Oral Health Group

Biomimicry, Neuroplasticity, and Sleep: Introducing Myofunctional-Assisted Maxillomandibular Advancement Surgery (MAMMA)

March 1, 2018
by Elysa Kliman; Stanley Liu

Before you were born, there were countless forces shaping your growth and development. You had your own set of prenatal conditions and a unique path to birth before your very first taste of oxygen. This inaugural breath was then shaped by primitive reflexes, breast feeding (or lack thereof), oral tethered tissues, oral habits, oral nasal coordination during sleep, posture, etc. During this early process, neuromuscular patterns were created that would eventually shape the structure of your upper airway and the influences affecting your sleep.

Myofunctional therapy (MYO) is the practice of neuromuscular retraining of these circuits, and in the case of OSA, it is founded on the neuroplastic concept that the brain will form new neural connections to adapt to, and even reshape the body’s structural airway maladaptations. Studies have now proved that, indeed, MYO can reduce snoring and AHI values in mild-moderate OSA patients. However, in the case of severe OSA, only PAP therapy or surgery have been proven to markedly decrease AHI and morbidity.


PAP is highly successful in reducing OSA, but is palliative, must be worn indefinitely, and has a very low adherence rate. The benefit of maxillomandibular advancement (MMA) surgery is that it is meant to be a one-time operation to recapture upper airway space and allow a patient to thrive in a new, open airway position. Unfortunately, surgical recovery is daunting, and in many cases relapse occurs after 10-15 years (or sooner), requiring PAP therapy or another surgery.

So why isn’t MMA surgery curative, and how come opening the airway doesn’t fix the sleep breathing problem? The reality is that the stomatogthathic system is incredibly complex, and the functions of chewing, breathing, and swallowing require a carefully choreographed dance of neuronal and muscle memory.

Sleep breathing, as with all human and natural problems, is intricately interwoven within its surrounding ecosystem. We propose that myofunctional therapy is the missing link that marries form and function, allowing the body to integrate and thrive in its new airway position after MMA surgery.

Take, for example, the following agricultural instance that parallels restoring health to a process by first restoring balance within an optimized system. In his book about the future of food, The Third Plate, Dan Barber describes two different approaches to farming. The first, using chemicals to kill pests that are attracted to susceptible crops, regardless of the diversity of the crops or type of pests. The second, understanding which susceptible crops are attracting pest proliferation, and understanding how to create soil conditions that promote the healthier plant varieties to which pests are not attracted. The second approach is much more challenging than blanket pesticide spraying, but serves to solve the pest problem while promoting sustainable farming practices that ensure healthy soil for future crops.

Barber astutely writes, “Treating causes instead of symptoms is elegant, but not as simple, as it sounds. To address the cause, you need to look for underlying problems – which means you need to have a certain kind of worldview.”

In this instance, biomimicry provides a convenient parallel to the severe OSA problem. PAP, like pesticide sprays, eradicates the obstructive airway problem temporarily, but must be continued indefinitely and does nothing to restore the natural independent vitality of the body’s airway system. MMA surgery, on the other hand, recaptures the form of a well-adapted human airway; however, reconditioning neuromuscular patterns so that the patient can thrive in this new position integrates the functional aspect which is “not as simple as it sounds.”

Taking cues from nature, and respecting the neuro-muscular balance within the airway-breathing ecosystem of the human body is the reasoning behind Stanford’s proposed research for a new myofunctional-assisted MMA surgery (MAMMA). We hypothesize that integrating myofunctional exercises before and after MMA surgery will not only improve short-term quality of life and rapid return to function following surgery, but also decrease the rate of OSA relapse long-term.

While we believe the main focus of research in this field should be on preventing early factors that shape airway maladaptation that leads to OSA, we need to be realistic about the rising numbers of severe OSA cases. This significant and vulnerable population represents a large burden to our healthcare system, and we need to be proactive and innovative in our approaches to nurturing a sustainable population of healthy, well-rested citizens. OH

Oral Health welcomes this original article.

About the Authors
Dr. Elysa Kliman is an airway centric dentist that is passionate about integrative medicine and the whole body health of her patients. She is a diplomat of the American Board of Craniofacial Dental Sleep Medicine, a fellow of the American Academy of Craniofacial Pain, and the secretary of the Academy of Applied Myofunctional Sciences (AAMS). Currently, she is a visiting research scholar in the department of sleep surgery at Stanford University investigating the role of myofunctional therapy in sleep surgeries.

Dr. Stanley Liu is as an Assistant Professor of Otolaryngology in the Division of Sleep Surgery, and serves as co-director of the Stanford Sleep Surgery Fellowship. He is a committee member of sleep medicine in the American Academy of Otolaryngology. He currently serves on an expert task force directed by the American Academy of Sleep Medicine (AASM) to update surgical guidelines for obstructive sleep apnea in adults.

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