32M, MSE, class III…
 
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32M, MSE, class III malocclusion with a recessed jaw?!

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Mastermewer
(@mastermewer)
Posts: 7
Topic starter
 
Hi all,
 
I’ve had the first consultation with the orthodontist and seeking advice on whether to proceed with MSE or not. 
 
So the first thing my orthodontist said was that I’m missing a bottom incisor (I have 3 instead of 4) which I wasn’t even aware of. He also said that I have a class III malocclusion as shown in the attached pics of the invisalign simulation where you will notice that my bottom molars are forward of my top molars (especially on the right side). Which is confusing to me how I can have a recessed jaw and class III malocclusion…?
 
So the treatment plan would be MSE + with cortipuncture following Moon’s procedures of 4-6 turns until the suture splits then 1-2 turns per day. He said we could expect around 5mm of expansion. (I don’t think I can expand that much further since my bottom jaw is also kind of narrow). And then in order to align the bottom jaw, invisalign for a year plus and if I wanted, carriere motions to move the bottom teeth back to speed up the process. Now, I’m quite worried that with a class III maloclussion and if I use invisalign to move the bottom teeth further back, is it possible that it would make my jaw even more recessed? He said he wouldn’t recommend a facemask, since that would protract my maxilla even more forward, which would counteract the invisalign which is trying to adjust the bottom teeth back…
 
The main reasons I am interested in getting the MSE is firstly for health reasons, to expand my nasal passageway, although of course I care about aesthetics as well. I believe my nose-breathing is sub-optimal and it’s holding me back from my exercise goals, I often get a runny/stuffed nose (especially when eating, anyone else?) and I lightly snore (but nothing too serious, although I’m aware of the massive importance of sleep).
 
I’ve also trying to fix my forward head posture, and I found that if I chin tuck and mew, it becomes harder to breath (anyone else?)
 
Oh and I have a fairly small palate (35mm IMW) which makes mewing hard to do. It’s impossible for me to get the entire tongue on the roof of the mouth.
 
The entire operation will set me back about $10,000USD and I’m based in Japan FWIW. I’m just wondering is it worth it to go through all this trouble and if it’s possible that in the end it will make my face worse off… Thoughts???

Edit 1: I’ve added photos of the x-ray my ortho took, so if anyone has any opinions about it, please feel free comment

 
InkedPXL 20220102 063840036 LI
InkedPXL 20220102 063855208 LI
Narrow palate   35mm IMW
PXL 20220104 111712503
Right side (before)
Right side (after)
front (before)
front (after)
Left side (before)
left side (after)
4239 20220101 20220118182604 DX
4239 20220101 20220118182430 DX
4239 20220101 20220118182842 PX

 

 
Posted : 12/01/2022 8:20 am
Topic Tags
MSE
Apollo
(@apollo)
Posts: 1681
 

I’m a man a little older than you with a skeletal class iii relationship and a starting IMW around the same as yours. I’m happy with the results of my MSE treatment so far. My snoring and nasal breathing are significantly improved. The risk that the suture fails to separate is higher in men our age, but it worked for me after some initial complications. A slower turn schedule reduces the risk of failure. Dr. Ting recommends just 1 turn per day in many patients. Dr. Moon is now advocating a subjective protocol of turning until you feel resistance and then advancing one more turn, but that can be hard to interpret for someone who has never experienced the process before. There’s also the risk that the expansion can make asymmetries worse by expanding the wider side more. My wider side moved a little more than my narrower side. I have seen a few cases where the asymmetry becomes much more noticeable. There is a clinic in South Korea that uses splint therapy during the expansion to correct asymmetry. Even without facemask, the MSE alone tends to advance the maxilla very slightly. I think I got a little more using reverse-pull headgear, but haven’t had follow-up imaging to measure yet. I don’t really understand why your orthodontist is discouraging it. Seems like the worst that could happen is it doesn’t work, but it is inconvenient and uncomfortable to put in the necessary hours. What are your plans for the missing lower incisor? If they are going to create enough space on the bottom to place an implant, I imagine that would allow for a fair amount of upper expansion.

 
Posted : 12/01/2022 11:25 am
drunkwithcoffee
(@drunkwithcoffee)
Posts: 218
 

@Apollo how many turns did it take you to split? Did you get corticopuncture?

 
Posted : 12/01/2022 1:51 pm
Mastermewer
(@mastermewer)
Posts: 7
Topic starter
 

Great to hear your expansion was successful Apollo. How much upper expansion were you able to get? 

In regards to the turning protocol, do you have a source where Moon says turning at a slower rate? His website still shows 4-6 days until the suture splits and 1-2 afterwards.

My ortho says he doesn’t recommend the facemask before my maxilla is already in front of my jaw. Nothing was said about the possibility of putting in an implant for the missing incisor on the bottom, just using Invisalign to align the teeth afterwards 

 
Posted : 12/01/2022 5:55 pm
Apollo
(@apollo)
Posts: 1681
 
Posted by: @drunkwithcoffee

@Apollo how many turns did it take you to split? Did you get corticopuncture?

I had cortipuncture and split around turn 35.

 
Posted : 12/01/2022 8:48 pm
Apollo
(@apollo)
Posts: 1681
 
Posted by: @mastermewer

Great to hear your expansion was successful Apollo. How much upper expansion were you able to get? 

In regards to the turning protocol, do you have a source where Moon says turning at a slower rate? His website still shows 4-6 days until the suture splits and 1-2 afterwards.

My ortho says he doesn’t recommend the facemask before my maxilla is already in front of my jaw. Nothing was said about the possibility of putting in an implant for the missing incisor on the bottom, just using Invisalign to align the teeth afterwards 

I maxed out a 10mm MSE, but some of that expansion gets lost to tilting of the teeth and TADs. 

Dr. Moon talks about the protocol in a virtual lecture here:

  https://youtu.be/LJ3H8eWbj1Q

With regard to your missing lower incisor, maybe they don’t think they can get enough expansion of the lower to create space for an implant. Aesthetically, it would be nice to have the upper and lower midline meet up. 

 
Posted : 12/01/2022 8:57 pm
Mastermewer
(@mastermewer)
Posts: 7
Topic starter
 

10mm…amazing! How did you align the bottom afterwards?

Thanks for sharing the talk, so optimal expansion rate would be until it’s tight and then 1 or 2 more. 

Well I’m not sure how it’s possible to expand the bottom and put in an implant unless I have surgery to split open the mandible… Anyway he said it’s genetic and 5% of people are missing a bottom tooth, which sucks because it probably means my jaw is smaller than it should be.

 
Posted : 12/01/2022 9:38 pm
drunkwithcoffee
(@drunkwithcoffee)
Posts: 218
 
Posted by: @apollo
Posted by: @drunkwithcoffee

@Apollo how many turns did it take you to split? Did you get corticopuncture?

I had cortipuncture and split around turn 35.

Wow that seems super fast.  I’m almost 30 and my ortho said it may take 4-5 weeks.  Only on turn 10, fingers crossed for a split.

 
Posted : 12/01/2022 11:17 pm
Apollo
(@apollo)
Posts: 1681
 
Posted by: @mastermewer

10mm…amazing! How did you align the bottom afterwards?

We’re just using invisalign to bring my uppers and lowers back together. I guess some orthodontists use different kinds of expanders on the bottom to help that process, but my ortho doesn’t think it’s necessary in my case.

 
Posted : 13/01/2022 7:51 pm
Apollo
(@apollo)
Posts: 1681
 
Posted by: @drunkwithcoffee
Posted by: @apollo
Posted by: @drunkwithcoffee

@Apollo how many turns did it take you to split? Did you get corticopuncture?

I had cortipuncture and split around turn 35.

Wow that seems super fast.  I’m almost 30 and my ortho said it may take 4-5 weeks.  Only on turn 10, fingers crossed for a split.

I was only advancing about 1 turn per day to reduce the risk of failure, so it took more than a month. Good luck! I know how stressful the suspense can be before the split.

 
Posted : 13/01/2022 7:52 pm
Mastermewer
(@mastermewer)
Posts: 7
Topic starter
 

Edit 1: I’ve added photos of the x-ray my ortho took, so if anyone has any opinions about it, please feel free to comment

 
Posted : 18/01/2022 7:30 am
Apollo
(@apollo)
Posts: 1681
 
Posted by: @mastermewer

Edit 1: I’ve added photos of the x-ray my ortho took, so if anyone has any opinions about it, please feel free to comment

It looks like the A point on your maxilla is behind the B point on your mandible relative to your nasion. I’m still not sure why your provider is opposed to trying facemask to get as much forward advancement as possible.

 

 
Posted : 18/01/2022 11:24 am
Mastermewer
(@mastermewer)
Posts: 7
Topic starter
 

@apollo can you clarify what you mean by the A point on the maxilla and B point on your mandible are ?

My provider said on the initial consultation that since my upper teeth are already in front of my lower teeth he doesn’t want to pull my maxilla more forward as that would  give me a overbite. (Even though my molars indicate that I have class III malocclusion)

However, he may change his mind after taking a look at my scans now, we’ll see.

 
Posted : 18/01/2022 7:12 pm
Apollo
(@apollo)
Posts: 1681
 
Posted by: @mastermewer

@apollo can you clarify what you mean by the A point on the maxilla and B point on your mandible are ?

My provider said on the initial consultation that since my upper teeth are already in front of my lower teeth he doesn’t want to pull my maxilla more forward as that would  give me a overbite. (Even though my molars indicate that I have class III malocclusion)

However, he may change his mind after taking a look at my scans now, we’ll see.

Mastermewer LatCeph Angles

The A point is the most concave point on the anterior maxilla. The B point is the most concave point on the mandibular symphysis. It’s a little difficult to decide where to mark your A point. There’s a shadow of the alveolar ridge including the roots of your centrals ahead of the point I marked. If that’s your actual A point, then you probably fall within the normal range. If your A point is the more opaque point I marked, then your SNA (the angle between your sella, nasion, and A point) measures just over 79.9 degrees and your SNB as just under 82.3 degrees. If I’m measuring correctly, your SNA is right on the lower limit of normal (82 +/- 2 degrees) and your SNB is right at the upper limit of normal (80 +/- 2 degrees). What’s abnormal is that the A point should be in front of the B point for an ANB angle in the range of positive 2 +/- 2 degrees. My measurement is around negative 2.4 degrees. However, the actual A point might be a degree or less ahead of the B point. Regardless, your upper incisors are proclined (tipped forward) to compensate and achieve an overjet. If you used facemask to move the A point forward and bring your molars into class I occlusion, the upper incisors could be uprighted (tipped back) during realignment to avoid excess overjet. Of course, getting any forward change from facemask in an adult male is difficult, but might be worth trying.

 
Posted : 19/01/2022 11:09 am
Mastermewer
(@mastermewer)
Posts: 7
Topic starter
 

Fascinating, thank you so much for the analysis. I didn’t know anything about SNA and SNB points before this. I actually think my A point is about the same as the B point.

So well, I guess my face isn’t too fucked up then? Since I’m kind of within the normal ranges… 

Based on your measurements though, it would suggest that my maxilla is a bit recessed, so it’d be good if MSE / FM can give me some forward movement, even if it’s 1-3mm, that’d be heaps. And then as you said bring the teeth back to class I occlussion and uprighting the front teeth with invisalign.

But now I’m kind of questioning if I even need to go ahead with this treatment or not lol

One thing that is bothering me and is one of the reasons I am interested in the MSE is because my palate is narrow and it’s difficult for me to get my entire tongue on the top of my palate. The side of my tongue also gets a bit cut up. I’m interested in the idea of using the tongue as a lifelong retainer, and I can’t do that right now with my narrow palate. 

@apollo did you find that after expanding the palate that it was much easier to mew? 

 
Posted : 20/01/2022 8:05 am
Apollo
(@apollo)
Posts: 1681
 
Posted by: @mastermewer

Fascinating, thank you so much for the analysis. I didn’t know anything about SNA and SNB points before this. I actually think my A point is about the same as the B point.

So well, I guess my face isn’t too fucked up then? Since I’m kind of within the normal ranges… 

Based on your measurements though, it would suggest that my maxilla is a bit recessed, so it’d be good if MSE / FM can give me some forward movement, even if it’s 1-3mm, that’d be heaps. And then as you said bring the teeth back to class I occlussion and uprighting the front teeth with invisalign.

But now I’m kind of questioning if I even need to go ahead with this treatment or not lol

One thing that is bothering me and is one of the reasons I am interested in the MSE is because my palate is narrow and it’s difficult for me to get my entire tongue on the top of my palate. The side of my tongue also gets a bit cut up. I’m interested in the idea of using the tongue as a lifelong retainer, and I can’t do that right now with my narrow palate. 

@apollo did you find that after expanding the palate that it was much easier to mew? 

 

I think you’re right that I should have placed your A point more forward. So your SNA, SNB, and ANB values are probably within normal ranges. Of course, this is the “normal” distribution for modern humans who are retruded relative to ancestral standards. The ideal SNA and SNB are probably above the upper limit of normal. The figures for my skeletal class iii case have my SNA below the lower limit of normal, and my SNB within the normal range, putting my B point in front of my A point.

All of this cephalometric analysis is evaluating the anterior-posterior dimension. The MSE will have its greatest effect in the transverse dimension. It has gotten easier for me to fit my tongue within my dental arch since completing expansion, but I haven’t had the appliance removed from my palate yet. I still get some scalloping around the edge of my tongue but not as obvious as before.

 
Posted : 22/01/2022 3:47 pm
BasketCrisis
(@basketcrisis)
Posts: 1
 

@apollo 

Did you do a surgical mid-palatal split or was it just the corticopuncture? Also, did insurance cover any of it? (MSE, facemask, surgical assist, etc.)

I’m going down the same path and my ortho agreed that MSE+Facemask would benefit my situation. I’m just scared of the end cost.

 
Posted : 21/02/2022 10:58 pm
Apollo
(@apollo)
Posts: 1681
 
Posted by: @basketcrisis

@apollo 

Did you do a surgical mid-palatal split or was it just the corticopuncture? Also, did insurance cover any of it? (MSE, facemask, surgical assist, etc.)

I’m going down the same path and my ortho agreed that MSE+Facemask would benefit my situation. I’m just scared of the end cost.

Just cortipuncture. Paid out of pocket. Most of the cost is the realignment phase.

 
Posted : 25/02/2022 10:17 pm
Mastermewer
(@mastermewer)
Posts: 7
Topic starter
 

Update:

The orthodontist said that my palatial bone is too thin/narrow, risk of failure is too high and therefore I’m not a suitable candidate for MSE. Photos attached.

If you look at the CT scan between the second premolar and first molar (5th and 6th tooth) you will notice that the bone in my palate is extremely narrow. Also, for whatever reason my maxillary sinus is massive.

The CT scan between the first molar, there seems to decent-ish thickness but it’s too thin according to my orthodontist. In the CT scan between the second molar, the palate becomes too thin, basically non-existent. And if you look at the picture of my palate, there basically seems to be very little bone at the back. (I’m not really sure how they took this photo).

CT scan   second molar
CT scan   first molar
CT scan   second premolar and first molar
Palate bone
CT scan   first premolar

Anyone have any thoughts or a second opinion? It’d be much appreciated.

 
Posted : 06/05/2022 8:46 pm
Apollo
(@apollo)
Posts: 1681
 

If the bone is too thin, there’s a good chance the MSE TADS will tilt or drag rather than separating the suture. Sometimes they will position the TADS more anteriorly to engage thicker cortical layers, or I’ve also seen cases using modified MARPES with 6 TADS rather than 4. I can’t tell from your scans if either of those approaches would be possible for your case. Some people have gotten questions answered by emailing Dr. Won Moon himself, or you could pay to have a virtual consultation with Dr. Richard Ting who is an experienced MSE provider. Your ortho could post your scans on the MSE Facebook group (for doctors only) to request opinions. You might also consider an EASE expansion that uses a different type of transpalatal distractor with anchorage at the sides rather than the top of the palate with midplatal and pterygomaxillary osteotomies to ensure separation. I think this is expensive and only available from one provider in San Francisco.

 
Posted : 08/05/2022 8:06 pm

THE GREAT WORK