It's been many years, as of 2021 what is currently the best ways to move maxilla forward?

I saw something that was like the opposite of MSE where the facepulling anchorage was in the nostrils combined with headgear but it was extreme stuff.

@agendum

I suppose that could work on someone like me who still has the plates and screws under and to the side of the piriform rim (as a result of Lefort I), which could, in theory, be used as anchorage points, connected by wires or whatever coming through the skin inside the nostrils.

So basically there is nothing better than Le Fort Osteotomy?

@le_fort_or_bust

Technically, yes. 

I wonder why you’ve been turned down for such a procedure.  As long as your anterior nasal spine is behind the tip of your nasal bone, looking in the forward dimension, you’d be considered to have a recessed maxilla and therefore should be a candidate.  Periodontal issues perhaps?  (The periodontal issues in my case are what is holding me up from getting another Lefort at the moment)

Perhaps try another provider, especially at a university, if you can

@Le_Fort_or_Bust
Could you elaborate on why you are dissatisfied with MSE+FM? What did it achieve and what did it not?

@mr_man I have been turned down because risk/reward is just not there. I would benefit from Le Fort II or Le Fort III that moves the nose forward, but that is very invasive surgery performed on those with messed up bite (my bite is perfect after braces) and those who are syndromic. I am neither of both, also don’t have any breathing issues. I don’t think a highly qualified surgeon would ever perform Le Fort II or modified Le Fort III on a non-syndromic patient purely for aesthetic gain. If a surgeon was to do that, then they are not a good surgeon.

> Perhaps try another provider, especially at a university, if you can

I DID go to University and the ortho at universities facility told me I’m not a candidate and that the board of surgeons will turn it down.

> Could you elaborate on why you are dissatisfied with MSE+FM? What did it achieve and what did it not?

@le_fort_or_bust

Looking at your cephalogram from this thread:

https://the-great-work.org/community/case-discussions/30-yo-male-looking-to-widen-palate-and-move-maxilla-upwards-and-forwards/

I can tell that just having a Lefort I advancement of maybe 4-5 mm would help with your bite and paranasal projection.  I doubt you’d have “chimp mouth”.  Are you at least a candidate for LeFort I?  Also, your cephalogram doesn’t look too bad as it is.  Did they do any analysis on it (like SNA, SNB, ANB, etc.)?

@le_fort_or_bust

I should also ask, now that I’m looking at your bite moulds from the same thread, do you require a retainer to keep your bite as it is?  If not, then I suppose that your bite is stable inasmuch as not needing skeletal correction.

How about your airway?  I do know that it’s possible to get a bimax advancement for that reason alone (i.e. if the airway is too narrow), even if your bite itself is fine.

@le_fort_or_bust
I am surprised to hear that. Did you see photos of those who did it and ended up dissatisfied with their results? I will admit that Ronald Eads case is the only one I am familiar with, but I definitely think he improved aesthetically. If one expands as much as possible with MSE, I have a hard time believing no significant results would be attained. The ones you conversed with, did they really go all the way(maximum expansion and face mask)? Or did they just expand a little bit?

Regarding le fort, no other surgery is of course as invasive and thus holds as much potential, at lest when it comes to aesthetic improvements. If you are not a candidate, why still not consider MSE? Keep in mind that once you finish the treatment, it will help you change naturally, as you will be able to have much better oral posture. 

Mewing

Posted by: @mr_man

@le_fort_or_bust

Looking at your cephalogram from this thread:

https://the-great-work.org/community/case-discussions/30-yo-male-looking-to-widen-palate-and-move-maxilla-upwards-and-forwards/

I can tell that just having a Lefort I advancement of maybe 4-5 mm would help with your bite and paranasal projection.  I doubt you’d have “chimp mouth”.  Are you at least a candidate for LeFort I?  Also, your cephalogram doesn’t look too bad as it is.  Did they do any analysis on it (like SNA, SNB, ANB, etc.)?

Problem with Le Fort I is that it doesn’t move the face forward within the borders of sutures. It makes a cut on natural bone, it doesn’t move forward whole nose, just lower part of nose. I will get a protruding nose at bottom and protruding “chimp mouth” without actually advancing the nose bridge and the nose crevice. I need to move the nose area forward, not just the lower part of maxilla.

How about your airway?  I do know that it’s possible to get a bimax advancement for that reason alone (i.e. if the airway is too narrow), even if your bite itself is fine.

how is it even possible that your upper jaw is so recessed and your mandible isn’t?

Posted by: @mr-mewing

how is it even possible that your upper jaw is so recessed and your mandible isn’t?

Are you referring to my scans? You will see that the gonial angle is very high.

It has been years. Myself and many others, probably everyone in this thread, knows that we will find a way to correct certain issues and prevent them going forward.

Currently? In terms of evidence:

1. Homeobloc (Dr Singh) most scientifically proven. Scans of bone growth and airway and such. Epigenetic science checks out. Not earth shattering effects, but health improvements documented.

2. Biobloc, Orthotropics (Drs Mew) Good cases presented in young children. Tropic premise. Probably best entry point for parents who are looking into their childrens health. Research currently ongoing for adults. Also Myofunctional therapy under this umbrella

   2a: Note that John Mew and Mike Mew have differing approaches

3. ALF (Dr. Nordstrom) excellent understanding of craniosacral thought, suture theories. Very lightweight appliance, much more effective for children. Good expansion device for kids*

4. AGGA (Dr. Belford). Moves alveolar ridge for sure. Bone growth in alveolar ridge allegedly documented. No hard evidence presented of maxillary changes. Many different schools of thought using this appliance, appliance is not a recent invention – it has existed in various patented forms for at least 40 years now. Not yet fully documented, may be beneficial for certain scenarios but not currently proven to make major nasomaxillary changes. 

5. Face Pulling/Bow (wat). Maybe loosens up the sutures. If this worked it would’ve worked by now. Not invalid, just not the whole picture.

6. MSE. Lots of force. Breaks sutures. Useful, not ideal. Not ideal at all. Too much force. Too much.

In my opinion?

Now begins the study of Yoga

*I’m not a doctor

@admin

Posted by: @admin

4. AGGA (Dr. Belford). Moves alveolar ridge for sure. Bone growth in alveolar ridge allegedly documented. No hard evidence presented of maxillary changes. Many different schools of thought using this appliance, appliance is not a recent invention – it has existed in various patented forms for at least 40 years now. Not yet fully documented, may be beneficial for certain scenarios but not currently proven to make major nasomaxillary changes. 

 

AGGA is a very poor way to even make alveolar ridge movements.  The mechanics are way off.  John Mew says Steve Galella (AGGA creator) invited him to give a lecture and then tried copying the principle of the biobloc with a poor understanding.  AGGA can cause bone loss, incisor root damage, dehiscence, bone death, and even molar distillation due to the mechanics being unbalanced and excessive.  My honest opinion is depending on the case MSE (major airway and nasal concerns, with the compromise being the very high force) or Biobloc/DNA (moderate airway and nasal concerns with minor aesthetic concerns) is the best option for an adult.  At the very least they will gain the oral volume to be able to practice proper oral posture which will give good changes in the long run.  

My post here details the principle behind biobloc (and thereby AGGA): https://the-great-work.org/community/main-forum/the-principles-behind-biobloc-and-agga-versus-what-they-actually-do/#post-37985

I think in the end people will figure out it is easier to grow additional bone on the face than move the existing skull fragments.

@le_fort_or_bust

True , i am watching this due doing bonesmashing, his face changed a lot but proportions are still same though.

@meowxilla This is probably worth attempting so long as you aren’t a moron about it, as in using your knuckles for a fairly light force and not swinging at your face with a hammer

@admin
What specifically makes you concerned about the strong forces from the MSE? And could you bother to elaborate on your thoughts on yoga(if not here perhaps in an article?)?

@loliboly I think he means with too much force: that the appliance is too strong and the body can’t recover enough from that.

and it’s also not that natural to have so much force on the bones.

Posted by: @le_fort_or_bust

So basically there is nothing better than Le Fort Osteotomy

Precisely

Posted by: @mr-mewing

@loliboly I think he means with too much force: that the appliance is too strong and the body can’t recover enough from that.

Why would one assume this? After a successful split, it is know that the sutures heal and that it even grows back stronger than before expansion.

and it’s also not that natural to have so much force on the bones.

This is of course correct. But unnatural isn’t always bad. Now, I am not saying expanding with MSE isn’t a big deal. It is obviously an invasive procedure, with a relatively high rate of failures and complications. But in my view, and I am sure in many others, it is also one of the most promising expanders out there.

For me, the transverse changes from MSE in terms of widening my nasal passages and palate/smile have been pretty remarkable. I think the impression that it’s using extreme force and ripping your face in half are overblown, especially if advancing with the slow 1 turn per day protocol. I never felt the kind of tension build up and release that Ronal Ead describes. I had some mild, localized pain on the day my diastema appeared and that was it. However, I’m less optimistic about the forward changes from adding reverse pull headgear that this thread is asking about. The adult case from a Won Moon article on MSE + FM that I posted here ( https://the-great-work.org/community/main-forum/mse-asymmetry-and-protraction/#post-37820 ) looks like she might have advanced as much as 5mm, but this is probably the most dramatic adult results they have documented. Even with high compliance, I’m not expecting to achieve that much. It’s challenging to make the headgear comfortable at higher tension, but COVID lockdown has made it a little easier to commit. I’ve noticed some improvement in my bite, but haven’t had any follow-up imaging yet.

Happy to hear about the positive changes, @apollo! I wish you luck regarding the forward changes. I hope you don’t mind some questions down below.

Regarding the widening of your nasal passages: Have you noticed any difference in sleep and/or energy levels?
Regarding the widening of your palate: What was your former IMW and by how much did you expand? What was your level of crowding and by how much has this changed since expanding?
Regarding your bite: What kind of occlusion do you have and in what ways has the MSE improved this, according to your judgement?

Posted by: @loliboly

Regarding the widening of your nasal passages: Have you noticed any difference in sleep and/or energy levels?

Regarding the widening of your palate: What was your former IMW and by how much did you expand? What was your level of crowding and by how much has this changed since expanding?

Regarding your bite: What kind of occlusion do you have and in what ways has the MSE improved this, according to your judgement?

I think I’m a little better rested, but wearing the headgear at night is uncomfortable and still disrupts my sleep. Hopefully my sleep and energy levels will continue to improve when I’m done with the protraction. I had one nostril that always had resistance to breathe through from a deviated septum. Now it’s always clear if I close the other nostril.

My intermolar width went from about 36mm to about 46mm, but some of that is probably dental tipping. I didn’t have crowding in my upper teeth to begin with. Now there are gaps between my incisors. 

I started with a skeletal class III relationship and an end-on-end bite. Now I have a normal amount of overjet.

@apollo

Does that mean that even with the expansion, one nostril has improved but the other one is usually jammed up?

same as me

Posted by: @farrusco

@apollo

 

Does that mean that even with the expansion, one nostril has improved but the other one is usually jammed up?

 

same as me

No, I’m saying that my left nostril always used to be congested because of my deviated septum while the right was always clear. Now after MSE expansion, both nostrils are always clear.

Posted by: @le_fort_or_bust

Posted by: @mr-mewing

how is it even possible that your upper jaw is so recessed and your mandible isn’t?

Are you referring to my scans? You will see that the gonial angle is very high.

no it’s not, are you sure you dont have dysmorphophobia ?

@mr_man

I would rather do MSE+ a well anchored facemask for 20 hours a day with 2kg+ of force for 3 months to gain 3mm than gain 4mm with a lefort.

The MSE+FM will probably pull your upper maxilla forward too.

@ascendinghero I don’t think MSE provides bone anchored protraction.If any protraction is gained it is probably nearly 100% dental not skeletal :/

@whyithink

Doesn’t seem to be dental at all. If anything it seems to be the least dental out of all the appliance options for adults.

The anchorage is actually in the pallette and they can even cute the arms of the MSE so…

@ascendinghero Yeah it’s nearly completely skeletal transverse expansion but I wasn’t talking about that.I was trying to say any saggital movement from mse + facemask seems to come from dental movement instead of skeletal.

@whyithink

Yes I know. I was talking about sagital movement too.

Posted by: @whyithink

@ascendinghero Yeah it’s nearly completely skeletal transverse expansion but I wasn’t talking about that.I was trying to say any saggital movement from mse + facemask seems to come from dental movement instead of skeletal.

I think the measurements of forward changes reported are based on cephalometric analysis of the difference in A points in superimposed before and after imaging. Since the A point is the most concave point on the anterior maxilla, the majority of change in this landmark is considered skeletal displacement of the body of the maxilla, but some of the change could be due to remodeling of the alveolar ridge. In many cases, you’d actually see decompensation of the upper incisors reducing the forward proclination of the teeth and alveolar ridge as the body of the maxilla moves forward. So even if some of the anchorage for extra-oral traction with the MSE relies on the molars because of the “soft” arms, they are still helping to drag the body of the maxilla forward skeletally. It’s just that we aren’t able to achieve substantial forward change on the order of magnitude seen with surgical advancement. This contrasts to something like AGGA, where the anterior alveolar ridge moves forward, but I don’t think they report significant forward change at the A point.

Posted by: @le_fort_or_bust

I am still suffering from recessed maxilla and unable to find orthodontic surgeons who would perform Le Fort on me.

FAGGA was a disappointment.

MSE+Facemask was a disappointment.

What else is there apart from surgery as of 2021?

No lefort man. The results aren’t even good. Go for bimax even if you have to fly to another country