D
Deleted member 19066
3 time felon, Interpol agent, Father of 2.
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Now before I cause any confusion or a potential tension let me express this. THE DESIGN IS NOT COMPLETELY MY IDEA. And it's not even completely finished yet. Ok? Obviously I have used and fused other ideas that were created by other people before. I will show those designs, explain the similarities and the differences as well.
Now with that out of the way... In this thread I am going to show the modified MSE design I have created and explain why I believe that comparing to normal MSE + Facemask or MSE + bollard plates, this design might actually have a chance to work. Also I gathered some of the information that got scattered between many of my posts. I think it will be useful for people to understand why things like MSE + facemask and Mewing does not work, if those informations are actually in 1 thread. If you have time and if you are interested in this topic, try to read the post or try to read the parts that you are interested in. If you don't have time, but still interested in the topic, just skip to the part where I show the modified MSE design, or just try read the bolded sentences in each spoiler. That will summarize the whole post
A while ago I saw these designs:
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While I am aware that the first design is not actually completely bone borne for protraction purposes, since even though the design does not have full molar bands, but it still has partial molar bands which are cemented onto teeth which makes it tooth borne for protraction purposes(I will explain this part more detailed later on), the second design is completely borne borne, meaning it has no contact with any teeth. I haven't seen the second design used by any orthodontists, yet... But to me this shows that MSE anchorage point can stay stable without the support from molar bands(after the midpalate suture split is achieved of course)not just for transversal expansion, but also for protraction as well. Otherwise, why would such a design actually exist? However the pulling force is downwards, which in my opinion, could dislocate the miniscrews over time if high forces are used. It could also be the reason why it is not frequently used. Therefore I decided to create a new design.
To be able to explain this lets look at the regular rapid palatal expander design that is usually used on children, and how it works. ''When heavy and rapid forces are applied to the posterior teeth, there is not enough time for tooth movement to occur and the forces are transferred to the sutures. When the force delivered by the appliance exceeds the limit needed for orthodontic tooth movement and sutural resistance, the sutures open up while the teeth move only minimally relative to their supporting bone.'' This is how the classic rapid palatal expander works for children. Now for adults the situation is different. Regular rapid palatal expanders don't work for adults, because adult midpalatal suture is much more resistant than that of a childs. The amount of force that goes onto the midpalatal suture with a classic rapid palatal expander, is simply not enough to overcome the resistance that comes from it since the adult midpalatal suture is partially fused, not completely open like a childs, therefore for a split to be achieved it requires a higher amount of force. And so the midpalatal suture split is not achieved, and all that force goes onto teeth. After a while of this kind of expansion, what happens instead is that teeth starts to shift. Which could have devastating consequences. It could cause gum loss, tooth roots might get pushed out of the alveolar bone... People got similar results from AGGA as well because it gets its support from teeth.
Now returning to regular rapid palatal expanders... ''Rapid palatal expanders generate forces 2-5 kg per turn with accumulated loads more than 9kg''. In case of children, some of that force goes onto teeth and some of that force goes onto bone and it is enough to open up the midpalatal suture. With adults the classic rapid palatal expander does not open the midpalatal suture. However MSE/MARPE is a whole nother story. Lets return back to: ''Rapid palatal expanders generate forces 2-5 kg per turn with accumulated loads more than 9kg''. In the case of MSE, all of that force actually gets transferred onto bone, without getting lost on teeth(especially after the midpalatal suture split is achieved and molar bands are cut). Which means that with MSE generated forces of 2-5 kg per turn with accumulated loads more than 9kg, nearly completely gets transferred onto actual bone itself. Obviously that is a huge amount of force. This is I believe, is the reason why MSE/MARPE is able to overcome the resistance that comes from the midpalatal suture. Even such a big amount of force is sometimes not enough to overcome the resistance that comes from adult midpalatal suture, and so things like screw drag or screw tilting happen and midpalatal suture split cannot be achieved, thus expansion does not happen. Keep in mind that the midpalatal suture is the weakest suture on the whole skull.
Now onto the topic of protraction. First let's talk about MSE + Facemask. When someone is attempting to use MSE alongside with protraction facemasks, the molar bands and MSE arms are not cut after the midpalatal suture is split. Because with the current design, facemask hooks are soldered onto molar bands. Now MSE has 2 types of arms. One is soft arms and one is hard arms. However, most of the time soft arm option is used in case things doesn't go as predicted, so if midpalatal suture split cannot be achieved teeth wont get pushed out of the alveolar bone or arms doesn't start pushing onto palate and get burrowed underneath the tissue/cause inflamation of the tissue.
Here is how a hyrax expander is made: . MSE is made in a similar way, its modified according to a persons dental impression by a dental technician. Skip to 7:58 . Notice how he bends the arms by using a simple device, essentially by using the force of his hands. So those arms are bent by hands. Hands. Obviously bone is going to be more resistant than those MSE arms. Because of this reason, when attempting to protract from the molar bands, for adults the results are disappointing. Those arms start to bend and while it is not noticeable to the eye, teeth start to shift and tilt instead. I have seen a lot of results like that. Here are a few of them:
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As you can see the result is only upper teeth tipping more forwards and lower teeth tipping backwards and some alveolar bone remodelling(Which has nothing to do with true skeletal movement. Alveolar bone is the most malleable bone in the whole skull, and alveolar bone remodeling is what makes braces treatment work as well. Teeth is moved with braces, new alveolar bone remodels on the new area and the remaining gap is filled with alveolar bone as well. This is the way braces works. If alveolar bone remodelling was not possible for adults, braces would not work for adults as well. Obviously even this type of treatment has its limits...) So what happens is just another form of camouflage treatment with the help of protraction facemask, which is a much more tedious process then using braces for the same type of treatment
While the hard arm options seems better, still the facemask hooks are soldered onto molar bands and you are essentially pulling from molar bands again. No one knows if the protraction force actually gets transferred onto the anchorage point even with the hard arm option. This is very different than maxillary expansion with MSE. With transversal expansion, MSE anchorage point, so miniscrews and expansion device is what generates the force. While the protraction force is delivered via facemask hooks onto the molar bands. So the force is transfered onto teeth first, than any of the remaining force(if any is remaining anyways...)gets transfered onto the arms... Then the remaining of that remaining force gets transferred onto the actual anchorage point........ You might understand it now, only a tiny bit amount of protraction force actually gets transfered onto the ancorage point and onto bone itself.
Protraction with MSE for adults was not designed to ''get the advantage of protracting from actual bone'' to start with, it was designed to ''get the advantage from the other disturbed sutures that takes place during the expansion'' and trying to protract the maxilla. So essentially, its the adult version of rapid palatal expander + protraction facemask. Therefore expansion with MSE is definetely considered true skeletal expansion so bone borne expansion, while protraction with MSE cannot be considered bone borne protraction.
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First let's explain why mewing does not work for adults. With children growth guidance can take place. With adults however growth guidance doesn't take place, because ''growth'' is finished anyways(Alveolar bone remodelling can take place on an adult as well, but I don't think that can be considered ''growth guidance''). If growth guidance took place on adults we would be able to see adults who respond to classic RPE expanders, or adults who respond to protraction with the help of facemask. Even those treatment generate more force than tongue can exert. But only the treatments that work by either seperating the sutures; or surgeries, that induce trauma onto an area and triggers the healing healing process, actually works for adults(So surgeries like Lefort, sliding genioplasty, BSSO, IMDO, Leg lenghtening surgery etc...I think MSE can be considered a trauma induced healing process as well). Its like breaking a bone, unless you break it you can't trigger that healing process and magically hope that your arm or leg bone is going to get thicker(There are some studies show that broken bone heals to be much more thicker). If that healing process didn't take place for adults, it would be over for anyone who had an accident. And 500g of force is not enough to trigger that healing process. Nor enough to seperate any of the skeletal sutures, including the midpalatal suture(Remember what I said, the midpalatal suture is the weakest suture on the whole skull, even with MSE sometimes forces as high as 9kg is not enough to open the adult midpalatal suture. Imagine how 500g is going to be enough for sutures that are much more resistant than that... This comes for people who fantasize about putting their tongue on their palate and hope that they will magically achieve ''forward growth''...)
However, that doesn't mean you should not breathe from your nose. Humans are designed to breathe from their nose when resting. Mouth does not have the ''filtering'' functuon nose has. So the only instance mewing would work for someone is if they have an issue with their throat, like if they chronic pharyngitis, which mewing does help with because breathing from nose humidifies the air and removes the airborne particles; or if they have abnormally inwards tilted teeth without any actual malloclusion issue or a palatal narrowness issue(which is kind of an impossible case to see...). The reason why it would work for such a case is, like shown in the chart, tongue is able to exert up to 500g of force, and teeth only need 1.7g of force to move. That is the only 2 instances mewing could actually work for someone, and those are not skeletal changes. They are either dental, or dentoalveolar changes, not skeletal.
Now onto bollard plates... Bollard plates %100 work for children, it gives actual skeletal results for children with actual CCW rotation. However for adults... I am still open to discuss this since there isn't a lot of adult cases which involves bollard plates, however I highly believe that it won't work for an adult if somebody decides to try it, because of the following reasons. So while bollard plates are a completely skeletal type of protraction, the screw lenght of bollard plates are usually between 5-7 milimeters, while MSE screw lenght is between 11-13 milimeters(sometimes even longer than that, I saw miniscrews that are used with MSE which was 24mm long...) You might ask ''why can't bollard plates be used with longer screws for better stabilization?''. Which is a question I also used to ask. It has to do with the area bollard plates are used. You can't go beyond a certain lenght on that area otherwise you risk the miniscrew penetrating onto the sinus cavity. That could create the risk of causing a sinus infection, which is a big no. On the other hand, MSE miniscrews are actually supposed to penetrate onto the nasal cavity. This is the reason why MSE can stay stable under such high forces, because MSE miniscrews are supposed to penetrate onto the nasal cavity, which provides bicortical engagement. In fact failed MSE cases are usually caused by miniscrews that weren't able to penetrate the nasal cavity and provide bicortical engagement. Bollard plates can't provide such a stable anchorage. Therefore usually the force load is between 350-600g(I haven't heard of anyone who goes higher than 600g yet). Which is an amount of force that is similar, maybe just a little bit higher than the amount of force tongue can exert. Again, that amount of force is not enough to seperate any of the sutures of an adult, even midpalatal suture, which is the weakest suture on the whole skull, cannot get seperated with that amount of force. Obviously other sutures that are stronger than the midpalatal suture won't be effected. So for adults, bollard plates can neither give growth guidance nor will split any of the sutures, even when used alongside with MSE, so it won't trigger the healing response that MSE or surgeries can induce.
By so far one can understand that for sutural seperation to actually take place on an adult, high forces are needed. Just like how MSE works
In fact I highly believe that the sole reason why the famous computer simulation for protraction with N2 implant actually gave results was because of the amount of protracton force that was used in the simulation.
''...Values of 1000g per side were applied for all simulations...''
''...For all simulations, 1000g of protraction forces were applied, as studies have shown that 500–1500 g is an appropriate force load for maxillary protraction...''
1500g per side. That is 3kg at total, which the article indicates as ''appropriate'' force load for maxillary protraction. Considering that the N2 implant were designed to be used alongside MSE, alongside with disturbed maxillary sutures, 3kg for bone borne protraction could have actually worked, if that implant could become a reality. But again that is just a simulation. No one can actually know if 3kg of force would be enough to achieve skeletal protraction or if that N2 implant could actually stay stable under big amounts of forces unless a real study takes place.
While the N2 implant simulation indicated that the N2 implant was designed to stay stable under high amounts of force, that implant isn't becoming a reality anytime soon. What we already have in hand that is already stable enough to stay under high amounts of forces though, is MSE
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Bollard miniplates Modified C plate used for protraction
All the other means of protraction be it bollard miniplates, or modified C plate used for protraction, or TAD's etc... are not stable enough to not get dislocated under high loads of forces. The only type of miniscrew we have on hand that has already proved itself to be very stable, is MSE miniscrews; because the place they are used, they can give bicortical engagement and that makes them very stable. We already know that they can stay stable under accumulated loads more than 9kg until the suture split is achieved. That makes it a very useful tool to use for protraction
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So initial idea came from these 2 designs. First one was designed by either @nelson or a user called @CopeAndRope. I don't know who is the one that originally designed it. I used the idea to bend the MSE arms behind the last molar, or behind the last molars gums. However unlike this design, my design does not get its support from the gums. It gets its support from MSE anchorage point, MSE arms are bent around the gums, but not touching it or getting any sort of support from it. That is the difference of my design and this one. While it is not completely same design, I still wanted to mention it since the idea came from this design. The second design is actually a very frequently used type of MARPE for a failed first MSE attempt. The additional 2 screws provide extra anchorage. I used the additional 2 miniscrews to provide more stabilization in my design, since my design does not have any contact with teeth to get support. Here is the design I created:
Version 1(which is bent around the gums, not touching the gums):
View attachment 1633355
additional 2 screws for extra stabilization
Version 2(which is bent around the last molars, not touching the molars):
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additional 2 screws for extra stabilization
With this kind of design there won't be any contact with teeth. AT ALL. All of the protraction force will actually get transfered onto bone, without getting lost on teeth. It won't create unwanted dental side effects since it has no contact with any teeth to start with. Either you will get results, or you won't get results
Like I said, this design is not completely finished. Since it has 2 problems. First problem is that as the expansion and protraction happens MSE arms might start getting pushed into the tissue which could cause a problem like this:
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Second problem is the bending of the MSE arms. After a while of protraction the arms in my design might start to bend and start pushing onto the last molars or the gums behind the last molars.
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To overcome those problems, I thought about covering the parts I marked with red, with acrylic. So the end result was actually going to look similar to the ones on right. Hovewer I wasn't able to animate that yet. That is the reason the design is not completely finished yet
With this design I believe that higher amounts of protraction force can be delivered onto bone without the unwanted dental effects. Would it be enough to achieve skeletal protraction on an adult? Who knows, but I believe this could be a useful design nevertheless
Here are the sources of some of informaton I wrote on this thread. Putting it on here in case someone wants to check them out...
Maxillary Expansion
Maxillary transverse discrepancy usually requires expansion of the palate by a combination of orthopedic and orthodontic tooth movements. Three expansion treatment modalities are used today: rapid maxillary expansion, slow maxillary expansion and surgically ...www.ncbi.nlm.nih.gov
The efficacy of maxillary protraction protocols with the micro-implant-assisted rapid palatal expander (MARPE) and the novel N2 mini-implant—a finite element study
Maxillary protraction with the novel N2 mini-implant- and micro-implant-assisted rapid palatal expander (MARPE) can potentially provide significant skeletal effects without surgery, even in older patients where conventional facemask therapy has limited ...
What age does skull development completely halt/ At what age does mewing become a cope?
