pain—that would be hard to describe in any textbook that we have, what to do with it—now we know what to do with it. But her quality of life is a lot better, and she’s younger, healthier, and she may live longer.

This is the last case I’ll present for the day. This is my favorite case because it’s not an orthognathic case, but it’s stepping out of the box and using the tools that we have—all the tools that we mention. The kid is eight years old when he comes in, and I know his mother—she’s a nurse at the hospital that recovers our patients. So I know his mother, and I have a child, a son, the same age. So for me, it hits hard when I see an X-ray like this and a kid who has a large tumor in his mandible. And I treat a lot of children at Texas Children’s Hospital—I’m the director there, so I have a lot of experience with kids, and it’s different operating on them. Yes, they heal well relative to adults, but their post-operative course is completely different because how they respond to pain is different—how they’re able to adjust to it is different. So things as simple as drinking and eating, which are so important—staying hydrated after surgery is not so simple for these kids, no matter what the operation.

So what this kid needs is a large resection, obviously, to get rid of this benign tumor. And the options again at the time or even standard would be to resect that and put a fibula with a 12-hour surgery, long ICU stay, we’re talking about two weeks on a feeding tube, and the inability to compete in sports. He’s only eight—what does he want to play? You know, you take that away from him. The other option, and not a great bone graft option, is that the pediatric fibulas don’t grow, so it’s about pencil-thin, and it’ll stay pencil-thin. The other option would be a neck incision, Frankenstein-type incision, large resection, a hip graft, and a reconstruction plate. Again, long procedure, a scar, a two-week stay, feeding tube, all these things. These things really bother me. And I remember saying, “You know what? Tomorrow we’ll just get on a meeting and plan it on a computer, see what we can do,” because that’s where the practice has gone.

So I know the tumor needs to come out, so I plan the resection for the tumor, and it was a lightbulb there. I look at this resection, and to me, it’s like every case I just showed you that I do four times a week inside the mouth. It’s a resection that I can do all guided with titanium guides and plates and print a custom titanium plate to put it there in as little as an hour. This case became an intraoral case in about an hour or an hour and a half. And instead of hip bone, I’m using new tools—a regenerative product called Vivigen, which is a cellular allograft. So just briefly, an allograft, as you know, is human bone, and it has not only the triad of bone quality, which is scaffold and proteins, but it also has the cells because it’s cryopreserved and has osteoblasts in them. And they, you know, these—it’s basically technology—we have better regenerative products.

So this is called Vivigen. Instead of going to the hip—I haven’t gone to the hip in five years because I just plug this in, put the custom plate in—he has no arch bars, I don’t have to put him in braces, I don’t have to wire him shut, I don’t have to go through the neck, I don’t have to go through his hip. It becomes an hour-and-a-half procedure—he goes home that very day. So no ICU stay, no two weeks on a feeding tube. And this is him a week later, with the bite exactly where he had it beforehand, and a very, very easy recovery for him. He didn’t miss a beat. So for me, and look at the bone—much better than we would have got with a hip or with a fibula. So less invasive, more efficient, better outcome, better recovery—for me, this was my favorite case to date because of how I know the kid may not know what the difference would have been, but I know the difference would have been for him in any other office. So for me, this is very, very rewarding to see it every day.

So, how do you change your practice? You already have. Just being aware of this, I think, is going to change your practice completely. You’re not going to miss the broken teeth, the gingival recession, the crowding for what they are. They’re not leaves—they’re a tree. And once you start treating the tree, you’re going to get such better results and so much more joy in practice. And that’s what’s happened for me, and it just takes simple awareness. You don’t have to use STOP-BANG or any fancy questionnaire. Like I said, I just ask them, "Are you tired? Do you snore? Do you feel rested? Do you hit the snooze button, or do you just jump out of bed?" And it’s obvious what those answers are going to be for all these patients. And a simple "yes"—I’m going to get a sleep study on that patient.

I think a sleep study is the gold standard. You have to find a center that does a good sleep study—they’re not all the same. Some read them a lot more, just like how we do dentistry. Dentists that are not DSD are not the same as DSD dentists. But it’s the same thing with sleep studies—you’ve got to find one that uses the new technologies and techniques, and you’ll get a significant finding on all these patients, and now you have a roadmap of where to go with it. And what we can do now with this technology and what DSD does so well, for example, is to collaborate. And this is exactly what I was talking about. We don’t refer to each other—we collaborate with each other because we have a team. And I urge you to find a team—have like-minded people on my team. We have periodontists, orthodontists, myofunctional therapists, ENTs, restorative dentists, and we’re routinely working with each other and planning together to get these patients through these transformations.

So, things you’ll never see in a textbook, but these are things I hear in my office every single day from these patients: running a marathon now, six months after surgery, was easier than running the half marathon a year before. I had a bodybuilder say that he’s 40 years old, and six months after surgery, he gained more lean muscle mass at 40 than he could in all his competing as a bodybuilder, which he finds mind-blowing. "I no longer have TMJ symptoms, I don’t have migraines." I’ve had a lot of patients with migraines—migraines is another one. Fibromyalgia is another one. There are so many pain syndromes that we just medicate and give names to that are really just sleep. And guess who can help them? You can. We can. That’s all I got.

Christian Coachman: That’s a lot, but at the same time, very simple, straight to the point. Let’s not miss it.

Dr. David Alfi: Yeah, it doesn’t harm to explore.

Christian Coachman: Exactly. I don’t know if somebody has any questions? Please, I see a hand.

Audience Member: Yeah, I got a question. In the limited jaw surgery cases I’ve seen, the general preference of surgeons and orthodontists has always been to wait until growth is finished. But in a couple of these cases, it appears you did not wait until growth was finished. Is that no longer required?

Dr. David Alfi: Yeah, exactly. It’s similar to the same concepts about avoiding something we didn’t have the right tools for. You know, we wanted something that was unpredictable to be as predictable as possible. So we weren’t making the right movements, and we weren’t making the right decisions. But I really customize the care for the patients. I’ve had a jaw surgery patient as young as eight years old—he had Nager syndrome, and he had been distracted as an infant. And the option for him was to get a tracheostomy or let me try this surgery. So we put him in a class three underbite—I did the mandible only at eight years old with one of these intraoral inverted C-type procedures, and he’s thrived, he’s breathing better, he doesn’t need the tracheostomy. And later on, if he needs a maxilla to be done, we’ll do it then. For the underbites, for a lot of these kids, the growth potential for the mandible is limited, so you can go as early as 12 or 13, and you’re not going to have relapse, you’re not going to outgrow that mandible. So yeah, I think that those requirements are different now.

Audience Member: And then somebody mentioned it, but I wondered too, on that last case with the kid with a benign lesion, how did you manage the jaw growth?

Dr. David Alfi: It’s a great question—I get that every time. And this has been through experience treating a lot of kids, not only with tumors and reconstruction plates, but also trauma and titanium plates. And what happens is—and you really won’t see this in a book, it’s just an experience thing—but if you go down to the basics, it’s in the books. When you put titanium and screws in bone, it’s not like putting metal to wood. Bone is different than wood. So there’s constant turnover and homeostasis in natural, living bone, as long as it’s not necrotic bone, which a lot of these kids have non-necrotic bone. If you zoom out in a time lapse, it may look like wood in a still photo, but if you zoom out, that constant homeostasis—osteoclasts and osteoblasts—are continuously turning over. So that patient is going to grow appropriately, and that plate, even though it looks like it’s stationary, is going to, in essence, grow with that kid.

Audience Member: Does that make sense? What you’re talking about—let me see if I get it right—is that if you were to map the edges of the plate in relationship to locators, be it the tooth or the joint, that position will shift because the plate will stay the same. Titanium, we know, is not going to grow inside the person, but it’s going to move in its location in the native bone as the bone is moving.

Dr. David Alfi: Correct.

Audience Member: Thank you.

Christian Coachman: Definitely a great question—I get that one almost every time.

Audience Member: What’s the pathway to be able to do such surgeries for general dentists and periodontists? Do you enroll in new school from zero, or is there a shorter way?

Christian Coachman: You mean if you want to do the orthognathic surgery?

Audience Member: Yes.

Christian Coachman: Oh my God, we were talking about that yesterday. It took you what, 14 years?

Dr. David Alfi: Yeah, I mean, if you wanted to do orthognathic surgery, probably the quickest way is to get into a four-year residency and get it done. Or just come to the OR and watch me do it and enjoy it.

Audience Member: What else? Here we have Dr. [inaudible]

Audience Member: I have a question as well, if you don’t mind. I think with the combination of Dr. Reynolds’ question with the child, obviously you can see his lower left—he’s edentulous in that area. So as his growth happens and so forth, are we assuming, like you said, because of the osteoblastic and osteoclastic activities that are still stable, we shouldn’t have problems with implants and osseointegration and so forth? Or is there anything else specifically that would be done to prepare them for the future prosthetic restorative aspect?

Dr. David Alfi: Yeah, I think that’s true. And I think implants in pediatric populations are very interesting to me. Obviously, there are considerations to make, but I think that these things—the way my philosophy is to treat them individually. So, for example, if a kid will benefit from having implants to secure some teeth during development versus waiting five, ten years before they can have anything because of social pressures and even development, to me, it makes sense to put implants. They will integrate. The only thing that may change is the occlusion and position of that implant in relation to the opposing dentition over time. So the implants will work—you may have to tell a patient that we may have to change the restorations as the kid grows, or we may have to take them out and replace the implants. But they will be functional for some time, and I think in a lot of kids, there may be a window where that may be beneficial.

That’s a controversial topic, for sure.

Audience Member: With the child, is Vivigen stable enough for healing without keeping the inferior border intact?

Dr. David Alfi: Yes, and the reason is that Vivigen is a pretty amazing bone graft. I even use it in adults with large reconstructions, and it works well. Kids have an amazing potential for bone growth—the pluripotency of their stem cells and that periosteum is way more powerful than it is in an adult. So I’ve treated patients with that before. I had Vivigen, and before we had these options, I’ve had some where we just put a recon plate and plan to come back to put bone later in huge defects, and they will bridge the gap with a small inferior border over time themselves. So with Vivigen, like this kid, a lot of them, with the help of their potential, it actually works very well.

Audience Member: Ali, I’ve got another question for you. With regard to the surgery that you do, am I assuming that anybody on a sleep apnea machine or an orthotic device can now become obsolete?

Dr. David Alfi: Yeah, most of my patients, I say, “Get ready to put that CPAP on eBay.” But most of them—most of them come off of CPAP. Almost all of them come off of CPAP. The only exceptions are I have some older, obese patients that have AHIs of 80 and are very severe, and they may not come off CPAP, but their setting requirements become much easier and less—you know, more compliant. But I would say about 90% of my patients come off CPAP and appliances completely.

Audience Member: Yeah, because I think the other thing that I think you could probably associate with, or that we experience, obviously, in the restorative aspect—you’re trying to restore the patient, and then the patient goes to his ENT or whomever, and he puts them in an orthotic device that throws off the jaw, protrudes it out, and all of that. Now the patient’s still having jaw issues with regard to his teeth, and he can breathe better, granted, but now they’ve screwed up your plan. And so that’s where I’ve always had that fight or problem with whoever is in that aspect. They don’t care about the dental aspect, and it’s just a matter of, “Hey, let him breathe,” and who cares about the rest?

Dr. David Alfi: Exactly. And even the breathing is limited in those situations because you really need these three-dimensional movements in the upper jaw and lower jaw for expansion. So you’re right—it’s one, it’s limited, and two, it does change the bite, and then it puts the TMJ at risk. And early in my career with my sleep patients, before I had these tools, I was doing appliances, but I don’t do them anymore because I was seeing what you’re describing.

Audience Member: By the way, I’m in Houston as well, so cheers as well there.

Dr. David Alfi: Nice! We’ll have to meet up, we’ll do.

Audience Member: Let’s see… Sheena, how long is your residency and her fellowship that an oral surgeon can take?

Dr. David Alfi: So, I do a one-year fellowship for trained surgeons, and it’s one year. And I’m doing about 200 of these cases currently a year, so they get very well trained in it. But have them reach out to me for sure.

Audience Member: Does that one-year fellowship mean they have to be in Houston for the full year kind of thing?

Dr. David Alfi: Yeah, so I think that it is—it's interesting. It's something I'm exploring to get more people that come for shorter times, maybe a month. I’ve had a lot of surgeons from outside the U.S. even contact me for such requests, so it’s something that I look...

Audience Member: My very progressive, awesome oral surgeon is on this, and she’s listening now. But I think it would be difficult for her to leave her practice and her family for a year to do this kind of training. But we need—you know, I’m very passionate about this. I think it’s really important that we bring this and spread it out because there’s no way you’re going to be able to do everybody in the world, but everybody in the world needs this standard of care. This is for sure a necessity, and we need to get people trained—oral surgeons that are practicing, that understand this, that are capable of this, have the skills and the resources, they need to be trained. So that’s my thing.

Dr. David Alfi: Yeah, I’m excited. I think it’s cool. I’m going to think about that. I like that idea of a mini-type fellowship where...

Audience Member: Yeah, practical surgeons might be able to…

Dr. David Alfi: It doesn’t necessarily have to be like one weekend or one month—it could be like several over time, so that people can balance their life and their practice and still get the training that makes them capable and comfortable in doing the surgeries.

Audience Member: Yeah, Shina.

Dr. David Alfi: Yeah, I like that idea a lot, actually—I’m going to explore that.

Christian Coachman: OK, cool, thank you.

Dr. David Alfi: Like five days a month, you come Monday, you leave Friday, and you do that for several months.

Christian Coachman: Yeah, that’s a great idea—that’s a great idea, Sheena.

Christian Coachman: OK, anybody, any other questions?

Christian Coachman: I can see from the volume of questions and interactions—I hope you guys enjoyed. I think that the key here, as GPs, as restorative dentists, as smile rehabilitators, we need to identify these things and not miss these things in the evaluation of our patients and work with our team to really make this happen because it’s amazing. I think that there is no way back from this concept—once you realize this, you’ll just want to see it, you know? When you see the patient, you’ll want to see the patient with a different lens, and the patient will want you to see the patient with this lens. The worst thing that can happen is that you want to be treated as a whole, and your doctor is still seeing you like a tooth or like a set of teeth, right? And I think that that’s the transition we have to make. And DSD helps in that transition. This lecture helps in that transition. But we are going into this transition, and it’s unstoppable. And that’s why I think DSD, when I mentioned before, we are an old company doing something that is becoming mainstream now. And that’s why I think it’s so exciting and powerful for all of us here that were part of this evolution because we really helped shape the future of dentistry and health care as a whole. So I think we should all be very proud of that.

And once again, David, thank you very much for being with us. I hope this is the first of many times you will be able to lecture to us, and I’ll see you in Houston next week.

Dr. David Alfi: All right. Thank you very much.

Christian Coachman: Thank you. Thank you, everybody.