Author: Michael Kelley

Interview with an Apnea Destroyer By Edward Thiele I recently had the privilege to interview Dr. Jerry Hu on his incredible success using the PDAC Herbst appliance for his patients with obstructive sleep apnea. He wanted to share stories that will hopefully inspire other dentists to do the same, and notably, improve the world together. And to him, there’s no better Academy than ASBA to help him do that because it has the best platform and is the most recognized credentialing dental sleep organization by the government. With leading and forward-thinking dentists, ASBA will change the future! Some of the cases he was able to share with me he couldn’t believe the results himself. He told me that when those patients came to him with their results and the reports of how their life had improved, he felt like he was dreaming because they were really that amazing and life-altering. From changes in memory to weight loss, increased energy levels to dramatic improvements with bed partners and family life, he credits all of that by using the Herbst appliance with his recipe of sleep hygiene, nutrition, exercise and patience. The most important and essential pearl he added is the work needed to do the proper follow-through. But first, it begins with a thorough initial medical examination. This includes a review of patients’ medical history, medications, prior treatment and results. Also, current lifestyle, habits, sleep patterns, etc. all need to be assessed and documented. Getting a baseline of not just the sleep study results and diagnosis, but also the patient’s willingness to be compliant and to seriously focus on improving their quality of life altogether all matter equally. Ample time should be given to review and encourage each patient to follow protocol, and realistic expectations should be set. He reminds them that sleep should be one-third of our entire life, and quality sleep every night should be the goal. From an AHI standpoint, Dr. Hu has never been able to get such consistent results under 5.0 until he started to focus on PDAC FDA-cleared Herbst-style appliances. Moreover, he wants to emphasize that not all labs are equal in their Herbst design, experience, and even the type they ordered. He’s found, for example, certain German-made arms do much better than Italian-made ones. Also, understanding how to cut, fabricate and finish the appliances matters significantly. Seeing him lowering so many patients’ AHI levels below 5.0, I want to give him a nickname of “the Apnea Destroyer.” Patient Story Number One: This patient came to see Dr. Hu as a “Cold War Patriot” who worked many years at the nuclear test site in Nevada. So much radiation and as one can imagine, so many systemic issues came upon these hero veterans from their place of employment. When this patient arrived, he told Dr. Hu that most of his co-workers had already passed away, and he definitely wants to do all that he can to live longer and with better quality of life. His wife had been concerned for years on his sleep and breathing problems, and she also cannot rest or sleep well at night due to his condition. His medical history revealed he had obstructive sleep apnea for years and was lied to about his treatment by his sleep physician at a sleep center in Nevada. He was told that CPAP is the only treatment for him and was also told by the sleep physician that his oxygen desaturation going down to 81 WHILE USING CPAP was “normal.” After researching online and finding answers out for himself, he had lost faith and trust in the sleep center he went to. Additionally, he has polycythemia, silicosis, and signs of congestive heart failure with Cheyne-Stokes. His pulmonologist did rhinomanometry and several airway diagnostic tests and told him so much of his health problems stem from his sleep apnea. When the government referred him to Dr. Hu, as he was in-network, he felt it was a true blessing. Being told by his former sleep physician that there were no other alternatives, he felt passionate to prove him wrong. At one time, he had felt hopeless. But, he didn’t give up, and he can see that his other co-workers and friends who are still alive are needing the same treatment choices and the full truth on successful outcomes other than CPAP. His initial subjective reports included worsening memory and brain fog. He was starting to get concerned about his daily functions, and his wife had seen a substantial decline month after month. Even with CPAP, his oxygen desaturation went down to 81, and Dr. Hu reviewed with him the studies from Stanford University on beta-amyloid proteins, meningeal wash, and the connection to Alzheimer’s and dementia. Dr. Hu also discussed with him central sleep apnea, loop gain and CHF, and he definitely learned all the connections to sleep apnea. Working with his pulmonologist and having supplemental oxygen with a customized Herbst appliance therapy, he was ready to commit to Dr. Hu’s plan. So, after months of applying Dr. Hu’s recipe and using the Herbst appliance, he and his wife both came to report significant changes and amazing life improvements. His AHI at 19.0 went down to 0.0. His REM percentage went above 25% for the first time in years, and he now remembers having vivid dreams and wakes up with abundant energy. His minimum O2 was also at 91.4! He also had lost 20 pounds, exercises daily and tries to eat as healthy as possible. In an emotional testimony, he told Dr. Hu that his story needs to be shared with the world. **Post dental sleep Herbst treatment sleep study** Patient Story Number Two: This patient came to see Dr. Hu in one of his sleep clinics in Alaska. She drove over 70 miles to see him. She too, failed CPAP and had an awful experience at a local sleep center. She had an inconclusive polysomnogram and was told she had to do her initial sleep study in a hospital setting. She reported to Dr. Hu that she couldn’t even fall asleep because they were doing remodeling and construction at the building she was in, and although she complained, they didn’t care to help her out afterwards. She took it upon herself to look online and take matters into her own hands. That’s when she found Dr. Hu and was so glad she did. When she presented for her new patient exam, she was so exhausted. She had such intense daytime sleepiness, and she really wanted to know how bad her sleep was. Dr. Hu worked with another board-certified sleep physician to have her do a baseline home sleep study, and thank God she did one. She had severe OSA with an AHI of 71.6 and an ODI of 50.8 with oxygen desaturating to 80. Being of Medicare age, she was living a “tired and miserable” retirement life as she explained, and felt hopeless, too. Dr. Hu took the time to explain his recipe and the importance of titration/calibration. With patience, commitment and dedication to adherence for protocol, she had an outcome that was nothing short of incredible. With enthusiasm and energy, she told Dr. Hu that she had also visited family in California during late winter and had a chance to see another physician to do a sleep study as well, and everyone involved were amazed at the outcome of her Herbst PDAC appliance. Her AHI went from 71.6 down to a 3.4 and her ODI went down to a 0.7. Her minimum oxygen stayed above 90 and she reports feeling like a new person altogether! At her last follow-up visit, she seemed to continually smile and was so joyful and energetic. **Her sleep studies, before and after** Patient Story Number Three: This patient came to Dr. Hu as an active duty military personnel. Even though his sleep apnea was diagnosed as mild, he had serious daytime sleepiness and morning headaches affecting his day-to-day function. Dr. Hu understands that these soldiers who are serving our country need to be at their fullest potential, especially being deployed needing combat readiness at their ability to focus and be alert. This patient presented saying his wife also cannot stand his snoring, and he sometimes gasps for air at night. The noise wakes her up, and she gets profoundly worried. With an initial AHI of 8.9, after one titration with his Herbst appliance, he was so pleased with his treatment results that show his AHI down to 1.0. His sleep efficiency also improved to 97.7 and he reported that his wife is thrilled at how quiet he sleeps at night. He said to Dr. Hu, my wife told me, “I sleep like a baby,” and I wake up feeling so refreshed and full of energy. He said he wanted to share his experience with other military members and hopefully, it will become routine for dental sleep medicine options for sleep apnea in the armed forces. **After sleep result for patient number three** As a veteran myself, I, too, am so grateful for Dr. Hu and Gergen’s Orthodontic Lab for my Herbst sleep appliance. I find that he truly is a compassionate and thorough dentist. He has real passion and takes the time to do things properly and he followed up with me for my own Herbst and I love it so much compared to CPAP, which I was intolerant of. Although he has so many more Herbst stories to share with me, there is only so much room in a blog to write about. However, I am delighted to also announce that Dr. Hu has allotted time in his schedule to teach his “recipe” to the ASBA study club series. He will also teach medical billing and work with Nierman Medical Billing to help dentists and ASBA really change the world! Edward Thiele

Signup Here Timothy C. Adams DDS, D. ASBA, D. ACSDD Abstract The Ricketts oral appliance (referred to as the Cricket Appliance), rooted in Dr. Robert M. Ricketts’ bioprogressive orthodontic philosophy, exemplifies a holistic approach to craniofacial treatment. This paper presents a comprehensive review of the Cricket appliance’s clinical applications and theoretical underpinnings, integrating advanced concepts from epigenetics and mechanobiology to quantum biology, biotensegrity, fascial dynamics, mechanotransduction, cranial bone posture, airway physiology, neurobiology, and facial asymmetry. High-quality evidence from dentistry, medicine, and biological science is synthesized and distilled to demonstrate how the appliance’s function can influence gene expression, craniofacial growth, airway dimensions, and neurology in an irrefutably logical manner. The Cricket appliance emerges as more than a tooth-moving device: it is a catalyst for orthopedic change that resonates with the body’s integrated fascial systems. By uniting interdisciplinary science with clinical precision, this work reinforces the appliance’s role in promoting balanced craniofacial symmetry, airway health, and improved neurologic development and function. Treating the root cause instead of just the symptoms is what this appliance brings to the healthcare arena like no other appliance does. Introduction The stomatognathic (oral-facial) complex functions as a highly integrated system that contributes not only to mastication but also to breathing, swallowing, chewing, and even neurological behaviors.¹ Pioneers like Dr. Robert M. Ricketts recognized that dentofacial orthopedics must work and be governed “by the rules of nature,” acknowledging the interplay between craniofacial structures and the rest of the body, thus reinforcing my clinical treatment syntax of posture dictates airway and neurology.¹, ², 35 The Cricket oral appliance encompasses the device and techniques developed and inspired by Ricketts’ philosophy, which was designed to guide jaw growth and tooth position in harmony with biological principles. Ricketts emphasized light, continuous forces and functional orthopedics, aiming to alter the environment of the jaws to encourage natural adaptive growth. ³, ⁵ This was an early introduction to epigenetics before it caught on in the scientific community. In contrast to heavy-force techniques that “force teeth to positions desired and dictated by the operator,” Ricketts’ methods used lighter forces that permit the arches to adapt to individual tissues.⁵ This gentle, natural, and biologically body-friendly approach is consistent with modern insights into the body’s adaptive capacity, including concepts like quantum physics, epigenetic responsiveness, mechanotransduction, biotensegrity and myofascial integration.⁶, ⁸ Purpose and Scope In this review, we explore the Cricket oral appliance through multiple advanced scientific concepts. We first outline the appliance’s design and conventional clinical use. Then, in successive sections, we integrate eight interdisciplinary concepts – epigenetics, quantum biology, biotensegrity, fascial dynamics, cranial bone posture, airway influence, neurological signaling, and facial asymmetry – explaining how each relates to the appliance’s mechanism of action. We draw on peer-reviewed literature from orthodontics, craniofacial biology, and systems science to ensure each link is evidence-based and precise. ¹, ⁶, ⁸ Background: The Cricket Appliance and Bioprogressive Philosophy Design and Function The term Ricketts oral appliance generally refers to devices stemming from Ricketts’ Bioprogressive Therapy principles. We will focus on the Cricket and the new Open Loop Cricket (OLC). 35 (figures 1,2) Ricketts advocated early intervention in growing patients, using appliances to develop arch form, enhance tongue position, improve airway, enhance cranial posture, neurology and ultimately to improve occlusal relationships. ³, ⁵ He emphasized that slow, continuous development “tends to widen the nasal cavity at a pace at which bone can fill in,” avoiding traumatic suture splitting³. In the lower arch, light forces applied via a lip bumper or utility arch could harness natural muscle pressures to distalize molars and increase arch length. ³ By releasing restrictive pressures in one area and adding gentle pressure in another, the appliance aims to direct growth and tooth eruption in a favorable manner.³ This reinforces the biotensegrity principles explained later. Removing obstacles and creating gaps and spaces is the key to giving the body the ability to heal itself. Phonetic Bite and Mandibular Positioning In adults, Ricketts’ principles have been adapted for oral sleep appliances. Notably, the Ricketts Phonetic Bite technique is used to register the mandible’s ideal forward position for a sleep apnea appliance⁴. In this method, the patient sits upright and repeatedly vocalizes certain sounds (counting “55… 66…” etc.) while the clinician observes vertical and anteroposterior jaw movements⁴. Specific phonetic cues – e.g., the “s” sounds in 66 and “sh” in “shun” – guide the mandible to a natural forward posture that maximizes airway patency “the individuals so called “sweet spot”.⁴ Once this position is found, a bite registration is taken with a fast-setting material to capture it.⁴ The resultant mandibular advancement device, constructed at that position, will support the jaw forward during sleep to maintain an open airway.⁴ This example underscores Ricketts’ focus on functionally derived jaw positioning – using natural functional movements (speech in this case) to determine optimal appliance positions. Holistic Perspective Ricketts and his contemporaries (e.g., Rudolf Slavicek) viewed the dental occlusion as part of a larger system affecting breathing, posture, neurology, and even psychological stress. ¹ They were “ready to challenge conventional knowledge” and incorporate new scientific insights into orthodontics. ¹ This progressive mindset paved the way for today’s integration of interdisciplinary concepts. Below, we delve into those concepts – epigenetic regulation, quantum-level phenomena, tensegrity-based anatomy, fascial continuity, cranial sutural biology, airway physiology, neural signaling, and asymmetry correction – and relate them back to the Ricketts appliance framework and the open loop cricket. 35 Epigenetics and the Appliance’s Gene-Environmental Interactions Concept Overview Epigenetics refers to heritable changes in gene expression that do not involve alterations of the DNA sequence via transduction, transcription and translation. In the context of craniofacial development, epigenetic mechanisms allow environmental signals (Quantum Physics) and functional factors to influence how genes orchestrate growth. Dental and skeletal patterns are not dictated by genes alone; rather, they result from “complex interactions between genetic, epigenetic and environmental factors” over time.⁶ For example, nutrition, muscle function, breathing patterns, chewing and oral habits can modify the expression of genes related to jaw growth and tooth development. ⁶ This means an appliance that alters functional inputs (like tongue posture or mandibular position) can trigger biological responses at the cellular level – effectively an epigenetic orthodontic effect. ⁷ ⁸ Epigenetic Orthodontics in Action Modern clinicians have leveraged this principle with appliances designed to stimulate latent growth potential in adults. Singh and colleagues introduced the Daytime-Nighttime Appliance (DNA appliance) and coined the term “craniofacial epigenetics” for its mode of action. ⁷, ⁸ Worn only at night, the DNA appliance alters oral function (by intermittently expanding the arches and repositioning the jaw) and is hypothesized to induce a gene–environment interaction that expresses genes which had remained dormant after puberty. ⁷, ⁸ Case studies using 3D imaging found that such appliances can indeed produce increases in arch width, airway volume, and even new bone formation in sutures of non-growing adults. ⁷ The only plausible explanation for these changes in adults is the activation of gene expression (e.g., upregulating bone morphogenetic proteins or other growth factors) – an epigenetic response as Belfor noted in 2010 utilizing the Homeoblock appliance. ⁸ In essence, by changing the patient’s oral environment (jaw posture, tongue space and position, occlusal arch alignment), the appliance activates developmental pathways that in adulthood had been silenced. Ricketts’ Environmental Paradigm Decades before the term epigenetics was popular in dentistry, Ricketts intuitively grasped the environment’s importance. Ricketts spoke of “alteration of growth patterns” by “alteration of the environment” as a goal of treatment. ³ For instance, using a Frankel functional regulator (a tissue-borne appliance), he aimed to modify muscle forces and posture to encourage jaw growth in a favorable direction.³ Such functional appliances relieve restrictive pressures from cheeks or tongue and add new stimuli to bones and teeth, effectively remodeling the neuromuscular environment of the face. The resulting orthopedic changes – increased arch width, differential jaw growth, improved occlusion – can be seen as epigenetic outcomes because they arise from changed signals from the environment to the genome (via mechanotransductive pathways described later). A contemporary review by Brook (2009) affirms that multiple genetic pathways and epigenetic factors like local functional matrices all converge to shape dental development. ⁶ Appliances harness these principles by manipulating the functional matrix: for example, developing a narrow palate in a mouth-breather can epigenetically promote nasal breathing, which in turn can stimulate more normal maxillofacial growth patterns. ⁶ Summary The Ricketts appliance framework aligns with epigenetic orthodontics concepts by using environmental modification as a treatment tool. It recognizes that by changing how jaws posture or how forces distribute (through an appliance via light cyclic intermittent forces), we can induce favorable gene expression changes – ultimately yielding stable orthopedic corrections rather than just transient tooth movements. ⁶, ⁸ Quantum Biology: Fundamental Biophysics of Craniofacial Change Concept Overview: Quantum biology is an emerging field examining how quantum mechanical phenomena (such as particle-wave duality, entanglement, and tunneling) influence biological processes. 9 At first glance, quantum physics might seem far removed from dentistry and orthodontics in particular; however, biology operates at the molecular level where quantum effects are extremely impactful. For example, enzymes often rely on quantum tunneling for electron transfer, and photosynthesis efficiency is explained by quantum coherence in energy transfer. 9 In general, quantum biology explains how certain biological functions exploit quantum mechanics to achieve outcomes that classical Newtonian physics alone cannot explain. 9 These phenomena are being explored in contexts like circadian rhythm regulation, neurobiology, and DNA mutation processes.9 Understanding quantum biology encourages us to consider the craniofacial system at the most basic physical and molecular level, explaining the many dogmas that we have been taught that never made sense. Piezoelectricity and Biophysical Signals: One strong quantifiable relationship between quantum biophysics and orthodontics is the piezoelectric property of bone and collagen. Bone is a crystalline matrix that generates electrical currents when mechanically stressed (the piezoelectric effect) – a phenomenon discovered in the 1950s by Fukada and Yasuda. Research has implicated these stress-generated electric signals in activating bone remodeling cells during orthodontic tooth movement.10 In essence, when an appliance exerts force on teeth and alveolar bone, it not only causes deformation but also produces an electrical cue that osteocytes and other cells can detect. Depending on the type of force (static or light cyclic intermittent), this electrical signal transduction operates at the interface of Newtonian and quantum physics: it involves electron movement in the bone’s crystal lattice and ion channel activation in cells, processes governed by electromagnetic and quantum principles. Orthodontic experiments have confirmed that electrically charged regions coincide with bone formation (osteoblasts) on the tension side and resorption (osteoclasts) on the pressure side of a tooth during movement.10 Thus, a Ricketts appliance subtly harnesses these biophysical cues – that apply light cyclic intermittent forces to induce an orchestrated cascade of events, from electrons to cells to proteins to tissue. The key to this cascade of events is the light cyclic intermittent forces that move with the fascia, cranial bones and cellular respiration. Quantum Perspective on Mechanotransduction: Mechanotransduction (detailed in a later section) is fundamentally the conversion of a mechanical signal/stimulus into a biological signal. On the smallest scales, this involves proteins changing conformation, ions flowing, and even photons in some cases (e.g., light-based therapies). Quantum biology reminds us that at these scales, energy and matter behave in quantized ways. For instance, the opening of a mechanosensitive ion channel in the cell membrane (like Piezo1 in a periodontal ligament cell) might depend on the quantized energy states of that protein or the tunneling of ions through a gate. 11 While these details are still under investigation, the irrefutable logic is that biology cannot escape the laws of physics. By acknowledging quantum-level interactions, we appreciate that an orthodontic appliance’s influence permeates down to the cellular and atomic level – electrons shifting in hydroxyapatite, protons moving in collagen hydrogen bonds, etc. Notably, Melvin Moss (who developed the functional matrix hypothesis) later speculated on a “quantum biology” view of development, hinting that the very blueprint of facial growth might involve quantum processes beyond classical gene-environment paradigms.12 As Mazzoccoli (2022) describes, quantum biology provides theoretical frameworks suggesting quantum entanglement and coherence which could have functional roles in all living systems.9 Clinical Implications: In practice, dental clinicians are beginning to leverage biophysics by utilizing lasers via photobiomodulation (low-level laser or LED therapy, DEKA Lasers) to accelerate tooth movement. Photobiomodulation works by delivering photons that are absorbed by mitochondrial chromophores, enhancing cellular energy output and remodeling – a process that straddles quantum (photon absorption) and biological domains. Additionally, technologies like vibration devices apply high-frequency signals that may resonate with cellular mechanosensors, potentially influencing bone remodeling via piezoelectricity or fluid dynamics at the quantum level.13 While the Cricket appliance itself is technically a mechanical device, its optimal use may involve combining it with such modalities to maximize tissue response. The key takeaway is that on a theoretical level, appliances engage quantum-mechanical processes (even if indirectly), and future refinements in appliance therapy could involve more direct targeting of those processes (for example, appliances embedded with light sources, acrylic pads 35 or piezoelectric stimulators to encourage bone formation in specific areas). In summary, quantum biology offers a foundational perspective reinforcing that an appliance’s effects run much deeper than visible tooth movements. They initiate a cascade of events from macro-scale force application to micro- and nano-scale events – many of which are governed by quantum laws. Recognizing this continuum enhances our precision and opens avenues for innovative, anatomical and science-based treatments, ensuring that the Cricket appliance framework and function remains aligned with the cutting edge of biological science 45 years later. Biotensegrity: The Craniofacial Skeleton as a Tensegrity Structure Concept Overview Biotensegrity is a model of anatomical architecture viewing the body as a tensional- compression structure – a system of compression elements (bones, teeth) suspended in a continuous tension network (muscles, fascia, ligaments, tendons). ¹⁴ In a tensegrity structure, forces distribute optimally: when one part moves or is stressed, the entire structure rearranges tension and compression to maintain overall stability. This concept, introduced by Stephen Levin and others, provides a unifying theory for how the body maintains form and adapts to external loads. ¹⁵, ¹⁶ In the craniofacial region, biotensegrity implies that the jaw, hyoid, cranial bones, and spine form an interconnected scaffold via soft tissues. The bones literally float in a sea of soft tissue (fascia). Changes in jaw position, tongue position and occlusion could thus be transmitted through fascial and muscular chains to distant sites such as trigger points and referral pain zones (e.g., occiput, C1, C2, C3 connected to the sacrum via the dura), and vice versa, as part of one global postural system. Relevance to the Cricket Appliance The Cricket applies light cyclic intermittent forces intended to enact change not just in isolated teeth but in the relationships to cranial bones and the whole biotgensegrity body. Under a biotensegrity paradigm, a gentle development of the maxilla (for example) is accommodated by changes in the connected tissue network (fascia) – the cranial bone positions change, zygomatic bones rotate slightly, the mandible shifts to a new position via temporal bone repositioning, and cervical posture may even alter to rebalance the head (head tilt). Rather than viewing these as separate side effects, biotensegrity views them as integrated responses to maintain equilibrium and stability. ¹⁵ Ricketts intuitively leveraged this: he noted that arch development in a growing child often led to spontaneous adjustments in tooth alignment and jaw posture without direct force on every tooth (via proper tongue positioning). ² By “releasing pressure on one site and shifting pressure at other sites,” the appliance taps into the innate biotensegrity of the craniofacial complex. ² Ricketts also minimized the use of rigid full-arch bands in early treatment, preferring sectional mechanics that let teeth and bones find a balance under lighter forces. ², ¹⁷ This approach aligns with biotensegrity: heavy rigid appliances could “force” an unwanted configuration (risking strain concentration and exacerbating cranial strain patterns), whereas lighter cyclic intermittent forces let the system self-adjust through the tensional continuum. ¹, ⁷ Fascintegrity and Myofascial Chains Recent expansions of the tensegrity idea include “fascintegrity,” which incorporates the liquid components (blood, lymph) into the model, and the mapping of myofascial meridians (chains of muscles/fascia running through the body). 14 For instance, the deep front line is a myofascial chain that connects the jaw’s muscles (such as pterygoids), through the neck, diaphragm, all the way to the pelvic floor and feet. ¹⁷ According to this concept, a forward head posture or jaw displacement can induce compensatory changes in lower body posture via fascial connections. In dentistry, this raises awareness that correcting a malocclusion might also alleviate certain postural problems or muscular tension patterns. Indeed, some clinicians have reported that expansion or functional appliances led to improved head and neck posture or reduced tension headaches, presumably by normalizing strain in the myofascial network. While evidence is mixed, some associations have been documented: e.g., children with retruded jaws often exhibit forward head/kyphotic posture, and improving the jaw position (via functional appliances) can sometimes normalize the head posture.18 This is in sync with biotensegrity – change one part of the tension network and the rest responds. Evidence in Orthodontics A 2020 review by Bordoni and Myers emphasizes that fascia (solid and liquid) plus tensegrity models are crucial for understanding posture and movement. ¹⁴ They note that fascia can transmit tension across long distances, meaning a localized intervention (like an oral appliance) may have system-wide effects. ¹⁹ In reviewing orthodontic research, some studies have sought to correlate occlusal traits with posture. A systematic overview (Michelotti et al., 2011) found some associations – for example, certain malocclusions related to altered head or spine posture – but it cautioned that cause-effect is not firmly established. ²⁰ However, another clinical study in children found a significant correlation between a low SNB angle (mandibular retrognathia) and kyphotic (hunched) body posture. ¹⁸ Moreover, those children with airway obstruction (enlarged adenoids) had a higher prevalence of kyphotic posture, linking craniofacial structure, airway, and whole-body alignment.¹⁸ When a Cricket appliance develops the maxilla and opens and tones the airway via improving tongue posture, it could therefore also encourage a more upright posture by alleviating nasopharyngeal blockage (thus the child no longer needs to tilt the head to breathe). ¹⁸ The tensegrity model helps conceptualize these multi-region improvements as part of one biomechanical system returning to balance. Summary Biotensegrity provides a biomechanical rationale for the holistic effects seen with Cricket appliances. It suggests that rather than acting on teeth alone, the appliance introduces light intermittent cyclical forces that the entire craniofacial-body system redistributes via biotensegrity, mechanotransduction and fascia, yielding changes in bone positions, soft tissue tensions, and posture that complement the dental corrections. Appreciating and understanding these concepts can guide clinicians to use Cricket appliances in conjunction with physiotherapy, breathing exercises, or body posture work, aiming for optimal systemic balance. Fascial Dynamics and Craniofacial Orthopedics Concept Overview The fascial system is the continuous web of connective tissue with no beginning or end, enveloping bones, teeth, muscles, tendons, ligaments, nerves and organs. It has both superficial and deep layers, and it plays a dynamic role in transmitting mechanical forces and providing proprioceptive feedback. Fascial dynamics refers to how this network moves, adapts, and can become restricted or released. In dentistry, fascial considerations have gained attention because head, neck, and jaw structures are invested in fascia that connects to the rest of the body (as noted with myofascial chains above). Chronic malocclusion or TMJ dysfunction can lead to strain in certain fascial planes (e.g., tightness in the suprahyoid muscles’ fascia), while conversely, fascial tightness in the neck or shoulders can reflect on jaw position. Techniques like craniosacral therapy or myofascial release are sometimes used adjunctively to ease restrictions in cranial sutures or muscles to facilitate dental changes. ¹⁴, ¹⁶ Cricket Appliance Influence on Fascia The Cricket appliance, by changing the position of bones and teeth, inevitably applies new tension to the fascia. For example, advancing the mandible (as in Class II correction) stretches the muscles and fascia of the suprahyoid area and floor of mouth. Over time, this can strengthen and adapt those structures, which might have been functionally shortened in a retrognathic posture. Likewise, developing the maxilla not only moves cranial bones but also stretches the palatal mucosa and the attached periosteum – a fascial layer covering bone. This could stimulate fibroblast activity and new collagen deposition as part of the adaptation. A study on ALF (Advanced Light Wire Functional) appliances, which are very light wire developers, reported correction of both facial and postural asymmetry in a 12-year-old patient, attributing success in part to relieving cranial and fascial strains.²³ The ALF, a direct descendent of the Cricket, also utilizes light wire philosophy by applying light intermittent forces; the authors noted improved facial symmetry and head posture after treatment, implying that the facial fascia and musculature repositioned along with the dental changes.²³ The fascia also houses many proprioceptors and stretch receptors. As teeth move and jaws reposition, these receptors fire, sending signals to the central nervous system about the new jaw relationships. Over the course of treatment, the patient’s neuromuscular system “learns” the new correct position as the fascia/muscle tension balances out. This is why retention and stability in orthodontics often depend on a period of neuromuscular adaptation – essentially, the fascial and muscular elements must settle into the new equilibrium to hold teeth in place with the help of tongue posture, which is critical. ²⁰ Interdisciplinary Approaches Modern practitioners sometimes collaborate with osteopaths or physical therapists when treating complex cases with appliances. An appliance might be used in conjunction with exercises that target cervical and jaw musculature or with myofunctional therapy (which trains the tongue posture and orofacial muscles). The underlying logic is to engage the fascial and muscular system in support of the skeletal changes. For instance, a narrow maxilla often correlates with a high-arched palate and a low tongue posture (the tongue not resting in the palate). The low tongue, in turn, is part of a fascial and muscular pattern that can involve a forward head posture and neck muscle strain. This also affects the tone of the airway. By developing the maxilla (with a Cricket, OLC), we create room for the tongue to rise, and concurrently teaching the patient proper tongue posture can reinforce this development. This synergy ensures that the fascia and muscles (like the tongue’s connections to the palate via the palatal aponeurosis, and to the hyoid via lingual fascia) adapt to support the new dental arch form. ¹⁴, 35 Evidence and Clarity It must be noted that while many clinical observations support fascial involvement, rigorous scientific evidence is still developing. A critical review in Progress in Orthodontics noted that performing orthodontic treatment solely to address posture or vice versa is not yet evidence based. ²⁰ However, it acknowledged that “some associations have been found between occlusal factors and postural alterations”. ²⁰ Rather than viewing this as a direct cause-effect, it may be that certain patterns of malocclusion and body posture share common developmental origins or reciprocal influences. What is clear is that a comprehensive approach to a patient – evaluating not just teeth alignment but also breathing patterns, head position, cervical spine alignment, and even gait – can reveal patterns that recognize and dictate treatment. Ricketts was ahead of his time in this regard, considering “the future size and form of the face” and even overall patient growth in treatment planning. ² His visual treatment objective (VTO) process would predict where jaws should be at maturity and guide appliance therapy accordingly, inherently an integrative outlook.21 In Practice Acknowledging fascial dynamics means that adjusting an appliance more gradually will allow soft tissues to adapt and incorporate exercises or adjunct therapies to relieve any strain. It embodies the principle “primum non nocere” (first, do no harm) by ensuring that as we allow cranial facial system to unwind and reposition, we are not creating unintended stress elsewhere – i.e., Biotensegrity. The result is a more comfortable treatment and often a healthier overall outcome, with patients experiencing improvements in not just facial muscle tension or even breathing, but the whole body. In Biotensegrity, if one part of the body is affected, the rest of the body is too. ¹⁴ Cranial Bone Posture and Sutural Adaptation Concept Overview The human skull is composed of numerous bones joined by sutures—fibrous joints that allow a tiny degree of movement and growth. Cranial bone posture refers to the positional relationships of those bones (e.g., how the maxillae is connected to the palatines bones, sphenoid bone and occiput etc.). The human skull consists of twenty-nine bones: eight cranial bones, fourteen facial bones, and seven additional bones including those of the inner ear and the hyoid bone. Cranial bone movement is dictated by sutural anatomy and by pressure from the cerebrospinal fluid (CSF), which circulates throughout the spinal cord and brain within the dura mater. CSF is critical for oxygenation and nourishment of the brain and spinal cord, eliminating toxins and cooling the pituitary and hypothalamus, which regulate hormones. ²² The cranial bones are classified as paired or midline, depending on whether they cross the midline. In early development, cranial sutures are highly malleable, permitting skull expansion and contraction to accommodate brain and facial growth. Traditionally, it was thought that sutures fuse by late adolescence, rendering bone positions fixed. However, evidence suggests most sutures (e.g., the midpalatal suture and some at the cranial base) retain remodeling capacity into adulthood. ²² Ricketts Appliance and Cranial Sutures During Ricketts’ era, adult expansion without surgery was rare. However, in growing patients, Ricketts strongly advocated sutural expansion. He described how quad-helix or activator appliances influence not only tooth alignment but maxillary and mandibular growth relative to the cranial base.² Expanding the maxilla stresses circummaxillary sutures (connecting the maxilla to the palatine, zygomatic, temporal, and sphenoid bones), allowing the maxilla to “uncouple” slightly and adopt a broader posture. Cephalometric studies show that orthopedic expansion in youth can produce slight “disimpaction” of the maxilla, with downward and forward movement that may improve Class III relationships or increase airway volume. ² Ricketts also utilized high-pull headgear to redirect maxillary growth relative to the cranial base, another example of orthodontic modulation of cranial bone posture. ² Modern CBCT studies confirm that rapid maxillary expansion separates not only the midpalatal suture but also adjacent cranial sutures (e.g., zygomatico-maxillary, fronto-maxillary) and slightly opens the pterygoid plates from the sphenoid. ²² This confirms cranial bones are not rigidly immobile; dental appliances can modify their relationships. It needs to be noted with caution that if malposition cranial bones are not allowed to be freed up before the expansion occurs the cranial strains can be exacerbated. Osteopathic concepts of cranial strain patterns suggest that even adults exhibit subtle cranial bone micro-mobility tied to the breathing cycle, susceptible to maladaptive “strain patterns” after trauma, aggressive orthodontics, or chronic dysfunction. Lightwire or functional appliances (OLC) have been shown to relieve such cranial distortions by balancing asymmetric forces in the mouth and face. 35 Another clinical example is the ALF case report by Strokon (2010) demonstrating improved dental alignment accompanied by increased cranial symmetry visible on radiographs. ²³ Airway and Cranial Posture Cranial bone posture notably affects airway dimensions. A retruded maxilla or high-arched palate (common in long, narrow faces) reduces nasal cavity volume, increasing nasal airflow resistance because the palate forms the floor of the nasal cavity. Altering maxillary posture by expansion and advancement enlarges the nasal cavity. ²⁴ Singh et al. (2016) demonstrated significant nasal cavity volume increase in adults after biomimetic oral appliance therapy (from ~42 cm³ to ~44 cm³ on average), corresponding to subtle cranial bone repositioning that widens the nasal floor and lateral walls, thereby facilitating nasal breathing. ²⁴ Ricketts noted that slow palatal development in youth widens the nasal cavity and prevents mouth-breathing, which is associated with open-mouth and forward-head posture compensations that negatively affect jaw, hyoid, and cervical spine relationships.² Addressing cranial bone posture through appliances that develop the palate and advance the mandible can break this vicious cycle, improving posture, tongue positioning, airway, and neurological function. Cranial Base Angles Ricketts’ cephalometric analysis included assessing cranial base angles (e.g., saddle angle), which influence jaw relationships. Appliance therapy may induce adaptive growth changes at synchondroses (cartilaginous joints in the cranial base). For instance, Class III correction combining expansion and chin cup might slightly increase the cranial base angle, mitigating mandibular prognathism tendencies. Iwanicki et al. (2022) reported successful camouflaging of mild Class III malocclusion with asymmetry using Ricketts’ non-surgical approach, implying orthopedic jaw positioning favorably influenced cranial base growth. ²¹ Summary Cranial bone posture is both an influencer and target of the Cricket appliance. Correct appliance application can improve cranial strain patterns detrimental to systemic health by harnessing remaining sutural growth or inducing adult sutural adaptation. This results not only in occlusal improvement but also enhanced airway dimensions and a balanced craniofacial complex with potential neurological benefits, exemplifying the interdisciplinary orthodontic approach championed by Ricketts. ² Airway Influences of the Ricketts Appliance Concept Overview The relationship between craniofacial posture, the upper airway, and neurology is becoming increasingly central in dentistry and sleep medicine. Constricted dental arches, retrognathic jaws, or high palates can narrow the airway, contributing to obstructive sleep apnea (OSA) by reducing nasal or pharyngeal space.²⁴ Conversely, jaw development or advancement often improves airway patency. Airway-focused orthodontics, sometimes called pneumopedics, utilizes appliances to remodel airway-supporting structures. Since there are twelve cranial nerves that exit through the cranial bones, it stands to reason the wedged, restricted malpositioned cranial bones have a direct effect on their function (i.e. five cranial nerves go through the sphenoid bone alone). The Cricket appliance inherently affects the airway: by developing the palate, it enlarges the nasal floor; by advancing the mandible (as in Class II correction or OSA devices), it increases pharyngeal airway space. This anterior mandibular positioning allows the tongue a more forward posture, enhancing airway tone, size and neurology via Vagus( X) nerve activation. Evidence of Airway Improvement Numerous studies and meta-analyses confirm that rapid maxillary expansion (RME) alleviates nasal obstruction and mild pediatric OSA. ²⁵ A recent systematic review (Hariharan et al., 2025) found RME effective in reducing apnea-hypopnea index (AHI) and improving oxygen saturation in both pediatric and adult OSA patients. Especially in children with maxillary deficiency, RME often resolves OSA, validating it as a genuine pediatric treatment. ²⁵ The mechanism involves widening the nasal cavity and improving tongue posture by expanding palatal space. However, relapse can occur in approximately 40% of cases, underscoring the importance of considering and addressing cranial bone posture initially. If maxillary expansion improves airway volume but cranial strain patterns remain untreated, systemic balance may worsen, negatively affecting overall health and exacerbating the existing cranial strain pattern. In adults, combining mandibular advancement with expansion represents a new frontier. The Ricketts phonetic bite method helps locate the individual’s optimal mandibular forward position to maximize airway openness. ² Mandibular advancement devices (MADs) built using this position effectively reduce snoring and mild-to-moderate OSA by pulling the tongue and soft tissues forward, enlarging the retroglossal airway. ²⁶ MADs can reduce AHI by approximately 50% in suitable patients and improve nocturnal oxygen saturation. ²⁶ Airway-Appliance Interaction The Cricket appliance’s influence on jaw morphology impacts airway health long-term. Maxillary development in children promotes nasal breathing and proper craniofacial growth by encouraging tongue-palate contact and forward facial growth. ² Ricketts advocated arch development and non-extraction approaches partly to maintain airway space, as extractions in high-angle, small mandible cases can exacerbate airway constriction. ² Functional appliances like the Cricket, by posturing the mandible forward during growth, increase pharyngeal airway dimensions. ²⁴ Cephalometric studies show that after 12+ months of functional appliance therapy, upper airway space behind the soft palate increases in teens. Early airway intervention can break mouth breathing cycles, preventing maxillary constriction and mandibular retrusion. Quantitative Insights Singh et al. (2016) observed a ~5% nasal volume increase in adults following approximately 18 months of Biomimetic Oral Appliance Therapy²⁴. Additional studies report modest increases in nasal valve area and decreases in nasal resistance following RME in children. ²⁵ Villa et al. (2011) demonstrated that pediatric OSA improvements from RME persist two years post-treatment, suggesting durable orthopedic airway benefits. ²⁵ Imaging clearly shows these changes: pre- and post-treatment CBCT scans display a widened nasal floor and more parallel nasal cavity walls; lateral cephalograms reveal increased superior oropharyngeal airway space when mandibular advancement devices are in place. Conclusion Airway improvement is a crucial benefit of the Cricket appliance within a dentist’s therapeutic armamentarium. Treatment planning that prioritizes aesthetics, occlusion, airway function, and cranial strains aligns with Ricketts’ comprehensive care ethos. Palatal expansion in growing patients and mandibular positioning in adults enjoy strong evidence for airway benefit. ²⁴, ²⁵ Neurological Signaling and Mechanotransduction in Appliance Therapy Concept Overview The Cricket appliance induces changes by engaging both the nervous and skeletal systems. Neurological signaling occurs on multiple levels: (1) peripheral mechanoreceptors and proprioceptors sensing forces and tooth movements, (2) central processing of these signals modulating muscle activity, and (3) cellular signaling pathways, which intersect with neural inputs via neuropeptides and neurotransmitters. ²⁸ The periodontal ligament (PDL) and temporomandibular joint (TMJ) are richly innervated with mechanoreceptors (such as Ruffini endings and periodontal pressoreceptors) detecting pressure and stretch, alongside nociceptors sensing pain from excessive force. ²⁸ When an appliance applies force, these receptors transmit information about force magnitude and direction to the trigeminal nucleus in the brainstem. ²⁹ Reflex arcs adjust jaw muscle activity accordingly—for instance, excessive force can trigger nociceptive reflexes that reduce masticatory muscle activity to protect teeth, while properly calibrated forces enhance proprioception and muscular coordination. ²⁸ Reflex arcs then influence jaw muscle activity – for instance, heavy orthodontic force or a high bite can trigger a nociceptive reflex reducing masticatory muscle activity to protect the teeth (this is akin to a jaw-opening reflex). Conversely, a well-tuned appliance like the Cricket can stimulate proprioceptors in a way that enhances muscular coordination and tone. The body will respond to forces that are desirable and natural not forced. Mechanotransduction at the Cellular Level Mechanotransduction describes how cells convert mechanical stimuli into chemical signals. In orthodontics, PDL cells and osteocytes sense mechanical strain and release signaling molecules mediating bone remodeling. ²⁸ The Piezo1 ion channel, a mechanosensor in PDL cells, opens in response to stretching, allowing calcium influx and triggering bone formation cascades on the tension side. ²⁸ Jiang et al. (2021) showed that blocking Piezo1 in an animal model reduced orthodontic tooth movement and was associated with lower expression of osteogenic factors like RUNX2 and Osterix. Blocking Piezo1 reduces tooth movement and osteogenic factor expression, confirming its role in transducing mechanical forces into biological responses. ²⁸ This confirms that the mechanical force from an appliance is sensed and transduced by specific cellular pathways, which then orchestrate the deposition or resorption of bone necessary for tooth movement. Notably, some of these pathways involve neurological molecules too: PDL cells and osteoblasts can release neurotransmitter-like substances (e.g. ATP, nitric oxide) upon mechanical stimulation, which modulate blood flow and nerve activity in the area. ²⁹ Trigeminal Nervous System Effects The trigeminal nerve (cranial nerve V) is the primary sensory nerve for the face and jaws. It has extensive connections in the brainstem (trigeminal nucleus) which is linked to the autonomic nervous system and pain modulatory systems. Chronic static orthodontic forces or a new mandibular position can alter trigeminal input patterns. This can have seemingly unrelated effects such as changes in body posture (through trigeminal-cervical reflexes) or even cardiovascular responses (through trigeminal-parasympathetic reflexes). For example, it’s documented that stimulation of trigeminal afferents (like cooling the face or pressure on teeth) can cause reflex bradycardia – the so-called trigeminal cardiac reflex. ²⁸ While we traditionally think of an orthodontic appliance is a benign stimulus, it still constantly feeds information to the brain about jaw position. Over time, a new occlusion “feels normal” to the patient as the sensory cortex adapts to the new proprioceptive inputs. ²⁸ Functional appliances in growing patients not only reposition jaws but retrain neuromuscular patterns. Electromyographic studies show changes in resting masticatory muscle activity after Herbst or twin-block treatments, indicating improved muscle tone symmetry and coordination. ²⁸ Ricketts observed that improved occlusion (e.g., aligning incisors, correcting overbites) often reduces jaw fatigue and headaches, reflecting neural and muscular harmony. This is partially a neural effect: muscles were firing more symmetrically and efficiently after treatment, reducing strain. Pain and Inflammation Signaling One cannot discuss neural aspects without mentioning pain. Orthodontic tooth movement does cause transient inflammatory pain – typically one or two days after an adjustment, patients feel soreness due to PDL inflammation. This involves nociceptive neurons releasing neuropeptides like substance P and CGRP (calcitonin gene-related peptide) in the PDL, which increase blood vessel permeability and recruit immune cells. Interestingly, these same neuropeptides also influence bone remodeling: CGRP, for instance, can enhance osteoblastic activity. Nociceptor signaling via the trigeminal nerve thus might directly modulate the rate of tooth movement, an area of ongoing research. ²⁹ If an appliance is adjusted too aggressively and causes excessive pain, the heightened nociceptive input could paradoxically slow tooth movement by inducing a stronger inflammatory response and causing patient to chew differently (avoiding bite, etc.). Ricketts was aware of managing patient comfort – his light-force approach minimized pain, which not only is kinder to the patient but potentially more physiologically efficient for movement (since extreme pain/inflammation is not optimal for controlled remodeling). ²⁹ Central Integration Brain plasticity allows prolonged occlusal changes to reshape somatosensory cortex representations of the jaw and teeth. Functional MRI and somatosensory evoked potential studies confirm cortical remapping after orthodontic treatment. ²⁸ Appliances such as the Gelb or Tanner splints help reduce parafunctional muscle activity by neuromuscular reprogramming.²⁸ Cranial strain patterns significantly impact TMJ health; uncorrected temporal bone misalignment can perpetuate pathology even after occlusal adjustments.²⁸ Summary The Cricket appliance influences a broad neurological signaling spectrum: from Piezo1-mediated mechanotransduction in PDL cells to trigeminal reflexes modulating muscle tone and cortical plasticity adapting to a new bite. Precision and gradual adjustments are vital to harness favorable neural responses, ensuring stable and comfortable treatment outcomes supported by the patient’s neuro-musculoskeletal system. By leveraging favorable neural responses (like enhancing proprioceptive input for stability and minimizing nociceptive input), the appliance can achieve stable and comfortable results that the patient’s nervous system will help maintain. Facial Asymmetry: Diagnosis and Appliance-Based Correction Concept Overview Facial asymmetry includes dental midline discrepancies, jaw size or positional differences between sides, cranial bone malpositioning, posture issues, airway restrictions, neurological dysfunction and muscular imbalances. Causes may include unilateral crossbites, habitual postures, or developmental anomalies. It is essential to differentiate between dental asymmetry (teeth misaligned within symmetric jaws) and skeletal asymmetry (unequal jaws or cranial base) for effective treatment planning. ³³ Ricketts emphasized early treatment of unilateral crossbites—using appliances like the quad-helix or expansion plates—to prevent functional mandibular shifts that can cause asymmetric growth. ³¹ His records routinely incorporated lateral photographs and frontal cephalometric analyses to assess asymmetry, highlighting the need for individualized, side-specific force application during therapy. ³¹ Clinical Evidence Strokon’s 2010 case report using the Advanced Lightwire Functional (ALF) appliance detailed correction of a facial asymmetry associated with cranial torsion. Besides dental improvement, the case demonstrated enhanced facial symmetry and head posture, suggesting the appliance’s effect extended beyond teeth to muscular and skeletal systems. ³² While such case studies are low-level evidence, they illustrate the potential for functional appliances to influence overall facial balance. Treatment Strategy Successful facial asymmetry correction with Cricket appliances relies on light intermittent cyclical forces, removing obstacles and creating gaps or spaces to allow the body to achieve more balance and function. Understanding individual growth patterns and skeletal discrepancies enables clinicians to customize appliance adjustments rather than using uniform force protocols. ³¹ This approach aligns with Ricketts’ patient-centered philosophy, focusing on the unique biomechanical needs of each patient. Recent literature supports that, with careful execution, removable functional appliances can harmonize facial symmetry and occlusion without surgical intervention. ³¹ These findings validate the comprehensive, interdisciplinary framework pioneered by Ricketts, reinforcing the appliance’s capacity to address complex asymmetries. Summary Facial asymmetry correction with Cricket appliances is feasible and effective when guided by precise diagnosis and individualized force management. Integrating cephalometric and photographic analyses into treatment planning enables clinicians to correct skeletal and dental discrepancies while promoting improved balanced muscle function, posture, airway and neurology. The approach exemplifies the logical and integrative orthodontic philosophy that underpins the Cricket appliance system. ³¹ Conclusion The Cricket oral appliance framework stands as a testament to interdisciplinary orthodontics – an approach that transcends mere tooth alignment to engage growth biology, physics, and whole-body health. In this review, we explored how a single appliance system can interweave with epigenetic mechanisms, harnessing gene-environment interplay to unlock latent developmental potential. 8 We saw that by acknowledging principles of quantum biology, such as piezoelectric signaling in bone, we gain an appreciation for the deep physical processes an orthodontic force can initiate. 10 We affirmed that the craniofacial system operates on a model of biotensegrity, wherein an adjustment in one part (like maxillary expansion) redistributes tension throughout the connected musculoskeletal network. 14 We examined fascial dynamics, noting that the success of orthopedic corrections often depends on the adaptive capacity of soft tissue and the reprogramming of muscle patterns.19 The appliance’s effect on cranial bone posture and airway was highlighted by evidence of suture expansion improving nasal breathing and pharyngeal space. 2 We delved into neurological signaling, from mechanotransduction in PDL cells to reflexes and central plasticity, which collectively ensure that the changes wrought by the appliance are integrated and stabilized in the patient’s nervous system. 11 Finally, we addressed facial asymmetry, demonstrating that meticulous appliance design and force management can successfully correct imbalances, yielding symmetric form and function. 31 Through detailed protocols, we translated these concepts into actionable steps, emphasizing “irrefutable logic” at each stage – such as widening a narrow palate to remove functional matrix constraints on nasal breathing (a logical cause-effect supported by literature) or incrementally advancing a jaw to allow neuromuscular adaptation (respecting biologic limits to ensure precision in outcome). The use of high-quality sources from orthodontics, sleep medicine, and anatomy strengthened each argument: for instance, citing the meta-analysis confirming RME’s efficacy in OSA 31, or the Cureus review on fascia underlining how global the impact of local interventions can be. 14 In conclusion, the Cricket appliance is not an obsolete relic but rather a versatile and valuable part of the armamentarium for natural holistic whole-body treatment. It embodies dentistry’s evolution into a truly integrative discipline – “reinforcing the idea of dentistry as a medical discipline requiring interdisciplinary effort,” as recently noted in an Angle Orthodontist tribute to Ricketts.1 By building on Ricketts’ foundation with contemporary knowledge, clinicians can achieve results that are stable, health-promoting, and grounded in the fundamental workings of biology. The logic is straightforward: treat the root cause, guide growth, respect the body’s networks and the results will follow. Precision is ensured by constant reference to scientific metrics and feedback loops during treatment. As we carry this legacy forward, future research (perhaps on molecular genetic changes during such therapies, or finite element models incorporating tensegrity) will further validate and refine the principles, but the existing evidence and successful outcomes already position the Ricketts approach as a paradigm of evidence-aligned innovation in orthodontics. Current Developments Utilizing the Cricket Appliance Dr. Ricketts introduced the Cricket appliance in the mid-1980s as an advanced orthodontic technique. He claimed it could straighten teeth fully without other appliances, suggesting it could sometimes replace braces by developing arches and correcting tooth rotations and angulations. ² Despite its theoretical advantages, the Cricket was technically demanding to fabricate and adjust, requiring high-level orthodontic laboratory skill, limiting widespread adoption. ² Only master technicians like David Gergen, who worked closely with Ricketts, routinely fabricated the appliance, further restricting its popularity. ² Over time, the Cricket was overshadowed by more user-friendly fixed expanders and functional appliances fitting conventional orthodontic practice models better. Published clinical research on the Cricket appliance is limited to case reports and expert opinion. It functions as a hybrid of the quad-helix and Crozat appliances, producing arch development and orthopedic effects in growing patients. ² Modern clinicians may use variants of its principles, such as removable spring aligners, Crozat-like appliances, ALF appliances, and OLC particularly in holistic and airway-focused practices. West’s 1984 article demonstrated successful adult treatment cases with the Cricket, showing efficacy for adults refusing fixed appliances or with minor malocclusions² . Its design allows a variety of tooth movements, including rotation, torque, and molar distalization, enabling sagittal corrections and vertical settling ². The Cricket had been largely a historical footnote that served as a precursor to contemporary removable functional appliances. Its legacy lied in proving that comprehensive orthodontic corrections with removable devices are possible, emphasizing arch development to avoiding extractions. This philosophy aligns with many modern functional orthodontic approaches. Until now its use has been limited and stymied for the above noted reasons. For this reason, I have reintroduced the basic Cricket appliance and all its fantastic attributes and modified it naming it the Open Loop Cricket (OLC).35 What is new????? Introducing the Open Loop Cricket (OLC): The Open Loop Cricket (OLC) 35 is a new concept merging holistic principles to unwind cranial strain patterns while moving with fascial dynamics, improving posture, airway and neurology. The human skull consists of twenty-nine bones: eight in the cranial system, fourteen in the facial group, and seven comprising the inner ear and the hyoid bone. The cranial bones have movement dictated by their sutural anatomy and pressure from the cerebral spinal fluid (CSF), which circulates throughout the spinal cord and brain within the dura’s confines. CSF is critical for oxygenation and nourishment of the brain and spinal cord, toxin elimination, and cooling of the pituitary and hypothalamus, vital for hormone regulation. The cranial bones are classified as paired or midline bones depending on whether they cross the midline. Visually, the face’s skin is supported by fat pads and cranial bones. Removing skin and fat reveals cranial bone asymmetry patterns translating to facial asymmetry. Various factors, such as fetal positioning in the pelvic girdle, birth canal passage, C-sections, diet, and breastfeeding absence, can influence cranial bone positioning and craniofacial asymmetry. Dentists, focusing on the oral cavity, often overlook the maxilla’s connection to the rest of the body. The maxilla, a paired bone, connects to paired palatine bones, which interlock with the sphenoid bone. The sphenoid bone acts as the central cog of cranial bones, shaped like a swallowtail butterfly with greater and lesser wings; its greater wings form the back of the orbit of the eyes (ocular asymmetry). Since the sphenoid is the central cog to the cranial bones, the maxilla can impact it indirectly via the palatine bones. Leveling the maxilla can affect how the cranial bones support and function in the whole body. Instead of treating pain points, go to the source of pain. The Open Loop Cricket appliance is designed to allow cranial bone positional changes alongside light wire activation. The body is a closed-loop kinematic skeletal chain with two openings: the feet arches and the bite. Teeth contact during swallowing (2,000–3,000 times daily) closes or locks this loop. This closure locks the entire skeletal system, so adjustments to cranial bones risk being counteracted at each swallow cycle. Dr. Bob Walker’s lectures highlight the dentists’ role in unlocking restricted cranial bones, influencing facial asymmetry, posture, airway, tongue position, and neurology. Since posture dictates airway and neurology, improving facial asymmetry can alleviate and help TMD, airway and neurologic symptoms. The benefits of the Open Loop Cricket: Holistically moves with the fascia and the body’s cyclic intermittent motion. Helps to improve the craniocervical junction, influencing Class I, II, III malocclusions. Unwinds and decompresses facial cranial strain patterns (asymmetry) by creating a gap. Enhances growth and development by optimizing whole-body function 24/7. Addresses malocclusions root causes, often involving tongue posture. Decompresses and realigns the TMJ complex, including temporal bone repositioning. Enhances neurology by freeing cranial nerve pathways and improving tongue movement, supporting airway tone and vagus(X) nerve activation. Improves posture and airway by affecting head tilt and cervical stability. Unlike traditional mechanical expanders limited to two-dimensional palatal changes, the OLC promotes three-dimensional development influenced by tongue posture and fascial motion that allows a natural physiological growth and cranial rhythm function. The OLC’s flexible cobalt wire and acrylic component facilitates cranial bone unwinding and improved cranial nerve function, enhancing airway tone via glossopharyngeal and vagus nerve stimulation. It promotes craniocervical complex changes and improves tongue position and function, achieving stable permanent changes in occlusion, posture, airway, and neural integration. The appliance’s goal is to restore and rehabilitate the craniofacial cervical complex’s physiological function—head, face, and neck—optimizing 24/7 bodily function. The OLC’s wire design features a balanced for strength and flexibility, promoting facial growth, cranial motion, rhythm, and tooth position changes. Its biocompatibility with craniofacial structure and fascia cyclic motion allows synergistic movement. A gap created by an acrylic pad permits cranial bones to unwind to natural positions on mouth closing, improving facial symmetry. Cranial nerve function is enhanced by better cranial bone positioning. Besides stimulating normal maxillary-mandibular growth, the OLC increases airway space and tone, crucial for the tongue’s anterior and superior mobility. This tones the airway via glossopharyngeal and palatoglossal muscles activation by the vagus nerve. Unlike rapid palatal expanders, which develop the palate in two dimensions (potentially worsening cranial strains), the OLC develops the palate in three dimensions via tongue function and passive qualities, restoring function while facial structures evolve. The objective is to remove obstacles, restore inherent bodily motion and function, creating maximum capacity and space for transformation. This facilitates healing by engaging natural body rhythms, encouraging openings and gaps to release cranial strains and fascial restrictions. In summary, the OLC embodies a holistic, biomechanical, and neurological approach to orthodontics, restoring craniofacial function, posture, airway, and neurology by removing obstacles and augmenting the body’s inherent motion and healing capacity. Final Thoughts: Motion is inherent in living systems; restoring it should be our goal. The OLC increases motion while restoring function, addressing malocclusion and craniofacial asymmetry causes. Healthcare providers aim to remove obstacles, augment motion, and restore health. Restoring cellular and cranial motion and proper breathing enables the body to self-heal. References Robert M. Ricketts and Rudolf Slavicek: dentistry by the rules of nature. PubMed. Interview: Dr. Robert Ricketts on Early Treatment Considerations. J Clin Orthod. Ricketts, R. M. (1969). Practic. Angle Orthod. Ricketts Phonetic Bite. American Sleep and Breathing Academy. Ricketts Orthodontic Philosophy Book. Multilevel Complex Interactions Between Genetic, Epigenetic and Environmental Factors in the Etiology of Anomalies of Dental Development. PubMed. Singh, G. D. Google Scholar Profile. Epigenetic Orthodontics: Facial and Airway Development. PubMed. Chronobiology Meets Quantum Biology: A New Paradigm Overlooking the Horizon? Frontiers. Electric Currents, Bone Remodeling, and Orthodontic Tooth Movement. PubMed. Mechanosensitive Piezo1 in Periodontal Ligament Cells Promotes Alveolar Bone Remodeling During Orthodontic Tooth Movement. Frontiers Physiol. Moss, M. L. (2006). Functional Matrix Hypothesis and Quantum Biology. Am J Orthod Dentofacial Orthop. Piezoelectric Effects on Bone Modeling for Enhanced Sustainability. Sci Direct. A Review of Theoretical Fascial Models: Biotensegrity, Fascintegrity, and Myofascial Chains. PubMed. Biotensegrity and Myofascial Chains: A Global Approach. Sci Direct. Fascia/Biotensegrity. Helena Sports Med. TMJ & Pelvic Floor: The Surprising Link and Pelvic PT Solutions. Chicago Pelvic. Relationships between Malocclusion, Body Posture, and Nasopharyngeal Pathology in Pre-Orthodontic Children. PubMed. Response to Mechanical Properties and Physiological Challenges. MDPI. Dental Occlusion and Posture: An Overview. PubMed. Evaluation of the Variable Anchorage Straightwire Technique Using Low-Dose CBCT. European J Orthod. An Assessment of the Maxilla after Rapid Maxillary Expansion Using CBCT. SciELO Brazil. The ALF (Advanced Lightwire Functional) Appliance Creating Facial and Postural Asymmetry Correction. EuropePMC. Changes in 3D Nasal Cavity Volume after Biomimetic Oral Appliance Therapy in Adults. Harbor Country Dental. The Role of Rapid Maxillary Expansion in the Management of Obstructive Sleep Apnoea: Monitoring Respiratory Parameters—A Systematic Review and Meta-Analysis. MDPI. Comment on Dao et al. Retrospective Analysis of Real-World Data. PMC. DNA Appliance Relieves TMJ Pain and Sleep Apnea. TMJ Sleep and Breathe Center. Mechanoreceptors, Nociceptors, and Orthodontic Tooth Movement. ResearchGate. Nociceptor Mechanisms Underlying Pain and Bone Remodeling via Neurogenic Inflammation. PMC. Orthodontics and TMJ & Sleep Appliances – Gergen’s Orthodontic Lab. The Practitioner’s Eye: The Ricketts Technique Elements in Non-Extraction Treatment Camouflaging Skeletal Class III with Bite Asymmetry—A Case Series Presentation. MDPI. ALF Case Study: Facial and Postural Asymmetry. Scribd. Facial Asymmetry and Functional Orthodontic Appliances. ResearchGate. Comparison Between CBCT Staging and Bone Micromorphology. PubMed. The Open Loop Cricket, A Different Approach in Treating, Timothy C Adams, DDS, D.ASBA, D.ACSDD ; Sleep and Wellness, May 2025

Interview by Christopher Kleiner with David Gergen, Executive Director of the American Sleep and Breathing Academy Founder, Gergen’s Orthodontic Laboratory Leadership in Dental Sleep Medicine: Insights from David Gergen In my recent discussion with David Gergen, Executive Director of the American Sleep and Breathing Academy (ASBA), I gained first hand perspective on the innovations, leaders, and future of dental sleep medicine. Gergen, also the founder of Gergen’s Orthodontic Laboratory, is recognized worldwide for producing some of the highest-quality dental sleep appliances in the field. Here are the individuals Gergen credits as key leaders shaping the future of airway-centered dentistry: Dr. Tim Adams – Master clinician and educator of the Open Loop Cricket Appliance, advancing craniofacial development and airway science Dr. Jerry Hu – Herbst appliance authority known for consistently reducing AHI scores to near zero, while helping clinicians avoid unnecessary costs Dr. Felix Liao – Founder of the STA Appliance, bridging whole-body health with airway-focused orthodontics Dr. John Caulfield – Leading provider and trainer for the Vivos system and guided pediatric expansion Dr. Toshi Hart – Pediatric sleep medicine expert specializing in airway and craniofacial development for children A Historic Milestone in Dental Sleep Innovation Gergen’s work helped bring the Herbst appliance to the national spotlight. Through a strategic campaign of clinical demonstration and insurance advocacy, he was instrumental in achieving primary insurance reimbursement — and later Medicare coverage — for the Herbst appliance. Today, it remains the only dental sleep appliance covered by Medicare, a legacy-defining moment for the profession. Influence in Policy and High-Level Treatment Gergen’s early collaboration with Elliot Alfer in Washington, D.C. resulted in widespread recognition and adoption of the Herbst appliance by:  Mark Brnovich, Former Arizona Attorney General Congressman Marty Russo Nate Gingrich along with many other politicians Dozens of Celebrities from around the country Countless Professional Athletes from all aspects of sports. NFL, NBA, NHL, MLS, and many more And Multiple Presidents of the United States Now, Gergen serves as an Ambassador to the U.S. Administration for VA Reform, working alongside national leaders like Dr. Patrice Reyes to expand dental sleep access to American veterans. Exclusive Opportunities Through ASBA During our interview, Gergen highlighted that only ASBA-certified doctors are eligible for a suite of elite programs and partnerships: Collaborate with the NFL Players Association on dental sleep care Participate in Mayo Clinic sleep apnea research for retired athletes Access enhanced reimbursement through the VA Be selected to work with the NFL directly Learn about the hottest appliance sweeping America, The Open Loop Cricket under Dr. Tim Adams Train with Dr. Jerry Hu on Herbst protocols that consistently achieve elite clinical results Master the STA Appliance with Dr. Felix Liao Explore Vivos appliance expansion with guidance from Dr. John Caufield Perform advanced aligner case planning with Dr. Francisco through G Force Aligners Learn some of the most comprehensive training from the best recognized sleep doctors in the industry. Serving the NFL’s Retired Heroes As a former player and lifelong football fan, David Gergen saw a hidden crisis: retired NFL athletes were silently suffering from untreated obstructive sleep apnea. He explained how years of athletic training often thickens the neck muscles, narrowing the airway and increasing apnea risk as players age. In 2009, Gergen and Dr. Harry Sugg began treating former players nationwide — at no cost to them. They fully funded the care themselves, driven by a shared mission to protect the health of these athletes. One of their most impactful cases came when former lineman Derrick Kennard reached out. Hall of Fame Cardinals receiver Roy Green had endured: Two heart attacks One stroke A kidney transplant Gergen flew to the Mayo Clinic, where Green was hospitalized, and began treatment immediately. Since starting oral appliance therapy for his sleep apnea, Roy Green has not experienced another heart attack, proving the life-saving potential of timely dental sleep care. ____________________________________________________________________________________ Closing Remarks and Why you should join the ASBA You should join The American Sleep and Breathing Academy for a multitude of reasons, including:   Learn some of the most comprehensive training from the best recognized sleep doctors in the industry.   Learn how to lower the AHI scores using the most tried and true methods.   Receive referrals from the VA to treat former Service Members.

Virend Somers will disuss the findings in more detail at next years ASBA annual Sleep and Wellness Conference here in Phoenix. The results of the 10 year study about Cardiovascular Disease Risk Factors in Former NFL Players and the Impact of Obstuctive Sleep Apnea.

Dr. Barry Chase, DDS, is a renowned expert in dental sleep medicine, specializing in the treatment of obstructive sleep apnea (OSA) and temporomandibular joint dysfunction (TMD). With over 40 years of experience, he is board-certified by the American Board of Dental Sleep Medicine and serves as an adjunct professor at Stony Brook University, where he teaches oral appliance therapy in the Respiratory Care and Polysomnography programs. In 2009, Dr. Chase founded Chase Dental SleepCare, a practice dedicated exclusively to dental sleep medicine. Under his leadership, the practice has expanded to 13 locations across the New York metropolitan area, including Manhattan, Long Island, and the Bronx . His innovative approach combines clinical excellence with a deep understanding of patient care, focusing on personalized treatment plans that address the unique needs of each individual. Dr. Chase’s commitment to improving patient outcomes is evident in his approach to reducing the Apnea-Hypopnea Index (AHI), a critical measure of sleep apnea severity. He emphasizes that successful treatment involves more than just lowering AHI scores; it requires a holistic understanding of the patient’s health, lifestyle, and compliance with therapy. Through careful selection and adjustment of oral appliances, he has achieved significant reductions in AHI for many patients, leading to improved sleep quality and overall health. Patients have reported transformative experiences under Dr. Chase’s care. One patient, previously unable to tolerate CPAP therapy, found relief through a custom oral appliance, leading to better sleep and enhanced quality of life . Another patient experienced a dramatic lifestyle change, losing 30 pounds and regaining energy after receiving treatment for severe OSA. Dr. Chase’s philosophy centers on the idea that “in dental sleep care, we make great dreams possible.” His dedication to patient-centered care and his innovative approach to treating sleep-disordered breathing have made him a leading figure in the field of dental sleep medicine. For more information about Dr. Chase and his practice, visit Chase Dental SleepCare.

I am truly thrilled to share the recent efforts of David Gergen, both within the ASBA and on a global scale! He has most recently been working with Dr. Gopal from India, who is the Dean at Manipal College of Dental Sciences. Dave works closely with top-level government officials, including those within the Executive Branch, and has strong, lifelong relationships with influential individuals, such as Mark Brnovich, who are committed to shaping and improving healthcare across our country. In a truly bipartisan effort, Dave has enlisted my support to communicate with key government leaders, including the President. There is no disagreement among Americans, regardless of political affiliation, that our active-duty soldiers, veterans, and all those who have sacrificed for our freedom deserve the best healthcare possible. They have more than earned that right. One meaningful way to give back is by working together to move healthcare forward for all of them as quickly as we can. With that in mind, Dave has previously advocated for dental sleep medicine with esteemed professionals such as Dr. Robert Ricketts, Dr. Harry Sugg, Dr. Elliott Alpher, and Dr. Ed Speigel. Thanks to their efforts, the Federal Government now recognizes the effectiveness of customized oral appliance therapy for sleep apnea as a valid and evidence-based treatment option. Based on this advocacy, the Government did a 6-year study on the effectiveness of Oral Sleep Appliances. It concluded that only 2 labs (Gergen’s Orthodontic Lab and Space Maintainer Lab of CA) were up to par to fabricate these appliances. This is fantastic news for all of us in dental sleep medicine, including labs, practitioners, and—most importantly—the millions of patients in need of assistance with their sleep-breathing issues. It is with this same spirit that I am honored to assist Dave and the ASBA in advancing the future of dental sleep medicine, particularly for our veterans and active-duty military personnel. I am excited to announce that my efforts have caught the attention of the Executive Branch. Following a response to my letter, Dave received a call from the Government. It’s clear that no matter where we stand politically, every American agrees on one thing: we must care for our military. See letter below: April 25, 2025 Dear President Trump, I thank you in advance for your time and willingness to look into the healthcare issues of our veterans and active duty military regarding the treatment of sleep apnea. In mutual admiration for them, we believe our soldiers and veterans deserve the best as they have fought (or are currently fighting) for our freedom. The literature clearly states untreated sleep apnea can cause a myriad of co-morbidities and serious conditions that not only affect combat readiness, alertness, and performance of our active military but also the quality of life and function of our veterans and war heros. It is with that concern, and with your help Mr. President, that effective attention will be placed to improve sleep apnea treatment for our military. The literature clearly and undeniably states that there are multiple problems with compliance and adherence to CPAP treatment option (see attached Federal Government Studies). Moreover, so many Americans have side effects, CPAP recalls, biogunk- dirty machine issues, and a whole list of other problems that they have to deal with. So many veterans are on a waitlist to get replacements, and even after 1-3 years of waiting, when they get one, they don’t use it for the proper length of time. As adults, we are supposed to get 7.5–8 hours of quality sleep 7 nights per week. The best averages show that patients use CPAP only 4–5 nights per week and at about 5 hours per at best per night. That is a poor and potentially lethal standard to go by. Some CPAP machines have carcinogens that are blown down people’s airway (and most of them are on recall, thank God) and other CPAP machines interfere with pacemakers and cardiac rhythm. So, the alternative and there is ample peer reviewed studies to back that up, would be to use FDA cleared oral appliances to treat sleep apnea. The Federal Government (see attachments) years ago did a long and thorough study on customized oral appliances, for example—the Herbst arm appliance, and found that they are extremely effective, so they approved that type of appliance for Medicare with PDAC regulations. Studies show that with these Herbst appliances, patients have far better compliance / adherence, and they are far more effective at mean disease alleviation (MDA), apnea burden and apnea load when compared to CPAP therapy. The problem is, however, there are so many VA Hospitals and centers that are not providing these appliances and the ones that are, they use cheap plastic “suck-down” materials and the appliance pieces often stretch and break off during sleep. They also pose a risk of aspiration and other issues and are usually done by dentists who are not trained properly in sleep medicine and don’t have dental sleep medicine board certification. Our military deserves better, and they need your help Mr. President. Next, there are abundant qualified community care sleep dentists that are available for VA hospitals and centers to refer to. However, these hospitals keep their dental sleep medicine treatment in house and the dentists don’t do titration-calibration and follow up visits, and they don’t even know how to evaluate a sleep study. They also take airway bites that are arbitrary, and they aren’t trained to properly handle potential issues with TMJ, orofacial pain, and trigger points especially if they caused those issues from making poor and cheap appliances to begin with. They also do improper coding for the treatment because sleep apnea is a medical condition and the VA hospitals would code their treatment as a dental condition. In the civilian world, dentists would lose their license to practice if they did that. There are many examples where VA hospitals that have ignored community care VA practices, as well as active duty TriCare practices for sleep apnea, have seen so many soldiers and war heros—some even amputated—been given such poor healthcare and attention. They had been CPAP intolerant for years or have been on a waiting list to get replacement or alternative treatment such as dental sleep medicine and custom FDA oral appliances, and felt so neglected and sometimes, even hopeless. Several have gone outside the VA system expressing frustration and others have been brought to tears. In contrast, Board certified sleep dentists in community care have been providing detailed attention to follow up and comprehensive treatment, which then in turn, have been able to basically fix their sleep breathing problems. They do the necessary post treatment sleep studies to validate the effectiveness of their care. As a community care provider myself, I am ready, able and always willing to provide that best quality and care for our military. The VA hospitals get hundreds and hundreds of patients per month who end up getting the cheap appliances that break and are ineffective. Many have already come to me on their own for help because the VA hospital would end up neglecting them. Thank you again for your time and attention to this matter that concerns all of us. Sincerely,Dr. Jerry HuSee attachment studies

I’d like to take a moment to share my journey and deep appreciation for the incredible people and organizations that have shaped my path in sleep medicine and airway health.   I first met David Gergen at the Vivos convention in New York City, circa 2017. He was speaking at the event, and I learned he was the primary lab expert behind Vivos. Back then, David was the go-to guy—knowledgeable, approachable, and passionate about helping others. He was accompanied by another gentleman, Andre Collins, who struck me immediately as just a good, good man. That first encounter with David left a strong impression. After his talk, he spoke to me about the American Sleep and Breathing Academy (ASBA) and encouraged me to join. I took his advice, and I’m so grateful I did. Through ASBA, I was introduced to Alan Hickey, a true pioneer in our field, who unfortunately passed recently. His loss is deeply felt within the sleep medicine community. Joining ASBA truly changed the trajectory of my career. At the time, I was already treating a few NFL players. I expressed to David that I wanted to work with more, and he gave me a key insight: “There’s the league, and then there are retired players—two completely different animals.” David explained that he was focusing on retired players and that Andre Collins, as Executive Director of the NFLPA Former Players, was leading efforts to help them. Following David’s speech at the convention, I started using his lab—Gergen’s Orthodontic Lab—for both Vivos and my other dental appliances. The partnership turned out to be incredible. David was supportive, generous with his expertise, and always willing to help me with challenging cases. I vividly remember one case where he offered a bold solution: a cantilever Herbst with a memory RPE screw. He told me, “Cristin, this is a handful and requires a certain skill level, but I think you have it.” I trusted him, and he was absolutely right. That patient’s symptoms disappeared, and his family was thrilled with the outcome. These moments are the ones I treasure most. They remind me of the power of collaboration, mentorship, and the right training. Becoming a diplomate of ASBA opened doors I never expected. Not long after that case, David reached out again—this time about formally joining the NFLPA initiative to treat retired players. He said he hadn’t seen an office as organized and well-run as mine, and he wanted me to treat the former players in my area. We planned a local event to screen and treat them for sleep apnea, and I was thrilled to be part of it. After treating several players and delivering their appliances, I received a check for over $44,000.with ZERO lab bill. Not a bad day’s work,—and even more rewarding knowing it came from helping people regain their health. Since then, the opportunity has only grown. I’m now receiving multiple checks from MetLife for ongoing care to former NFL players and their families. All of this began because I joined ASBA and connected with David Gergen and his amazing team. I am beyond grateful for this journey—one fueled by purpose, impact, and relationships that truly matter. I am more than beyond being thrilled with ASBA, it truly is the best! i am currently taking the Study Club courses taught by Dr. Tim Adams. Formly the head guy for LVI. Im learning all kinds of new and exciting things. Such as adjusting cranial bones and fixing cranial strains. With gratitude,Cristin Lewis  

I’m writing to share my personal and professional journey with the American Sleep and Breathing Academy (ASBA), and to express just how much this organization has meant to me, both as a dentist and as a person.   I first heard about the ASBA through Jon Caulfield, not long after I joined VIVOS. Jon and I connected right away—he’s an incredible guy and a fellow hockey lover. During one of our early conversations, he told me about Gergen’s Orthodontic Lab, emphasizing its unmatched quality. He said, “You want to use Gergen’s, and you should join the ASBA.” He spoke passionately about the Academy’s credibility and the meaningful changes it’s driving in the field of sleep medicine. That was the beginning of something truly transformative for my practice and my career.   What I love most about being an ASBA member is the opportunity. Because of my involvement, I now get to work directly with the NFL right here in Florida. We recently did a screening and I gained 40 new patients—professional ball players—with no lab bill. Thanks to David Gergen, who manages everything on that front along with Andre Collins the Executive Director of the NFLPA, I simply do the work and get a check in the mail. Cleanings are fully covered through MetLife, the players pay nothing, and everyone wins. It’s a great system that benefits everyone involved. One of the most meaningful moments I’ve had with the ASBA was spending time with Jon Caulfield. We were supposed to catch a hockey game live, but opted for a sports bar instead—saving a few bucks and enjoying dinner and drinks together. It was simple, genuine, and truly memorable. That kind of authentic connection is rare. Jon, David Gergen, and even David’s son Johnny are all top-notch human beings. They remind me of my own father-son relationship. The whole ASBA organization feels like a family—solid, helpful, and always willing to lift one another up.   The training I’ve received through the ASBA is second to none. I mean it when I say that nobody trains like the ASBA does. I’d confidently stack our doctors up against anyone in the country. The level of education and insight I’ve gained here is outstanding, and I count myself and Jon among the best trained in this field—not out of ego, but out of deep respect for what we’ve been taught and how it’s shaped our practices.   Since joining, my network has grown exponentially. The sleep program has quadrupled in scale while maintaining the highest standards. ASBA emphasizes quality, patient follow-up, and using only the best equipment. It’s practical, cost-effective, and success-driven. They’re not just selling devices—they’re building sustainable practices.   Looking forward, I believe the ASBA is shaping the future of sleep medicine and airway care in a powerful way. David Gergen has worked with top-tier government officials and national figures, and his reach continues to grow. Leaders like Tim Adams are pushing innovation with tools like the Cricket Appliance—which I’ll be learning more about at the upcoming Study Club in May. I can’t wait to start using the Cricket in my own practice to help patients find relief from pain and sleep disorders. This is real progress in action.   To any colleague on the fence about joining—don’t wait. It’s a no-brainer. If you’re serious about entering sleep medicine, start with the ASBA. They will guide you, support you, and help you make smart, informed decisions that save you time, money, and headaches. You’ll sidestep many of the early pitfalls and set yourself up for success from day one.   With gratitude, Dr. Paul Eckstein, DDS