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Potentially starting treatment with orthotropic doctor  

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zosogg
(@zosogg)
Active Member

Sup guys, just wanted to share the beginning of my potential journey into treatment. I googled orthotropics practitioners near me and there was literally only 1 I could find in my state and she was hours away from me by drive. I decided the drive was worth it though and went through with an "ortho consultation". My major reasons for doing this, beyond just aesthetic reasons (definitely a plus), are that I'm only 22 years old (male) and have sleep apnea and also have pretty horrible recurring TMD induced migraines. 

Anyway, they basically they took some x-rays and measurements. The nurse and doctor both took my cosmetic line measurements and two different intermolar width measurements (not sure what theyre called). One was between the first molars behind the canines (I think), and the other deeper in the palate. The first one was, and I'm sorry I'm fuzzy on these, around 34mm or something and the deeper palate one (which might be the intermolar width), was around 31mm. So ya I have a narrow palate which I already knew. My cosmetic line was 50mm. That's all I remember. 

Basically the treatment they do is a biobloc appliance for palate expansion and a sagittal appliance for bringing the front teeth forward. Then I believe they continue with biobloc stage 2. Because I'm in the US, she was very careful about not promising me any good results to my sleep apnea and TMJ problems, because of lawsuits and shit. She seemed to have a very dismal attitude towards getting any real results. However, it wasn't that my case was personally very bad because I asked her directly if I was an extreme case and she said I was pretty normal for her patients and that she treats adults with some degree of frequency. The only downside she noted in my case was that I didn't actually have any extractions in my orthodontic treatment (besides wisdom teeth), and so they were limited in the amount that they could expand my palate before interfering with my bite. I asked if they could expand the lower palate but she seemed to say they couldn't really do that, but that they would probably "straighten" the bottom teeth upright to align more with the expanded upper dental arch. However, she said that she could probably get my palate to around 36-38mm, which seems to be about the right amount to have good tongue space iirc. (correct me on this). 

Right now I'm thinking of just moving forward with this because its very non invasive and I don't have much to lose. My other options are getting my tonsils removed/ maxillofacial surgery, but I am trying to avoid surgery at all costs.  Let me know if you guys have any experience with biobloc phases 1 and 2 and any sagittal appliances, and what ya'll think of my case. If I continue, I'll probably bless the forum with progress pictures/ updates, etc.

 

PS: These appliances are expensive AF in America

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Posted : 12/09/2018 11:18 pm
Apollo
(@apollo)
Reputable Member

If I was in your situation, I would also look for AGGA providers in your area to compare what they can accomplish and the cost. I believe many cases just need the help of a device to create enough tongue space to achieve the correct oral posture that will yield its own progress. So either option (removable expanders or AGGA) might be good enough to get you moving in the right direction.

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Posted : 13/09/2018 1:10 am
zosogg
(@zosogg)
Active Member

@Apollo Thanks for turning me onto the AGGA appliance, I had never looked into this. I've heard good things about biobloc, but after reading a blog like this it makes me doubt it's effectiveness. It looks like it just accomplishes the same things as traditional palate expanders, but in a different way

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Posted : 13/09/2018 2:10 am
Apollo
(@apollo)
Reputable Member
Posted by: zosogg

@Apollo Thanks for turning me onto the AGGA appliance, I had never looked into this. I've heard good things about biobloc, but after reading a blog like this it makes me doubt it's effectiveness. It looks like it just accomplishes the same things as traditional palate expanders, but in a different way

I agree that the biobloc probably isn't substantially different in effect from other palate expanders, but that isn't necessarily bad. More important than the type of the expander is the philosophy of the clinician using it. If the provider you are working with seems to understand the importance of creating tongue space and achieving good oral posture, then the type of appliance they use might not matter too much. I will say that the few results I have seen from AGGA cases seem to be more impressive than what can be accomplished in adults using removable sagittal expanders, but for transverse expansion, the type of expander probably isn't too important. I used a basic Schwarz-style expander to increase my intermolar width by about 6mm. I mentioned the case you linked to with complications from removable appliances in this post ( https://the-great-work.org/community/case-discussions/cautionary-palate-expander-case/# ).

This post was modified 2 weeks  ago 4 times by Apollo
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Posted : 13/09/2018 5:07 pm
varbrah
(@varbrah)
Active Member

Looks like our cases are pretty similar.

Look into MARPE and specifically Won Moon’s MSE — I am getting mine put in next week.

Biobloc at our age isn’t going to help much and while your palate may expand some, the majority of the gains are going to be due to teeth tipping and you ideally want bone-anchored expansion of the palate. Get this also — the expansion process/skeletal growth of the maxilla with MSE will disarticulate all contiguous sutures, so if you throw protraction into your routine, you’ll literally be able to achieve distraction osteogenesis-like improvements of the entire midface, zygos and everything.

The MSE + braces to correct the diastema is only slightly more expensive than the quote i got for biobloc from the two orthotropic orthos I consulted with, and the gains are basically guaranteed, so it makes sense imo

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Posted : 14/09/2018 9:45 am
varbrah
(@varbrah)
Active Member

Oh and I forgot to mention, the expansion process by itself (no protraction protocol) oddly enough results in a small but significant amount of forward growth and ccw rotation of the maxilla. More bang for your buck.

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Posted : 14/09/2018 10:05 am
zosogg
(@zosogg)
Active Member

@varbrah Interesting. I'm looking into it but a cursory google search unfortunately doesn't show any providers of MARPE/MSE appliances near me. There is a FAGGA provider quite close to me however. This is probably the route I'll go. It'd be nice to see an apples to apples comparison of these appliances. FAGGA and MARPE appear to be pretty similar but MARPE is drilled into the palate and probably more aggressive of an expansion. 

so if you throw protraction into your routine, you’ll literally be able to achieve distraction osteogenesis-like improvements of the entire midface, zygos and everything.

What is protraction? Like bringing the maxilla forward with sagittal appliances?

Also, I'm curious where you've found a clinician using this, if you're comfortable with that? I'm in Texas.

I'm honestly a little skeptical of the ability to actually remodel bone and not just end up tipping your teeth, which would be unfortunate, for my TMJ in particular.  

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Posted : 14/09/2018 11:43 am
varbrah
(@varbrah)
Active Member

Plenty of orthodontists use MSE or at the very least vanilla MARPE. Look for orthodontists whose specialty is in dentofacial orthopedics. The first one I hit up through e-mail ended up regularly using the MSE in treatment so it made my job quite a bit easier.

FAGGA and MARPE are pretty dissimilar tbh (one expands length one expands width) and I am not quite convinced of the formers efficacy, since there is very little literature on the subject and x-rays show extreme tipping of the front teeth and it is not bone-anchored. Even if FAGGA does grow the maxilla forward, it is not actually displacing the maxilla forwards and up in relation to the rest of the skull. What is most important is changing the position and orientation of the maxilla relative to the other facial bones. Since FAGGA doesn’t do this, the appliance will do nothing for your upper airway/sleep apnea and will MAYBE just improve your profile slightly.

Conversely, MARPE/MSE will widen your nasal passages and upper airway dimensions, providing immediate relief. Additionally, because you are not surgically/segmentally expanding the palate, the expansive forces will widen the facial bones adjacent to the maxilla resulting in more prominent zygos and stronger lateral orbitals + more. MSE is completely bone-anchored (the arms connecting to the molars from the MSE are only used to help with stability and as support to direct growth along a consistent axis), so you can be positive you are getting actual skeletal growth/remodeling. Google some studies and you can actually see the suture open on x-ray.

Maxillary protraction just means face pulling basically. In the case of MSE, the metal orthodontic bands on the molars connecting to the arms of the MSE have hooks on them. You can use these hooks as anchorage for extraoral elastics, the force of which will be distributed directly into the palate: Bone-anchored facepulling with minimal dentoalveolar effects and can easily be done 8-12 hours per day.

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Posted : 14/09/2018 12:16 pm
CaptainCrunch2574
(@captaincrunch2574)
New Member

What about retaining the changes after appliance removal? If using mse/marpe, assuming the expansion with these appliances are done fairly aggressively, would you need to wear retainers? And if so, would that prevent you from further expansion/growth?

This post was modified 1 week  ago by CaptainCrunch2574
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Posted : 14/09/2018 6:14 pm
varbrah
(@varbrah)
Active Member

Short answer: no. Long answer: it depends only on whether or not you are trying to retain your teeth in an artificial position after closing the diastema. I am not planning to wear my retainer for long, personally, but you are right that wearing a retainer would prevent you from expanding further (not that you would need to, as you would already have achieved god tier width), but not from displacing the maxilla forward and up via correct oral habits.

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Posted : 15/09/2018 2:00 am
zosogg
(@zosogg)
Active Member

@varbrah

I looked into dentofacial orthopedics and you're right that they have MARPE type appliances. Not sure if they have the hooks for face pulling, but I can ask. I'm scheduling an appointment as we speak.

My question is how would you do this face pulling? I imagine youd have to make your own kind of stationary contraption to pull via elastics, but you would have to be in front of this for 8-12 hours a day. Otherwise, you would have to manually pull via your hands. 

Also, what do you think of using MARPE for lateral expansion then FAGGA for sagittal expansion afterwards? 

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Posted : 16/09/2018 12:30 pm
varbrah
(@varbrah)
Active Member

You can ask the orthodontist about doing protraction concurrently, mine offered during my consultation. There are plenty of contraptions you can use to facepull, i am going go be using a facemask.

And like I said I am not a fan of FAGGA nor convinced of its efficacy, i personally think it is a waste of time with very little actual skeletal expansion occuring, as well as minimal displacement of the maxilla

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Posted : 16/09/2018 2:34 pm
Apollo
(@apollo)
Reputable Member

We discussed the MARPE in this thread (  https://the-great-work.org/community/main-forum/alt-ramec-protocol/# ). AGGA (as it's name implies) is mostly intended for sagittal/"anterior" expansion, but might also induce some transverse expansion, especially during the "controlled arch" phase of treatment. Whereas MARPE is mostly intended for transverse expansion, but might achieve some minimal forward growth in the process by creating more tongue space. As I wrote in the thread above, I'm not entirely convinced of the need for invasive bone anchorage for transverse expansion in adults since I was able to increase my intermolar width by about 6mm using a removable expander with minimal side effects. I suppose you could choose an appliance based on whether you need more forward or transverse expansion. The idea of extra-oral traction using bone-anchorage is appealing and some have speculated that this was the concept behind the Neymarjr "Maxilla Method" discussed on claimingpower.

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Posted : 18/09/2018 9:16 pm
zosogg
(@zosogg)
Active Member

@Apollo

What are your opinions on ALF appliances?

Also, with your expansion, how much teeth tipping was involved and how much did this affect your occlusion with your bottom teeth? And which appliance did you use?

Also, what about myobrace? Theres a doctor near me that uses myobrace plus ALF appliance, and also a new DNA appliance I have never heard of. 

This post was modified 6 days  ago 3 times by zosogg
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Posted : 18/09/2018 9:52 pm
Apollo
(@apollo)
Reputable Member
Posted by: zosogg

@Apollo

What are your opinions on ALF appliances?

Also, with your expansion, how much teeth tipping was involved and how much did this affect your occlusion with your bottom teeth? And which appliance did you use?

Also, what about myobrace? Theres a doctor near me that uses myobrace plus ALF appliance, and also a new DNA appliance I have never heard of. 

The only appliances I have experience with are a basic Schwarz-style removable acrylic expander and a large myobrace A2, so my thoughts on the other devices are just educated guesses. The ALF seems to be a gentler way to stimulate expansion and it has the advantage of occupying minimal palate space. However, I don't think its expansion is as direct as the more brute-force expanders. The myobrace seems to be useful for correcting dental alignment and malocclusions. If your current intermolar width is narrower than the myobrace mouthpiece it will also apply some expansion force but I believe this is also on the gentler side of the scale like the ALF. I am mostly hoping the myobrace will help stabilize the expansion I got from my acrylic expander, reduce the minor crowding of my lower incisors, and upright my lingually tipped lower molars. It can also help to train correct tongue position if that is something you still struggle to maintain and this can contribute to expansion. To my knowledge, the DNA appliance is like a standard removable acrylic expander except that it has acrylic covering the molars which might help protrude your mandible by unlocking your occlusion and (like the homeoblock) it often has wires to make adjustments to individual anterior teeth to improve alignment during the course of expansion. I'm not sure that either of these features are worthwhile. With my basic expander, I experienced some minor tipping of my first bicuspids, but I think this has totally resolved. I practiced regular gum chewing during the course of my expansion which is supposed to help keep the teeth upright and maintain occlusion with the mandibular arch.

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Posted : 19/09/2018 12:16 am
zosogg
(@zosogg)
Active Member
Posted by: Apollo
Posted by: zosogg

@Apollo

What are your opinions on ALF appliances?

Also, with your expansion, how much teeth tipping was involved and how much did this affect your occlusion with your bottom teeth? And which appliance did you use?

Also, what about myobrace? Theres a doctor near me that uses myobrace plus ALF appliance, and also a new DNA appliance I have never heard of. 

The only appliances I have experience with are a basic Schwarz-style removable acrylic expander and a large myobrace A2, so my thoughts on the other devices are just educated guesses. The ALF seems to be a gentler way to stimulate expansion and it has the advantage of occupying minimal palate space. However, I don't think its expansion is as direct as the more brute-force expanders. The myobrace seems to be useful for correcting dental alignment and malocclusions. If your current intermolar width is narrower than the myobrace mouthpiece it will also apply some expansion force but I believe this is also on the gentler side of the scale like the ALF. I am mostly hoping the myobrace will help stabilize the expansion I got from my acrylic expander, reduce the minor crowding of my lower incisors, and upright my lingually tipped lower molars. It can also help to train correct tongue position if that is something you still struggle to maintain and this can contribute to expansion. To my knowledge, the DNA appliance is like a standard removable acrylic expander except that it has acrylic covering the molars which might help protrude your mandible by unlocking your occlusion and (like the homeoblock) it often has wires to make adjustments to individual anterior teeth to improve alignment during the course of expansion. I'm not sure that either of these features are worthwhile. With my basic expander, I experienced some minor tipping of my first bicuspids, but I think this has totally resolved. I practiced regular gum chewing during the course of my expansion which is supposed to help keep the teeth upright and maintain occlusion with the mandibular arch.

And how much expansion did you get with the acrylic expanders?

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Posted : 19/09/2018 12:02 pm
varbrah
(@varbrah)
Active Member

@Apollo not convinced of the need for bone-anchored expansion either — I’ve been mewing for the past 4 years since age 18 after first learning about the concept after chancing upon sluthate  (i know, lol). I’ve made some incredible progress just from fixing oral posture, but MARPE/MSE might legit be what some older users here with severe transverse deficiency need in order to create a strong base for proper mewing, since growth is not on their side. In my case, despite my palate improving substantially via natural methods, progress has slowed down my lower jaw is still quite a bit wider. Also, a big limiting factor for me is my obstructed upper airway (72mm^2 cross sectional area, whereas ~100mm^2 is the generally minimally acceptable cross sectional area for non-obstructed breathing) which still results in difficulty nasal breathing/mewing during sleep and other unconscious activities.

You are correct MSE is supposed to achieve a degree of forward growth and ccw rotation of the maxilla, but this is due to the disruptive effect the appliance has on the maxillary bones and related complexes— it disarticulates the intermaxillary suture, as well the sutures in contiguous facial bones, and the expansion process itself is responsible for the movement of the maxilla into its new forward/rotated position, and not just due to there being more space for the tongue.

As an added plus to this, the MSE can serve as an anchor for pure skeletal protraction, which as you mentioned is appealing. I’ve attached an FEM model by Won Moon on the effect of MSE-borne protraction, force directed -30 degrees to the occlusal plane, 1g of force per side. The result is significant forward growth/displacement and mild anterior tipping of the maxilla (ccw rotation). Bone-anchored protraction will have also have incredible synergy with MSE, due to the aforementioned disarticulation of all sutures contiguous to the maxilla during expansion. This means protraction will yield forward skeletal growth at all of these sutures, which means better orbitals, zygos, midfacial fullness, etc.

I’m getting the MSE installed next Monday, so I will hopefully be throwing a log together once I have more documentation. My plan is to maximize growth at the sutures with MSE + protraction, and then continue mewing and if need be using various appliances from there to achieve further marginal gains from skeletal remodeling.

 

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Posted : 19/09/2018 12:13 pm
Apollo
(@apollo)
Reputable Member
Posted by: zosogg

And how much expansion did you get with the acrylic expanders?

About 6mm

 

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Posted : 19/09/2018 3:37 pm
Apollo
(@apollo)
Reputable Member
Posted by: varbrah

You are correct MSE is supposed to achieve a degree of forward growth and ccw rotation of the maxilla, but this is due to the disruptive effect the appliance has on the maxillary bones and related complexes— it disarticulates the intermaxillary suture, as well the sutures in contiguous facial bones, and the expansion process itself is responsible for the movement of the maxilla into its new forward/rotated position, and not just due to there being more space for the tongue.

I agree. I've documented my experience with hearing shifting sounds in one or both ears when I push up on my palate with my tongue, which tended to increase in frequency and intensity after advancing my expander. I hypothesized that this reflected the kind of suture disarticulation you're describing (but it's still the tongue exerting the force of displacement along those loosened sutures unless you add some kind of external protraction). I tried to apply concurrent extra-oral traction using a DIY headgear attached to my removable acrylic expander using a facebow with 5 attachment points, but I found that it was loading the force onto my teeth rather than my palate, so I abandoned the practice. I suspect you will have more success if you try this connected to your bone-anchored expander. Good luck, and please keep us updated about your treatment! If you check out the thread I linked above, Mike Mew references Won Moon's success with MSE but he wasn't able to replicate it without direct training from Dr. Moon.

This post was modified 5 days  ago 3 times by Apollo
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Posted : 19/09/2018 3:45 pm
zosogg
(@zosogg)
Active Member

@varbrah

How long will you have the MSE installed?

Also, Im curious why you included the -30 degree simulation result in your post and not the +30 degree simulation. I'm looking at the paper now and the +30 degree simulation seems to produce the best results, with no posterior tipping and the maxilla moving entirely upwards and forwards.

Anyway, I appreciate you sharing this idea with us. This could be very effective, it makes a lot of sense. Do you know if there have been any clinical trials or case studies of other's using this? In your time talking with orthos, have they shed any insight into whether this has worked for other people before? If not, your experience will certainly be a very important case study

This post was modified 5 days  ago 3 times by zosogg
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Posted : 19/09/2018 8:03 pm
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As you undergo correction in the near future, please consider keeping records for your own sake and for others. Pictures of dental impressions, scans, medical reports reports can be very helpful even with all personally identifying information blocked out.

Your input could help many, many people

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