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26F MARPE/MSE not splitting suture, only posterior expansion so far

MalarBagMetalMouth
Active Member

I had MARPE/MSE installed last month, with 4 screws (tads) anchored into the palate. For the first 2 weeks, I turned it 2x a day. I might have added a few turns, totaling about 32 turns after 2 weeks.

When my suture failed to split, my ortho told me to rest for 3 weeks without turning. Now, that time has passed, and I am told to turn very slowly again -- 1 turn every other day.

So far, my posterior palate has expanded, and my bite is now different. But my frontal palate won't budge, and my front teeth are still tightly crowded (no diastema). My molars attached to the appliance are tipping.

Any thoughts on this current course?

 

Some variables:

  • It seems my suture is not completely fused yet, according to x-rays.
  • My palate bone is also thin, so my surgeon did not drill the screws in completely (They protrude and dig into my tongue, but they have been functioning fine without bending or dragging).
  • I did not have cortico puncture performed before the appliance was installed. My ortho is waiting to see how things go before recommending it.
  • My ortho is hesitant to prescribe a more intense and rapid turning regimen because this has caused sudden extreme teeth tipping in a previous patient.

 

Some hacks I've considered (maybe horrible ideas, so please advise):

  • Would hard mewing encourage a split or frontal expansion?
  • Would thumb-pulling / face-pulling assist with the frontal palate not expanding?
  • Someone once posted here, mentioning their doctor prescribed alternate turning -- alternating between tightening and loosening the screw to encourage splitting. What if I did this but stayed within my ortho's current pace?
  • Should I push for a faster turning regimen or stick with ortho's advice?
  • Should I push for cortico puncture?

 

Thanks in advance for any thoughts.

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 24/03/2021 12:43 am
Apollo
Reputable Member

Did they do a CBCT after installing the MSE? Are all 4 TADs seated bicortically without engaging the septum? Do any of the TADs appear to be tilting or dragging during your expansion? What length TADs did they use (9mm, 11mm, or 13mm)? I'm worried your front TADs where the bone is thicker might not have reached the second cortical layer if they didn't screw them in completely. During installation, I could feel a tickle in my nose when the TADs reached the nasal floor. Even if all 4 TADs extend through both cortical layers, it might not be a good enough anchor if the bone is too thin. You might need to have the current MSE removed and install a new one a little more forward where the bone is thicker to get better stability.

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Posted : 26/03/2021 12:17 pm
MalarBagMetalMouth
Active Member

@apollo No scans done after installation. The TADs do not appear to be tilting or dragging, according to ortho. The surgeon was very careful not to screw them in too deep. Did not have any nasal bleeding. No idea if there was tickling because I was not conscious during installation. Unfortunately I don't know the TAD length, but I will ask. (UPDATE: They are the 12mm ones...)

Ugh, that is unfortunate if I'd need a new installation. I imagine that'll require waiting for the first holes to heal, more $$$, and then another year of this...

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 26/03/2021 3:04 pm
Apollo
Reputable Member
Posted by: @metalmouth

@apollo No scans done after installation. The TADs do not appear to be tilting or dragging, according to ortho. The surgeon was very careful not to screw them in too deep. Did not have any nasal bleeding. No idea if there was tickling because I was not conscious during installation. Unfortunately I don't know the TAD length, but I will ask.

Ugh, that is unfortunate if I'd need a new installation. I imagine that'll require waiting for the first holes to heal, more $$$, and then another year of this...

There's not a significant risk from screwing the TADs in too deep into the nasal cavity. The real risk is not screwing them in far enough and missing the second cortical layer. Frankly, I'm concerned your orthodontist might not be very experienced with the MSE. They should have measured the thickness of your bone from the initial CBCT and then ordered the correct length of TADs so that they could be seated all the way rather than leaving the heads protruding. If they were worried about the bone being too thin they should have selected a more forward placement. I suspect either they didn't get bicortical engagement on some or all of the TADs or your bone is too thin at the placement they selected to act as a stable anchor. A CBCT after installation confirms proper placement but might be unnecessary radiation exposure. The bone gets thicker toward the front, so it can be more stable as long as it isn't too thick to prevent bicortical engagement. The forward position doesn't oppose the zygomatic buttress resistance as well so it's a trade-off. If moving the MSE forward a couple millimeters would give thick enough bone, you can generally install a new MSE with the TADs staggered from the old position without having to wait 3 months for the bone to heal. I suggest your orthodontist should upload the details of your case to the "MSE user group" on facebook to get advice from experienced MSE providers. They might have some tricks to try. A woman your age isn't necessarily indicated for cortipuncture, but I think I would request it if they are going to reinstall a new MSE, just to try everything before resorting to surgical assist, even if your problem is most likely the placement of the TADs. Also, a slower 1 turn per day protocol has less risk for failure, but also gives less perimaxillary changes, so it might not be as beneficial for airway improvement, protraction, cheekbone enhancement, etc.

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Posted : 26/03/2021 4:37 pm
MalarBagMetalMouth
Active Member

Update: I learned my TAD screws are the 12mm ones.

My ortho is not one of the MSE specialists listed on Won Moon's site. I didn't even know the "MSE" terminology before starting this, just knew that adult palate expanders are a thing... I regret not researching MSE more and finding a local expert before committing to a multi-thousand-dollar regimen. (Not like I didn't research... I put assloads of effort into researching my wisdom teeth surgery.) I just felt so rushed to start an expansion regimen before I moved further away from the >25 mark... But realizing I didn't need to rush, as my suture is still not fused.

Anyone wanna validate my horrible DIY ideas of face-pulling/thumb-pulling to manually assist the MSE? I'm drunk and enraged at life. 🙂

Here are some embarrassing photos featuring my lunch in the "after"... I've since bought a tiny flashlight and mirror to assist in cleaning the device >_<

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 27/03/2021 5:23 am
Apollo
Reputable Member
Posted by: @metalmouth

Update: I learned my TAD screws are the 12mm ones...

It's true, my ortho is not listed as one of the MSE specialists on Won Moon's site. I didn't even know the "MSE" terminology before starting this, just knew that adult palate expanders are a thing...

Welp I'm definitely regretting not researching MSE more and finding a local expert before committing to a multi-thousand-dollar regimen. (Not like I didn't research... I put assloads of effort into researching my wisdom teeth surgery.) I just felt so rushed to start an expansion regimen before I moved further away from the >25 mark... But realizing I didn't need to rush, as my suture is still not fused.

Anyone wanna validate my horrible DIY ideas of face-pulling/thumb-pulling to manually assist the MSE? I'm drunk and enraged at life. 🙂

Here are some embarrassing photos featuring my lunch in the "after"... I've since bought a tiny flashlight and mirror to assist in cleaning the device >_<

Just because a provider isn't listed on Won Moon's website doesn't necessarily mean they aren't proficient. I think it just means they haven't completed Dr. Moon's course. But I know of a couple experienced providers who aren't on the list. Your orthodontist might be very competent. I was just guessing they weren't based on your description of the TAD heads protruding out rather than being tightened all the way down, since bicortical engagement is crucial. It's hard to tell from your pictures, but it doesn't look like the heads of the TADs extend too far out from the body of the MSE, so they might be seated correctly. Even if they are tightened all the way, they irritate the tongue at first. I used orthodontic wax over the heads of the TADs until my tongue got used to it. I also recommend a waterpik to clean the appliance after eating. 12mm is the width of the expansion screw. You can see the little "12" etched on the framework of the MSE. I was asking about the length of the TADs themselves, which come in 9mm, 11mm, and 13mm sizes depending on how thick your palate bone is. Knowing the size wouldn't tell us much. I was just trying to figure out why they would have left the TAD heads protruding.

At this point, I think I would keep turning at 1 turn per day. Sometimes, in cases like this, it helps to pause for several days to a week to give your osteoclasts time to break down the obstructions and then resume turning. I'm not seeing significant tilting or dragging of your TADs in the pictures. My diastema didn't appear until turn 35, and I was going through the same doubts as you. I don't think hard mewing or thumbpulling are likely to help facilitate the split, but I also don't think they can do much damage. You could see an osteopath with cranial manipulation experience to try and help mobilize the sutures, but I'm even a little doubtful they know how to help much. I still think it might be a good idea for your orthodontist to get advice about your case on the facebook group I mentioned. Do you have a copy of your initial lateral cephalogram you could share to see how thin the bone of your palate is?

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Posted : 27/03/2021 11:40 am
MalarBagMetalMouth
Active Member

Update: I had another x-ray done, which confirmed that my front TADs were not drilled deeply enough to reach the nasal floor. Apparently the surgeon experienced so much resistance when drilling the front TADs, they feared any extra force would push them in too far and damage something (some glands I forgot the name of).

Ortho says this likely explains the lack of expansion in front. However, I do have a slight "split" which is much greater in back than in front. Still no diastema or visible frontal expansion, and front teeth are still tightly crowded.

I've been given the option of having the front TADs re-drilled (not just pushed in further, due to the resistance the surgeon was concern about with the current placement). The issue is, this could potentially weaken the traction of the whole device. Ortho says my posterior expansion progress could relapse. 

Another option is to replace the whole device in another position like @Apollo mentioned, but ortho thinks this is overkill, given I've already expanded so well in the back. There are also concerns about expanding too much in the back (where there is already expansion), as well as teeth tipping.

In either case, cortico-puncture is recommended to assist with the splitting.

My ortho is a member of the MSE facebook group, and feedback from that group is mixed... I believe both my ortho and oral surgeon are proficient, but this device is still very new... There doesn't seem to be a clear path forward.

Ortho thinks my current progress is sufficient, so it's really a matter of what my goals are... And my goals are to maximize the effects from this device (within financial reason), since I've already invested so much money, time, and energy into it. I really wish I could achieve frontal expansion, just to feel confident this process paid off.

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 15/04/2021 9:11 pm
Apollo
Reputable Member

It's hard to know if your orthodontist's advice makes sense without all of the information they have. How many turns are you at currently? Has your nasal breathing improved? I'm not sure what you mean by redrilling the front TADs. Here's another case from youtube that failed to separate the suture because the front TADs didn't have bicortical engagement:

Posted by: @apollo
Posted by: @nakedespresso

@apollo It's not looking good.  2 turns per day, I'm at turn 58.  I'm running out of threads on the device.  What have you and this group seen as potential options?  

I'm sorry to hear this! I know from personal experience that failing to disarticulate the suture can be very demoralizing. In his recent lecture, Dr. Moon mentioned pausing for a while to allow the biological response to breakdown the interdigitations and then resuming expansion. It might be worth a shot. In my case, I needed a second MSE, but it's not worth trying the same methods over again and hoping they work the second time. You can adjust your strategy with cortipuncture or surgical assist to help facilitate separation, perhaps slowing to the more reliable 1 turn per day protocol, and reevaluate the position (which will have to be adjusted anterior or posterior to the previous TADs unless you wait several months for the bone to heal). I think a second attempt has a better chance if you can identify a possible reason why the first attempt failed and correct it. Did your TADs tilt or drag through the bone? For example, Evan Lavizadeh on youtube just posted that he's going to try another round after his first MSE failed. His palate is very thick and he didn't get bicortical engagement in the anterior TADs. He might have had more success if his MSE was placed a little more posteriorly and if he had 13mm long TADs in the front. Instead, his ortho is planning a custom MARPE with 6 TADs for his second round.  

He got the suture to split with a second appliance. Like you said, I guess it depends on your goals to decide if that's necessary in your case.

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Posted : 16/04/2021 1:32 pm
MalarBagMetalMouth
Active Member

@apollo I'm at 45 turns, and I was told to stop turning completely before we had taken the x-ray. Ortho thinks my progress is sufficient and, in fact, the expansion was not critical in the first place. It was just something I wanted to try (despite the breathing and facial improvements not being guaranteed), since my childhood orthodontics left me with a narrow palate, and I needed to do corrective Invisalign treatment anyway.

Still, it was an investment for me, and it bothers me to not achieve that full split due to operator error.

Personally, I haven't noticed much change in breathing, but I don't have significant enough breathing problems to notice a difference. I enjoyed some initial short-lived facial changes (prominent cheekbones), but these were likely due to swelling. My smile is more full now though, and I think my posterior expansion is good.

Now that the x-ray has revealed the problem with my frontal TADs, my ortho and surgeon are offering those options. By re-drilling the front TADs, they mean removing and re-inserting them in a slightly new position (without replacing the whole appliance). Apparently this weakens the appliance, but I didn't fully understand why. I would opt for cortico-puncture (out of pocket) to help as much as possible and hopefully reduce any posterior "relapsing" that could supposedly occur.

It seems like I could definitely achieve a split if I completely replaced the appliance, since we've identified the initial problem. Ortho is so hesitant to do this though (strongly advises that it's "overkill") and would charge for the new appliance, and I am also weary of wearing this appliance...

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 17/04/2021 2:40 am
Apollo
Reputable Member
Posted by: @metalmouth

@apollo I'm at 45 turns, and I was told to stop turning completely before we had taken the x-ray. Ortho thinks my progress is sufficient and, in fact, the expansion was not critical in the first place. It was just something I wanted to try (despite the breathing and facial improvements not being guaranteed), since my childhood orthodontics left me with a narrow palate, and I needed to do corrective Invisalign treatment anyway.

Still, it was an investment for me, and it bothers me to not achieve that full split due to operator error.

Personally, I haven't noticed much change in breathing, but I don't have significant enough breathing problems to notice a difference. I enjoyed some initial short-lived facial changes (prominent cheekbones), but these were likely due to swelling. My smile is more full now though, and I think my posterior expansion is good.

Now that the x-ray has revealed the problem with my frontal TADs, my ortho and surgeon are offering those options. By re-drilling the front TADs, they mean removing and re-inserting them in a slightly new position (without replacing the whole appliance). Apparently this weakens the appliance, but I didn't fully understand why. I would opt for cortico-puncture (out of pocket) to help as much as possible and hopefully reduce any posterior "relapsing" that could supposedly occur.

It seems like I could definitely achieve a split if I completely replaced the appliance, since we've identified the initial problem. Ortho is so hesitant to do this though (strongly advises that it's "overkill") and would charge for the new appliance, and I am also weary of wearing this appliance...

Do they think they can get bicortical engagement by removing and replacing the front TADs? Would they remove them at your current position of 45 turns and then try to reinsert them at a slightly different angle, or would they reverse some or all of your turns backward before replacing the front TADs and proceeding with the expansion? At 45 turns you've only used up half of the 90 turns in your 12mm MSE. I suppose they could try removing the front TADs, then reverse turning the expansion by a couple millimeters, and then reinserting the TADs to try and place them in undisturbed bone. The problem with putting the TADS back in right around where they were is that it undermines the stability. It's the same if you were putting a hardware screw into a piece of wood, if you screw it in and then remove it and try to screw it back in at a slightly different angle, you have the void of the old position that the screw is going to want to follow, and if you succeed in diverting the angle slightly then you have a space that the screw could shift into when you load force onto it. Also, the barrels of the MSE framework guide the angle of TAD insertion, so your orthodontist would have to deliberately divert the TAD as its going in and this is hard to control with the hand driver. Still, it might be worth trying. What have you got to loose? If they are keeping the posterior TADs in place, I would think they should prevent relapse. If x-rays show that your posterior nasal spine has already separated, you're not worried about improving your nasal breathing and you've already seen enough expansion to widen your smile and reduce crowding for your invisalign treatment, I agree that it's probably not worth putting in a whole new MSE. Even in cases were everything goes right, I think the change in cheekbones is pretty subtle. When they perform the cortipuncture, in addition to drilling along the midpalatal suture, they could also drill between the roots of the central incisors below the anterior nasal spine from the front to help encourage that anterior section to separate. My provider just uses a narrow drill for the cortipuncture like Dr. Ting demonstrates on youtube, but Dr. Moon and others sometimes use TADs screwed into the suture and back out to weaken it. Here's a case that initially failed to separate but opened after a cortipuncture procedure with TADs ( https://class3mse.medium.com/finally-have-a-diastema-28c012d35464 ). Like you, he also thinks he had more expansion in the back than the front. Good luck and keep us posted!

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Posted : 17/04/2021 11:46 am
sunflower
New Member

Wow, what a journey! I'm an MSE hopeful, eagerly learning from all of you who are going through the process. Hope this isn't too off-topic, but how difficult is it to mew with an MSE? Where does your tongue go? From doing myofunctional therapy I got my tongue to stay on the roof of my mouth during sleep, but I'm guessing this isn't possible with an MSE in.

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Posted : 17/04/2021 10:50 pm
Apollo
Reputable Member
Posted by: @sunflower

Wow, what a journey! I'm an MSE hopeful, eagerly learning from all of you who are going through the process. Hope this isn't too off-topic, but how difficult is it to mew with an MSE? Where does your tongue go? From doing myofunctional therapy I got my tongue to stay on the roof of my mouth during sleep, but I'm guessing this isn't possible with an MSE in.

Obviously it's not ideal that the appliance obstructs part of the palate and prevents a good seal, but the tongue can press against the MSE and the uncovered areas. Initially, the TADs irritate the tongue, but you get accustomed to it and applying orthodontic wax can help. I think Jaw Hacks has a "How to Mew with the MSE" video.

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Posted : 18/04/2021 4:25 pm
sunflower liked
MalarBagMetalMouth
Active Member
Posted by: @apollo
Posted by: @metalmouth

@apollo I'm at 45 turns, and I was told to stop turning completely before we had taken the x-ray. Ortho thinks my progress is sufficient and, in fact, the expansion was not critical in the first place. It was just something I wanted to try (despite the breathing and facial improvements not being guaranteed), since my childhood orthodontics left me with a narrow palate, and I needed to do corrective Invisalign treatment anyway.

Still, it was an investment for me, and it bothers me to not achieve that full split due to operator error.

Personally, I haven't noticed much change in breathing, but I don't have significant enough breathing problems to notice a difference. I enjoyed some initial short-lived facial changes (prominent cheekbones), but these were likely due to swelling. My smile is more full now though, and I think my posterior expansion is good.

Now that the x-ray has revealed the problem with my frontal TADs, my ortho and surgeon are offering those options. By re-drilling the front TADs, they mean removing and re-inserting them in a slightly new position (without replacing the whole appliance). Apparently this weakens the appliance, but I didn't fully understand why. I would opt for cortico-puncture (out of pocket) to help as much as possible and hopefully reduce any posterior "relapsing" that could supposedly occur.

It seems like I could definitely achieve a split if I completely replaced the appliance, since we've identified the initial problem. Ortho is so hesitant to do this though (strongly advises that it's "overkill") and would charge for the new appliance, and I am also weary of wearing this appliance...

Do they think they can get bicortical engagement by removing and replacing the front TADs? Would they remove them at your current position of 45 turns and then try to reinsert them at a slightly different angle, or would they reverse some or all of your turns backward before replacing the front TADs and proceeding with the expansion? At 45 turns you've only used up half of the 90 turns in your 12mm MSE. I suppose they could try removing the front TADs, then reverse turning the expansion by a couple millimeters, and then reinserting the TADs to try and place them in undisturbed bone. The problem with putting the TADS back in right around where they were is that it undermines the stability. It's the same if you were putting a hardware screw into a piece of wood, if you screw it in and then remove it and try to screw it back in at a slightly different angle, you have the void of the old position that the screw is going to want to follow, and if you succeed in diverting the angle slightly then you have a space that the screw could shift into when you load force onto it. Also, the barrels of the MSE framework guide the angle of TAD insertion, so your orthodontist would have to deliberately divert the TAD as its going in and this is hard to control with the hand driver. Still, it might be worth trying. What have you got to loose? If they are keeping the posterior TADs in place, I would think they should prevent relapse. If x-rays show that your posterior nasal spine has already separated, you're not worried about improving your nasal breathing and you've already seen enough expansion to widen your smile and reduce crowding for your invisalign treatment, I agree that it's probably not worth putting in a whole new MSE. Even in cases were everything goes right, I think the change in cheekbones is pretty subtle. When they perform the cortipuncture, in addition to drilling along the midpalatal suture, they could also drill between the roots of the central incisors below the anterior nasal spine from the front to help encourage that anterior section to separate. My provider just uses a narrow drill for the cortipuncture like Dr. Ting demonstrates on youtube, but Dr. Moon and others sometimes use TADs screwed into the suture and back out to weaken it. Here's a case that initially failed to separate but opened after a cortipuncture procedure with TADs ( https://class3mse.medium.com/finally-have-a-diastema-28c012d35464 ). Like you, he also thinks he had more expansion in the back than the front. Good luck and keep us posted!

Great questions, thanks for putting them into words. I will hopefully get clarification soon on the recommended approach, i.e. specifically how they'd re-insert the front TADs while keeping the back ones in place. I did ask about reversing turns before re-inserting, and ortho agreed that's an option, so might have a definitive answer soon. 

That wood analogy is exactly what my ortho explained over the phone, but I had trouble processing it in real-time, so thanks for putting that into text also.

I appreciate some reassurance in this approach, since I really don't want to deal with another whole appliance. Between adding cortico-puncture and understanding the initial error, I feel like I have a good chance of splitting. Or at least it will be worth a try. 

Posted by: @sunflower

Wow, what a journey! I'm an MSE hopeful, eagerly learning from all of you who are going through the process. Hope this isn't too off-topic, but how difficult is it to mew with an MSE? Where does your tongue go? From doing myofunctional therapy I got my tongue to stay on the roof of my mouth during sleep, but I'm guessing this isn't possible with an MSE in.

Good work researching before committing to the treatment... Mewing is definitely a challenge, but the discomfort does get surprisingly tolerable. I've struggled to keep wax on the sharp spots, but silicone (Mack's Pillow Soft Silicone Earplugs on Amazon) actually works great. Very helpful when tongue needs a break. 

The first couple weeks were agonizing, because it feels so wrong. Had to re-learn how to eat and talk, plus how to clean the thing. I got the hang of it though. Waterpik is good for cleaning, and I now use needle-nose tweezers to get stubborn foods out.

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 19/04/2021 2:47 am
sunflower liked
MalarBagMetalMouth
Active Member
Posted by: @apollo

Do they think they can get bicortical engagement by removing and replacing the front TADs? Would they remove them at your current position of 45 turns and then try to reinsert them at a slightly different angle, or would they reverse some or all of your turns backward before replacing the front TADs and proceeding with the expansion?

My ortho says they will actually just re-insert the front TADs deeper, using an additional drill between removing and reinserting to reduce whatever resistance is there in the nasal floor bone.

They're saying doing this can possibly reduce "all or most of the retention" supporting the TADs in the bone where the screws have already been sitting. (This doesn't really make sense to me, but apparently the wood analogy still applies.)

For this reason, they are not recommending reversing turns because there has not been enough time for the bone to reform and retain my current expansion progress. Could lose the ability for expansion in the back TADs as well apparently, since we're risking compromising the device's retention.

I don't like the sound of that risk, but I still feel like it's worth trying to drill the TADs deeper and assist with cortico-puncture.

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 19/04/2021 11:39 pm
Apollo
Reputable Member
Posted by: @metalmouth
Posted by: @apollo

Do they think they can get bicortical engagement by removing and replacing the front TADs? Would they remove them at your current position of 45 turns and then try to reinsert them at a slightly different angle, or would they reverse some or all of your turns backward before replacing the front TADs and proceeding with the expansion?

My ortho says they will actually just re-insert the front TADs deeper, using an additional drill between removing and reinserting to reduce whatever resistance is there in the nasal floor bone.

They're saying doing this can possibly reduce "all or most of the retention" supporting the TADs in the bone where the screws have already been sitting. (This doesn't really make sense to me, but apparently the wood analogy still applies.)

For this reason, they are not recommending reversing turns because there has not been enough time for the bone to reform and retain my current expansion progress. Could lose the ability for expansion in the back TADs as well apparently, since we're risking compromising the device's retention.

I don't like the sound of that risk, but I still feel like it's worth trying to drill the TADs deeper and assist with cortico-puncture.

Hmm, so I guess they just got a lot of resistance from a dense second cortical layer of bone at the floor of the nose when they were initially inserting and that's why they didn't tighten them down all the way. There's the risk that the TADs can break off and then the piece is suck in there unless you surgically fish it out. Dr. Moon discourages the use of a motor torque driver to overcome the resistance because breakage is more likely at high continuous torque. I would use the manual ratchet that comes with the MSE kit to attempt to tighten the TADs down all the way again before removing them and drilling pilot holes that can reduce their stability. Your orthodontist might find that the TADs are easier to tighten now than they were before after expansion has tilted or dragged them to a new position. It might also be possible to try a longer handle on the manual driver to increase the torque. There's less risk of breakage when high torque is applied intermittently by hand. Like the woodscrew analogy, if you remove a screw from a board and then drill through to the other side of the board with a drill bit and then reinsert the screw, there's less material for the threads of the screw to grip onto, compromising the stability.

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Posted : 20/04/2021 12:22 pm
MalarBagMetalMouth
Active Member

And the journey continues. Today, I finally had my TAD-tightening appointment (delayed due to a month of horrible food poisoning). My surgeon agreed to try tightening the TADs manually first, though they still expected to require the pilot holes. Turns out, pilot holes were not needed. Surgeon screwed the TADs in deeper, but still careful to avoid my turbinates. Afterwards, a scan was taken to show the screws now engaging the cortical bone.

Some things my surgeon had mentioned prior: My nasal floor bone is really thin, so there was a lot of concern for drilling too deep and hitting my turbinates. Despite this, there was so much resistance when initially inserting my TADs that the surgeon did not want to apply any more torque, even manually, for fear that (1) the screw would go too deep, or (2) the screw might break, like @apollo mentioned, or (3) the threads could be damaged, causing the screw to "spin".

Next steps: Ortho wants to proceed with turning 1x per day up to 10 turns, starting a couple days after TAD tightening and corticopuncture. We thought I would have corticopuncture done today, but surgeon wants to discuss this further. I like to think maybe I won't need it, but suppose it's best to try. I'm more than halfway through my MSE treatment, and ortho had previously wanted me to stop expanding at 45 turns. So it's a bit late for me to be finally engaging the front cortical bone...

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 13/05/2021 7:31 pm
Apollo liked
MalarBagMetalMouth
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Instead of turning an additional 10 turns, my ortho suggested I go ahead with corticopuncture, since I wasn't feeling much tension while turning (rather felt it in the anchored teeth instead).

So today I had corticopuncture. When one of the holes was drilled, I felt a release of tension in the nasal area.

Now ortho wants me to start turning back 4 turns a day, until I've gone 22 turns back. Then I can start turning forward again (the normal way) 2x a day.

I definitely feel something when turning back. It's more sensitive now and makes me want to just keep going forward and see if it will split. But these are the current instructions from my ortho, maybe because I've already turned so much before getting the TADs tightened.

Wondering how these instructions compare to others who've undergone corticopuncture with MSE?

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 03/06/2021 5:17 pm
Apollo
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Posted by: @metalmouth

Instead of turning an additional 10 turns, my ortho suggested I go ahead with corticopuncture, since I wasn't feeling much tension while turning (rather felt it in the anchored teeth instead).

So today I had corticopuncture. When one of the holes was drilled, I felt a release of tension in the nasal area.

Now ortho wants me to start turning back 4 turns a day, until I've gone 22 turns back. Then I can start turning forward again (the normal way) 2x a day.

I definitely feel something when turning back. It's more sensitive now and makes me want to just keep going forward and see if it will split. But these are the current instructions from my ortho, maybe because I've already turned so much before getting the TADs tightened.

Wondering how these instructions compare to others who've undergone corticopuncture with MSE?

I only had cortipuncture at the time of my MSE installation. I'm not entirely sure why they want you to back turn after the cortipuncture, or why they didn't do the back turns before the cortipuncture. 22 backward turns at 4 turns per day is 5 and a half days, and then 22 forward turns at 2 turns per day is 11 days. So it will be over 16 days before you've advanced back to the position you were at the time of the cortipuncture. I hope those punctures and the inflammation they provoke doesn't have time to heal before you get back to really putting strain on the suture now that your anterior TADs are bicortically engaged. I'd trust that they know more than we do about the process, but you could ask for a better explanation of their plan.

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Posted : 03/06/2021 8:15 pm
MalarBagMetalMouth
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@apollo I voiced these concerns to my ortho, explaining that I felt tension no matter which direction I turned the screw, forward or backward. I also assured that I felt tension in the "right place" not in my molars. Given this feedback, ortho decided to proceed turning forward at 2x per day (once in the morning and once at night). After trying this, I updated that the tension feeling is much more defined when turning 2x at a time rather than 1x, so ortho said I could try turning this way (4x a day) and see how that goes. 

I could never really get an answer why they wanted me to turn backwards to begin with...

After a couple days of turning 4x, the tension feeling is starting to decline, and I'm starting to feel it in my molars again. 😕 I really hope the suture splits because I paid full price for that corticopuncture out of pocket...

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 07/06/2021 1:41 pm
Apollo
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Posted by: @metalmouth

@apollo I voiced these concerns to my ortho, explaining that I felt tension no matter which direction I turned the screw, forward or backward. I also assured that I felt tension in the "right place" not in my molars. Given this feedback, ortho decided to proceed turning forward at 2x per day (once in the morning and once at night). After trying this, I updated that the tension feeling is much more defined when turning 2x at a time rather than 1x, so ortho said I could try turning this way (4x a day) and see how that goes. 

I could never really get an answer why they wanted me to turn backwards to begin with...

After a couple days of turning 4x, the tension feeling is starting to decline, and I'm starting to feel it in my molars again. 😕 I really hope the suture splits because I paid full price for that corticopuncture out of pocket...

Well, after some backward turns, there would be some slack that would have to be taken up when you switch to forward again. So it makes sense that you would start feeling more pressure on the molars after a few days at 4 turns per day. I advanced at 1 turn per day the whole time. Slower expansion is supposed to have less risk for failing to separate because it gives osteoclasts time to break down the restrictions along the suture. You might want to slow back down to 2 or even 1 turn per day.

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Posted : 07/06/2021 1:56 pm
MalarBagMetalMouth
Active Member
Posted by: @apollo

Well, after some backward turns, there would be some slack that would have to be taken up when you switch to forward again. So it makes sense that you would start feeling more pressure on the molars after a few days at 4 turns per day.

I was only turning backwards for one day, so hopefully that didn't set me back too much. I'm sad the tension feeling is no longer happening with 1x turn, but I'll try to stay positive. 

Posted by: @apollo

I advanced at 1 turn per day the whole time. Slower expansion is supposed to have less risk for failing to separate because it gives osteoclasts time to break down the restrictions along the suture. You might want to slow back down to 2 or even 1 turn per day.

@apollo This is the opposite of what I would have expected. Thanks for sharing this. (Any source by chance, besides your own experience?)

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 07/06/2021 3:28 pm
Apollo
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Posted by: @metalmouth
@apollo

I advanced at 1 turn per day the whole time. Slower expansion is supposed to have less risk for failing to separate because it gives osteoclasts time to break down the restrictions along the suture. You might want to slow back down to 2 or even 1 turn per day.

@apollo This is the opposite of what I would have expected. Thanks for sharing this. (Any source by chance, besides your own experience?)

Dr. Richard Ting generally follows a 1 turn per day protocol. He discusses this on his JawHacks youtube interview here ( https://youtu.be/37Yug7sA3Fw ). He even advises patients to pause turning if they encounter too much resistance turning to avoid tilting/dragging the TADs or deforming the MSE framework. Dr. Won Moon's published protocol seems to contradict this, recommending a faster turn schedule for older patients. However, in a recent online lecture here ( https://youtu.be/LJ3H8eWbj1Q ), he says a slow protocol minimizes the risk of failure by allowing more time for biological rather than mechanical breakdown along the suture. Although he claims there are some tradeoff advantages to turning faster, but if you're at risk of failure, it's better to get the suture to split than nothing at all. Here's a slide from the presentation:

Here's a thread about this topic:

https://the-great-work.org/community/main-forum/how-many-turns-day-for-mse-in-june-2020-seems-like-the-advice-has-changed-is-it-just-1-day-now-when-did-this-new-info-come-out/

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Posted : 07/06/2021 4:43 pm
MalarBagMetalMouth
Active Member

Wow I think things are happening now. For the past couple days, there had been a slight pressure feeling in my front palate and around my front teeth. Earlier today after lunch, I randomly felt sutures splitting apart. It was not a "pop" as often described, but a slower "tearing" from the front TAD area towards my front teeth. I don't know for sure what happened. Maybe the front palate just "caught up" to the back. Didn't feel anything in the back.

My front teeth have the slightest ~0.5mm gap now. They had been less tight since last weekend, so not a dramatic change.

Since @apollo's message, I had resumed turning 1-2x per day, depending on how it "felt". I think I'll skip a turn tonight and see how it feels tomorrow?

26F | MARPE/MSE + Invisalign + mewing | Nasolabial folds, malar bags / festoons, tear troughs, weak chin & jawline

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Topic starter Posted : 11/06/2021 4:20 am
Apollo
Reputable Member
Posted by: @metalmouth

Wow I think things are happening now. For the past couple days, there had been a slight pressure feeling in my front palate and around my front teeth. Earlier today after lunch, I randomly felt sutures splitting apart. It was not a "pop" as often described, but a slower "tearing" from the front TAD area towards my front teeth. I don't know for sure what happened. Maybe the front palate just "caught up" to the back. Didn't feel anything in the back.

My front teeth have the slightest ~0.5mm gap now. They had been less tight since last weekend, so not a dramatic change.

Since @apollo's message, I had resumed turning 1-2x per day, depending on how it "felt". I think I'll skip a turn tonight and see how it feels tomorrow?

That sounds like you might be getting the suture to split! I didn't have a distinct "pop," but I did have a dull pain in the area around my upper front teeth, and a gap opened between the central incisors over the course of a few hours that was probably a little less than 1mm by the end of the day, but clearly visible from a distance.

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Posted : 11/06/2021 11:24 am