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I would really appreciate advice for my case. I am 27 years old male living in Greater Vancouver Area, BC, Canada. I have had metal braces from 2017 to 2018 but my teeth have become crooked again (although my smile is somewhat better than before getting braces), I tried SmileDirect Club for about 6 months in 2020 but did not get the desired results, please see below my pictures from a recent consultation I had. You can see that I have a recessed lower jaw and an underdeveloped maxilla and my face has not grown forward nor wide enough. I also have one wisdom tooth that is impacted but I have no pain at all and this tooth has been impacted for a long time (like more than 5 years since I got the last X-ray), I also have all 4 of my wisdom teeth in place - didn't get them removed. I have been Mewing for the last 2-3 years, but I think it is a very slow process and although I have had some improvement, I am considering more options as well.
Orthodontists suggested treatment:
I have been to a few traditional orthodontists here in Vancouver and they all recommend removal of wisdom teeth (all 4 of them), as I was opposed to wisdom teeth removal from the beginning (been watching a lot of Dr Mew's videos since a long time) and even didn't get them extracted the first time I had braces. So I decided not to go with the traditional orthodontists treatment plan (they also only cover the smile portion and not the skeletal development). Further, my concern is that since my face has not developed forward, by removing wisdom teeth, my face will sink even further, so having a straight smile at the expense of bad overall facial form is not my desire.
My Concerns (Please share your feedback and challenge my thoughts):
I think the main reason for my relapse after the initial braces was due to my Maxilla being narrow. As of last year (Feb - 2020), my inter-molar width is 32mm (see below image from consultation). My face has not developed neither wide nor forward enough. In order to achieve this, based on my research following Ron from Jaw Hacks, Dr. Derek Mahony and other posts on this website. The best option would be to get an MSE expander + Facemask? But what about lower jaw - please suggest (I would prefer non surgical solutions if any, anyone know of Trombone Appliance from Mike Mew video - https://www.youtube.com/watch?v=j4sH7MVFmMQ&t=73s)? .
My aim with is to get a wider face (prominent cheek bones) using MSE and to achieve forward growth using Facemask. The challenge I am facing is I have reached a few orthodontists here in Vancouver but they are not familiar or have no experience performing this procedure.
Further, the leading expert in MSE + Face Mask, Dr. Ting in California does not accept patients from outside the state anymore. Although I checked his website and it seems he can give a detailed written treatment plan. Now I need to find a dentist who would implement this plan. Does anyone know any dentist that would implement his plan. I found a surgeon ( https://www.abbotsfordoralsurgery.com/procedure/surgical-palate-expansion/index.html ) but I think He may only assist me in MSE installation and I might need an orthodontist to monitor the rest of the process.
How long do you think the whole process might take?
And how much would it cost me - I mean full treatment along with any braces/Invisalign if needed?
I really appreciate you taking the time to assist me with this, its quite a struggle finding the right options and the right people to perform all this. Please feel free to PM me.
Thank you so much.
You were unfortunately stuck in the spam filter for a few days! Post approved, sorry for the delay.
I'm envious that you still have your wisdom teeth! I am happy with the results of my MSE treatment. However, expanding the maxilla wouldn't create space for your impacted lower third molar. So be planning how you are going to expand the mandible to meet up with the maxilla before you commit to MSE. In many cases, invisalign is used to bring the bite back together after MSE, but I think you would need something else. Maybe a quad helix expander or a lower light wire appliance like the ALF could be enough, but a surgical approach might be your only option. I don't know if SFOT bone grafting could create the space you need on the bottom or if you would require something like MSDO. There's a Canadian MSE patient posting at class3mse.medium.com. Dr. Bockow in Seattle might be a relatively close option for you to consider.
@apollo Thank you so much for your input. I am so lucky to have discovered Mike Mew before getting my first braces. And since then I have been against removing wisdom teeth. With regards to mandible, so in one of my consultations, the dentist told me that my right upper and lower teeth do not occlude properly. I was thinking by using MSE and expanding my maxilla by say about 6-8mm (currently I'm at 32mm IMW, so that will bring it to 38-40mm), and as you suggested using quad helix expander or ALF to expand the lower jaw by a few mm. Both my upper and lower teeth will occlude properly. And the gaps created due to MSE can then be closed by Invisalign.
You are right about the impacted wisdom tooth, apparently there is no room for it to grow, but since I have no pain so I will leave it as is. Unless there is a mechanism to make it upright?
Luckily I found this site ( https://www.moonmse.com/distributors-1) by Prof. Won Moon and I found an orthodontist in Vancouver. I have an appointment with her tomorrow, I hope she will be able to provide me with this service and not suggest removal of any additional teeth like the rest.
@alexroyf2 Thank you for sharing your information on your case!
Here is what I see:
You are downward grown (hooked nose since the part of the nose attached to the maxilla is down and back as the maxilla is down and back).
Your jaws are too far back in your face (I can see this from the frontal photo where you smile, 3rd picture).
Your upper jaw is too narrow. Your upper and lower posterior teeth are flush laterally (the uppers should be wider than the lowers). This means your bite is unstable, which is probably also why your previous orthodontic work did not result in a stable result.
You need to widen and impact your maxilla (I think MSE is good in your case. It will do both at the same time). Then your lower jaw can also close more and come forward more (right now, even when you close your mouth, your lower jaw posture is kind of like an opened position for someone with horizontal growth. This is because your upper jaw has fallen down and back and meets your opened lower jaw).
@limebike thank you so much for analyzing my case.
I went to the orthodontist and she will install the MSE appliance to get expansion in my upper jaw, although she does not recommend face mask in my case as she said that it will give me an open bite (currently I have a class 2 open bite). Further she said the facemask will pull my maxilla forward and down which is not desirable. Do you think I should get online consultation with Dr. Richard Ting from California, just to get a second opinion on the best treatment, He has done more than 300 cases using MSE and facemask.
@alexroyf2 You're welcome!
You can see how much forward and upward movement of the maxilla you get from splitting the suture alone. Usually it is pretty good, about 2 mm forward for every 10 mm expansion. Some additional protraction via external anchorage would not hurt. It may produce an open bite, which is due to your upper incisors being first to move up and forward while the posterior teeth lag behind. This is the classical orthotropic preparation, see https://www.youtube.com/watch?v=6f4hxJL820E . This temporary open bite can be resolved by impacting the posterior teeth (either by keeping your teeth together all the time, i.e., biting on them to intrude them, or more forcefully, using TADs).
The crude photoshop is what I envision how your face would change favorably if successful:
The lower is the first stage of the protraction of the frontal part of the maxilla. The posterior part needs to be impacted and mesialized and then your lower jaw can swing forward and close more.
@limebike thank you so much for telling me this. If I had known this before the consultation, I would have brought this point up with her (regarding fixing open bite with TADs). I have a few concerns now, and I would be grateful if you can give me your opinion on them:
I didn't know that MSE results in a slight forward expansion as well (as I only read about lateral expansion), do you have resources supporting that? Can you please share them with me.
I don't think the orthodontist I am visiting (This is her -> https://www.evergreenorthodontics.ca/meet-dr-lee/) practices the concepts of orthotropics (as she did suggest IPR and molar extractions to fix crowding in my lower jaw which I am against). Although she was listed in Prof. Won Moon's website ( https://www.moonmse.com/distributors-1) and she is one of the two MSE persons in British Columbia in Canada. So basically my options are limited and I need her to get the MSE. Her main concern was that my open bite would get worst with a facemask. Since she does not practice orthotropics, therefore I can not just ask her to give me an open bite and I will press on my posterior teeth and the bite will close (she is reluctant to give me a partial treatment). So my only option is to convince her to treat me using TADs, can you share some pictures or clips on how this would work as I don't understand it very well (I googled as well)? I looked at Dr. Mew's clip but I couldn't really understand how he closed the gap and that was also in a kid, so not sure how it works for adults.
Also, not sure if you know about Dr Richard Ting in California, he has a lot of experience with MSE + Facemask, do you think getting online consultation to find out his opinion on facemask is worth it? would it convince my current orthodontist to get me a facemask and then use TADs?
Also, I have a confusion with regards to my treatment sequence, this is how I think it might go (please advise), so starting with about 10 months on MSE for a 10 mm or so expansion, facemask in the first 2-3 months of MSE to get a few mm forward growth, then Invisalign for about 1 year or more to close the gaps in upper teeth and to expand the lower teeth so they occlude properly with the upper teeth. This will finally be followed by TAD to close the open bite. Is this the correct sequence?
single tooth intrusion via TADs:
intrusion of whole posterior segment (you can think of less bulky versions where you have a less thick splint that can also be removable, such as an aligner piece for the posterior segment):
I would plan the sequence as follows:
Phase 1: Expansion of maxilla using MSE at the rate of 1 mm per week. Aim for 10-16 mm expansion or even more if you need more. This will take from around 3-4 months. Simultaneously use forward-pull device to protract maxilla (I am not a fan of anything anchoring to the lower jaw, like face mask. Consider the Facebow instead: http://www.forwardontics.com/bow.html ).
While you are expanding the maxilla, this would be a good time to expand the mandibular arch using a simple acrylic expander that expands the width but also proclines the incisors.
When your upper and lower incisors are proclined (this will automatically make the upper incisors go up and the lower incisors go down, as seen in the video on the orthotropic preparation -- it is simply the how the anterior teeth move when pushed on as a group), this is where you will be having an open bite.
Phase 2: Intrude the posterior teeth (both upper and lower teeth) so that the open bite closes. (give it 0.5 mm per week, which will give you 4 mm intrusion per arch in two months).
Phase 3: Closure of gaps by moving all teeth to the midline (mesialization). If you look at orthotropic case pictures, you will notice that the posterior teeth are all very far back compared to the anterior teeth. This is because everything has been so far back and also because expanding at the midline suture will naturally distalize all teeth as a direct consequence. I estimate the need to mesially move teeth about 10 mm, which could take 3-4 months.
The problem with Orthodontists is that they are too much focused on teeth alone and do not want to change things drastically. If you commit to this and work hard, you can achieve huge changes to the jaws and hence your whole craniofacial structure. It is like achieving the effects of a Lefort 3 surgery gradually and without the drastic actual surgery. It takes time and commitment though. I learned this by self-studying the very useful materials on orthotropics provided by Drs. John and Mike Mew and also by the contributions in this community. I am implementing these things on myself as we speak. I started out with more classical orthodontic techniques using DIY aligners and class 3 elastics, which was resulting in too small a change. This is when I taught myself to fabricate acrylic expanders (around September 2020) and when things took off. I am male and in my 30s and the 1mm-per-week expansion protocol worked charms. I went through a sequence of acrylic expanders, about 4 or 5, expanding each to around 4-5 mm. I have huge gaps everywhere that I am now closing.
After I am done, I will probably go with another expansion. My tongue still does not fit and I have an IMW of around 43-45 mm (it will decrease when you mesialize as the arch is narrower towards the midline).
Regarding forward movement of maxilla upon expansion, see, e.g., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4993819/
This is due to the natural resistances at the sphenoid and zygoma area forcing the maxillary halves to squeeze out in the forward direction upon expansion.
@limebike So I just had a consultation with Dr Richard Ting and he said that I am a double jaw surgery case.
He said to get the forward growth that I am looking for, I would need to get double jaw surgery. That's quite expensive and it's scary too as some people have lost senses in their nerves after the surgery and in rare cases there has been a relapse as well.
I was wondering, how did you achieve the forward growth in your case as you did it by yourself, do you think if I get MSE + braces and Mew hard after wards, can I get the forward growth with time? Dr Richard Ting thinks it's not possible to get any forward growth from posture alone.
What do you think would be my best option? MSE + Braces + Mewing? Or do you think I should consider DJS?
Also, have you achieved forward growth in your case? and how?
@Alexroyf2 I also have poor forward growth and bad facial features, but I'm choosing genioplasty + rhino not only because DJS is much expensive, but also because the recovery time lasts at least for a few months and it isn't rare to get complications during it (you can get irreversible speech issues, for example). Genioplasty would only give me a very small functional benefit as it help expanding the airways, but there's no problem as I breath normaly, while the aesthetic results would be huge.
By the way, I'm currently using MSE to achieve a few milimeters of expansion and to improve my smile and cheekbones.
If you are in Canada, you should consult Dr Sylvain Chamberlain once...He does the MSE with MSDO.
Have you had a consultation with him before? I've looked at his site but most of the content is around kids. Curious about the possibility of MSE + FM for adults, and how willing to take on a patient he is.
I'm in a similar boat as you - similar age, also in Canada, poor forward growth etc so I'm very interested in your case. Would you mind sharing how more about how your consultation with Dr Ting went?
Did he say you're a DJS candidate because even with a facemask/protractive head gear you wouldn't achieve the results you want? What is the amount of forward growth that would be beneficial for you? (I'm not well versed in movements).
I had high pull headgear as a teen and now have small jaws and a really flat mid face. Currently trying to find ways to rebalance my face so I don't look like a gremlin. I know I have an uphill battle since technically my bite is aligned now and I don't have major breathing issues, though I do have jaw discomfort/tension/locking from time to time.