# Alt-RAMEC with MSE + FM for class III



## MSEFM (Dec 22, 2020)

Aeons said:


> ALT RAMEC is used to protract the maxilla faster with FM. It’s essential because of longer duration pulling and more loosen sutures.



I've almost finished my MSE expansion using the Ting 1 turn/day protocol. I started with a slight class III malocclusion. I've been pretty committed to using the facemask protraction and my upper incisors seem to have moved forward a couple millimeters relative to the lower incisors, but I'd still like at least 3 more millimeters of sagittal expansion based on where it feels most comfortable to position my mandible. Dr. Ting says men my age are lucky to get 2 millimeters with the reverse pull headgear and @varbrah estimates he got 3-4mm. I'm considering alternating expansion and contraction to help loosen the perimaxillary sutures and prolong the period for the facemask to work. Typical Alt-RAMEC protocols call for 4-9 weeks cycling between opening the expander all the way one week and then closing the expander all the way the next week. My diastema is only a couple millimeters wide and I don't want to loose the limited transverse expansion my 10mm MSE has achieved by going backward, but I really want to maximize my sagittal expansion. So I'm trying to decide:

1) How far back to turn before turning forward again
2) How rapidly to open and close the appliance
3) How many cycles to expand and contract before moving on to stabilization with the appliance fully open

Currently, I think I'm only going to turn the expander back to about 35 turns when my diastema appeared. I don't want to crush any new bone that is starting to fill in the midpalatal gap. Typical Alt-RAMEC protocols might open and close as fast as about 1mm per day, or around 8 turns on the MSE. The Moon protocol recommends opening at 4-6 turns per day for mature adults before the diastema. Until now, I've been turning slowly at 1 turn per day to minimize tilting, dragging, and warping of the appliance. Maybe turning backwards rapidly would help upright the tilted TADs. So I think I might try closing the appliance at 6 turns per day and then reopen at 2 turns per day. I guess that I'll give this a try and decide how many cycles to complete based on if it seems to be helping or hurting my expansion.

I'd really appreciate any advice from people like @Aeons who have tried alternating expansion and contraction with the MSE or anyone like @Sergio-OMS @retard and @Agendum knowledgeable on the topic! @Aeons said he had to slow down because his overjet is getting worse. I need more overjet to correct my occlusion. Should I worry about losing my progress to tilting or dragging the TADs by closing and reopening the MSE? I don't want to get greedy and loose the improvements to my nasal breathing from transverse expansion by chasing more forward expansion.


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## Pharoah (Dec 22, 2020)

What direction are you pulling?


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## MSEFM (Dec 22, 2020)

Pharoah said:


> What direction are you pulling?


I am pulling with an angle slightly down relative to the occlusal plane.


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## Deleted member 6382 (Dec 22, 2020)

How old?


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## MSEFM (Dec 22, 2020)

tapout said:


> How old?


late 30s


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## JFM05 (Dec 22, 2020)

MSEFM said:


> I've almost finished my MSE expansion using the Ting 1 turn/day protocol. I started with a slight class III malocclusion. I've been pretty committed to using the facemask protraction and my upper incisors seem to have moved forward a couple millimeters relative to the lower incisors, but I'd still like at least 3 more millimeters of sagittal expansion based on where it feels most comfortable to position my mandible. Dr. Ting says men my age are lucky to get 2 millimeters with the reverse pull headgear and @varbrah estimates he got 3-4mm. I'm considering alternating expansion and contraction to help loosen the perimaxillary sutures and prolong the period for the facemask to work. Typical Alt-RAMEC protocols call for 4-9 weeks cycling between opening the expander all the way one week and then closing the expander all the way the next week. My diastema is only a couple millimeters wide and I don't want to loose the limited transverse expansion my 10mm MSE has achieved by going backward, but I really want to maximize my sagittal expansion. So I'm trying to decide:
> 
> 1) How far back to turn before turning forward again
> 2) How rapidly to open and close the appliance
> ...


Yo, Im getting MSE w Ting. Did you get better under eye support w just MSE? Pics?


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## MSEFM (Dec 22, 2020)

JFM05 said:


> Yo, Im getting MSE w Ting. Did you get better under eye support w just MSE? Pics?


Dr. Ting isn't my orthodontist. I'm just following the 1 turn/day protocol he recommends. I have observed a subtle increase in midface volume using the MSE and FM. I think this is most obvious in the paranasal area of my cheeks, but there might be a little more support under my eyes. My dark undereye circles have improved, but I attributed that to better sleep and breathing. I'm still hoping for more forward expansion from the FM and might try Alt-RAMEC to further reduce my underbite. Let me know if Dr. Ting has any advice about alternating expansion and contraction to maximize protraction!


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## MedMaxxing (Dec 22, 2020)

You are wasting your time. You're in your 30s, MSE will have next to no effect at all aesthetically and jaw surgery is far superior for fixing bite problems.


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## Autismmaxxed (Dec 22, 2020)

How much did MSE implant cost? Did they split your suture surgically or just implant MSE?


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## MSEFM (Dec 22, 2020)

MedMaxxing said:


> You are wasting your time. You're in your 30s, MSE will have next to no effect at all aesthetically and jaw surgery is far superior for fixing bite problems.



My main goal is improved nasal airway and I've already achieved that, with a little bit of aesthetic improvement for good measure. My class-III isn't so severe as to require surgery. I'd just like 3 more millimeters of maxillary protrusion if at all possible. Maybe alternating expansion and contraction could help me eke out just a little more forward change.


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## MSEFM (Dec 22, 2020)

Autismmaxxed said:


> How much did MSE implant cost? Did they split your suture surgically or just implant MSE?



The majority of the expense is in the orthodontic alignment required after the expansion messes up your bite and puts a gap in the middle of your teeth. My initial installation cost over 3K. I had cortipuncture to help facilitate separation of the midpalatal suture.


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## Autismmaxxed (Dec 23, 2020)

3k wow cheap


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## MSEFM (Dec 23, 2020)

Autismmaxxed said:


> 3k wow cheap


There will probably be another 7K+ for the realignment phase.


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## Autismmaxxed (Dec 23, 2020)

do they need to use braces or invisalign ok? Can’t do Invisalign with big diastema?


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## MSEFM (Dec 23, 2020)

Autismmaxxed said:


> do they need to use braces or invisalign ok? Can’t do Invisalign with big diastema?


My orthodontist plans to use invisalign. I don't know if the size of the diastema is a factor. Mine is only just over 2mm.


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## ascentium (Dec 23, 2020)

@MSEFM 

any aesthetic changes to nose?


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## MSEFM (Dec 23, 2020)

ascentium said:


> any aesthetic changes to nose?



I think the columella between the nostrils might be a little wider. One of my nostrils started narrower than the other and I think it might be a little more symmetrical now. The bridge of my nose always deviated to one side and I think the opposite side got a little wider and might have evened it out slightly. Generally I think the aesthetics of my nose are the same or slightly better.


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## ascentium (Dec 23, 2020)

MSEFM said:


> I think the columella between the nostrils might be a little wider. One of my nostrils started narrower than the other and I think it might be a little more symmetrical now. The bridge of my nose always deviated to one side and I think the opposite side got a little wider and might have evened it out slightly. Generally I think the aesthetics of my nose are the same or slightly better.



do you have photos for comparison? Just the nose in dm. I’m considering mse but don’t want to ruin my nose.


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## MSEFM (Dec 23, 2020)

ascentium said:


> do you have photos for comparison? Just the nose in dm. I’m considering mse but don’t want to ruin my nose.


Umm, I have old pictures of my face that I could crop out the nose. I haven't taken any new pictures to compare. Let me finish all of my turns and then I'll try to replicate the same lighting and camera angle as the before shots. For me, I really think the changes in the nose are so minute as to not be noticeable offhand. I suppose the changes could be more dramatic in someone younger with less rigid perimaxillary sutures or more transverse skeletal expansion than me. Maybe if I start Alt-RAMEC my frontomaxillary sutures will open more and expand the bridge of my nose.


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## Agendum (Dec 23, 2020)

MSEFM said:


> I've almost finished my MSE expansion using the Ting 1 turn/day protocol. I started with a slight class III malocclusion. I've been pretty committed to using the facemask protraction and my upper incisors seem to have moved forward a couple millimeters relative to the lower incisors, but I'd still like at least 3 more millimeters of sagittal expansion based on where it feels most comfortable to position my mandible. Dr. Ting says men my age are lucky to get 2 millimeters with the reverse pull headgear and @varbrah estimates he got 3-4mm. I'm considering alternating expansion and contraction to help loosen the perimaxillary sutures and prolong the period for the facemask to work. Typical Alt-RAMEC protocols call for 4-9 weeks cycling between opening the expander all the way one week and then closing the expander all the way the next week. My diastema is only a couple millimeters wide and I don't want to loose the limited transverse expansion my 10mm MSE has achieved by going backward, but I really want to maximize my sagittal expansion. So I'm trying to decide:
> 
> 1) How far back to turn before turning forward again
> 2) How rapidly to open and close the appliance
> ...



Very interesting read, thank you for posting in detail. Ive hit a bit of a roadblock in my own expansion and havnt finished it yet so Im not at the FM phase ( tbd 2021 after expansion). This protocol seems very interesting and Ive heard it circulating around abit about expansion->contraction. My ortho hasnt had me do anything like that though, she is doing kinda barebones stuff. 

I was @ 2 turns a day the whole way, (I secretly added 1 extra turn every other mid-day on my 2nd MSE to break the suture since the 1st mse failed to break the suture @24 turns + molar tipping.) The 2nd MSE was placed a few mm anteriorly and suture breakage @21 turns with heavy corticopuncture. IMO I think that extra 'umph' helped break the suture but I dont think I got any maxillary sutures loosened. I think that happens only when you expand past a certain amount, where the zygos begin to flare and rotate outwards disrupting the other facial sutures due to positional changes. Im not sure if cycles of reversal/expansion matter until that overall rotation is changed.

My ortho advised against ever reverse turning during expansion for my case (I had to since the arms were digging into my gums+pushing aveolar bone,) thats why its interesting to hear that your protocol includes cycles of reversal. In the Great Work I think I also saw Sergio talking about it to another MSE user. My ortho didnt care to explain to me her reasoning behind her ideas of expansion protocols but I get the feeling she is operating on and older+simpler methods thats more one-size-fits-all approach. I believe the limiting factor of loosening perimaxillary sutures is related to the frontal bone restricting tension that leads to the zygomatic flaring that relates to the canthal tilt of the orbits. The bone shape is different for everyone so it might give different results.

Ive heards someone say that some of the growth from protraction can be from the stretching of the actual sutures before any split. Not sure how true that is but might be something to consider.

Ever since Ive been told to wait for the new bone to form in the middle of the parallel split Ive noticed that some sort of relapse occurred where it feels like my nasal passages arent as open as there where when I initially split the suture. I dont really have an explanation for why this occurred, I think its related to maxillary cant. It is worth considering since you want to preserve the expansion of your nasal floor but I dont think screw drag is an issue if you have dense bone (seen in scans.)


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## MSEFM (Dec 23, 2020)

Agendum said:


> Very interesting read, thank you for posting in detail. Ive hit a bit of a roadblock in my own expansion and havnt finished it yet so Im not at the FM phase ( tbd 2021 after expansion). This protocol seems very interesting and Ive heard it circulating around abit about expansion->contraction. My ortho hasnt had me do anything like that though, she is doing kinda barebones stuff.
> 
> I was @ 2 turns a day the whole way, (I secretly added 1 extra turn every other mid-day on my 2nd MSE to break the suture since the 1st mse failed to break the suture @24 turns + molar tipping.) The 2nd MSE was placed a few mm anteriorly and suture breakage @21 turns with heavy corticopuncture. IMO I think that extra 'umph' helped break the suture but I dont think I got any maxillary sutures loosened. I think that happens only when you expand past a certain amount, where the zygos begin to flare and rotate outwards disrupting the other facial sutures due to positional changes. Im not sure if cycles of reversal/expansion matter until that overall rotation is changed.
> 
> ...



Thanks @Agendum! It's nice to compare notes with someone else going through the same process! I'm sorry to hear that your improved nasal breathing might be relapsing while you're waiting to start another round of expansion! You're stabilizing with the current MSE in place before replacing it, right? Have you had any more imaging since your suture separated? I also immediately noticed better breathing out of my narrower side the same day my diastema appeared, but I've occasionally had a day or two where it seemed stuffy again. Maybe it's just the dry winter air. My whole goal is better breathing and sleeping, so I'd hate to cancel that by attempting alternating expansion and contraction. Since using Alt-RAMEC with MSE is entirely experimental, I don't expect anyone to have a definitive answer, but I would like to hear from someone like @Aeons who has tried it to hear how many turns per day he used, how many times he cycled, if he closed the MSE all the way before opening it again, and if he noticed loss of any transverse expansion as he gained sagittal expansion.


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## Deleted member 3020 (Dec 23, 2020)

MSEFM said:


> but I would like to hear from someone like @Aeons who has tried it to hear how many turns per day he used, how many times he cycled, if he closed the MSE all the way before opening it again, and if he noticed loss of any transverse expansion as he gained sagittal expansion.


I was doing 1 turn a day, until my orthodontist told me to do 2 turns then 2 reverse turns the next day, I decided to convert more towards the ALT RAMEC technique and did 2 turns everyday for a week, then the next week i relapsed all of that this was to keep the sutures loose for the FM. Can’t say I lost any transverse expansion.


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## MSEFM (Dec 23, 2020)

Aeons said:


> I was doing 1 turn a day, until my orthodontist told me to do 2 turns then 2 reverse turns the next day, I decided to convert more towards the ALT RAMEC technique and did 2 turns everyday for a week, then the next week i relapsed all of that this was to keep the sutures loose for the FM. Can’t say I lost any transverse expansion.



Thanks @Aeons! This is very helpful! Just to be sure I understand, sometime after your diastema had already opened, you started advancing 2 turns every day for 1 week and then reversing 2 turns every day for the next week and repeated this a few times until you felt that your overbite was getting bad. Is that correct? So you were just cycling through about 14 turns forward and then 14 turns back without ever closing the device back farther. This sounds safer to me than the typical Alt-RAMEC protocol that calls for opening and closing the MARPE all the way each week. About how many times did you cycle back and forth?


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## Deleted member 3020 (Dec 23, 2020)

MSEFM said:


> Thanks @Aeons! This is very helpful! Just to be sure I understand, sometime after your diastema had already opened, you started advancing 2 turns every day for 1 week and then reversing 2 turns every day for the next week and repeated this a few times until you felt that your overbite was getting bad. Is that correct? So you were just cycling through about 14 turns forward and then 14 turns back without ever closing the device back farther. This sounds safer to me than the typical Alt-RAMEC protocol that calls for opening and closing the MARPE all the way each week. About how many times did you cycle back and forth?


ive done it for 7-8 weeks now


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## MSEFM (Dec 26, 2020)

Dr. Ting alludes to alternating expansion and contraction in this Jawhacks interview:



Starting at about 4:04 he says, "One technique that I use is for patients who are slacking off on headgear, then I will intentionally overexpand them, have them continue to wear it for another month or two, and then I can back turn them and make it go back in a little bit… or I can decrease it first and then increase it to play around with the suture, hopefully that will help." This sounds similar to what @Aeons described, in that he doesn't contract the MSE all the way before he starts expanding again. It also sounds like Dr. Ting maybe only does one cycle of contracting and expanding again. He doesn't mention how many turns per day he uses, but maybe he continues with his typical 1 turn per day. There's no consensus among the other MSE providers that I've seen discuss Alt-RAMEC about its utility in adult non-growing patients or the protocol to follow. I still haven't decided what I'm going to do, but I'll probably be more conservative than my original plan.


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## MSEFM (Dec 27, 2020)

Pharoah said:


> What direction are you pulling?



I decided to pull at an angle slightly downward from the occlusal plain to encourage growth at the circummaxillary sutures. This is the angle used in MSE studies, mostly in growing children and adolescents, and @varbrah used the same vector. Because I'm brachycephalic, even a little downward displacement wouldn't be bad for me. Especially on my left side, which seems to be generally less developed with a narrower dental arch, canted higher, and a less prominent zygoma. I've felt a couple popping sensations around the left pterygopalatine suture and I have a little tenderness if I press in that area.


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## RichardwillImprove (Dec 27, 2020)

MSEFM said:


> I decided to pull at an angle slightly downward from the occlusal plain to encourage growth at the circummaxillary sutures. This is the angle used in MSE studies, mostly in growing children and adolescents, and @varbrah used the same vector. Because I'm brachycephalic, even a little downward displacement wouldn't be bad for me. Especially on my left side, which seems to be generally less developed with a narrower dental arch, canted higher, and a less prominent zygoma. I've felt a couple popping sensations around the left pterygopalatine suture and I have a little tenderness if I press in that area.


what facemask are u using currently lol.


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## MSEFM (Dec 27, 2020)

RichardwillImprove said:


> what facemask are u using currently lol.


Haha, I try to clock upwards of 20 hours per day, whenever I'm not eating, drinking, showering, or brushing my teeth (one advantage of social distancing). Right now I'm using a typical reverse pull headgear with the pad on the forehead and the chin, but I also use the forwardontics bow, mostly during sleep.


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## spark (Dec 27, 2020)

MSEFM said:


> Haha, I try to clock upwards of 20 hours per day, whenever I'm not eating, drinking, showering, or brushing my teeth (one advantage of social distancing). Right now I'm using a typical reverse pull headgear with the pad on the forehead and the chin, but I also use the forwardontics bow, mostly during sleep.


Should have used the mew vector which doesn't do CW but CCW instead.


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## RichardwillImprove (Dec 28, 2020)

MSEFM said:


> Haha, I try to clock upwards of 20 hours per day, whenever I'm not eating, drinking, showering, or brushing my teeth (one advantage of social distancing). Right now I'm using a typical reverse pull headgear with the pad on the forehead and the chin, but I also use the forwardontics bow, mostly during sleep.


how many mm have u gotten so far.


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## MSEFM (Dec 28, 2020)

RichardwillImprove said:


> how many mm have u gotten so far.


So far, MSE+FM seems to have moved my upper incisors 2-3 millimeters forward relative to the lower incisors. This is around the total that Dr. Ting suggests is realistic for adults. My baseline lateral cephalogram, before treatment, showed my SNA was about 1 degree less than my SNB. In other words, my maxilla started slightly behind my mandible. The proclination of my upper incisors camoflagues my borderline class iii maloclusion to some extent. I would need to increase my SNA by at least 1 degree to get my A point back within normal range and by about 3 degrees to reach the average. Unfortunately, I don’t have a current ceph to compare, but my A point might already be about the same AP position or even ahead of my B point now. I’d really like to get at least a couple more millimeters of sagittal expansion to comfortably position my mandible with a normal overbite and upright my upper incisors to improve my incisal display. Maybe alternating expansion and contraction could help me get there.


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## RichardwillImprove (Dec 28, 2020)

MSEFM said:


> So far, MSE+FM seems to have moved my upper incisors 2-3 millimeters forward relative to the lower incisors. This is around the total that Dr. Ting suggests is realistic for adults. My baseline lateral cephalogram, before treatment, showed my SNA was about 1 degree less than my SNB. In other words, my maxilla started slightly behind my mandible. The proclination of my upper incisors camoflagues my borderline class iii maloclusion to some extent. I would need to increase my SNA by at least 1 degree to get my A point back within normal range and by about 3 degrees to reach the average. Unfortunately, I don’t have a current ceph to compare, but my A point might already be about the same AP position or even ahead of my B point now. I’d really like to get at least a couple more millimeters of sagittal expansion to comfortably position my mandible with a normal overbite and upright my upper incisors to improve my incisal display. Maybe alternating expansion and contraction could help me get there.


thank u for the answers did u get upper maxilla movement or was it mostly teeth movement. also how much bands are u using on each side.


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## MSEFM (Dec 28, 2020)

RichardwillImprove said:


> thank u for the answers did u get upper maxilla movement or was it mostly teeth movement. also how much bands are u using on each side.


I've had some dental tipping, but not too bad. Most sources I've seen recommend 1kg traction per side in adults. I've tried to exceed that, really using as much traction as tolerable. In practice this varies depending on which headgear I'm using, which combination of elastic sizes and resistance levels, and how worn out they get before replacing them with new. Some people find that too much traction makes their molars uncomfortable, but for me the limiting variable is mostly the pressure on my forehead.


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## MSEFM (Dec 29, 2020)

spark said:


> Should have used the mew vector which doesn't do CW but CCW instead.


The Mew Vector headgear isn't something you can just purchase. Dr. Mew makes his headgear for each patient in the office. He uses a facebow connected to buccal tubes on the first molar wires of his removeable appliances and this wouldn't fit with the J-hooks on my MSE. I experimented with some DIY headgear designs but they weren't as practical as the basic rphg and the forwardontics bow that I use. Some have also speculated that the posterior placement of the MSE TADs means that pulling down in the back would counterclockwise rotate the maxilla. I'm not convinced that CCW rotation is required in my case. I'm more interested in displacing the maxilla along a forward and slightly downward vector to induce separation and growth at the circummaxillary sutures. I guess chewing in the front or back during expansion might be another way to modulate the rotation as @retard proposed.


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## MSEFM (Dec 30, 2020)

ascentium said:


> @MSEFM
> 
> any aesthetic changes to nose?



The more I look at my crooked nose, I think the nasal bone itself is still just as deviated to the left as it always was, but the sidewalls made up of the frontal processes of the maxilla have shifted laterally just slightly on both sides, making the bridge overall a little wider and camouflaging some of the dorsum discrepancy. Any advice for how to correct this short of surgery?


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## MSEFM (Jan 1, 2021)

With only a couple turns of my initial expansion left, I'm rethinking my plan for alternating contraction and expansion to be a little more conservative based on the comments by Aeons and Dr. Ting. I still want to be aggressive enough to disrupt the perimaxillary sutures. So I'm currently thinking that I will reverse at 4 turns per day for 1 week, totaling 28 turns. This is about half the 1mm per day rate of typical Alt-RAMEC protocols. Then I think I'll advance again even slower at 2 turns per day for 2 weeks, and repeat these cycles at least 4 times. I'll continue the reverse pull headgear throughout. I've had pretty significant resistance to advancing my MSE even after the diastema. I suspect the backward and forward turns should have less resistance during the alternating phase, but I will slow down if I feel too much resistance, and I might speed up if there's very little resistance. Does this sound reasonable? I don't want to cancel out the progress I've made from the initial expansion.


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## Fgsfds (Jan 1, 2021)

This is the future of maxillary protraction for sure. It's known, by experienced MSE practitioners such as Ting, that there's a two-month window after the suture split where where adults can get maxillary protraction. This suggests that the major rate-limiter that prevents adults from achieving childlike protraction is suture articulation. And therefore, Alt-RAMEC will keep the sutures disarticulated and allow great expansion.

I've emailed the top researchers in the field and all have told me that nobody has tried Alt-RAMEC with an MSE yet in any age group. However, it's not unknown principles by any means. I'm optimistic that this will achieve unprecedented results, especially once practitioners nut up, stop being retards, and adopt Alt-RAMEC into the MSE protocol (like they have with tooth-borne RPE).

Godspeed OP, go for it and report back.


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## Fgsfds (Jan 1, 2021)

MSEFM said:


> With only a couple turns of my initial expansion left, I'm rethinking my plan for alternating contraction and expansion to be a little more conservative based on the comments by Aeons and Dr. Ting. I still want to be aggressive enough to disrupt the perimaxillary sutures. So I'm currently thinking that I will reverse at 4 turns per day for 1 week, totaling 28 turns. This is about half the 1mm per day rate of typical Alt-RAMEC protocols. Then I think I'll advance again even slower at 2 turns per day for 2 weeks, and repeat these cycles at least 4 times. I'll continue the reverse pull headgear throughout. I've had pretty significant resistance to advancing my MSE even after the diastema. I suspect the backward and forward turns should have less resistance during the alternating phase, but I will slow down if I feel too much resistance, and I might speed up if there's very little resistance. Does this sound reasonable? I don't want to cancel out the progress I've made from the initial expansion.


I wouldn't worry about losing expansion progress as transverse expansion is an incredibly easy problem, and you've already solved it. Sagittal protraction is, however, a difficult problem, and with the MSE currently in your mouth, you are in a unique opportunity to get some. Once your sutures re-articulate it's game over for protraction.


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## MSEFM (Jan 2, 2021)

Fgsfds said:


> This is the future of maxillary protraction for sure. It's known, by experienced MSE practitioners such as Ting, that there's a two-month window after the suture split where where adults can get maxillary protraction. This suggests that the major rate-limiter that prevents adults from achieving childlike protraction is suture articulation. And therefore, Alt-RAMEC will keep the sutures disarticulated and allow great expansion.
> 
> I've emailed the top researchers in the field and all have told me that nobody has tried Alt-RAMEC with an MSE yet in any age group. However, it's not unknown principles by any means. I'm optimistic that this will achieve unprecedented results, especially once practitioners nut up, stop being retards, and adopt Alt-RAMEC into the MSE protocol (like they have with tooth-borne RPE).
> 
> Godspeed OP, go for it and report back.



I know of one MSE practitioner who says he has used it in teens. The one paper I've read about alternating expansion and contraction with a MARPE in an adult was using it as a strategy to get the midpalatal suture to separate but didn't add protraction. I guess it's a bit of a leap of faith, but thanks for the encouragement! I have a 10mm MSE and I'm wishing I had those extra 2mm of the 12mm to really get my nasal breathing perfect. But If I can get my mandible and tongue out of my throat by bringing the maxilla farther forward, it might give me some additional airway/sleep improvements. Without alternating expansion and contraction, the adult class-III correction MSE-FM cases I've seen are never as dramatic as some of the child/adolescent cases, even when the occlusion looks right in the end. I think they sometimes involve retracting the mandible to align with the maxilla and I don't want that. It would be nice to even over-correct a little to allow for uprighting of the upper incisors and account for any AP relapse. I started skeletally class III with some dental compensation. I think my upper incisors might be decompensating a little already. I'll start contracting in a couple days and update here with how much resistance I feel.


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## Fgsfds (Jan 2, 2021)

MSEFM said:


> I know of one MSE practitioner who says he has used it in teens. The one paper I've read about alternating expansion and contraction with a MARPE in an adult was using it as a strategy to get the midpalatal suture to separate but didn't add protraction. I guess it's a bit of a leap of faith, but thanks for the encouragement! I have a 10mm MSE and I'm wishing I had those extra 2mm of the 12mm to really get my nasal breathing perfect. But If I can get my mandible and tongue out of my throat by bringing the maxilla farther forward, it might give me some additional airway/sleep improvements. Without alternating expansion and contraction, the adult class-III correction MSE-FM cases I've seen are never as dramatic as some of the child/adolescent cases, even when the occlusion looks right in the end. I think they sometimes involve retracting the mandible to align with the maxilla and I don't want that. It would be nice to even over-correct a little to allow for uprighting of the upper incisors and account for any AP relapse. I started skeletally class III with some dental compensation. I think my upper incisors might be decompensating a little already. I'll start contracting in a couple days and update here with how much resistance I feel.


Oh wow. Who is it, if I may ask (you can PM if you want to keep it private). I talked to the top authors who publish in facial orthopedics e.g. De Clerck.

This paper is the closest I'm aware of to what we want (BAMP + Alt-RAMEC) https://www.researchgate.net/public..._with_the_Hybrid_Hyrax_and_Alt-RAMEC_protocol
but I contacted Wilmes and he said he hadn't heard of anyone trying this in adults. 

FWIW I'm class III same as you. I consulted with a few top MSE providers and a couple wanted to do the mandible retraction BS. This will have REALLY bad aesthetic results and will probably require lower extractions to make room. If it comes down to it, get bimax after with a redpilled surgeon, do not retract your mandible or do extractions. 

I don't really see how this could go wrong, as RPE + Alt-RAMEC in children is a well-trodden path. Since the midpalatal suture (and many other sutures) aren't fused yet in children, doing RPE + Alt-RAMEC on them is about just as "intense" on their face as MSE + Alt-RAMEC would be on an adult's, and the kids are fine.


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## MSEFM (Jan 2, 2021)

Fgsfds said:


> Oh wow. Who is it, if I may ask (you can PM if you want to keep it private). I talked to the top authors who publish in facial orthopedics e.g. De Clerck.
> 
> This paper is the closest I'm aware of to what we want (BAMP + Alt-RAMEC) https://www.researchgate.net/public..._with_the_Hybrid_Hyrax_and_Alt-RAMEC_protocol
> but I contacted Wilmes and he said he hadn't heard of anyone trying this in adults.
> ...



Here's the adult MARPE Alt-RAMEC (without protraction) case report (it's in Italian): 








Espansione rapida del mascellare secondo l’Alt-RAMEC protocol mediante apertura della sutura palatina in paziente adulto - Orteam


dott. Giorgio Vazzoler ABSTRACT L’utilizzo del protocollo “Alt-RAMEC” (Alternate Rapid Maxillary Expansion and Constriction) del Dr. Eric Liou impiegando



www.orteam.it





I'd have to keep searching for the name of the orthodontist who claimed to have good results using MARPE and FM with Alt-RAMEC in adolescents. I remember he was also outside the United States, but I can't remember where.


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## MSEFM (Jan 11, 2021)

After advancing all of the turns on my MSE at 1 turn per day, I've been contracting at 4 turns per day. There is less resistance on the reverse turns than there were on the forward turns, but there is still some resistance. It feels a little funny along my mid palatal suture for a couple minutes after I turn back. I'm trying to be consistent about getting as many hours of facemask protraction in during the day in addition to my sleeping hours. After one week, totaling 28 reverse turns, I'll start turning forward again. I haven't decided if I will expand forward at 2 turns per day for 2 weeks or 4 turns per day for 1 week. This will depend on how much resistance I feel. If the turns are as hard as they were during the initial expansion, I'll probably go with the slower 2 turns per day, but they might be easier because I'll be retreading ground I've already covered. So far, I still think I'm getting some minor advancement based on how my incisors meet up. Hopefully alternating expansion and contraction will give my facemask more time to work. Ideally, I'd still like to protrude at least 3 more millimeters.


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## schneebly (Jan 11, 2021)

spark said:


> Should have used the mew vector which doesn't do CW but CCW instead.


How do you get mew vector headgear if you aren’t a patient of Mew’s?


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## spark (Jan 11, 2021)

schneebly said:


> How do you get mew vector headgear if you aren’t a patient of Mew’s?


No idea if he would sell it to someone who is not his patient but of course the only way would be by contacting Mike Mew.


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## schneebly (Jan 11, 2021)

MSEFM said:


> Haha, I try to clock upwards of 20 hours per day, whenever I'm not eating, drinking, showering, or brushing my teeth (one advantage of social distancing). Right now I'm using a typical reverse pull headgear with the pad on the forehead and the chin, but I also use the forwardontics bow, mostly during sleep.


Why do you have both the typical and forwardontics bow? Do they do anything different? Do they feel any different?


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## MSEFM (Jan 12, 2021)

schneebly said:


> Why do you have both the typical and forwardontics bow? Do they do anything different? Do they feel any different?


I use the typical reverse pull headgear during the day because it is less cumbersome and easier to take on and off. I use the forwardontics bow at night because it is more comfortable to sleep with and doesn't put pressure on the mandible.


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## highT (Jan 12, 2021)

@MSEFM how long did it take before your suture split and you noticed a diastema? How many days / turns?


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## MSEFM (Jan 12, 2021)

highT said:


> @MSEFM how long did it take before your suture split and you noticed a diastema? How many days / turns?


My diastema appeared on day and turn 35 (following a 1 turn/day protocol).


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## MSEFM (Jan 13, 2021)

As I've continued 4 reverse turns per day, I guess it's not surprising that my diastema has gotten narrower. I've also started to feel more resistance to turning, but I've continued with 4 turns each day, and this has resulted in some sensitivity in my molars. I wonder if @Aeons had the molar arms removed before he started alternating expansion and contraction.


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## MSEFM (Jan 13, 2021)

MSEFM said:


> I wonder if @Aeons had the molar arms removed before he started alternating expansion and contraction.


Sorry, this was a stupid question since you need the molar arms and bands attached to the J-hooks to continue protraction and transfer the tension to the TADs.


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## MSEFM (Jan 14, 2021)

I'm considering switching to 2 turns per day for both forward and backward. The molar sensitivity makes it uncomfortable to apply the same amount of tension with the facemask. The changes are so small that it's impossible to judge on a day to day basis if there has been any incremental protrusion, but sometimes I think my bite feels a little different, and I'm not really noticing anything this morning after using the facemask all night. I wonder if contracting the MSE might hinge the bones back together in the AP dimension in addition to the lateral dimension. The real test will be if I notice improvement when I start expanding again.


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## schneebly (Jan 14, 2021)

MSEFM said:


> I'm considering switching to 2 turns per day for both forward and backward. The molar sensitivity makes it uncomfortable to apply the same amount of tension with the facemask. The changes are so small that it's impossible to judge on a day to day basis if there has been any incremental protrusion, but sometimes I think my bite feels a little different, and I'm not really noticing anything this morning after using the facemask all night. I wonder if contracting the MSE might hinge the bones back together in the AP dimension in addition to the lateral dimension. The real test will be if I notice improvement when I start expanding again.


You’re the man with these updates. Keep it up!


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## MSEFM (Jan 15, 2021)

I decided to make just 3 reverse turns yesterday on my last day of the first contraction week. My molars weren't as sensitive and it was more comfortable to use the facemask traction last night. I started expanding again this morning. If I'm able to comfortably expand at 3 turns per day, it will take me 9 days to get back to fully open. Maybe then I can do cycles of 3 turns per day for 7 days forward and backward. This would amount to a little less than 3mm back and forth. This time I contracted almost 4mm and my intermolar width measures about that much less than the maximum when I had finished expanding. There's still a little gap between my central incisors, but the tips are almost touching. I'll feel better if my diastema and intermolar width seem to open back up smoothly as I expand again without tilting the teeth or TADs.


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## MSEFM (Jan 18, 2021)

When I switch directions, turning forward to turning backward or turning backward to turning forward, the first several turns have less resistance. So I've been doing 4 forward turns per day. I'd like to get back to fully open within a week if possible, but if I start feeling significant resistance or tenderness in my molars, I'll slow down. I have a theory that the traction doesn't make much forward progress during the reverse turns, but just prevents the maxilla from shifting backward as you close down the expander. Then when you start turning forward again, the traction swings out the halves of the maxilla farther than before. Maybe I'm just imagining this, but I'll try to observe how my bite changes in the sagittal dimension during this expansion week since it didn't seem to change much during the contraction week.


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## MSEFM (Jan 22, 2021)

I've had to go down to 2 forward turns per day because of tenderness not just in my molars but generalized around the back of my hard palate. There's also a good amount of resistance when I turn. I guess this suggests my perimaxillary sutures are still resisting and maybe this alternating schedule will get them to release and allow for more forward displacement with the facemask. I can't say that I've noticed a lot of forward change in my bite during the past couple weeks. I was hoping once I started going forward again I would notice progress. I'm also a little concerned that my diastema doesn't seem to be opening back up as much, but hopefully my teeth are just shifting together while the bone is still separating. It will take me longer to get back to fully open since I'm making fewer turns per day. When I switch to reverse again, I'll probably just make 2 or 3 turns per day for a week.


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## MSEFM (Jan 27, 2021)

After completing one cycle of contracting and expanding, my diastema did open up so that the tips of the incisors were slightly separated, but not as much as they were when I finished my initial expansion. They appear to be tilting together with a wider gap near the gums. I guess this just reflects dental movement and not skeletal relapse. For my second contraction/expansion cycle, I'm making fewer turns per day and won't wind it back as far.


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## Fgsfds (Jan 28, 2021)

Thanks for the updates.


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## ascentium (Feb 5, 2021)

Any updates boyo? I’m getting mse installed in April. Need to do the dental cleaning, checkup, sizing. Will be using a facemask, as prescribed by ortho.

like you, my a point is slightly behind my b point but occlusion ‘appears’ class I to novices, with no prior ortho. I have class III tendency, so only need to squeeze out a few mm of sagittal. Did you get any a-point advancement?

my ortho is using bite turbos to correct a deep bite and swing my mandible CW. I’m fine with it because when I simulate the occlusion effect my mandible rests more forward, my chin appears taller from frontal, and more projected from side. My theory is that I have compensation for the class III tendency such that my mandible is being pushed back to a certain extent and that correcting the bite will allow it to rest more forward. That said, you mentioned retraction. What are some of the things I should look out for if the ortho attempts to retract the mandible? I want to be able to protest if he attempts it. He insisted I have wisdom teeth removed if that’s relevant.


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## MSEFM (Feb 5, 2021)

ascentium said:


> Any updates boyo? I’m getting mse installed in April. Need to do the dental cleaning, checkup, sizing. Will be using a facemask, as prescribed by ortho.
> 
> like you, my a point is slightly behind my b point but occlusion ‘appears’ class I to novices, with no prior ortho. I have class III tendency, so only need to squeeze out a few mm of sagittal. Did you get any a-point advancement?
> 
> my ortho is using bite turbos to correct a deep bite and swing my mandible CW. I’m fine with it because when I simulate the occlusion effect my mandible rests more forward, my chin appears taller from frontal, and more projected from side. My theory is that I have compensation for the class III tendency such that my mandible is being pushed back to a certain extent and that correcting the bite will allow it to rest more forward. That said, you mentioned retraction. What are some of the things I should look out for if the ortho attempts to retract the mandible? I want to be able to protest if he attempts it. He insisted I have wisdom teeth removed if that’s relevant.


Still not much to report. The past couple days I've thought that maybe I detected some forward changes in my bite. I was noticing improvement earlier during my expansion, but not for a while. I still only think I've gotten a few millimeters of maxilla advancement and haven't had new x-rays or CBCT to measure. My mandible used to want to comfortably rest with my lower incisors ahead of my upper incisors and now it wants to rest about end-on-end. I guess I'm worried that my invisalign might line up the upper and lower teeth in a position that crams my mandible back into my throat when I bite together to force class I occlusion. The chin cup on facemask protraction and typical class iii elastics can also retrude the mandible. I have been using the typical facemask during the day for convenience. All of my wisdom teeth were removed long ago. I don't know if there's any hope that the space created by MSE expansion could upright impacted wisdom teeth, but I feel like there's enough room where I could fit them now without crowding if I still had mine.


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## MedMaxxing (Feb 5, 2021)

I'm getting MSE in April likely as well (have a posterior crossbite). Have you noticed any cheekbone changes? And how is your breathing currently?


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## ascentium (Feb 5, 2021)

MSEFM said:


> Still not much to report. The past couple days I've thought that maybe I detected some forward changes in my bite. I was noticing improvement earlier during my expansion, but not for a while. I still only think I've gotten a few millimeters of maxilla advancement and haven't had new x-rays or CBCT to measure. My mandible used to want to comfortably rest with my lower incisors ahead of my upper incisors and now it wants to rest about end-on-end. I guess I'm worried that my invisalign might line up the upper and lower teeth in a position that crams my mandible back into my throat when I bite together to force class I occlusion. The chin cup on facemask protraction and typical class iii elastics can also retrude the mandible. I have been using the typical facemask during the day for convenience. All of my wisdom teeth were removed long ago. I don't know if there's any hope that the space created by MSE expansion could upright impacted wisdom teeth, but I feel like there's enough room where I could fit them now without crowding if I still had mine.



I have all my wisdom teeth. One on the mandible is .18% covered in gum. Ting said that all will have to be removed because they are tipped and wisdom teeth cannot be moved. Where can I obtain the forwardontics facemask? I will be using the facemask all day except when eating. I’m low inhib so I’ll wear it out in public.

I will be happy with even a few mm of forward growth.

How were your zygos changes?


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## Fgsfds (Feb 5, 2021)

MSEFM said:


> Still not much to report. The past couple days I've thought that maybe I detected some forward changes in my bite. I was noticing improvement earlier during my expansion, but not for a while. I still only think I've gotten a few millimeters of maxilla advancement and haven't had new x-rays or CBCT to measure. My mandible used to want to comfortably rest with my lower incisors ahead of my upper incisors and now it wants to rest about end-on-end. I guess I'm worried that my invisalign might line up the upper and lower teeth in a position that crams my mandible back into my throat when I bite together to force class I occlusion. The chin cup on facemask protraction and typical class iii elastics can also retrude the mandible. I have been using the typical facemask during the day for convenience. All of my wisdom teeth were removed long ago. I don't know if there's any hope that the space created by MSE expansion could upright impacted wisdom teeth, but I feel like there's enough room where I could fit them now without crowding if I still had mine.


Ask your ortho about "The Crane". I know Ting gives patients The Crane.

Keep in mind the projected protraction for a PEREFECTLY compliant adult male (23 hours a day wear) is 3 mm which is very small. Alt-RAMEC might allow you to fight for--who really knows--probably around 5 mm.

Here is inspiration from a recent ortho who is doing backturning:


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## ascentium (Feb 5, 2021)

Fgsfds said:


> Ask your ortho about "The Crane". I know Ting gives patients The Crane.
> 
> Keep in mind the projected protraction for a PEREFECTLY compliant adult male (23 hours a day wear) is 3 mm which is very small. Alt-RAMEC might allow you to fight for--who really knows--probably around 5 mm.
> 
> Here is inspiration from a recent ortho who is doing backturning:



What is the crane?


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## MSEFM (Feb 5, 2021)

MedMaxxing said:


> Have you noticed any cheekbone changes? And how is your breathing currently?





ascentium said:


> Where can I obtain the forwardontics facemask?
> 
> How were your zygos changes?


Any change in my zygos/cheekbones isn't obvious, but I started out with pretty prominent cheekbones in the lateral dimension. I'd really like to see my cheekbones look more convex on profile from the protraction. The forwardontics bow is available for purchase through their website. Although, for the price, I would have expected better quality and have had to make modifications to the padding and straps.



Fgsfds said:


> Ask your ortho about "The Crane". I know Ting gives patients The Crane.


I thought in one of his interviews Dr. Ting said he uses a combination of the typical facemask that braces on the forehead and chin and another design that braces on the forehead and cheeks. I haven't considered the second type because I don't want to push back on my zygomas.


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## MSEFM (Feb 5, 2021)

ascentium said:


> ting is my ortho. What is the crane?


The crane uses a neck brace for extra-oral anchorage. So there's no reciprocal force on the face. JawHacks showed it in one of his videos. I haven't tried it.


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## MedMaxxing (Feb 5, 2021)

MSEFM said:


> Any change in my zygos/cheekbones isn't obvious, but I started out with pretty prominent cheekbones in the lateral dimension. I'd really like to see my cheekbones look more convex on profile from the protraction. The forwarontics bow is available for purchase through their website. Although, for the price, I would have expected better quality and have had to make modifications to the padding and straps.
> 
> 
> I thought in one of his interviews Dr. Ting said he uses a combination of the typical facemask that braces on the forehead and chin and another design that braces on the forehead and cheeks. I haven't considered the second type because I don't want to push back on my zygomas.



Ah, well mine are kind of flat from an anterior POV so do you think it would make a difference? I have read anterior projection is the biggest benefit in the upper maxilla from MSE.


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## MSEFM (Feb 5, 2021)

MedMaxxing said:


> Ah, well mine are kind of flat from an anterior POV so do you think it would make a difference? I have read anterior projection is the biggest benefit in the upper maxilla from MSE.


Honestly, I'd temper your expectations for cheekbone changes based on my results, but maybe a younger case or someone who advanced faster than I did might have gotten more dramatic changes in that area. Maybe another CBCT would measure significant increase in my interzygomatic width and it just isn't obvious under my soft tissue. I guess there's still a chance my ogee curve could still show more definition if I get any more forward advancement. My infraorbital and paranasal hollowing are bigger falios than my zygomatic prominence. My main goals were breathing and sleep improvements and I'm still pretty hopeful that these effects will be worth it.


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## MedMaxxing (Feb 5, 2021)

MSEFM said:


> Honestly, I'd temper your expectations for cheekbone changes based on my results, but maybe a younger case or someone who advanced faster than I did might have gotten more dramatic changes in that area. Maybe another CBCT would measure significant increase in my interzygomatic width and it just isn't obvious under my soft tissue. I guess there's still a chance my ogee curve could still show more definition if I get any more forward advancement. My infraorbital and paranasal hollowing are bigger falios than my zygomatic prominence. My main goals were breathing and sleep improvements and I'm still pretty hopeful that these effects will be worth it.



I only say this because of Ronald's results. He did too much expansion but the change in his zygos was night and day. IIRC he did 10-12 mm, I plan on 8-10 (posterior crossbite)mm. He went from flat zygos to essentially full zygos through his expansion.






Mouth got noticeably wider too.


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## MSEFM (Feb 6, 2021)

MedMaxxing said:


> I only say this because of Ronald's results. He did too much expansion but the change in his zygos was night and day. IIRC he did 10-12 mm, I plan on 8-10 (posterior crossbite)mm. He went from flat zygos to essentially full zygos through his expansion.
> 
> View attachment 968764
> 
> ...


Maybe I'm just a bad judge of these things. Unless the changes are dramatic like surgery, it's hard for me to say definitively that I see a difference beyond just lighting and camera effects. Ron compares his cheekbones in 3/4 view in a video and says one side changed more than the other. I expanded 10mm. Since my cheekbones were relatively prominent to begin with, it might be harder to identify if they got slightly more prominent.


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## MedMaxxing (Feb 6, 2021)

MSEFM said:


> Maybe I'm just a bad judge of these things. Unless the changes are dramatic like surgery, it's hard for me to say definitively that I see a difference beyond just lighting and camera effects. Ron compares his cheekbones in 3/4 view in a video and says one side changed more than the other. I expanded 10mm. Since my cheekbones were relatively prominent to begin with, it might be harder to identify if they got slightly more prominent.



He has a legit Ogee curve especially on the side that had slightly more expansion. But yes, if you already had prominent cheekbones prior, you probably won't notice a difference. For myself and @ascentium it would likely be more obvious since we both have relatively wide cheekbones but lack in the anterior (frontal) projection of the zygoma.

Beyond the aesthetics, have you noticed better function? Breathing, swallowing, easier to keep your mouth closed at night etc.


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## MSEFM (Feb 6, 2021)

MedMaxxing said:


> Beyond the aesthetics, have you noticed better function? Breathing, swallowing, easier to keep your mouth closed at night etc.


My nasal breathing is definitely improved, especially through the side my septum deviates toward. My snoring has stopped. My sleep seems a little better, but I think the headgear keeps it from being really restful still and sometimes I still catch my mouth open, maybe because the elastics break my lip seal. Good tongue posture will probably become more spontaneous once the MSE comes out, but there's definitely more tongue space, and I guess this is why my forward head posture has improved.


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## ascentium (Feb 6, 2021)

MSEFM said:


> My nasal breathing is definitely improved, especially through the side my septum deviates toward. My snoring has stopped. My sleep seems a little better, but I think the headgear keeps it from being really restful still and sometimes I still catch my mouth open, maybe because the elastics break my lip seal. Good tongue posture will probably become more spontaneous once the MSE comes out, but there's definitely more tongue space, and I guess this is why my forward head posture has improved.



how long is the mse protocol? Have you discussed alt-ramec with ortho?


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## MSEFM (Feb 7, 2021)

ascentium said:


> how long is the mse protocol? Have you discussed alt-ramec with ortho?


The retention phase for MSE is supposed to be 6 months after completing expansion until the appliance comes out to allow time for the bone to fill in and stabilize. The length of the expansion phase depends on how fast you advance (turns/day) and the size of your MSE (60, 75, or 90 total turns). My orthodontist wasn't happy about the idea of alternating expansion and contraction. He said I could experiment with it if I started the 6 month stabilization window after I finish turning back and forth. So it will significantly prolong my treatment time.


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## ascentium (Feb 7, 2021)

MSEFM said:


> The retention phase for MSE is supposed to be 6 months after completing expansion until the appliance comes out to allow time for the bone to fill in and stabilize. The length of the expansion phase depends on how fast you advance (turns/day) and the size of your MSE (60, 75, or 90 total turns). My orthodontist wasn't happy about the idea of alternating expansion and contraction. He said I could experiment with it if I started the 6 month stabilization window after I finish turning back and forth. So it will significantly prolong my treatment time.



When is your next check in? I’d assume you’d want to do it sooner rather than later to test if the protocol is working with CBCTs.


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## MSEFM (Feb 7, 2021)

ascentium said:


> When is your next check in? I’d assume you’d want to do it sooner rather than later to test if the protocol is working with CBCTs.


I think we're waiting on another CBCT until everything is done to reduce radiation exposure. I would like to see another lateral cephalogram to measure any change in my SNA angle.


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## MSEFM (Feb 8, 2021)

During this expansion cycle, I've noticed wider diastemas between my lateral and central incisors. In the past I had a hairline gap on the left side, but as I've been expanding the MSE this week, there are <1mm gaps opening on both sides visible from a distance, but still narrower than the central diastema. I guess this just reflects that my central incisors are continuing to shift to the center.


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## ascentium (Feb 8, 2021)

MSEFM said:


> During this expansion cycle, I've noticed wider diastemas between my lateral and central incisors. In the past I had a hairline gap on the left side, but as I've been expanding the MSE this week, there are <1mm gaps opening on both sides visible from a distance, but still narrower than the central diastema. I guess this just reflects that my central incisors are continuing to shift to the center.



i am assuming they are shifting in place without ortho?


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## ascentium (Feb 8, 2021)

Fgsfds said:


> Ask your ortho about "The Crane". I know Ting gives patients The Crane.
> 
> Keep in mind the projected protraction for a PEREFECTLY compliant adult male (23 hours a day wear) is 3 mm which is very small. Alt-RAMEC might allow you to fight for--who really knows--probably around 5 mm.
> 
> Here is inspiration from a recent ortho who is doing backturning:



are you willing to disclose where this case was presented?


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## MSEFM (Feb 9, 2021)

ascentium said:


> i am assuming they are shifting in place without ortho?


Yes, I think my central incisors are just tilting and shifting together due to transseptal fibers and mesialization. I haven't started invisalign treatment yet. I have worried that maybe my central diastema not opening up as much as it did after completing my initial expansion could reflect skeletal relapse, but I don't think that this is the case and these little gaps between the central and lateral incisors are more evidence that it's just dental movement.


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## MSEFM (Feb 11, 2021)

Fgsfds said:


> Here is inspiration from a recent ortho who is doing backturning:





ascentium said:


> why did the mandible shift back in the first study?
> 
> View attachment 979085



The adult class III correction case @Fgsfds posted is one of the most dramatic I've seen, but I suspect much of it is actually retrusion of the mandible rather than protrusion of the maxilla. If you cover everything from the lower lip down, the cheek line doesn't appear much more convex in the after than the before. The distances from the alar crease to the subnasale and from the subnasale to the pronasale look relatively unchanged. Is the tip of the nose tilted up a bit in the "after"? I notice if I wear the facemask for a few hours, I'm able to position my mandible with a greater underjet and can't position it with as much overjet.


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## MSEFM (Feb 13, 2021)

Here's an overlay of the class iii MSE+FM case @Fgsfds posted. The before is colored red and the after is colored blue. There aren't a lot of good landmarks to align the before and after, so it's possible that the way I lined up the images makes it look like the maxilla moved forward when actually the mandible moved backward. It's probably a combination of both.


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## MSEFM (Feb 15, 2021)

I've written before that the aesthetic changes to my face are very subtle. If I look in the mirror, I can convince myself that certain features might look different, but they aren't obvious. However, my cheekbones seem to dramatically stand out when I go to brush my teeth in a way that I never used to notice. It's not surprising that my cheekbones would look more prominent while holding the toothbrush in my mouth, but it's just that they never seemed so conspicuous while brushing my teeth in the past. So maybe I got more interzygomatic expansion from MSE than I thought, but it's hidden under my soft tissue. I'd estimate that my body fat percentage is in the high teens. I suspect my cheek hollows would look good if I got a little leaner. I lost about 25 pounds a while ago, but my weight has plateaued. There's also a chance that my buccinators are being recruited during swallowing, since it's hard to swallow with correct form with the MSE obstructing the palate.


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## MSEFM (Feb 17, 2021)

It has been significantly easier to reverse turn on my fourth cycle so I've kept to 3 or 4 turns per day. I hope this means that the sutures are putting up less resistance and not that the TADs are just wobbling back and forth.


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## ascentium (Feb 17, 2021)

MSEFM said:


> It has been significantly easier to reverse turn on my fourth cycle so I've kept to 3 or 4 turns per day. I hope this means that the sutures are putting up less resistance and not that the TADs are just wobbling back and forth.



any a-p changes noted on this last cycle?

are the cortical screws tipping or dragging?


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## MSEFM (Feb 17, 2021)

ascentium said:


> any a-p changes noted on this last cycle?
> 
> are the cortical screws tipping or dragging?


The TADs look about the same as they did when I first completed expansion before starting the alternating cycles. I think there has been some very gradual forward change from the 4 cycles together, maybe <1mm, but its too subtle to notice a difference each week. The change in my bite hasn't been as noticeable as the forward change I estimated at 2-3mm from my initial expansion. My mandible has gone from feeling relaxed with the lower incisors ahead of the upper incisors to about end-on-end when I first completed expansion and now the lower incisors seem to meet slightly behind the edges of the upper incisors when I make "s" sounds or hold a tongue depressor between my teeth. If my teeth are decompensating, then the skeletal A-P change could be even more significant. I'm really curious to see a lateral x-ray.


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## Mongrelcel (Feb 23, 2021)

MedMaxxing said:


> IIRC he did 10-12 mm, I plan on 8-10 (posterior crossbite)mm


He didnt _really_ get that much. Calculated form the MSE screw turns it would come out to that amount, but due to device banding and screw drag it was MUCH less. Dr. Ting mentioned that in one of the interviews. The way to measure MSE expansion is by front teeth gap.


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## MSEFM (Feb 23, 2021)

Mongrelcel said:


> He didnt _really_ get that much. Calculated form the MSE screw turns it would come out to that amount, but due to device banding and screw drag it was MUCH less. Dr. Ting mentioned that in one of the interviews. The way to measure MSE expansion is by front teeth gap.


I don't think there is a 1:1 relationship between the width of your diastema and the width of your suture separation. Dr. Moon suggests that patients who follow a slow turn protocol might not even see a diastema at all, or just a small one, but their suture is still separated on imaging. Dr. Ting recommends the slow protocol in his interviews to reduce dragging and tilting of the TADs, so more of the total expansion should go to suture separation, but the teeth have a tendency to pull together and move to the center. Dr. Moon also says the slow protocol achieves less perimaxillary changes, so the surrounding sutures might not move as much at the slower rate even though the midpalatal suture is separating.


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## Mongrelcel (Feb 23, 2021)

MSEFM said:


> I don't think there is a 1:1 relationship between the width of your diastema and the width of your suture separation. Dr. Moon suggests that patients who follow a slow turn protocol might not even see a diastema at all, or just a small one, but their suture is still separated on imaging. Dr. Ting recommends the slow protocol in his interviews to reduce dragging and tilting of the TADs, so more of the total expansion should go to suture separation, but the teeth have a tendency to pull together and move to the center. Dr. Moon also says the slow protocol achieves less perimaxillary changes, so the surrounding sutures might not move as much at the slower rate even though the midpalatal suture is separating.


Interes_ting_ - so youre saying that a slow protocol is not the best choice if one wants to widen the entire maxilla (to see change in cheekbone)?
I dont understand how could that happen - i mean, youre splitting the entire skull anyway right?
Does that mean that using slow protocol the split happenes, but with slow expansion the bones surrounding the split sututre so t ospeak bends because surrounding sutures that are tough? and with fast expansion they do not have time to adapt so they all get forced at the same time?


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## MSEFM (Feb 23, 2021)

Mongrelcel said:


> Interes_ting_ - so youre saying that a slow protocol is not the best choice if one wants to widen the entire maxilla (to see change in cheekbone)?
> I dont understand how could that happen - i mean, youre splitting the entire skull anyway right?
> Does that mean that using slow protocol the split happenes, but with slow expansion the bones surrounding the split sututre so t ospeak bends because surrounding sutures that are tough? and with fast expansion they do not have time to adapt so they all get forced at the same time?


That's how I understand what Dr. Moon said in a recent virtual lecture. So you might choose a slow protocol if you're at higher risk for the midpalatal suture separation to fail (i.e. male and older like me), but you're probably trading off some of the potential for midface expansion. The very reason failure might be less likely at the slower rate is because it gives the resistance of the surrounding structures time to dissipate through bending and/or remodeling. Dr. Moon talks about a biological and a mechanical process. Fast relies more on mechanical breakage (but there's a risk the appliance will fail before the bone). Slow relies more on biological remodeling. Both will occur in different ratios depending how fast you advance.


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## Mongrelcel (Feb 23, 2021)

MSEFM said:


> That's how I understand what Dr. Moon said in a recent virtual lecture. So you might choose a slow protocol if you're at higher risk for the midpalatal suture separation to fail (i.e. male and older like me), but you're probably trading off some of the potential for midface expansion. The very reason failure might be less likely at the slower rate is because it gives the resistance of the surrounding structures time to dissipate through bending and/or remodeling. Dr. Moon talks about a biological and a mechanical process. Fast relies more on mechanical breakage (but there's a risk the appliance will fail before the bone). Slow relies more on biological remodeling. Both will occur in different ratios depending how fast you advance.


Link to lecture bro?


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## MSEFM (Feb 23, 2021)

Mongrelcel said:


> Link to lecture bro?


It has been posted on here a few times. I think this is where I first saw it:


Junaid1800 said:


> I’m at intermolar width of 38 (not including teeth) going to go up to 46 mm. If you don’t think you’ll get a facial change from that you’re ignorant asf. I’ll get increase of mm to zygomatic bone . Majority of this forum is like me . I have watched to whole presentation . It even has results from older patients
> View attachment 897118
> 
> here’s a 19 year old male
> ...


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## ascentium (Feb 23, 2021)

MSEFM said:


> That's how I understand what Dr. Moon said in a recent virtual lecture. So you might choose a slow protocol if you're at higher risk for the midpalatal suture separation to fail (i.e. male and older like me), but you're probably trading off some of the potential for midface expansion. The very reason failure might be less likely at the slower rate is because it gives the resistance of the surrounding structures time to dissipate through bending and/or remodeling. Dr. Moon talks about a biological and a mechanical process. Fast relies more on mechanical breakage (but there's a risk the appliance will fail before the bone). Slow relies more on biological remodeling. Both will occur in different ratios depending how fast you advance.



i wouldn’t put too much stock on moontake on “biological remodeling,” as it’s merely conjecture. Even with the Ting protocol mechanical disarticulation is observed, along with a diastema.

remodeling is on the extreme end of the spectrum with something like RPE in early adolescence, 

additionally ting has mentioned that Moon’s conjecture was true with MSEI, but not with MSEII.


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## MSEFM (Feb 23, 2021)

ascentium said:


> i wouldn’t put too much stock on moontake on “biological remodeling,” as it’s merely conjecture. Even with the Ting protocol mechanical disarticulation is observed, along with a diastema.
> 
> remodeling is on the extreme end of the spectrum with something like RPE in early adolescence,
> 
> additionally ting has mentioned that Moon’s conjecture was true with MSEI, but not with MSEII.


In the context of the lecture, Dr. Moon's "biological remodeling" just means giving time for osteoclasts to be recruited and break down the interdigitations of the suture rather than going so fast that mechanical force breaks them. It still results in disarticulation of the suture. He suggests in all cases, there will be some traumatic breaking and some controlled, cellular-signaled breakdown along the suture, but the ratio depends on how fast you advance. Of course, this is all theoretical. I got a <3mm diastema advancing at 1 turn per day. The thumbnail of that video shows how the suture can be separated farther than the gap between the central incisors.


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## MSEFM (Feb 26, 2021)

I've now completed 6 weeks with 3 cycles of alternating backward and forward. The original alt-RAMEC protocol calls for 4 cycles. So I plan to do at least 1 more cycle over the next 2 weeks. I haven't noticed dramatic improvement during the alternating cycles, but I think there has been a very slight change in my bite. I have to decide if I want to do one extra cycle afterward for good measure before I move on to the 6 month stabilization phase in the hopes that those stubborn coronally-running circummaxillary sutures will mobilize.


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## MSEFM (Feb 28, 2021)

While biting off a piece of hard food with the right side of my mouth, I felt a twinge beside my left eye, near the frontozygomatic suture. I was able to repeat the same feeling by taking a couple more bites, and chewing gave a duller sensation in the same area. Maybe this reflects more mobilization of perimaxillary sutures. I'm on day two of this cycle, reversing 4 turns per day so far.


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## N1c (Mar 1, 2021)

Was your expansion symetrical? And did your nose and eye area like ipd change?


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## MSEFM (Mar 1, 2021)

N1c said:


> Was your expansion symetrical? And did your nose and eye area like ipd change?


My bite looks like I got 1-2mm more expansion on the side that started out wider. I don't notice a difference in my ipd, and my nose might be very slightly wider but it's hard to say. I think the bridge of my nose might look a little more symmetrical than it used to.


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## N1c (Mar 1, 2021)

MSEFM said:


> My bite looks like I got 1-2mm more expansion on the side that started out wider. I don't notice a difference in my ipd, and my nose might be very slightly wider but it's hard to say. I think the bridge of my nose might look a little more symmetrical than it used to.


Have you noticed any more improvments of the cheekbones and is your midface "fuller"? If so do you think it is more because of the mse or the facemask?


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## MSEFM (Mar 1, 2021)

N1c said:


> Have you noticed any more improvments of the cheekbones and is your midface "fuller"? If so do you think it is more because of the mse or the facemask?


Any midface changes are subtle. My perinasal area might have a little more volume in the lateral dimension, but I don't notice any more cheek convexity in a profile view. I do think my upper lip might have a little more support. I've definitely expanded more transversely than anteriorly, so any midface changes are probably mostly from the MSE. My orthodontist thinks the facemask is unlikely to have much effect at my age.


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## Fgsfds (Mar 1, 2021)

Thanks again for the frequent updates mate. Please keep it up, you're breaking new ground here.


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## ascentium (Mar 3, 2021)

MSEFM said:


> Any midface changes are subtle. My perinasal area might have a little more volume in the lateral dimension, but I don't notice any more cheek convexity in a profile view. I do think my upper lip might have a little more support. I've definitely expanded more transversely than anteriorly, so any midface changes are probably mostly from the MSE. My orthodontist thinks the facemask is unlikely to have much effect at my age.



is the ortho aware that you’re following ALT-RAMEC?


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## MSEFM (Mar 3, 2021)

ascentium said:


> is the ortho aware that you’re following ALT-RAMEC?


My orthodontist was skeptical, but he said that I could experiment with it if I started the 6 month stabilization window after I finish the alternating cycles.


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## patricknotstar (Mar 3, 2021)

MSEFM said:


> I've almost finished my MSE expansion using the Ting 1 turn/day protocol. I started with a slight class III malocclusion. I've been pretty committed to using the facemask protraction and my upper incisors seem to have moved forward a couple millimeters relative to the lower incisors, but I'd still like at least 3 more millimeters of sagittal expansion based on where it feels most comfortable to position my mandible. Dr. Ting says men my age are lucky to get 2 millimeters with the reverse pull headgear and @varbrah estimates he got 3-4mm. I'm considering alternating expansion and contraction to help loosen the perimaxillary sutures and prolong the period for the facemask to work. Typical Alt-RAMEC protocols call for 4-9 weeks cycling between opening the expander all the way one week and then closing the expander all the way the next week. My diastema is only a couple millimeters wide and I don't want to loose the limited transverse expansion my 10mm MSE has achieved by going backward, but I really want to maximize my sagittal expansion. So I'm trying to decide:
> 
> 1) How far back to turn before turning forward again
> 2) How rapidly to open and close the appliance
> ...


Hi can I ask how much ur MSE cost , If u don’t answer I will physically harm myself hahahjahahahahahhahahah


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## MSEFM (Mar 4, 2021)

patricknotstar said:


> Hi can I ask how much ur MSE cost , If u don’t answer I will physically harm myself hahahjahahahahahhahahah


The MSE and installation cost about 3 thousand dollars, but the majority of the expense is the realignment afterward to close the diastema and fix your bite.


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## Agendum (Mar 4, 2021)

2K of my cost (of $8K) was for MSE but my ortho thought Id only need one. I will be on my 3rd.


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## MSEFM (Mar 5, 2021)

Aeons said:


> ive done it for 7-8 weeks now


@Aeons have you finished alternating backward and forward? How many total weeks did you cycle through? I'm debating if I should stop after 7 weeks or continue to 9 weeks or more.


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## ascentium (Mar 8, 2021)

Will you compare your before and after CBCTs for us?

did you notice your inter-canthil distance increase or that area get ‘enhanced’ in some capacity?


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## MSEFM (Mar 8, 2021)

ascentium said:


> Will you compare your before and after CBCTs for us?
> 
> did you notice your inter-canthil distance increase or that area get ‘enhanced’ in some capacity?


I'm not sure if my orthodontist will want to take another CBCT or not. It would be interesting to measure the changes, but probably isn't clinically necessary, so we might avoid the radiation exposure. I'll report any observations from any imaging we do. I don't notice an obvious difference in the space between my eyes. There might be a little less asymmetry in the bridge of my nose there.


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## MSEFM (Mar 12, 2021)

Tomorrow I will complete 8 weeks of contracting and expanding. This is when a typical Alt-RAMEC protocol would stop, but I think I'm going to go for at least 2 more weeks since I feel like I'm still making gradual progress but haven't reached my goal.


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## MSEFM (Mar 13, 2021)

I'm feeling a little tenderness around one of the TADs if I tap on it with something hard. I don't want hylinization of the bone from all of this rapid back and forth pressure. So I think I might stop the alternating cycles today, after 8 weeks rather than going ahead with an extra cycle beyond the typical alt-RAMEC protocol. Hopefully the sutures will remain mobile for a couple more months to allow me to make a little more progress with the extra-oral traction. I'm also eager to start the 6-month countdown before the appliance can be removed.


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## ascentium (Mar 13, 2021)

MSEFM said:


> I'm feeling a little tenderness around one of the TADs if I tap on it with something hard. I don't want hylinization of the bone from all of this rapid back and forth pressure. So I think I might stop the alternating cycles today, after 8 weeks rather than going ahead with an extra cycle beyond the typical alt-RAMEC protocol. Hopefully the sutures will remain mobile for a couple more months to allow me to make a little more progress with the extra-oral traction. I'm also eager to start the 6-month countdown before the appliance can be removed.



It’s been a long journey. Thank you for advancing the MSE frontier. Mine is being installed soon.

any mid-facial gains to note?


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## MSEFM (Mar 13, 2021)

ascentium said:


> It’s been a long journey. Thank you for advancing the MSE frontier. Mine is being installed soon.
> 
> any mid-facial gains to note?


When I look in the mirror, I think I see improvement, but when I took some standardized "after" pictures 8 weeks ago after completing my initial expansion before starting my alternating protocol I couldn't identify obvious changes. I'm curious to take some new pictures now.


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## MSEFM (Mar 21, 2021)

I've been playing around with the webceph morphing feature, and the main thing I've realized is that even drastically advancing my maxilla by about 5mm is subtle enough in the comparison that it would be hard to say definitively there was improvement if these were real before and after pictures. Part of this might be because the morph only seems to advance the lefort 1 area. When you look at the animation it becomes more obvious. I think the increased support that I've noticed behind my upper lip is similar to what the morph shows, so it makes me hopeful that I'm getting actual forward results from my reverse pull headgear, as the change in my bite suggests, even though it's hard to definitively recognize in profile pictures so far.


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## ascentium (Mar 21, 2021)

MSEFM said:


> I've been playing around with the webceph morphing feature, and the main thing I've realized is that even drastically advancing my maxilla by about 5mm is subtle enough in the comparison that it would be hard to say definitively there was improvement if these were real before and after pictures. Part of this might be because the morph only seems to advance the lefort 1 area. When you look at the animation it becomes more obvious. I think the increased support that I've noticed behind my upper lip is similar to what the morph shows, so it makes me hopeful that I'm getting actual forward results from my reverse pull headgear, as the change in my bite suggests, even though it's hard to definitively recognize in profile pictures so far.



when will you get post expansion cephs, so you can superimpose ?


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## patricknotstar (Mar 21, 2021)

MSEFM said:


> I've been playing around with the webceph morphing feature, and the main thing I've realized is that even drastically advancing my maxilla by about 5mm is subtle enough in the comparison that it would be hard to say definitively there was improvement if these were real before and after pictures. Part of this might be because the morph only seems to advance the lefort 1 area. When you look at the animation it becomes more obvious. I think the increased support that I've noticed behind my upper lip is similar to what the morph shows, so it makes me hopeful that I'm getting actual forward results from my reverse pull headgear, as the change in my bite suggests, even though it's hard to definitively recognize in profile pictures so far.


Holy shit thanks for introducing me to this god tier site


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## MSEFM (Mar 21, 2021)

ascentium said:


> when will you get post expansion cephs, so you can superimpose ?


We might wait until the MSE comes out to take the "after" lateral ceph, but at least a couple more months since I'm still hoping for more progress.


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## MSEFM (Mar 21, 2021)

patricknotstar said:


> Holy shit thanks for introducing me to this god tier site


I learned of it from this thread, so props to @SixCRY 
https://looksmax.org/threads/surgery-simulation-at-home-2d.319479/


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## ascentium (Apr 23, 2021)

Any update?


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## MSEFM (Apr 23, 2021)

ascentium said:


> Any update?



Not really. It's been about 5 weeks since I stopped the alternating cycles. If I'm getting any more advancement it is very minor, but I'm continuing to use the reverse pull headgear.


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## ascentium (Apr 23, 2021)

MSEFM said:


> Not really. It's been about 5 weeks since I stopped the alternating cycles. If I'm getting any more advancement it is very minor, but I'm continuing to use the reverse pull headgear.



do you have to use the reverse pull headgear in the retention phase?


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## MSEFM (Apr 24, 2021)

ascentium said:


> do you have to use the reverse pull headgear in the retention phase?


You can use reverse pull headgear as long as you still have the molar arms and bands with the elastic hooks attached. Sometimes these need to be cut off during the expansion if they are tilting your molars.


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## Fgsfds (May 29, 2021)

@MSEFM whats good my boy


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## MSEFM (May 31, 2021)

Fgsfds said:


> @MSEFM whats good my boy


I still think I'm getting very gradual forward change.


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## Fgsfds (May 31, 2021)

MSEFM said:


> I still think I'm getting very gradual forward change.


Excellent. Even long after you discontinued the turning?


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## MSEFM (Jun 1, 2021)

Fgsfds said:


> Excellent. Even long after you discontinued the turning?


Yeah, it's been over 10 weeks since I finished my alternating cycles. My bite still feels like it's incrementally changing from the reverse pull headgear.


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## Fgsfds (Jul 10, 2021)

@MSEFM Any more updates mate?


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## N1c (Jul 10, 2021)

MedMaxxing said:


> I only say this because of Ronald's results. He did too much expansion but the change in his zygos was night and day. IIRC he did 10-12 mm, I plan on 8-10 (posterior crossbite)mm. He went from flat zygos to essentially full zygos through his expansion.
> 
> View attachment 968764
> 
> ...


I think one of the reason why he got so big change in his zygo is that his forward growth where already ok but his lateral growth was bad


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## MSEFM (Jul 10, 2021)

Fgsfds said:


> @MSEFM Any more updates mate?


I'm not sure if my forward progress has stopped or if it's just too gradual to notice. My bite when putting my mandible in the most comfortable position has gone from an underbite with the lateral incisors touching to and end-on-end bite with the right central incisors touching to now an end-on-end bite with the left central incisors touching. It feels like maybe my lower incisors now want to hit just behind the tips of the upper incisors, but not all the way back into maximal intercuspation. Even just one more millimeter of forward advancement would be great, but I think I'm reaching the point of diminishing returns. I'm planning to continue using the reverse pull headgear for at least a couple more months, maybe longer if I notice continued progress.


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## Fgsfds (Aug 19, 2021)

@MSEFM how's it going now?


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## MSEFM (Aug 29, 2021)

Fgsfds said:


> @MSEFM how's it going now?


Looks like it's been about 7 weeks since my last update. If there has been any forward progress since then, it is very small, a fraction of a millimeter at most. At that time I said that my teeth want to touch with the left central incisors hitting end-on-end or with the lower left central incisor just slightly behind the upper. Now it feels more definitive that they want to hit with a very small overjet, but I'd estimate still a millimeter or more away from being really comfortable in maximal intercuspation or with an overjet in the normal range of 1-3mm. There's more overjet on the right side, so maybe the left side could be proclined into a good position, but I really wanted to overcorrect to allow some room for relapse. My orthodontist has said he would be ready to remove the MSE in September, but I want to keep it to continue with the reverse-pull headgear for now.


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## Patient A (Aug 29, 2021)

MSEFM said:


> Maybe turning backwards rapidly would help upright the tilted TADs.


just loosen TAD screws theory


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## LooksOverAll (Aug 29, 2021)

MSEFM said:


> Looks like it's been about 7 weeks since my last update. If there has been any forward progress since then, it is very small, a fraction of a millimeter at most. At that time I said that my teeth want to touch with the left central incisors hitting end-on-end or with the lower left central incisor just slightly behind the upper. Now it feels more definitive that they want to hit with a very small overjet, but I'd estimate still a millimeter or more away from being really comfortable in maximal intercuspation or with an overjet in the normal range of 1-3mm. There's more overjet on the right side, so maybe the left side could be proclined into a good position, but I really wanted to overcorrect to allow some room for relapse. My orthodontist has said he would be ready to remove the MSE in September, but I want to keep it to continue with the reverse-pull headgear for now.


How much total maxilla forward advancement did you get? I have an edge-to-edge slight class 3 bite right now and would love to avoid surgery if I could while simultaneously expanding zygos.


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## MSEFM (Aug 29, 2021)

LooksOverAll said:


> How much total maxilla forward advancement did you get? I have an edge-to-edge slight class 3 bite right now and would love to avoid surgery if I could while simultaneously expanding zygos.


I haven't had a follow-up lateral ceph or CBCT to measure yet. If I had to guess, based on my bite, there might be 3mm of forward advancement. At least in my case, it takes a lot of effort for minimal change.


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## Fgsfds (Jan 23, 2022)

@MSEFM hello lad. What's new


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