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Here is why MSE+FM doesn't and won't produce much forward movement in adults

ThaGangsta
Eminent Member

Facemasks are unlikely to create much movement beyond a few milimeters in a grown adult, and tbh after the pubertal age. Facemasks rely on the circumaxillary sutures (the sutures that attach the maxilla to the skull) to be loosened so that the maxilla can be pulled forward.  Because the MSE opens the midpalatal suture with force, the maxilla squeezes against the zygomatic bone (a powerful action) and this force allows for the remainder of the circummaxillary sutures to become loosened along with it.  The sutures of an adult are often too firm to create much change (picture it like opening a door normally versus trying to open it while you have a wooden wedge stuck in the hinge area).

We must define movement as well.   The movement you get from facemasks+MSE will be movement of the whole bone via displacement and force. 

But one needs to understand that there is a second type of movement which is through peripheral resorption and deposition.  When bone detects a long term consistent light force (for example the tongue gently resting on the palate and swallowing) it has microtrauma, causing a signalling mechanism to remove a small amount of bone from that area.  However, the main bone remodeling mechanism in adults seeks to maintain the shape and/or mass of the bone (this does not include the alveolar tooth-bearing bone).  So for every bit of bone taken away from a surface, the same amount will be deposited at the opposite surface, effectively creating a displacement. I have attached a pic to better explain this.

 (Credit to Enlow and Hans 1996)

 

So the reason that maxillary movement is far easier in a young person is because of the looseness of the maxillary sutures, the much faster rate of bone remodeling, and the fact that their maxilla is still growing (which basically makes this 'growth guidance' in a very young person, rather than movement).

This shows that brute force is not optimal.  Gentle forces are the way to go, especially those applied in a proper vector, over the long term.  There can perhaps be ways to speed up this process, and further optimize the vector these forces have.

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Topic starter Posted : 05/02/2021 10:58 pm
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TheBeastPanda
Trusted Member

SO basically MSE+FM won't work in adults with the reasons you just listed? Do you think someone age 14 getting MSE+FM could warrant very good results?

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Posted : 06/02/2021 1:07 pm
ThaGangsta
Eminent Member

@thebeastpanda

It depends on your skeletal maturation, the farther along puberty you are the less effective it is/more forces you need, which in my opinion does more to traumatize the bone than create meaningful change. Keep in mind that MSE+FM will only correct transverse (sideways) and sagittal (back-front) areas, but not vertical (the length) of the maxilla.  Keep in mind if you have a class 1 or 2 bite, you'll also need the mandible to catch up after facemask use.  Because your mandible is still growing, I think that'll be easy, but I'd recommend getting something like a biobloc stage 3 appliance from a doctor to help posture your mandible forward such that it eventually grows there.

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Topic starter Posted : 06/02/2021 2:45 pm
TheBeastPanda
Trusted Member

@thagangsta What how can I figure out my skeletal maturation? Also if the maxila expands tranversely and comes forward that CERTAINLY effect midface height? Doesn't it? I'm class 2 division 1. Also you recommended me to get a stage 3 biobloc, what will that do? Also should I get that independent of my MSE+FM treatment or get both? How can i get optimal aesthetic change from MSE and FM?

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Posted : 06/02/2021 3:13 pm
ThaGangsta
Eminent Member

@thebeastpanda

The best way to determine skeletal maturation is cervical vertebral maturation, which basically measures how well developed the spine is and shows what growth phase you're in, and it's through an x ray.  But an "approximate" way is just to see if you've had your growth spurt, how long ago, and perhaps how much you've grown in the past year.  If you're late, then you can only get a few mm of forward movement from MSE+FM, you will have to rely on long term tongue posture and remodeling for significant change.

Posted by: @thebeastpanda

Also if the maxila expands tranversely and comes forward that CERTIAINLY affecs midface height

 

Not necessarily. Oftentimes people have a maxilla that's narrow, too long, and set back in the face.  MSE+FM treats the "narrow" and "set back" part of the equation, but seldom the "long" part.  The only time any kind of headgear can directly and effectively affect the vertical length of the maxilla is during the growth phase by restricting it from growing any further down, while the rest of the skull grows down (a normal part of growth), which gives the illusion of shortening it (CCW rotation), but is merely relative. 

To clarify, we must understand that even a maxilla that grows perfectly (during growth) still grows a little downward, it's just that or grows a lot more forward relative to downward.  For example, let's assume the maxilla stops growing at 15, and someone at that age with a perfect maxilla has a vertical growth score of 10 units.  Let's assume that at 5 someone with a perfect maxilla has a vertical growth score of 0.  So, someone who grows perfectly only has a vertical growth score increase of 1 unit every year from 5 to 15.  Someone who grows too vertically increases by more than 1 unit a year.

Bobby is 12 years old and he has a vertical score of 9 units, when it should be 7 units, 2 units too high.  Because Bobby is growing, the treatment is to restrict his vertical growth for the next 3 years, thereby making it grow more forward (since the growth is restricted on one direction it has to come out the other direction).  Bobby then finishes at the age of 15 with a vertical growth score of 10 units, though it appears his midface has shortened.

Jill is 25 years old and her vertical growth score is 15 units when it should be 10 units, 5 units too high.  Jill is no longer growing.  Because of this, Jill not only has a midface that is deficient sagittally, but it is also too long by 5 units.  So Jill needs to remodel her maxilla both up and move it forwards.  MSE+FM will maybe take care of the forwards component by only a couple mm at her age.  So long term light postural force (the tongue) is the way to go here.

I hope this is adequately clear.  

Posted by: @thebeastpanda

I'm class 2 division 1. Also you recommended me to get a stage 3 biobloc, what will that do? Also should I get that independent of my MSE+FM treatment or get both?

Since you are class 2 div 1, your maxilla and the front teeth are in front of the mandible, but the maxilla is still most likely down and back from its optimal position.  2 good ways to measure the position of your maxilla are to use the indicator line and the cheek line.  At your age if you are female, the indicator line should be 35, and if you're male it should be 37.  Every millimeter away from that represents 2mm excess vertical growth.  

I recommended the stage 3 appliance, because MSE+FM will only make your overjet larger, so the mandible will have to come forward for a proper bite and appearance.  The stage 3 is a postural trainer which trains you to keep your teeth gently touching, and also to posture your mandible forward, which will eventually make your mandible grow to that position.  I strongly recommend getting both from the same doctor if you intend on it, so that it is easier to coordinate.

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Topic starter Posted : 06/02/2021 4:03 pm
TheBeastPanda
Trusted Member

@mafiagang SO to clarify you want me to get BOTH Mse+FM and stage 3 biobloc?

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Posted : 06/02/2021 9:11 pm
ThaGangsta
Eminent Member

@thebeastpanda

The choice is up to you.  I'd recommend at the very least getting a stage 3 to get the mandible to a more optimal position.  My criticism of MSE is just how much brute force it uses on the sutures and this can be traumatizing to the bone from the research I've seen, as well as the possible asymmetry in expansion.  I think at your age a Stage 1 biobloc (an acrylic removable expander anchored to the teeth) can be another option because it goes at the "semi rapid" rate of 1mm a week, which apparently melts and stretches the suture rather than fracturing it like MSE.  A disadvantage to that appliance is it can sometimes fail to open the suture in someone your age or older.

As a disclaimer, I am not a doctor or any kind of professional and my "advice" is purely hypothetical.  It's optimal to consult with an ortho to see what would work best for you, given your age, skeletal maturity, degree of midface and mandibular deficiencies, and other factors, as they have the best diagnostic equipment and x rays and could give you a far better plan than a random stranger on the internet.  I know if you want to find an orthotropics/biobloc practitioner this link is useful: ( https://orthotropics.com/find-orthotropics/).   Here is an adequate one for MSE: ( https://www.moonmse.com/distributors-1).

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Topic starter Posted : 06/02/2021 11:32 pm
TheBeastPanda
Trusted Member

@ ThaGangsta Also quick question are those lists you gave me legit, esp for the mse list? Some of the orthos when I clicked on their website didn't see MSE affiliated with them at all? 

 

Also regarding MSE+FM how could one encourage the mandible to follow and also what type of "trauma" does it induce?

 

And lastly for someone around my age, -young adoloscent, do you think MSE+FM could bring about good functional and GOOD aesthetic changes?

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Posted : 06/02/2021 11:45 pm
ThaGangsta
Eminent Member

@thebeastpanda

Not entirely sure about the MSE list, might just be a list of people who completed the certification.

The mandible following the maxilla will have to be through it postured to the level of the maxilla, in this case some appliance like the stage 3 or some functional appliances like the bionator or twin block may work, especially if you are a low angle (low mandibular plane angle/gonial angle/ short lower third) individual. 

MSE and any expansion that focuses on the suture rather than the dental bone can bring about decent functional and mild to moderate aesthetic changes, especially since even expansion alone can move the maxilla forward a millimeter or two (with no headgear or facemask).

MSE uses a lot of force to separate the suture and this can cause headaches and other pains as can be heard from many people who underwent it.  The intention of this is to fracture the suture apart but the issue with something like that fractured in my opinion is that it can become harder to heal, be resisted by the body, and even become unstable because of the force used against the natural harmony/orientation of the skull, so things will want to move back to their original position (relapse).  MSE holds this from happening, going against the natural rubber band-like action of of the resistance to the expansion in the skull like the Zygomatic buttress area.  Imagine that you're holding a thick rubber band stretched apart for a long time, this is a good analogy to compare the resistance from the rest of the skull to the expansion, due to you moving the maxilla outside the balance and compensations the skull created over many years to accommodate a narrow maxilla. A gentler force would allow for adaptive changes in the remainder of the skull to happen while the expansion is happening, rather than move things very fast and then wait a while for the bone to fill in and balance to be restored (like MSE does). 

But I think there are long term effects to consider.  I would say to see if other expansion methods are possible at your  (like the biobloc or other things like a Schwartz expander) then make the decision. MSE can still be a very valuable tool in many cases, where the suture cannot split, or there is a large deficiency in the basal bone of the maxilla, and there are functional concerns such as the nasal airway.  

Of course, your doctor will be able to tell far better than I can as to what you'd be suited for.

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Topic starter Posted : 07/02/2021 1:40 am
mr.mewing
Estimable Member

@mafiagang  I don't if it's also for MSE but for SARPE here in the Netherlands you have it in for at least 2.5 years, this is to heal the bone and align the teeth 

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Posted : 07/02/2021 7:44 am
Fgsfds
New Member

MSE practitioners observe that the 3 mm possible of protraction in mid-20s adults males is all gained in the 2-month window after breaking the sutures, after which protraction halts completely. Explain how this fits into your theory, and why one can't re-break the sutures and gain 3 more mm. 

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Posted : 14/02/2021 2:02 am
ThaGangsta
Eminent Member

@fgsfds

Sure you can rebreak sutures and maybe pull the maxilla forward more.  This is especially helpful in class 3 underbite cases.  But most peoples maxillae are also too long.  MSE+FM does not solve this problem, no CCW rotation is possible with this.  

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Topic starter Posted : 14/02/2021 2:11 am
Fgsfds liked
aleksandr444200
Active Member
Posted by: @mafiagang

@fgsfds

Sure you can rebreak sutures and maybe pull the maxilla forward more.  This is especially helpful in class 3 underbite cases.  But most peoples maxillae are also too long.  MSE+FM does not solve this problem, no CCW rotation is possible with this.  

How do you think it is possible to achieve CCW rotation in an adult male?

If a facemask is anchored to a removable appliance like DNA at night with an upwards angle, every night, for 6-12 months, would the continuous force not cause CCW rotation? it makes sense that it would

 

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Posted : 24/02/2021 6:35 am
ThaGangsta
Eminent Member

@aleksandr444200

CCW rotation comes in two types, we are assuming a superimposition on the F-N stable landmark plane here so these movements may look a little different when superimposed otherwise.

The first type is the one surgery and some facemasks offer (through sutural movement and deposition) is through moving the front of the maxilla forward and the back of it down.  That is an ok option for those who have midface that isn't too short or long, as there is no change in the length of the midface here and can work for mild skeletal problems in these people in adulthood.  It is best done when bone anchored.

 A second more optimal type in my view for those with excessively long midfaces is one which moves the front of the maxilla both up and forward and the back of the maxilla slightly up but also forward.  This effectively shortens the length of the excessively long maxilla (midface) and moves it forward.  This is only possible in theory with lighter sustained forces which incite changes like the resorption and deposition of bone cells and material to change the shape of the maxilla on a cellular basis and a little bit suturally too.  The best tool for this is the tongue, but in theory a headgear that applies gentle forces in that forwards and up position can work too.  If one uses too much force however, the cancellous bone of the maxilla will thicken (making change harder) and resorption will happen at the sutures leading to an unsightly change (effectively jamming the maxilla up against the skull).

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Topic starter Posted : 03/03/2021 1:33 pm
aleksandr444200
Active Member

@mafiagang

By gentle forces what do you mean?

For example they usually use dental elastics for facemasks right - this sounds quite gentle for an adult.

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Posted : 07/03/2021 6:46 am
ThaGangsta
Eminent Member

@aleksandr444200

IMO those forces themselves may be too much.  Gentle forces like the resting force of the tongue.  These will lead to positive maxillary "deformation" via shape change rather than just pure movement of the bone.  MSE+FM is a great idea for class 3 underbite cases, especially in someone with a shorter midface.

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Topic starter Posted : 08/03/2021 12:12 am
WhyIThink
New Member

I also think any sort of protraction including MSE won't work in adults but for a completely different reason.And that reason is MSE is not really different than regular expanders with hooks for protraction.Before you say anything like ''but MSE is screwed onto the palate,so it is bone anchored! '' let me explain.MSE is connected to first molars with wire arms and molar bands.And the problem starts here.You see,when any sort of expansion device is made the maker has to ''bend'' those molar bands by just ''hands''.So what I am trying to point is those wire arms are bendable enough just by hand,it wouldn't be able to resist the force from the protraction.So even if you get 2-3 mm of expansion it will be solely dental movement not even alveoler bone remodeling.So the molars as well as the rest of the teeth will just slide forward without any maxillary bone change because only the wires will bend and the anchorage point of MSE will not change(in adults not children or teens) However if they devoloped some sort of applience or some type of new MSE that would be solely protracting from anchorage point of the MSE it might be possible to protract the maxilla on adults after regularly using it for a long time(like 2-3 years at least with little forces,but it has to be anchored from bone)

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Posted : 18/03/2021 11:13 am
Apollo
Reputable Member
Posted by: @whyithink

I also think any sort of protraction including MSE won't work in adults but for a completely different reason.And that reason is MSE is not really different than regular expanders with hooks for protraction.Before you say anything like ''but MSE is screwed onto the palate,so it is bone anchored! '' let me explain.MSE is connected to first molars with wire arms and molar bands.And the problem starts here.You see,when any sort of expansion device is made the maker has to ''bend'' those molar bands by just ''hands''.So what I am trying to point is those wire arms are bendable enough just by hand,it wouldn't be able to resist the force from the protraction.So even if you get 2-3 mm of expansion it will be solely dental movement not even alveoler bone remodeling.So the molars as well as the rest of the teeth will just slide forward without any maxillary bone change because only the wires will bend and the anchorage point of MSE will not change(in adults not children or teens) However if they devoloped some sort of applience or some type of new MSE that would be solely protracting from anchorage point of the MSE it might be possible to protract the maxilla on adults after regularly using it for a long time(like 2-3 years at least with little forces,but it has to be anchored from bone)

The "soft" arm option might be less effective for protraction than the "hard" arms, but the "soft" option seems to be used in the vast majority of cases because there's less risk for buccally tipping the molars. I think Dr. Moon and other MSE providers say that even with the "soft" arms, once everything is soldered together and cemented in places that it is unlikely to cause much dental movement and adequately translates the tension to the bone. Still, there might be better methods. For example, once the expansion is complete maybe they could reinforce the MSE arms in a rigid composite resin to prevent bending during protraction.

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Posted : 18/03/2021 1:48 pm
WhyIThink
New Member

@apollo Well I believe bone is much more resistant then any sort of wire whether soft or not.I know there are 2 types of wires but bending is bending still.As far as I know the sole reason why MSE might work with adults is that it distrupts the other sutures around the skull.So I wonder why no one is not using zygomatic miniplates alongside with MSE?(Here is what I am talking about minus the lower jaw miniplates and using a protracton facemask instead) This way it will ensure that only bone borne protraction happens? I know orthodontists say this isn't supposed to work out on adults but they say any kind of maxillary protracton isn't supposed to work out on adults anyways anyways.

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Posted : 18/03/2021 2:44 pm
Apollo
Reputable Member
Posted by: @whyithink

@apollo Well I believe bone is much more resistant then any sort of wire whether soft or not.I know there are 2 types of wires but bending is bending still.As far as I know the sole reason why MSE might work with adults is that it distrupts the other sutures around the skull.So I wonder why no one is not using zygomatic miniplates alongside with MSE?(Here is what I am talking about minus the lower jaw miniplates and using a protracton facemask instead) This way it will ensure that only bone borne protraction happens? I know orthodontists say this isn't supposed to work out on adults but they say any kind of maxillary protracton isn't supposed to work out on adults anyways anyways.

My understanding is that these bollard plates might be helpful, but there's also a risk they could pull loose or become unstable at the high tension required for protraction in adults without the bicortical engagement and dental support of the MSE TADs. It might be worth using them at lower tension to have a constant force throughout the day without the need for conspicuous headgear and then combine them with more tension on the MSE and facemask when not in public. But they require extra surgery to flap open the gums and I don't think there has been anyone using them consistently for this purpose to report on their efficacy. I kind of wish I could have tried them.

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Posted : 18/03/2021 3:29 pm
WhyIThink
New Member

@apollo Well placing them on is not a big issue as this has been used on small children for a long time with just local anesthesia.However you are right orthodontists say they are not stable and regularly get loose or get unscrewed by themselves but the point is someone can design a much more stable miniplate similar to MSE maybe one day? Also no one has used this on adults before,its just used on children.

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Posted : 18/03/2021 3:57 pm
WhyIThink
New Member

@apollo Also do you have any information about something called Novel N2 implant? Or is it just the name for the screws used on MSE?

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Posted : 18/03/2021 3:57 pm
Apollo
Reputable Member
Posted by: @whyithink

@apollo Also do you have any information about something called Novel N2 implant? Or is it just the name for the screws used on MSE?

According to Dr. Moon's protraction simulation study, the N2 implant has a short 2mm length and wider 3mm diameter, allowing more flexibility for where to place it without encroaching on nerves, blood vessels, etc. to provide anchorage separate from the MSE TADs for things like extra-oral traction, intruding teeth to correct cant, etc. The MSE fixation TADs are 11mm or 13mm in length and 1.5mm or 1.8mm in diameter. In the article, they simulate traction from some anterior positions, whereas the MSE TADs are typically on the posterior palate. 

 

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Posted : 18/03/2021 4:38 pm
sinned
Estimable Member

If light forces worked people would have results, you would go to the orthotropics subreddit and see amazing before and afters, you would see amazing before and afters on this forum, instead it's just fraud angling, lighting, surgery/implants (?) and mostly soft tissue changes. I don't know how you can explain that other than the fact that light forces can't overcome the resistance of the whole god damn midface. I'm beginning to believe "light constant forces" is a complete meme and conjecture that was made popular from the Mews. It's good for moving teeth but for GROWING actual bone it is ridiculous, bone is not clay. What's "light force" is relative anyway to how much force the bone can resist. It seems like Mew popularized the idiotic notion that bone is somehow resistant to hard forces while it'll magically start moving with light constant forces. If you just think about it simply it really makes no sense, bones will adapt under the load it is placed, if it can resist the load just fine it will not adapt to it, so why wouldn't you want to use a much higher force that the bone can't resist so it can adapt to it? Constant light forces work for moving teeth, not bone, not the whole midface.

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Posted : 18/03/2021 8:03 pm
WhyIThink
New Member

@apollo I wonder why its never used.It seems like a very useful tool providing bone anchored protraction even in adults.I remember reading that article a while ago but I wasn't able to remember where the implants were placed.Do you have any information if it is still in development stage? Is that why no one never uses it?

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Posted : 19/03/2021 3:12 am
Apollo
Reputable Member
Posted by: @whyithink

@apollo I wonder why its never used.It seems like a very useful tool providing bone anchored protraction even in adults.I remember reading that article a while ago but I wasn't able to remember where the implants were placed.Do you have any information if it is still in development stage? Is that why no one never uses it?

It seems hard to believe that an implant extending only 2mm into the bone could be very stable at high tension. I've only seen this N2 implant and the simulation article discussed on forums in the context of traction vectors and how an anterior anchor could give different results than pulling from the MSE TADs, which are typically on the posterior palate.

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Posted : 19/03/2021 12:15 pm
WhyIThink
New Member

@apollo Ah sorry I was talking about maybe it could work for slow protraction with less tension.Because most adults can't wear the face mask 7/24 maybe long treatment time with less tension could work over the years.Forgot to type it

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Posted : 19/03/2021 12:57 pm
Apollo
Reputable Member
Posted by: @whyithink

@apollo Ah sorry I was talking about maybe it could work for slow protraction with less tension.Because most adults can't wear the face mask 7/24 maybe long treatment time with less tension could work over the years.Forgot to type it

I suspect adults need higher tension than children because we're attempting to move the bone rather than just guide growth, but it might be helpful to have additional anchorage points like the bollard plates or this N2 implant to maintain lower tension consistently and then add higher tension on the MSE and facemask through the night.

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Posted : 19/03/2021 7:18 pm
Sergio-OMS
Trusted Member
Posted by: @apollo
Posted by: @whyithink

@apollo Ah sorry I was talking about maybe it could work for slow protraction with less tension.Because most adults can't wear the face mask 7/24 maybe long treatment time with less tension could work over the years.Forgot to type it

I suspect adults need higher tension than children because we're attempting to move the bone rather than just guide growth, but it might be helpful to have additional anchorage points like the bollard plates or this N2 implant to maintain lower tension consistently and then add higher tension on the MSE and facemask through the night.

As far as I know that N2 implant does not exist. On the other hand, bollard plates are very real. But, before anybody asks, I have no idea about the average (statistics-wise) real effects of using them in adults.

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Posted : 20/03/2021 5:30 am
WhyIThink
New Member

But bollard plates are very wobbly because of the type of screw used.They get dislocated so easily that even children using them with very small forces dislocate them from their position often because the screws used on it are very unstable.I don't think they can withstand the force that adults need to use to get any effect 🙁 If only there was another screw type to make them more stable...

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Posted : 20/03/2021 7:22 am
Sergio-OMS
Trusted Member
Posted by: @whyithink

But bollard plates are very wobbly because of the type of screw used.They get dislocated so easily that even children using them with very small forces dislocate them from their position often because the screws used on it are very unstable.I don't think they can withstand the force that adults need to use to get any effect 🙁 If only there was another screw type to make them more stable...

No, that is not correct. My daughter wears them and I have used forces up to 350 g without any problem.

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Posted : 20/03/2021 8:00 am
Sergio-OMS
Trusted Member

@whyithink

And if an adequate surgical technique is used and the patient is carefully chosen (basically no patients younger than 10) patient collaborates then no problems should arrive.

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Posted : 20/03/2021 8:03 am
Apollo
Reputable Member
Posted by: @sergio-oms
Posted by: @whyithink

But bollard plates are very wobbly because of the type of screw used.They get dislocated so easily that even children using them with very small forces dislocate them from their position often because the screws used on it are very unstable.I don't think they can withstand the force that adults need to use to get any effect 🙁 If only there was another screw type to make them more stable...

No, that is not correct. My daughter wears them and I have used forces up to 350 g without any problem.

Dr. Moon recommends 1 kg of traction on both sides for adults with the MSE and Dr. Ting has said essentially as much tension as tolerable. So the bollard plates probably aren't a stable replacement anchorage, but might be a good supplement.

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Posted : 20/03/2021 11:26 am
Sergio-OMS
Trusted Member

I know what they say.  But they are pulling from two molars.

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Posted : 20/03/2021 11:32 am
Sergio-OMS
Trusted Member

For instance, the BAMP protocol in early teens uses half the force than a facemask and gets better results 

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Posted : 20/03/2021 11:34 am