Notifications
Clear all

NOTICE:

DO NOT ATTEMPT TREATMENT WITHOUT LICENCED MEDICAL CONSULTATION AND SUPERVISION

This is a public discussion forum. The owners, staff, and users of this website are not engaged in rendering professional services to the individual reader. Do not use the content of this website as an alternative to personal examination and advice from licenced healthcare providers. Do not begin, delay, or discontinue treatments and/or exercises without licenced medical supervision.

MSE Asymmetry and Protraction

Page 1 / 2
Apollo
Reputable Member

This image comes from an article ( https://pubmed.ncbi.nlm.nih.gov/33225406/ ) about asymmetric MSE expansion in mature patients. More than half of the patients in the study had a discrepancy over 1.1mm in the expansion from the midline on one side versus the other. Figure C shows how the left side expanded farther from the midline than the right. Figure B superimposes the CBCTs before and after expansion. It's interesting to see how the maxilla comes forward a couple millimeters even without protraction, and this is reflected in more midface volume in the soft tissues. Most expert opinion suggests that adding reverse pull headgear might give adults an additional sagittal millimeter or two at best. If I remember correctly, @Varbrah said his CBCT showed 5mm of forward expansion. Besides simply increasing the force and time under traction, do you have any other ideas for strategies to maximize forward expansion and minimize asymmetry in the transverse expansion, especially in relation to existing asymmetry? A Korean source that uses splint therapy in combination with MSE ( http://www.gyo.co.kr/English ) suggested that the more internally rotated quadrant (i.e. the side canted closer to the midline) is generally more rigid.

Quote
Topic starter Posted : 11/12/2020 2:18 pm
Apollo
Reputable Member

Reading the Korean GYO website, I initially thought that the side canted lower was "internally rotated" and the side canted higher was "externally rotated." However, this didn't seem to correlate with @ronaldead who was canted higher on the right but got asymmetric MSE expansion predominately on the left. My case is the same in reverse: I am canted higher on the left and my osteopath tells me that my left side is more rigid. After reading this article ( https://sleepandtmjtherapy.com/wp-content/uploads/2020/02/Cranial-Strains-and-Malocclusion-Palatal-Expansion.pdf ), I now realize that the "internally rotated" side is just narrower and the teeth measure closer to the midline while the "externally rotated" side is broader with the teeth farther from the midline, regardless of the occlusal cant.

One maxillary quadrant is closer to the palatal mid-line, i.e. more internally rotated, in osteopathic terms. The other quadrant, which is further from the mid-line, is then said to be more externally rotated. This asymmetry is of major importance in treating palatal expansion. When a symmetrical force is applied, the more internally rotated quadrant is much more resistant to pressure than the more externally rotated quadrant. It follows that the result will not be a symmetrical reaction. The more externally rotated side will move more readily than the more internally rotated side. The
arch is indeed expanded but the asymmetry may actually increase.

In my case, the left side is narrower so it would be the "internally rotated" quadrant and more resistant to expansion. Looking back at Ron's blog, it does appear that his right side started with some cross bite, and the right half of the palate appeared narrower, so it makes sense that he got more expansion on the left. The article says the right side was found to be internally rotated in about 95% of cases. I guess my case is in the extreme minority. For ALF treatment, they propose using a light elastic from the buccal aspect of the maxillary appliance to the lingual aspect of the mandibular appliance on the externally rotated quadrant to limit lateral movement and act as a brake on the side more likely to move farther. I suppose something similar could be tried with MSE, and might help mitigate transverse expansion asymmetry. This might help reduce an occlusal cant if the higher side also happens to be the externally rotated side or maybe increase the cant if the lower side is externally rotated.

ReplyQuote
Topic starter Posted : 13/12/2020 11:17 pm
ronaldead
Verified Account

Good info. I would think that such asymmetry is a primary reason that MSE surgical assist is currently in vogue. 

ReplyQuote
Posted : 14/12/2020 7:42 am
Apollo
Reputable Member

This article ( https://62222079-9554-470a-8702-b9943649d392.filesusr.com/ugd/87f545_241a81b90ee449009084ba3c321e9234.pdf ) examines soft tissue changes from MSE. Areas of statistically significant change localized in the paranasal, upper lip, and cheek area, and extended into the zygomatic arch to some extent. Interestingly, the soft tissue expanded in both a forward and lateral direction, but mostly forward. There was little relapse after 1 year. This all sounds promising.

However, the study then subdivided their cases into asymmetric left and right expansion. Based on CBCT, they had 11 cases with asymmetric skeletal expansion to the left, 11 cases with asymmetric skeletal expansion to the right, and 4 cases with approximately symmetric expansion. When examining the asymmetric expansion groups individually, they saw no statistically significant soft tissue changes on the side with less skeletal expansion.

Overall, the areas of most change appear to be around the nose (paranasal area) and on the medial sides of both cheeks, but as previously mentioned, the nature of expansion appears to be asymmetric, usually yielding more soft tissue changes on one side than the other.
Our samples in the end appear to give symmetric changes which is simply due to the fact that almost half of the samples were dominantly expanded to the right side (n = 11) while the other half were expanded more toward the left side (n = 11). The separated p-maps clearly show this nature of asymmetry as when the right-sided samples are grouped together, the entire left side is statistically insignificant, and vice versa.

By subdividing their sample size, there would need to be more dramatic change for it to reach the level of statistical significance, but there are clear aesthetic concerns if one side of the face changes significantly and the other does not. This is consistent with the video Ronald Ead posted analyzing his asymmetry after MSE expansion ( https://www.youtube.com/watch?v=btD7CNDmKcQ&t ), although visually Ron noticed more discrepancy in his zygomatic area than the medial cheek and paranasal area identified in the study's 3D mapping.

ReplyQuote
Topic starter Posted : 15/12/2020 12:42 pm
Apollo
Reputable Member

As mentioned above, this article (  https://sleepandtmjtherapy.com/wp-content/uploads/2020/02/Cranial-Strains-and-Malocclusion-Palatal-Expansion.pdf ) recommends adding an elastic from the buccal side of the maxillary molars to the lingual side of the mandibular molars on the externally rotated quadrant that is more likely to expand farther during ALF treatment. I suggested that the same thing could be tried during MSE treatment. It later occurred to me that Ronal Ead actually had retroactively attempted something similar after his expansion was complete, with an elastic from the upper cheek side to the lower tongue side on his wider left and another elastic from the upper tongue side to the lower cheek side on his narrower right. This might have been even more effective during the expansion process to boost the narrower side and hamper the wider side.

ReplyQuote
Topic starter Posted : 17/12/2020 11:03 pm
Apollo
Reputable Member
Posted by: @apollo

If I remember correctly, @Varbrah said his CBCT showed 5mm of forward expansion.

I guess I was mistaken. @Varbrah responded to the same 5mm figure that someone quoted in the looksmax forum yesterday, saying he actually got 3-4mm from a minimum of 8-12 hours per day:

Posted by: @varbrah
Posted by: @[Rude Language or Insults are not tolerated]
@varbrah who claimed 5 mm forward growth while only pulling for 8 hours a day while never providing the xrays he claimed he got JFL
You just pulling [Rude Language or Insults are not tolerated] out of your [Rude Language will not be tolerated]?

I got 3-4mm of protraction (depending on measurement method). 8-12 hours was the daily minimum amount of time spent protracting - not the maximum.

And why tf would I purchase expensive software and then take time out of my day to make x-ray impositions for low functioning psl autists? I literally don’t care if anyone else gets it

This is more in the ballpark, but still on the high end, of what Dr. Ting says might be possible in adults. @Varbrah also listed some factors that could have facilitated his sagittal expansion:

Posted by: @varbrah
Posted by: @[Rude Language or Insults are not tolerated]
hm thought it was 5, anyways that is not nearly long enough to get 3-4 mm anyways

@Aeons had mse and did fm at 15, he should of gotten at a minimum 3-4 considering his age but i do not think he got near that

Anecdotally all of my protraction occured within the first 2 months or so following sutural disruption.

Keep in mind there are limiting factors to protraction apart from age (although age is the overarching factor), such as an individual’s craniofacial structure/physiology and how this translates to perimaxillary sutural disarticulation on a case-by-case basis.

Btw, if you read some of my older reports on here or TGW, I believe I mentioned I was on:
a) 500-800mg/wk of Test E for 20 weeks + Anavar for 8 weeks
b) GH peptides 3x daily + 25mg MK677 daily

All of the above improve bone growth and metabolism. Might be why I responded better than most. 

He's mentioned these strategies before, and I'm not really interested in self-medicating, but it was still good to hear from @Varbrah again!

ReplyQuote
Topic starter Posted : 19/12/2020 2:37 pm
toomer
Estimable Member
Posted by: @apollo

It's interesting to see how the maxilla comes forward a couple millimeters even without protraction

What I've always heard for this - is that for every mm of lateral expansion, the body kind of "knows" that it's supposed to maintain an overall "arch" shape for the maxilla ... so the body can do this on its own.  Otherwise, imagine if you were strong enough you could pull a horseshoe apart a bit...  the "arch" shape of it would probably start to flatten out.  So it's potentially a biological response from the body doing this.

I thought I did see in a journal article once that it might be something like for every 4mm of lateral expansion (no matter how it's achieved) you might expect 1mm forward generated by the body.  But I made the mistake of not logging it down.  Adding a FM on, obviously might improve things a bit.  So if you only need a few mm forward expansion (I need about 4-5), then maybe even a reasonable amount of lateral expansion + a FM might get you a good part of the way there.

And then there's another key question, did the maxilla grow forward, or did it move forward?  Obviously, the former creates more challenges in terms of believing what's possible in adults.  But the latter could be more plausible given sutural changes.

I'm a bit shocked at the high % rate of asymmetric expansions in MSE patients, though.  Hopefully if/when a good "bite" is finally delivered for those patients, the body will sort the remaining things out over time.  But I just saw another patient in a FB group I'm in that had a little bit of correction to their right, but a whole lot to their left ... and it made me glad I held off on consider MSE for now.

Personally, I'll hopefully be giving DNA a try soon with a TMJ/sleep speciality dentist - but I had my regular cleaning dentist just take a full iTero scan of all of my teeth last week, so we'll be able to see exact details as to what is moving, where ... and more importantly ... if there are any angular changes to the crowns that would be of concern - a.k.a. "just tilting teeth".  According to the folks at Vivos, they measure expansion at the CEJ ... not from "cusp-tip to cusp-tip" ... so that's hopefully a better indicator of more bone-derived expansion.

ReplyQuote
Posted : 21/12/2020 11:56 am
Thomas22 and Apollo liked
Silver
Trusted Member
Posted by: @toomer
Posted by: @apollo

It's interesting to see how the maxilla comes forward a couple millimeters even without protraction

What I've always heard for this - is that for every mm of lateral expansion, the body kind of "knows" that it's supposed to maintain an overall "arch" shape for the maxilla ... so the body can do this on its own.  Otherwise, imagine if you were strong enough you could pull a horseshoe apart a bit...  the "arch" shape of it would probably start to flatten out.  So it's potentially a biological response from the body doing this.

That's a plausible idea, but when I was actively expanding my own MSE, I noticed forward expansion happening as I turned the appliance. If you get that plastic skull model Ron Eades uses in his videos (I believe this is what I got https://www.amazon.com/4D-Master-Anatomy-Didactic-Exploded/dp/B00NP7JNOY/ ) and open the maxilla at the median palatine suture with your hands, you'll notice that the anterior edge of the maxilla (the face edge) moves forward at the same time.

ReplyQuote
Posted : 23/12/2020 1:00 pm
Silver
Trusted Member

@apollo

I believe one of the most reliable ways you can do this is to see a qualified osteopath who does cranial adjustments before and throughout the expansion process. I did that and in retrospect it seems frankly irresponsible to do it any other way. As an example, at one appointment during the active expansion process (a few weeks long), my osteopath did something that she said released or opened up a "locked-up" right cheekbone, and when she did it, I felt a warm flush across that area of my face, and when I left, I noticed that indeed that cheekbone was suddenly more pronounced and the overall effect was a more symmetrical face. She was very much opposed to the entire idea of my expansion ("if it isn't broken, don't fix it") but agreed to treat me nonetheless and apparently there was a number of different kinds of things to fix.

ReplyQuote
Posted : 23/12/2020 1:22 pm
Apollo
Reputable Member
Posted by: @toomer

What I've always heard for this - is that for every mm of lateral expansion, the body kind of "knows" that it's supposed to maintain an overall "arch" shape for the maxilla ... so the body can do this on its own.  Otherwise, imagine if you were strong enough you could pull a horseshoe apart a bit...  the "arch" shape of it would probably start to flatten out.  So it's potentially a biological response from the body doing this.

The way I've heard it explained is that there isn't enough space to accommodate the wider maxilla in the recessed position between the zygomatic buttresses, so it has to pop out a bit to have room to expand transversely.

ReplyQuote
Topic starter Posted : 23/12/2020 2:25 pm
Thomas22 liked
Apollo
Reputable Member
Posted by: @silver

@apollo

I believe one of the most reliable ways you can do this is to see a qualified osteopath who does cranial adjustments before and throughout the expansion process. I did that and in retrospect it seems frankly irresponsible to do it any other way. As an example, at one appointment during the active expansion process (a few weeks long), my osteopath did something that she said released or opened up a "locked-up" right cheekbone, and when she did it, I felt a warm flush across that area of my face, and when I left, I noticed that indeed that cheekbone was suddenly more pronounced and the overall effect was a more symmetrical face. She was very much opposed to the entire idea of my expansion ("if it isn't broken, don't fix it") but agreed to treat me nonetheless and apparently there was a number of different kinds of things to fix.

Thanks @silver! I have been seeing an osteopath who has some experience with cranial manipulation. Like yours, he was also against the idea of the MSE and recommended the ALF that he's worked with before, but said I definitely shouldn't do anything so invasive without osteopathic supervision, so he agreed to treat me. He tells me that the left side of my face is less mobile or more rigid than the right, and I do think that the right side has expanded a little more based on the crossbite. Maybe the manipulation sessions are helping mitigate the discrepancy, but I haven't had any dramatic experiences like the one you describe. Both the body and cranial adjustments have been very subtle, kind of coaxing the bones to correct themselves while breathing deeply and relaxing.

ReplyQuote
Topic starter Posted : 23/12/2020 2:36 pm
Apollo
Reputable Member

I guess even if the facemask protraction is no longer giving any progress a few months after the suture splits, it should still be used throughout the retention period to prevent relapse. Also, the changes are so imperceptible that it's hard to tell if/when progress stops. Does anyone remember how long @varbrah used his facemask?

ReplyQuote
Topic starter Posted : 24/01/2021 10:00 pm
Apollo
Reputable Member
Posted by: @apollo

I guess even if the facemask protraction is no longer giving any progress a few months after the suture splits, it should still be used throughout the retention period to prevent relapse. Also, the changes are so imperceptible that it's hard to tell if/when progress stops. Does anyone remember how long @varbrah used his facemask?

The discomfort of using the facemask during the night definitely disrupts my sleep. My main goal for MSE+FM was to improve my sleep quality and it seems like the headgear is preventing me from fully getting this benefit yet. I'd stop using it if I knew it wasn't working anymore, but I think I've had some minimal forward expansion. I don't want to relapse and I'd love to get a couple more millimeters, so I guess I'll keep using it for a few more months.

ReplyQuote
Topic starter Posted : 29/01/2021 1:43 pm
Apollo
Reputable Member
Posted by: @apollo
 
When I proposed this in the original MSE thread in 2018, @varbrah said that an alternating protocol isn't required for protraction with MSE.
 
Posted by: @varbrah
Posted by: Apollo

I'm also curious to read this citation, which suggests that alternating between expansion and constriction could help disarticulate perimaxillary sutures:

Wang YC, Chang PM, Liou EJ. Opening of circumaxillary sutures by alternate rapid maxillary expansions and constrictions. Angle Orthod. 2009;79(2):230–234.

http://www.angle.org/doi/pdf/10.2319/031208-141.1

The study, alternating between expanding and constricting the midpalatal sutures of cats as an animal model, found that sagitally-running circummaxillary sutures disarticulated significantly more than coronally-running circummaxillary sutures that required more than 5 weeks to increase opening. This makes sense that opening the midpalatal suture sideways would induce separation of other sutures around the maxilla sideways, but would be less effective at separating circummaxillary sutures in a forward direction.

Applies to less sophisticated forms of MARPE. MSE does this just fine without.

For about a month, I've been alternating between weeks of turning backward and forward after completing all of the turns on my MSE and not being satisfied with my protraction results. So far I haven't noticed dramatic change. The most obvious case I've seen of an adult who treated his class III malocclusion with MSE+FM incorporated some weeks of reverse turning, but that was just one case report and there's no consensus about it's utility. Dr. Ting mentioned using some backward turns in one of his interviews with JawHacks. I've been waiting to recommend it here until I see what it does for me. I think it might be worth trying, but it's not necessarily going to pop open all of your circummaxillary sutures or give you the kind of results seen in children.

I haven't noticed obvious forward expansion from about a month of alternating weeks of MSE expansion and contraction with facemask protraction. The mechanism is often described as keeping the sutures open longer to give the facemask more time to work. However, the article above where I first heard about this strategy distinguishes between circummaxillary sutures running sagitally and coronally. They suggest that coronally-oriented sutures might require more cycles of expansion and contraction to separate since they are perpendicular to the plane of transverse expansion. Transverse expansion requires separation of sagittal-running sutures and forward expansion requires separation of coronally-running sutures.

 

So maybe I shouldn't expect to observe much forward expansion until a few more cycles of expansion and contraction get those coronally-running sutures to separate. Another consideration is if I am turning rapidly enough and far enough to make that happen.

ReplyQuote
Topic starter Posted : 03/02/2021 1:51 pm
varbrah
Estimable Member
Posted by: @apollo

I guess even if the facemask protraction is no longer giving any progress a few months after the suture splits, it should still be used throughout the retention period to prevent relapse. Also, the changes are so imperceptible that it's hard to tell if/when progress stops. Does anyone remember how long @varbrah used his facemask?

Jeez, got me to log back in with the amount of mentions in this thread, hahaha.

Roughly 6 months, or up until I got my expander removed.

ReplyQuote
Posted : 04/02/2021 11:10 pm
Apollo liked
Apollo
Reputable Member

The Korean resource I referenced above ( http://www.gyo.co.kr/English ) includes this image to illustrate the use of a splint in combination with MARPE therapy to address asymmetries:

They call it Mandibular Cranial Balancing (MCB) because the premise is that the splint puts the mandible into the correct position and this in turn realigns the rest of the skull. "If the left and right positions of the lower jaw are twisted, the sphenoid bone that has already been twisted is further twisted. If the anteroposterior position of the lower jaw is misaligned, the temporal bone is twisted further. If the height of the lower jaw is not correct, the twisted occipital bone is further twisted." They use two different kinds of splints and make it sound more complicated than the picture, but I noticed how the splint is taller on the side canted higher to swing the mandible down on that side into a better position.

In my case, both the maxilla and mandible are canted higher on my left side. Today I've been experimenting with a homemade splint to make more separation on my left side and allow my mandible to sit comfortably in an end-on-end relationship. Their theory suggests that this should allow my occipital and temporal bones to work out their torsion. I'm ready to believe that, but what I don't understand is how the maxilla is supposed to shift from the middle image to the right image. If anything you'd think the splint on the side canted higher would only further intrude those teeth. So I'm a little skeptical, but it reminded me of the homeoblock appliance's unilateral bite block. The homeoblock website says "The unilateral bite-block of the Homeoblock appliance activates the lateral pterygoid muscles that displace the mandible anteriorly and inferiorly, providing space for putative condylar remodeling. Therefore, it is conceivable that during the correction of palato-maxillary structures the Homeoblock appliance will produce spontaneous correction of the mandible due to neuromuscular activity." This still doesn't explain how the maxillary cant is ultimately corrected and not exacerbated. I guess I'm going to try experimenting with this for a while and see what happens.

 

 

ReplyQuote
Topic starter Posted : 10/02/2021 5:00 pm
Apollo
Reputable Member
Posted by: @apollo

I noticed how the splint is taller on the side canted higher to swing the mandible down on that side into a better position.

Interestingly, the starecta rectifier seems to operate on the opposite principle, propping up the side of the maxilla canted lower:

Maybe the MCB splints try to create separation in the TMJ by putting the block on the side canted higher during their short active treatments and then use flat equal splints during their passive wear during the rest of the day. Here's another Korean clinic using similar types of splints to treat facial asymmetry without palate expansion:

http://www.fcstnet.com/introduction-to-functional/

The second appliance is essentially a splint activator like myobrace, soulet besombes, K3F, etc. So for now, I think I'm going to try adding just an even splint for extended wear. I might experiment with chewing hard gum on the side canted higher to mimic the thermoplastic disposable splints and the homeoblock unilateral bite block.

 

ReplyQuote
Topic starter Posted : 11/02/2021 1:20 pm
Apollo
Reputable Member

It appears that the FCST clinic creates their disposable splints by placing blocks of appropriate thickness between the molars on either side (I assume thicker on the side canted higher). Then they create an impression with thermoplastic over the anterior teeth, positioning the mandible forward enough to where it should be regardless of occlusion, with the cervical posture elongated, and allow the plastic to harden with the vertical dimension held in place by the posterior blocks and the AP dimension adjusted by jutting the mandible. Then they remove the posterior blocks and apply thermoplastic over the posterior teeth using the anterior section as the guide and allow the pieces to harden together as one appliance. They recommend that this type of splint is worn for a short period of time until "deflection" occurs, representing a cranial realignment. However, it's unclear how they decide that such an adjustment has occurred. It seems to be a kind of osteopathic assessment. Then they remove the disposable thermoplastic splint and switch to the splint activator type of appliance for extended wear to prevent relapse. During the next session another disposable thermoplastic splint is fabricated and this process is repeated many times until ideal balance is achieved, averaging 67 treatments for facial asymmetry.

The MCB clinic suggests that their disposable thermoplastic splints are used for about 10 minutes to 1 hour, rather than the subjective "deflection" timing. I guess that this is a short enough amount of time that it wouldn't intrude the teeth like starectica (which requires crowns or extrusion to fix the bite after treatment is complete to bring the molars back together) but long enough for the TMJ to decompress on the side canted higher. Anyway, I might experiment with making my own DIY termoplastic splints following the methods outlined above for short sessions and then switch to a flat equal splint to wear during sleep and some hours during the day. I'm hoping that this might help correct the cant in my mandible and maxilla better than the camouflage approach of using clear aligners to intrude and extrude just the teeth, leaving the skeletal structure misaligned. 

ReplyQuote
Topic starter Posted : 15/02/2021 1:21 pm
Apollo
Reputable Member
Posted by: @apollo

I've reported about the deviation in the bridge of my nose and how it has gone from around 4mm left of center to a little less than 2mm left of center during the course of my expansion. I don't think I've seen much improvement since then. Tonight I noticed in the mirror that simultaneously raising my eyebrows and scrunching my nose causes little folds of skin to stretch on either side of the bridge of my nose near the corners of my eyes. On the left side, this fold of skin is about 1mm wide. On the right side of my nose, it is about 3mm wide. This is consistent with the 2mm deviation. I'm still not sure, but these flaps of skin support my theory that I don't need to shift over the whole bridge of the nose 2mm, but instead the left side should stay where it is while the right nasal bone and the right frontal process of the maxilla shift over 2mm, making the bridge of my nose wider overall. My nose does look kind of spindly, so I like the idea of it getting thicker as it improves in symmetry. I think I'll need to achieve more expansion of my intermolar width to get more improvement in the deviation of my nose.

A few years ago, I measured the deviation in the bridge of my nose at 4mm left of my interpupillary midline, and I recorded improvements of about 2mm. At that point I noticed that contorting my face in a certain way created folds of skin on the sides of my nose near the corners of my eyes, and I measured the fold on the left side at about 1mm wide and the fold on the right side at about 3mm wide, consistent with the approximately 2mm deviation. Today, the middle of the bridge of my nose measures about 1mm left of center and the fold of skin on the left side of my nose measures about 2mm, while the fold of skin on the right side of my nose measures about 3mm (about a 1mm difference). This is all to say that I think my deviated nose bridge has improved by about 1mm during the course of my MSE treatment. The asymmetry is still pretty obvious to me, but people probably wouldn't notice in certain lighting if they didn't know to look for it. The deviation is a little more noticeable when I smile. Honestly, I have a hard time believing that my original measurement was accurate, and that I've achieved a total of about 3mm improvement, but the deviation does appear more conspicuous in old photos. 1mm change since a couple years ago before starting MSE is more believable. I can't say that the bridge of my nose has gotten much wider as I speculated in the old post above, so I'm not sure if the change is from transverse displacement of the frontal process of my maxilla or not.

ReplyQuote
Topic starter Posted : 17/02/2021 3:49 pm
Silver
Trusted Member
Posted by: @apollo
Posted by: @apollo

I've reported about the deviation in the bridge of my nose and how it has gone from around 4mm left of center to a little less than 2mm left of center during the course of my expansion. I don't think I've seen much improvement since then. Tonight I noticed in the mirror that simultaneously raising my eyebrows and scrunching my nose causes little folds of skin to stretch on either side of the bridge of my nose near the corners of my eyes. On the left side, this fold of skin is about 1mm wide. On the right side of my nose, it is about 3mm wide. This is consistent with the 2mm deviation. I'm still not sure, but these flaps of skin support my theory that I don't need to shift over the whole bridge of the nose 2mm, but instead the left side should stay where it is while the right nasal bone and the right frontal process of the maxilla shift over 2mm, making the bridge of my nose wider overall. My nose does look kind of spindly, so I like the idea of it getting thicker as it improves in symmetry. I think I'll need to achieve more expansion of my intermolar width to get more improvement in the deviation of my nose.

A few years ago, I measured the deviation in the bridge of my nose at 4mm left of my interpupillary midline, and I recorded improvements of about 2mm. At that point I noticed that contorting my face in a certain way created folds of skin on the sides of my nose near the corners of my eyes, and I measured the fold on the left side at about 1mm wide and the fold on the right side at about 3mm wide, consistent with the approximately 2mm deviation. Today, the middle of the bridge of my nose measures about 1mm left of center and the fold of skin on the left side of my nose measures about 2mm, while the fold of skin on the right side of my nose measures about 3mm (about a 1mm difference). This is all to say that I think my deviated nose bridge has improved by about 1mm during the course of my MSE treatment. The asymmetry is still pretty obvious to me, but people probably wouldn't notice in certain lighting if they didn't know to look for it. The deviation is a little more noticeable when I smile. Honestly, I have a hard time believing that my original measurement was accurate, and that I've achieved a total of about 3mm improvement, but the deviation does appear more conspicuous in old photos. 1mm change since a couple years ago before starting MSE is more believable. I can't say that the bridge of my nose has gotten much wider as I speculated in the old post above, so I'm not sure if the change is from transverse displacement of the frontal process of my maxilla or not.

Very cool! Thanks for the update. Have you considered whether the yaw of your maxilla has changed?

ReplyQuote
Posted : 17/02/2021 5:45 pm
Apollo
Reputable Member
Posted by: @silver

Very cool! Thanks for the update. Have you considered whether the yaw of your maxilla has changed?

It's hard to say. A few years ago, I believed that my dental midline was a couple millimeters right of center (compounding the discrepancy with the bridge of my nose deviating left of center). Before starting MSE, this discrepancy seemed to have resolved, or maybe it was always just the roll/cant of my maxilla that tipped the top of my central incisors right of center, but if they could be leveled parallel with my eyes, then they would be centered correctly. My dental midline still seems to be centered correctly, so I haven't noticed much of a change in the position of the midline during my MSE treatment. I believe both halves of my maxilla have moved forward a little, but my right side might have started out a little farther back than the left and maybe caught up by moving forward slightly more. The cant/roll of my maxilla might have improved by a degree or so during expansion but is still pretty obvious. I don't think the pitch or clockwise/counterclockwise rotation has notably changed as I've been using the facemask with traction angled down from the occlusal plane.

 

ReplyQuote
Topic starter Posted : 17/02/2021 8:09 pm
Apollo
Reputable Member

I've come up with an exercise that really feels like it is augmenting my facemask protraction. I can't say that I've seen remarkable results from it yet, but it feels pretty intense while I'm doing it. With a facemask pulling on my MSE, braced at my forehead and chin, I lay on my back with my feet elevated on a couch or chair to get my pelvis into a bit of a tuck and straighten my lumbar spine, spread my arms out like a T on the floor, and elongate the crown of my head to straighten my cervical spine. In this position, I breathe deeply and diaphragmatically. At the same time, I jut my mandible forward and chew on a level splint activator. If I'm doing everything right, within a couple minutes, I start feeling a burning sensation in my cheekbone area, sometimes even behind my eyes. It's intense enough that I often have to pause. I'll try to elicit the burning sensation maybe 5 times in a 10 minute session. What do you think I'm feeling? Could the medial pterygoid muscle be adjusting my sphenoid bone?

ReplyQuote
Topic starter Posted : 19/02/2021 2:05 pm
Apollo
Reputable Member
Posted by: @apollo

Honestly, I have a hard time believing that my original measurement was accurate, and that I've achieved a total of about 3mm improvement, but the deviation does appear more conspicuous in old photos.

I've been experimenting with mirroring a series of photos from about 4 years ago, about 6 months ago, and about 1 month ago. It's clear that my facial asymmetry has drastically improved, but it's also clear that my face is still significantly asymmetric. In all of them, my right side is much more robust than my left side. My dental midline was significantly off in the photos from 4 years ago, but it remains about a millimeter off in the more recent pictures, when I thought that it was totally centered now. In the first picture, mirroring the right side makes it look like I have an extra tooth in the middle of my mouth. In the most recent picture, there's just a little sliver of a tooth down the middle, and I suppose this could be the result of my occlusal cant and not a true midline discrepancy. The bridge of my nose appears a little more symmetrical, but still obviously deviated to the left, making it wider in the images mirroring my left side, but not as dramatically different in the more recent pictures. Generally, I think I look better than I did 4 years ago, except that my hairline and dark undereye circles have gotten worse.

ReplyQuote
Topic starter Posted : 26/02/2021 2:45 pm
Apollo
Reputable Member

The Won Moon article about MSE+FM for class III treatment includes the case of an 11 year old girl who increases her SNA angle from a reported 80.4 degrees to 87.4 degrees in 10 months.

This kind of dramatic improvement cannot be expected in adults, but it gives an idea for what the upper limit of possible change is. So if a growing child can increase her SNA angle by 7 degrees, maybe a dedicated adult could expect to increase their SNA angle by a couple degrees. If so, this would at least bring me within the "normal" range for SNA and advance my A point ahead of my B point. The same article presents a 24 year old patient without providing SNA values or details about the duration of treatment.

When I measure, it appears that the SNA has increased by about 5 degrees. I guess what I'm saying is that I don't need to get results on the magnitude of a child in order to be satisfied with my forward expansion.

ReplyQuote
Topic starter Posted : 04/03/2021 4:43 pm
Apollo
Reputable Member
Posted by: @apollo

The Korean resource I referenced above ( http://www.gyo.co.kr/English ) includes this image to illustrate the use of a splint in combination with MARPE therapy to address asymmetries:

MCB position

They call it Mandibular Cranial Balancing (MCB) because the premise is that the splint puts the mandible into the correct position and this in turn realigns the rest of the skull. "If the left and right positions of the lower jaw are twisted, the sphenoid bone that has already been twisted is further twisted. If the anteroposterior position of the lower jaw is misaligned, the temporal bone is twisted further. If the height of the lower jaw is not correct, the twisted occipital bone is further twisted." They use two different kinds of splints and make it sound more complicated than the picture, but I noticed how the splint is taller on the side canted higher to swing the mandible down on that side into a better position.

In my case, both the maxilla and mandible are canted higher on my left side. Today I've been experimenting with a homemade splint to make more separation on my left side and allow my mandible to sit comfortably in an end-on-end relationship. Their theory suggests that this should allow my occipital and temporal bones to work out their torsion. I'm ready to believe that, but what I don't understand is how the maxilla is supposed to shift from the middle image to the right image. If anything you'd think the splint on the side canted higher would only further intrude those teeth. So I'm a little skeptical, but it reminded me of the homeoblock appliance's unilateral bite block. The homeoblock website says "The unilateral bite-block of the Homeoblock appliance activates the lateral pterygoid muscles that displace the mandible anteriorly and inferiorly, providing space for putative condylar remodeling. Therefore, it is conceivable that during the correction of palato-maxillary structures the Homeoblock appliance will produce spontaneous correction of the mandible due to neuromuscular activity." This still doesn't explain how the maxillary cant is ultimately corrected and not exacerbated. I guess I'm going to try experimenting with this for a while and see what happens.

In this video ( https://www.youtube.com/watch?v=uK7Oio_0TCI ) around the 10 minute mark, Dr. Belfor, the homeoblock inventor, says "In TMD your jaw's out of line. One side of your jaw is up and back. The other side is out. Typically, the side that's up and back needs support, and the bite block on that side supports it." So that confirms Dr. Belfor typically uses a splint on the side canted higher. Later in the video, about 41 minutes in, he explains the mechanism: "Increase the amount of unilateral chewing strain to activate transcription factors for osteogenesis via suture stem cells, without negative TMJ outcomes." So I guess the rationale is that putting the block on this underdeveloped side will trigger growth at the sutures, displacing the maxilla down and forward to align with the opposite side, while condylar remodeling swings the mandible into alignment. I've seen some before and after images from homeoblock treatment with relatively convincing symmetry improvements. One example is Dr. Tom Colquitt, who treated himself with homeoblock. An overlay of his before and after CBCT scans shows growth of the maxilla on the right side (where he had the unilateral bite block) and his mandible swinging down to the left. This is after 2 years of treatment.

ReplyQuote
Topic starter Posted : 11/03/2021 1:20 pm
Apollo
Reputable Member

I decided to do some additional research about the monkey experiment that is often referenced as proof that extra-oral traction can advance the maxilla after growth has ceased. The paper ( https://www.sciencedirect.com/science/article/abs/pii/0002941678900805 ) describes 3 adult monkeys fitted with fixed intraoral splints and fixed halo headgears with a continuous force of 500 grams applied for 81 to 95 days. The angle of force ranged from 4 to 54 degrees above the occlusal plane. At the end of the study period, the horizontal displacement ranged from 2 to 3mm and the vertical displacement ranged from 2 to 5mm in the adult monkeys. This is in contrast to the growing monkeys, which showed a horizontal displacement ranging from 3.5 to 9 mm and a vertical displacement ranging from 2 to 7mm. I found it a little unremarkable that the adult monkeys only saw a maximum of 3 millimeters of forward advancement after about 3 months of constant force. It's interesting that the horizontal displacement is significantly greater in the growing monkeys, but the two groups had a similar range of vertical displacement. Maybe this is because the immature monkeys had maxillas that were already growing down and forward so some of the forward change can be attributed to normal growth whereas the upward displacement was not assisted by growth. How can we compare these results to an adult human with a fixed MSE appliance and a removeable headgear, used for about half of the hours in a day, with about twice to three times the force, who have their perimaxillary sutures disrupted by the transverse expansion? Interestingly, Dr. Ting suggests that same 2-3mm figure might be the most an adult could expect from using reverse pull headgear with the MSE, and it's right around what Varbrah observed in his case. I estimated that the adult case in the Dr. Moon article posted above got about 5mm of advancement. My primary take-away from this monkey study is that some modest advancement is possible in non-growing cases even without the disruption of the perimaxillary sutures from MSE, so even if the window of advantage might close a couple months after completing expansion, with enough compliance, you might still be able to get gradual change. I plan to continue using my reverse pull headgear until my MSE is removed. I think I've advanced at least a couple millimeters already, but I'd really like a couple more millimeters based on where my mandible feels most comfortable.

ReplyQuote
Topic starter Posted : 22/04/2021 9:22 pm
AscendingHero
Active Member

@apollo Very interesting stuff. 

My right side seems to be internally rotated too, this side also seems to be thicker and more muscular masseter etc. 

Does wider pallet = better teeth support and less muscle usage for the jaw making the face and cheeks more hollow? 

It seems to be the case.

 

ReplyQuote
Posted : 23/04/2021 6:44 am
AscendingHero
Active Member

@apollo

Are you using The Crane or The Bow facemask?

Howmuch pullforce are you putting on?

ReplyQuote
Posted : 23/04/2021 6:57 am
Apollo
Reputable Member
Posted by: @ascendinghero

@apollo Very interesting stuff. 

My right side seems to be internally rotated too, this side also seems to be thicker and more muscular masseter etc. 

Does wider pallet = better teeth support and less muscle usage for the jaw making the face and cheeks more hollow? 

It seems to be the case.

Posted by: @ascendinghero

@apollo

Are you using The Crane or The Bow facemask?

Howmuch pullforce are you putting on?

I haven't noticed drastic improvement in my cheek hollows from my expansion yet. I'm using both the forwardontics bow and a generic facemask. I haven't measured the tension, but I'm using as much as I can tolerate. It feels pretty strong, and I think it's definitely more than the 1 kg of force per side that Dr. Moon recommends for adults. 

ReplyQuote
Topic starter Posted : 23/04/2021 12:05 pm
AscendingHero
Active Member

@apollo

That’s amazing, and you mentioned you were basically alternating between expanding/contracting with the MSE correct? 
I read a case study in which they were pretty successful in loosening the surrounding sutures of the maxilla with that... see if I can find that.

Did you take photos/xrays of your starting point? Would love to see the actual data on howmuch forward growth you’re getting from this.
If you’ve gained like 3mm, howmuch of a difference is it?

Did you get the corticalpuncture assistance with your suture split? 
I heard from my orthodontist that it causes the other sutures to loosen less that way but I don’t know on what he bases that.

ReplyQuote
Posted : 23/04/2021 4:14 pm
Apollo
Reputable Member
Posted by: @ascendinghero

@apollo

That’s amazing, and you mentioned you were basically alternating between expanding/contracting with the MSE correct? 
I read a case study in which they were pretty successful in loosening the surrounding sutures of the maxilla with that... see if I can find that.

Did you take photos/xrays of your starting point? Would love to see the actual data on howmuch forward growth you’re getting from this.
If you’ve gained like 3mm, howmuch of a difference is it?

Did you get the corticalpuncture assistance with your suture split? 
I heard from my orthodontist that it causes the other sutures to loosen less that way but I don’t know on what he bases that.

I did several weeks cycling between expansion and contraction after completing my initial expansion. I'm not sure that it helped much, but I think I've gotten a very slight advancement since then. This is really hard to judge objectively. I do have baseline x-rays and CBCTs that I can compare/measure in a few months. I've tried comparing profile photos, but the change is subtle and difficult to reproduce the same camera and lighting conditions. I did have cortipuncture at the time of installation to help facilitate my midpalatal suture separation.

ReplyQuote
Topic starter Posted : 23/04/2021 5:01 pm
AscendingHero
Active Member

@apollo Thanks for all the info.

Looking forward to your end results. 

ReplyQuote
Posted : 24/04/2021 2:58 am
AscendingHero
Active Member

@apollo

Wow. Where do I sign up? Would be lovely to just be a recluse for 90 days and get those types of massive gains and forward growth. Lifechanging.

ReplyQuote
Posted : 24/04/2021 3:15 pm
Apollo
Reputable Member
Posted by: @ascendinghero

@apollo

Wow. Where do I sign up? Would be lovely to just be a recluse for 90 days and get those types of massive gains and forward growth. Lifechanging.

You're talking about the 3 month duration of the monkey experiment? I was kind of nonplussed by the 2-3mm forward advancement considering they had the headgear screwed into their skulls and maintained the traction constantly. It has helped me keep realistic expectations that you can't expect to recognize day-to-day changes when the monkeys were getting less than 1/30mm per day with 100% compliance.

ReplyQuote
Topic starter Posted : 24/04/2021 4:59 pm
Silver
Trusted Member

Why are we so sure we can't achieve the same or better with a completely untethered tongue (like what zaghimd.com is doing in LA) and the MSE on its own? Surely, if mewing works, and your tongue has its full range of motion, and your hard palate is now wide enough to fit it, why do you need something to pull your maxilla across a very simple, unnatural vector? Either mewing works or it doesn't, no? Apologies if I misunderstand.

ReplyQuote
Posted : 24/04/2021 7:48 pm
Apollo liked
Apollo
Reputable Member
Posted by: @silver

Why are we so sure we can't achieve the same or better with a completely untethered tongue (like what zaghimd.com is doing in LA) and the MSE on its own? Surely, if mewing works, and your tongue has its full range of motion, and your hard palate is now wide enough to fit it, why do you need something to pull your maxilla across a very simple, unnatural vector? Either mewing works or it doesn't, no? Apologies if I misunderstand.

While the MSE is occupying the palate, during the period when the perimaxillary sutures are mobilized, we can't practice totally correct tongue posture regardless of the status of the lingual frenulum. After the retention period and the MSE comes out, I do hope that tongue posture will help prevent relapse and even encourage further improvement in facial form. However, even with optimal tongue posture, I don't feel like the force vector has a large forward component. I think the tongue has it's greatest impact while the maxilla is still growing down and forward and the tongue pressure can guide the growth more forward than down. After growth has ceased, I'm not convinced the tongue against the roof of the mouth can advance the maxilla forward very much. I'm using extra-oral traction in the hope that it can achieve some stretching/separation of the perimaxillary sutures or at least supplement the tongue's effect.

ReplyQuote
Topic starter Posted : 24/04/2021 8:34 pm
Silver
Trusted Member
Posted by: @apollo
Posted by: @silver

Why are we so sure we can't achieve the same or better with a completely untethered tongue (like what zaghimd.com is doing in LA) and the MSE on its own? Surely, if mewing works, and your tongue has its full range of motion, and your hard palate is now wide enough to fit it, why do you need something to pull your maxilla across a very simple, unnatural vector? Either mewing works or it doesn't, no? Apologies if I misunderstand.

While the MSE is occupying the palate, during the period when the perimaxillary sutures are mobilized, we can't practice totally correct tongue posture regardless of the status of the lingual frenulum. After the retention period and the MSE comes out, I do hope that tongue posture will help prevent relapse and even encourage further improvement in facial form. However, even with optimal tongue posture, I don't feel like the force vector has a large forward component. I think the tongue has it's greatest impact while the maxilla is still growing down and forward and the tongue pressure can guide the growth more forward than down. After growth has ceased, I'm not convinced the tongue against the roof of the mouth can advance the maxilla forward very much. I'm using extra-oral traction in the hope that it can achieve some stretching/separation of the perimaxillary sutures or at least supplement the tongue's effect.

Cool, cool! You are right that it's not possible to mew with the MSE in—I've seen that on my own CT scans. Looking very much forward to having it out sometime in the next few months!

ReplyQuote
Posted : 24/04/2021 10:01 pm
Apollo
Reputable Member

This article ( https://62222079-9554-470a-8702-b9943649d392.filesusr.com/ugd/87f545_68402664f53f44f2a0920d96ff86e608.pdf ) describes the pattern of separation at the pterygopalatine suture from the MSE appliance: "With regard to the pterygopalatine suture split, 84 sutures out of 100 (84%) presented openings between the medial and lateral pterygoid plates on both right and left sides. Partial split was detected with 8 patients (5 females, 3 males). Five patients had split only in the medial pterygoid plates of both pterygomaxillary sutures, and 3 patients exhibited disarticulation on the right side only. No significant differences were found in the frequency of suture opening between males and females (P = 1.000)." The pterygopalatine suture is one of the perimaxillary sutures that the MSE is supposed to help mobilize, and separation there reflects some forward displacement of the maxilla. When I touch that area with my tongue or a finger, I can distinctly feel a separation between the maxillary tuberosity and the pterygoid process, which wasn't there before my MSE expansion. Interestingly, there is more of a separation on the left side than the right side especially in the area of the medial pterygoid plate. This is a little curious since I seemed to get more transverse expansion on the right. I haven't had follow-up imaging yet to visualize this, but I wonder if it's possible I only got a partial split of the right pterygomaxillary suture, and how this could impact the success of my reverse pull headgear.

ReplyQuote
Topic starter Posted : 25/04/2021 7:16 pm
Apollo
Reputable Member

The Mews and others talk about the sphenoid reshaping and remodeling during gradual treatment with tongue posture and/or removable appliances, making it difficult to superimpose before and after cephalograms to measure changes. If rapid procedures like a LeFort surgery or the MSE separate the pterygoid process of the sphenoid from the maxilla and leave the sphenoid behind as they advance the maxilla forward, are these gaps eventually filled in with new bone like the midpalatal suture separation, or does the sphenoid change shape and eventually bring the pterygoid processes forward to meet up with the new position of the maxilla? Maybe a little bit of both. I guess even the fate of the midpalatal suture is unclear and probably involves a combination of growth and remodeling. 

This image shows the pterygomaxillary separation after a LeFort I osteotomy. If, for example, the surgeon advances the maxilla 5mm, is that gap then a 1:1 translation of 5mm postoperatively, and then how does that gap heal over time? I imagine it's the same with the MSE pterygomaxillary disarticulation.

 

ReplyQuote
Topic starter Posted : 26/04/2021 2:19 pm
Apollo
Reputable Member

An article called "Assessment of bone healing after Le Fort I osteotomy with 3-dimensional computed tomography" ( https://pubmed.ncbi.nlm.nih.gov/20705473/ ) shows two class III cases immediately after LeFort I osteotomy and 1 year later:

Figure 5 shows complete healing between the maxillary segments and the pterygoid plate after 1 year. Figure 6 shows partial healing between the maxillary segments and the pterygoid plate after 1 year. The article speculates that healing was observed at this site because comparatively small advancement of the maxilla was performed in these class III cases. They also note "If the mechanical stress stimulation at the pterygomaxillary region increases according to recovery of the occlusal force after more than 1 year, bone healing volume may increase there." So chewing, rather than disrupting that gap, might actually help reestablish continuity. To me, it appears much of the healing is just new bone filling in the gap, but maybe there's also some remodeling going on to bring the existing edges back together. What do you think?

ReplyQuote
Topic starter Posted : 26/04/2021 10:53 pm
AscendingHero
Active Member

@apollo

I wouldn't know, maybe a bit of both. 

In any case everything in front of that gap, below the lefort cut, has to remodel to accomodate the protracted maxilla.

Btw had a talk with my ortho. Nothing 100% certain yet but I'm probably able to get MSE with the Bow and 2 miniplates somewhere on the sides for extra pull force. He actually suggested this himself.

The only thing is he doesn't seem to do cortipunctures with the MSE. How important is it to split the palletal suture in order to get protraction? My understanding is that a palletal suture split also losens the surrounding maxillary sutures more.

 

ReplyQuote
Posted : 27/04/2021 3:19 am
Apollo
Reputable Member
Posted by: @ascendinghero

Btw had a talk with my ortho. Nothing 100% certain yet but I'm probably able to get MSE with the Bow and 2 miniplates somewhere on the sides for extra pull force. He actually suggested this himself.

The only thing is he doesn't seem to do cortipunctures with the MSE. How important is it to split the palletal suture in order to get protraction? My understanding is that a palletal suture split also losens the surrounding maxillary sutures more. 

Yes, successfully splitting the midpalatal suture is important to disrupt the surrounding sutures. For example the pterygomaxillary sutures in the Won Moon article above opened in response to the transverse expansion without sagittal traction. I suppose the monkey experiment shows that some limited forward change is possible with high compliance to extra-oral traction in mature cases even without splitting the midpalatal suture, but I assume it wouldn't be as significant. If the sutures aren't mobilized, pulling on those molar bands might tip the molars more than moving the maxilla. I am curious to hear if adding bollard plates gives you good results. Unless you're young and/or female, I think cortipuncture is worth insisting on to know you've done due diligence to ensure the best chance of successfully disrupting the midpalatal suture. If your orthodontist doesn't want to perform it themselves, maybe a periodontist or oral surgeon could before the MSE installation.

ReplyQuote
Topic starter Posted : 27/04/2021 1:39 pm
AscendingHero
Active Member

@apollo really appreciate your insights and thoughts. 

Indeed I think I need the mid sutural split to make sure I get the most out of it.

He's never done cortipunctures I think so a great idea to potentially ask another professional to do it if he can't. 

ReplyQuote
Posted : 27/04/2021 2:28 pm
Apollo
Reputable Member
Posted by: @apollo

The pterygopalatine suture is one of the perimaxillary sutures that the MSE is supposed to help mobilize, and separation there reflects some forward displacement of the maxilla. When I touch that area with my tongue or a finger, I can distinctly feel a separation between the maxillary tuberosity and the pterygoid process, which wasn't there before my MSE expansion. Interestingly, there is more of a separation on the left side than the right side especially in the area of the medial pterygoid plate. This is a little curious since I seemed to get more transverse expansion on the right. I haven't had follow-up imaging yet to visualize this, but I wonder if it's possible I only got a partial split of the right pterygomaxillary suture, and how this could impact the success of my reverse pull headgear.

I still feel like I'm making very gradual progress with my reverse-pull headgear based on the changes in my bite. However, I'm increasingly concerned that the pterygomaxillary separation feels wider on my left side than my right side and I sometimes notice an achiness in that area during the night after a few hours under traction, which is more intense on the left than the right. I don't notice any shift in my dental midline, but I am worried about creating an asymmetry if the left side disarticulated more than the right and is now stretching farther forward. I experimented with using one more elastic on the right than the left, but it felt a little uncomfortable. Maybe I'll try that again tonight and see if I can get accustomed to it. I also wonder about the stability and potential for relapse if I pull the maxillary tuberosity too far from the pterygoid process (the way aggressive LeFort advancement can relapse). I suppose the gradual nature of the traction probably reduces the risk of relapse.

ReplyQuote
Topic starter Posted : 08/05/2021 8:38 pm
Apollo
Reputable Member

Since my left side is my "less developed" side, meaning the maxilla didn't grow down and forward as much, maybe it's a good sign that there now seems to be more of a gap at my pterygomaxillary suture on that side.

ReplyQuote
Topic starter Posted : 09/05/2021 2:15 pm
Rockyp33
Reputable Member

@apollo how has ur progress been from a few years ago any pics?

ReplyQuote
Posted : 10/05/2021 1:06 am
vplatt
Active Member

Seems a major issue if MSE causes more asymmetry.

Would it make sense to address asymmetries before MSE? Using homeoblock or ALF? what about after? 

How about doing osteo cranial adjustments before and throughout?

ReplyQuote
Posted : 10/05/2021 11:56 am
Silver
Trusted Member
Posted by: @vplatt

Seems a major issue if MSE causes more asymmetry.

Would it make sense to address asymmetries before MSE? Using homeoblock or ALF? what about after? 

How about doing osteo cranial adjustments before and throughout?

I've done osteopath adjustments frequently throughout MSE treatment and my experience with it is that it seems irresponsible to do MSE without it! Many times I've walked in there thinking I was fine, especially during expansion, and then my face was more symmetrical afterwards. My osteopath made all kinds of interesting comments about the things she was fixing, and I don't see a way to get those same changes another way.

ReplyQuote
Posted : 10/05/2021 12:15 pm
vplatt
Active Member

@silver that is good to hear. Has your expansion with MSE been symmetrical overall? I am likely going to be doing it and already have asymmetries so need a plan to address that.

ReplyQuote
Posted : 10/05/2021 12:40 pm
Apollo
Reputable Member
Posted by: @rockyp33

@apollo how has ur progress been from a few years ago any pics?

So far I'm satisfied with my MSE results. My IMW increased by about 10mm. My nasal breathing is improved and my snoring is basically gone. My sleep quality still seems disrupted by the discomfort of my reverse pull headgear. I'm hopeful that I will feel better rested after the device comes out. It's easier to correctly posture my neck/head. I'm beginning to doubt that I'll get as much forward movement as I would like, but I think I've gotten at least a couple millimeters, and maybe I'll get a little more in the next few months. Aesthetic changes have been subtle. I'm not going to share pictures publicly for anonymity but also because they don't show a lot of definitive differences.

ReplyQuote
Topic starter Posted : 10/05/2021 1:58 pm
Apollo
Reputable Member
Posted by: @vplatt

Seems a major issue if MSE causes more asymmetry.

Would it make sense to address asymmetries before MSE? Using homeoblock or ALF? what about after? 

How about doing osteo cranial adjustments before and throughout?

I don't think you would want to attempt expansion with homeoblock, ALF, etc. before MSE because it would limit how much bone-borne expansion you could perform without complicating the realignment with the mandibular arch afterward. I've mentioned a few strategies to address asymmetries in this thread including osteopathy, cross elastics, and splint activators. I don't really know what the answer is, but thankfully my wider right side only expanded a little farther than my left. I'm not sure if my osteopathic manipulations helped or not.

ReplyQuote
Topic starter Posted : 10/05/2021 2:05 pm
Apollo
Reputable Member
Posted by: @apollo

If rapid procedures like a LeFort surgery or the MSE separate the pterygoid process of the sphenoid from the maxilla and leave the sphenoid behind as they advance the maxilla forward, are these gaps eventually filled in with new bone like the midpalatal suture separation, or does the sphenoid change shape and eventually bring the pterygoid processes forward to meet up with the new position of the maxilla? Maybe a little bit of both.

The MSE+FM case of the 24 year old with class iii from the Dr. Won Moon article shows a cross section that doesn't go through the pterygomaxillary junction. So both the before and after layer in this superimposition show a gap between the pterygoid process and the maxillary tuberosity. What's interesting however, is that visible portion of the pterygoid plate has moved forward in the after layer along with the maxillary segment. In other words, there doesn't appear to be significantly more pterygomaxillary separation in the after layer. The pterygoid process of the sphenoid bone appears to be dragging forward with the maxilla in this case, while the Sella Tucica landmark of the sphenoid is aligned in the before and after of the Sagittal CT. Does this mean that the sphenoid is remodeling or repositioning, perhaps realigning at the sphenobasilar synchondrosis?

The gif I posted earlier showing the narrowing of the cranial base angle from the basion to the sella to the nasion makes me think there might be a cascade of realignments that result from pulling the maxilla forward, allowing me to posture my mandible farther forward, and posturing my mandible farther forward allows me to correct my forward head posture, and elongating my occiput shifts the basion, and potentially brings the pterygoid process of the sphenoid back closer to the maxillary tuberosity. My forward head posture has already improved, but maybe I should be more mindful of my head posture and practicing more chin tucks.

ReplyQuote
Topic starter Posted : 10/05/2021 3:29 pm
Agendum liked
Silver
Trusted Member
Posted by: @vplatt

@silver that is good to hear. Has your expansion with MSE been symmetrical overall? I am likely going to be doing it and already have asymmetries so need a plan to address that.

I think it conserved existing assymetries, which at a glance might look like it made things worse, but I'm pretty sure I just need to fix the yaw of my maxilla with my tongue when they pull this expander out in a few months (alongside, of course, bringing the whole thing forward), and I'll be set. Looking inside my mouth, it looks as though the expansionn was not symmetrical, but I'm not sure there's a way to have it be symmetrical because of the way the suture splits under the vomer like a wishbone, which makes sense given that there is not really any absolute point against which to widen since the palatal suture you open is literally the center of two halves of your skull. Some MSE papers I've skimmed have examined this and suggest that this may be a feature, not a bug, and that "symmetrical" expansion cases are actually just less obviously so to the eye.

Though my osteopath did note at one appointment that one of my zygomatic processes was inappropriately immobile and when she released it, I felt a warm flush in the region and noted that cheekbone was more attractively and symmetrically pronounced in the mirror after!

ReplyQuote
Posted : 10/05/2021 5:00 pm
vplatt and Apollo liked
Silver
Trusted Member
Posted by: @apollo
Posted by: @apollo

If rapid procedures like a LeFort surgery or the MSE separate the pterygoid process of the sphenoid from the maxilla and leave the sphenoid behind as they advance the maxilla forward, are these gaps eventually filled in with new bone like the midpalatal suture separation, or does the sphenoid change shape and eventually bring the pterygoid processes forward to meet up with the new position of the maxilla? Maybe a little bit of both.

The MSE+FM case of the 24 year old with class iii from the Dr. Won Moon article shows a cross section that doesn't go through the pterygomaxillary junction. So both the before and after layer in this superimposition show a gap between the pterygoid process and the maxillary tuberosity. What's interesting however, is that visible portion of the pterygoid plate has moved forward in the after layer along with the maxillary segment. In other words, there doesn't appear to be significantly more pterygomaxillary separation in the after layer. The pterygoid process of the sphenoid bone appears to be dragging forward with the maxilla in this case, while the Sella Tucica landmark of the sphenoid is aligned in the before and after of the Sagittal CT. Does this mean that the sphenoid is remodeling or repositioning, perhaps realigning at the sphenobasilar synchondrosis?

The gif I posted earlier showing the narrowing of the cranial base angle from the basion to the sella to the nasion makes me think there might be a cascade of realignments that result from pulling the maxilla forward, allowing me to posture my mandible farther forward, and posturing my mandible farther forward allows me to correct my forward head posture, and elongating my occiput shifts the basion, and potentially brings the pterygoid process of the sphenoid back closer to the maxillary tuberosity. My forward head posture has already improved, but maybe I should be more mindful of my head posture and practicing more chin tucks.

Fascinating analysis! Thanks for posting

ReplyQuote
Posted : 10/05/2021 5:17 pm
vplatt
Active Member

@silver thanks for the reply. I'm contemplating whether MSE would be better than another expansion method if it creates or makes asymmetry worse. Maybe I'd do better with less expansion but more symmetry. 

ReplyQuote
Posted : 11/05/2021 1:37 pm
Rockyp33
Reputable Member
Posted by: @apollo
Posted by: @rockyp33

@apollo how has ur progress been from a few years ago any pics?

So far I'm satisfied with my MSE results. My IMW increased by about 10mm. My nasal breathing is improved and my snoring is basically gone. My sleep quality still seems disrupted by the discomfort of my reverse pull headgear. I'm hopeful that I will feel better rested after the device comes out. It's easier to correctly posture my neck/head. I'm beginning to doubt that I'll get as much forward movement as I would like, but I think I've gotten at least a couple millimeters, and maybe I'll get a little more in the next few months. Aesthetic changes have been subtle. I'm not going to share pictures publicly for anonymity but also because they don't show a lot of definitive differences.

10 MM wow. That seems like a major difference. BUt you say it wasnt very noticeable? i desire expansion up top mainly the front but without MSE. something more natural maybe? or a level below it?

Also Thats good to hear. I would like to stop my snoring. I have an Appliance that proclined my front two teeth. Which has allowed my lower jaw to slide forward. Problem is front teeth still touch before back teeth. So i just braces on lowers to help bring up some height in the back that way i can bite without the appliance without hitting my front teeth hard. Althought I think the real problem is that the front top teeth are just too low. and need to be raised. probably due to lack up tongue posture mainly at the front tip due to tongue tie. My back pallette has decent width. Now it is just in maintainence and I havent twisted it for weeks. I feel the same. I cant wait to get this off my sleep feels disrupted heavily.

ReplyQuote
Posted : 12/05/2021 4:02 am
Apollo
Reputable Member
Posted by: @rockyp33

10 MM wow. That seems like a major difference. BUt you say it wasnt very noticeable?

The wider upper arch is noticeable when I smile, with reduced buccal corridors and 12 teeth visible. However, the structure of my face doesn't look drastically different. There are some features I think are slightly improved. I'm curious to get follow-up imaging to maybe measure some of the changes in interzygomatic width, nasal aperture width, SNA, etc. I don't know if we'll ultimately take another CBCT or not.

ReplyQuote
Topic starter Posted : 12/05/2021 11:35 am
mr.mewing
Estimable Member
Posted by: @apollo
Posted by: @apollo

If rapid procedures like a LeFort surgery or the MSE separate the pterygoid process of the sphenoid from the maxilla and leave the sphenoid behind as they advance the maxilla forward, are these gaps eventually filled in with new bone like the midpalatal suture separation, or does the sphenoid change shape and eventually bring the pterygoid processes forward to meet up with the new position of the maxilla? Maybe a little bit of both.

The MSE+FM case of the 24 year old with class iii from the Dr. Won Moon article shows a cross section that doesn't go through the pterygomaxillary junction. So both the before and after layer in this superimposition show a gap between the pterygoid process and the maxillary tuberosity. What's interesting however, is that visible portion of the pterygoid plate has moved forward in the after layer along with the maxillary segment. In other words, there doesn't appear to be significantly more pterygomaxillary separation in the after layer. The pterygoid process of the sphenoid bone appears to be dragging forward with the maxilla in this case, while the Sella Tucica landmark of the sphenoid is aligned in the before and after of the Sagittal CT. Does this mean that the sphenoid is remodeling or repositioning, perhaps realigning at the sphenobasilar synchondrosis?

The gif I posted earlier showing the narrowing of the cranial base angle from the basion to the sella to the nasion makes me think there might be a cascade of realignments that result from pulling the maxilla forward, allowing me to posture my mandible farther forward, and posturing my mandible farther forward allows me to correct my forward head posture, and elongating my occiput shifts the basion, and potentially brings the pterygoid process of the sphenoid back closer to the maxillary tuberosity. My forward head posture has already improved, but maybe I should be more mindful of my head posture and practicing more chin tucks.

The cool thing to hear is that your posture is getting better while your mandible is coming forwards I noticed myself as well 

when I put my head and tongue in the correct posture my jaw automatically  almost slides forwards in like an underbite position, this is also a sign that the mandible is not in the right position but can't come forward because the maxilla is underdeveloped so it would cause an underbite

ReplyQuote
Posted : 13/05/2021 9:59 am
Apollo liked
Rockyp33
Reputable Member

@apollo Any reccomendation for my case

ReplyQuote
Posted : 14/05/2021 5:48 am
Apollo
Reputable Member
Posted by: @rockyp33

@apollo Any reccomendation for my case

I am happy that I went ahead and committed to MSE treatment. The cut-and-dried either the suture splits and expansion is successful or it fails quality of MSE treatment appealed to me. You say you want something "more natural" or "a level below MSE," and I can understand the appeal of that, but I'm still unsure about what is accomplished with appliances like homeoblock, vivos, or ALF. I guess some people report that these improve sleep quality, but it seems like a long, expensive process that may or may not work.

ReplyQuote
Topic starter Posted : 14/05/2021 12:29 pm
Page 1 / 2