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Dr. Emanueli, the Vegas Orthodoc, we met just over a year ago. We broke the internet with our discussion of FME and maxillary skeletal expansion. Why don't you give us some perspective on what we're going to talk about today as
Deep dive into adult skeletal expansion, FME, and maxillary expansion techniques with Dr. Emanueli and Ron, exploring dental vs skeletal expansion.
Ask about this video. Answers come from its transcript only — with the timestamp, so you can check them.
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Key Takeaways
- Skeletal expansion is preferred over toothborne expansion for adult patients.
- Not all expansion methods produce the same skeletal changes; quality matters.
- Dental expansion carries risks such as tooth damage and does not increase skeletal width.
- Proper interpretation of imaging is crucial to understanding true expansion results.
- FME and related devices are evolving to improve predictability and outcomes.
What the video covers
- Discussion on the evolution from toothborne to skeletal expansion in orthodontics.
- Detailed explanation of types of expansion: dental, dental alveolar, and skeletal orthopedic expansion.
- Risks and limitations of dental expansion, especially in mature patients.
- Analysis of skeletal expansion quality and how different expanders affect outcomes.
- Preview of the FME Pro device and upcoming modifications.
- Case study review involving an unusual complication during expansion.
- Clarification on interpreting before and after images and airway cross-sections.
- Importance of critical evaluation of expansion photos and diagnostic tools.
- Exploration of surgical assists and their impact on expansion patterns.
- Discussion on lifestyle and environmental factors influencing expansion success.
Chapters
- 00:00Introduction and Overview of FME and Expansion
- 09:40Types of Expansion: Dental vs Skeletal
- 19:23Case Study and Imaging Analysis
- 29:00Risks and Limitations of Expansion Methods
- 48:59Lifestyle, Environment, and Expansion Outcomes
- 59:53Complications and Managing Expansion Delicacy
- 70:51Preparation for Jaw Surgery and Patient Management
- 90:36Anatomy and Cranial Nerve Considerations
Full Transcript — Download SRT & Markdown
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we get ready to geek out over expansion for the next couple of hours?
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>> Absolutely, Ron. I am so excited about today. I mean, we're going to be deep diving into the quality of expansion.
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For a long time, we talked about is it possible to expand or what do we need to do to make it possible to expand in adults. Today, we're going to deep dive into the quality of expansion and what
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that even means and the influence that we have over it. We're also going to take a look at some of the latest and greatest as it relates to Face Genics and the FME. Uh, we're going to preview the FME Pro and see what's going on
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behind that, see what modifications are in the works for that. And we're going to go through a case together too. Uh, this was from my coaching platform and a patient who had just a very, very unusual complication. Uh, and we'll walk through
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that process together and so I'm excited. So, uh, yeah, if you're ready, we can just dive in.
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>> Yeah, why don't we dive in and, um, you know, just my own two cents about where we're coming from here. So five years ago, actually seven years ago when I started in this space, the question was
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toothborne versus skeletal. That was actually a debated topic at the time. Since then, it's become clear skeletal is the way to go. But now that we're talking skeletal expansion, and let's leave double jaw orthognathic surgery out of the conversation just for a moment.
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Now that we're talking skeletal expansion, you can really double-click on that multiple times and really zoom in on the finer details. And that's what we're going to do today. We're going to talk about not just do we split or did
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we not split, but how did we split? How do different expanders split and expand differently? And what effect does that really have on a patient's skeleton? So, we're really gonna dive into this question that a lot of people have
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between FME, custom ARP, MSE, type two. Are they really different or are they just the same thing branded differently?
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Surgical assists and how they can affect expansion patterns and expansion outcomes. So, that being said, why don't we now dive in?
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>> Absolutely. Let's do it. Okay. So, so not all expansion is created equal. We're going to redefine what's possible with adult skeletal expansion. So, what I wanted to do first was just break down the types of expansion because I still
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see a ton of confusion over, you know, when people say expansion, what they even mean. So, you broke it down a little bit, but we're going to talk about dental expansion, we're going to define that as expansion that primarily
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moves the teeth. Dental alveolar expansion, we're going to define that as expansion that moves and tips the teeth, but also brings with it the bone around it. And then of course skeletal orthopedic expansion where the two halves of the upper jaw split which is
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what we're going to spend most of our time talking about. So if we have to define this and again this is hopefully helpful for your audience, you know, we can go through these things. The outward tipping and repositioning of
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teeth through dental movement. So mechanism it's achieved by applying orthodontic forces typically braces, aligners, or similar toothborne appliances and the result is the dental arch appears wider but the basal bone is unchanged. So limitations of course it's
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not going to increase the skeletal width and for clinical uses it's going to be helpful for resolving mild crowding, maybe some moderate crowding but it's not going to change the underlying skeletal discrepancy.
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>> Also worth mentioning, doctor, that dental expansion comes with the danger of damaging teeth, especially if it's overdone.
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>> Exactly. If you do it too much, you're going to push the teeth right outside the bone. And again the more mature the patient is, the thinner the biotype of the tissue, then the more at risk they are for this. So when we
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first look at this case here, I mean, we would not immediately think, oh, this is a dental expansion case. Okay. But what ended up happening with this case is that we did do dental expansion because at the time we didn't really have a
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great option other than that. Uh, and also we were pretty sure this patient was going to need jaw surgery so they could address, you know, any of the remaining jaw size discrepancies at that point. And so when we look at cases like
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this, I mean, this patient, what, you know, really couldn't get the ideal result at that age at that time. Uh hopefully one day we can look at a case like this and say, "Hey, uh we can knock this out of the park without surgery."
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Um I think that is a reality. I don't know if it's a reality today, but I definitely think it's a reality at some point in my lifetime. Um but here we had these canines blocked out. We had to do
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something to get him in just so he could make it to the next stage and, you know, be able to function and not have any issues before he could be older and be ready for jaw surgery. And so that's
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what we did. And you can see here, this is dental expansion. So, you can see those teeth on the top have tipped outward and the arch has broadened. It's not as V-shaped. Uh, but it's
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the teeth. It's not the bone underneath. It's literally just reshaping the teeth within the bone that was there. And, you know, at that point, we didn't do anything to the lower jaw. We just sort of let those go until he's older. The
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canines were brought in. That was the main problem. Uh, but when you look at this before and after, and this is where a lot of people get confused because they look at these pictures and they say, "Oh, wow. Look, he expanded." You
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know, look, he expanded. Well, yeah, the arch expanded, but the bones didn't actually expand. And unless you know how to dissect and look through the images to really know what happened, there's no way you can know. And so, that's what
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we're going to spend some time doing today. So, when we look at dental expansion, this is another point that I want to point out to you. When you look at the expansion from this standpoint here, back when it's right
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next to each other, it looks exactly the same. And then when you magnify it to where the teeth are actually the same dimension. So you can see here we're keyed on the premolar. Then you can actually appreciate how much those teeth
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actually moved. And so even the way that the photos are oriented or displayed can affect what you perceive as expansion or not expansion, which is pretty crazy to think about. So long story short, be careful, you know, who you watch and be critical when you
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see photos. Especially this, I thought was interesting because a lot of people get really hung up on airway and like they look at images like this and they either get really excited or they get
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really freaked out. Uh, so this was the before and after airway cross-sections from that patient we just saw. And you can see here I mean in the after the jaw is a lot further forward than it was in
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the before. But the jaw and the airway is certainly not bigger than it was before, certainly here. And that's because there's a multitude of things that goes into determining what this cross-sectional airway is going to look at. So, you know, if you have somebody
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talking to you like, hey, you know, they're really worried or really excited about this. Really, this is a diagnostic tool, it's not a diagnostic tool. It's just a screening.
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So, here you can kind of see the tongue posture was higher, the jaw was further back. Here, the tongue posture is lower.
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Maybe the head was back a little bit and you can see the differences in the reading here. I just thought that'd be interesting.
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>> But yeah, I mean, a lot of lay people who uh who are in this space look at those cross-sectional slices and they draw massive conclusions from them. But I I think you're right to point out that they're limited in terms of what data
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that they can provide because you can just alter the neck posture of the patient inside of the scanner and you can get a dramatically different reading of the of the cross-sectional area of the airway.
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>> 100%. and then depending on where their tongue is, were they swallowing, you know, all the things go into it. So, yeah, it's definitely not something that you want to put a lot of weight in as far as trying to make any, you know,
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concrete diagnoses from. >> Can I ask you a quick question about that, doc? How come how come a video MRI is not uh a video CT is not taken where you actually have the patient doing various neck postures and you can see
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sort of the range of the airway as the patient adjusts his head? >> Yeah. You know, >> wouldn't that get around this problem?
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>> Yeah. you know, honestly, if they did that, they'd probably be better off doing it with, like you mentioned, either MRI or ultrasound, right? Because if you're doing it video CT, I mean, that that's a lot of radiation dose for,
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you know, for something like this. Um, and so my my guess is that that's probably the biggest limitation when it comes to radioraphs. And of course, you know, as as orthodontists, we typically don't have MRI machines or ultrasounds
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in our office. Uh, and so, you know, we use the equipment that we have to get the information that we can. But to your point, I think that's a I think that's a great idea. I think that would give you
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a much better um idea of what's happening and and truthfully like really if you could have that imaging you know while they're sleeping that would be the most valuable ever right because then you can actually see what is causing the
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apnea what location it's at like where you know is it on your side is it on your back uh you know maybe one day there there will be an imaging uh system that is sufficient to you know record
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all night and and basically it's like you can see what's happening in your airway the entire night um I'm not aware of any to date can do that. Uh but I think that's that thinking is, you know, the right way to be going.
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>> Try going to sleep in an MRI machine. >> Right. [laughter] >> Yeah. So, let's look at this. Uh so, this is how you tell what actually happened to the teeth and bones. And this is that patient that we looked at
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before. So, we're going to dive through and actually see what changes were made. So, you can see here that the patient did grow. This was a growing teenager.
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So, you can see the cheekbones came down uh and the upper jaw came down as the growth happened. You can see that the lower jaw grew forward quite significantly. The white being the before, the blue being the after over
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the period of just a couple years. And you can see that that growth is what we would call, you know, pretty negative growth. Upper jaw is really not growing forward. Pretty much just those teeth are tipping forward and the lower jaw is
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is shooting forward. Again, you can see those adoids, too. Thankfully, those did shrink a little bit, which is good. But look at the change in that jaw and look at the position of the upper teeth. You can see here the changes that happened
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is it just tipped forward. Uh so again this is dental expansion and and and and dental expansion is not inherently bad but it is good to know what type of expansion that you want for your specific case. I mean if your teeth are
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tipped in then dental expansion might be great. Um here you can see again there's vertical growth so there are changes in the dimensions of the nasal cavity but when you look closely at the maxul especially compared to the mandible how
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far forward that's growing and how much wider it appears the actual teeth are actually translating through the bone.
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You can see that right here. There's more bone on the side of the tooth initially. So, let's go back. I'll show you this real quick. There's more bone on the side of the tooth here. And then as it goes outward, you can see that
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that bone, the tooth is literally translating through the bone all the way up to the buckle plate. So, now it's on the very outside of the bone compared to where it started, which was further in.
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So you know taking these images allows us to actually quantify and see you know what type of expansion we got because we can plan you know the best expander in the world but at the end of the day you
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know failure is a possibility and we won't know that unless we actually are are paying attention and looking.
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>> So dental ovular expansion this is one that a lot of people get confused on.
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Usually they understand orthopedic expansion they understand stand dental expansion but they're like dental aviola like what does that even mean? So let's define it. It's basically the outward movement of teeth accompanied by remodeling of the supporting alvolar bone and that results in an increase in
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arch width but not change in the two halves of the upper jaw. So basically not sutural expansion but the teeth are moving out and as the teeth move out the bone is moving out with the teeth and it's basically bending or remodeling in
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order to accommodate that. And so typically, you know, the expansion that that creates this type of the expanders that create this type of expansion, you can do it sometimes with braces or aligners. If the patient is young enough, it'll bring the bone with it or
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a lot of toothborne expanders like an RP. If you turn it slowly, an RP can produce primarily dental alvolar expansion or even uh dental expansion depending on how slowly it's turned. So even though a child is growing if if the
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rate is not fast enough then what happens is only the teeth move or only the teeth and and the bone around the teeth which would be dental aviola move uh instead of actually having sutral expansion. So the dental arch itself
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does become wider and both the teeth and the bone have changes but the two halves of the jaw are not inherently splitting like they are with something like Marpy.
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Um and so you're going to have limited stability. Uh but it can be helpful in certain situations specifically. You know a lot of patients who develop uh you know with mouth breathing tendencies sometimes the the overall width of the
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basil bone of the maxula is normal but the part of the teeth they've come down and in so far that really what they need to do is is be broadened and and have the the bone around them bent outward.
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So that's now upright over the basil bone. So there are circumstances where that's appropriate.
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>> And doc just uh if I could pause you for a second. So you said that I if you go at a certain slow rate with RP and I imagine by that you mean some kind of uh toothborne expander in a child somewhere
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in the age of you know 10 or 11 years old. You're saying the slower you go the more likely you are to get dental or dental alvolola movement. And does that mean that >> to in order to get a a mid palatal
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suture split with a toothborn expander in a young person you kind of need to shock the suture with a fast rate of turning? Uh yes to some extent. Now obviously there's too fast as well. So so and that's that's very well defined
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in our literature. So you know basically that there's there's a lot of studies that have compared like the rate of turning. Now the exact rate of turning you can't just say like hey you need to turn it this much per this patient
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because there's other factors besides the turning rate. Of course every patient's resistance is different. Every two halves of the upper jaw is different. The thickness of the midline suture is different. Uh the thickness of the sutures connecting the maxul to the
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zygomatic arch are different. So there's a lot of differences in resistance. But uh by and large, yes, you can hold fast as a rule. The you know, if you're comparing slow expansion to more rapid expansion or what we would traditionally
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call rapid palatal expansion, you were going to get more dental or dental alviolar movements. The slower you turn.
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For instance, if you were to turn a rapid pal expander like once per week um or once every other week, you know, you might get dental tipping, you might get dental alvolar bending. you're probably not going to get a lot of true sutral
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expansion because in order to get that sutral expansion what first needs to happen is we have to overcome the inherent resistance in the midline suture. So basically once that's overcome just like in a MARPY patient you know what happens when when we
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overcome that midline sutral resistance what do we see in the mouth >> a diastma.
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>> Yeah we see a diasma that's exactly right. So the same type of thing happens with with these kids, right? So when we overcome that, typically we'll see a diasma. Now that's not to say that you know every patient you expand has to
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have a diasma to know that you got sutral expansion. There are some where the teeth compensate and move so quickly that even you know turning it at a fairly rapid rate. Uh the the the teeth move together so quickly you never see a
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noticeable diasma. But those are the outliers. By and large most patients who have expansion and get sutral expansion you will see a diastma at some point during their expansion. Now once that diastma forms, we typically know that the two halves of the upper jaw have
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been separated. So there's a percentage of that resistance that's now um for lack of a better description gone. Uh so we've eliminated part of the resistance.
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So now the remaining resistance is everywhere else that the maxul attaches. And that's why a lot of times when we're doing, you know, expansion in adults, we we slow down the expansion protocol after we get that initial midline diasta
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because now the force is required. we don't need as much force required as we did in order to get that initial split if that makes sense.
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>> So you're saying that turn protocols change there's a pre a piestma turn protocol and then there's a post diastimema turn protocol in both children and adults. Yeah. And primarily in adults with kids there's a lot more flexibility because the sutures are so
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wide open. You can typically the same amount of turn like if you're turning once per day for instance on a kid um which is what a lot of people do. Some people do twice per day, some people do
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four times per day, which I think is just just just way um overdoing it.
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That's about a millimeter per day. Uh and so like I think that's way overdoing it. But if you're turning your your rapid pal expander like one time per day, um that is sufficient enough to overcome that initial uh sutral
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resistance in in the vast majority of patients, uh you know, 99 plus%. Uh and also the bone can continue to remodel at that same rate and it's just simpler for patients. Uh and so no, we typically with kids especially younger kids will
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just turn it like once per day. But as soon as you start to get older uh and and the resistance is higher then then yes, we have uh basically an initial loading force which is higher and then once we obtain that sutral split then we
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can slow down the turns and in adults we absolutely want to slow down the turns because eventually that resistance uh can break and bones can break and then you can have complications if you turn too fast. and help me understand the age
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range for getting a midpal suture split with the toothborne expander. >> Yeah. Well, I mean, so so that that's a great question as well. I mean, you can see case reports of people expanding with toothborne expanders all the way up
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to, you know, 19, probably even early 20s with different types of turning protocols and, you know, aggressive uh aggressive expansion protocols. So, is it possible? Yes, it's possible. But here's the thing, and this is what a lot of people don't understand as well.
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getting the diasma is really just the beginning of the expansion process. And and and here's a question for you, Ron.
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Um, let me ask you this. So, let's just say hypothetically here. Go with me. So, let's say you expand a child's jaw and and there's always a discrepancy between how much you turn the key and how much the bones have actually moved, right?
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So, let's say you expand the upper jaw and you've turned the key 10 mm. And I take an X-ray that we just finished our last turn. It's 10 millm expanded. and I take an X-ray and I show that like 9 mm
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that the the the actual bones of the maxul is 9 mm apart. Right? So I'm going to hold that expander there until that bone fills in. All right. So so I've turned it 10 mm. I've taken an X-ray.
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I've verified that I have 9 mm of expansion. Again, this is a toothborn expander in a kid. Uh now I let it sit for 3 or 4 months to let the bone fill in. If I take another X-ray and see how
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far apart the bones are. Mind you, I haven't done anything to the expander. I haven't turned it. I haven't, you know, like what is that going to show how far apart the bones are after that 3 or 4
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months? >> Would it show less than 9 mm because the teeth will just move and as a result of that inward collapse?
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>> Absolutely. So the teeth are being held in the positions that they are. So the teeth won't really move outright uh compared to each other, but the only thing that the teeth are connected to is the bone. And there's still pressure on
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that bone. So the pressure on the bone is pushing inward essentially. So, we stretched it out, but it still has force to want to go back in. And if the only thing holding the the the expander out is attached to the teeth, well, the only
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thing holding the bone out is the roots. And as we know, roots of teeth can move through bone. And so, as that pressure can basically constricts, the teeth relatively translate through the bone.
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Even though they're stuck in the exact same position in the expander, the bone is essentially relapsing around them.
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All right? And this is especially challenging in adults. Even let's just say you did get, you know, sutural split in a 19-year-old female or something like that doing a toothborne expander.
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Well, great. Like, show me the before and after CBCT after you've let that reconsolidate. You know, show me are their teeth still within their buckle plate or did you have to, you know, blow them out in order to get that? And how
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much true sutral chain did you actually end up with? So, the reason why, you know, you know, even 20 years ago, people were presenting cases on this trying to get everybody to do, uh, you know, normal toothborne expanders on
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adults. This was before we even had CBCT. And again, the challenge is it's not predictable. Um, and it's very very difficult to uh to maintain anything that you might obtain in the beginning, if that makes sense.
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>> Yeah, it makes perfect sense. >> Yeah. So, let's This is a good example of dental aviola expansion. And unfortunately, I don't have a before and after CBCT because this is not a patient that I treated. This was uh the first
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time that I had seen them in my office. But you can see the pattern here. So, a couple things worth noting. So, one, look how thick this midline suture is, right? Most adults don't have a midline suture that thick. So, yes, I know it's
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a child, but when we try to expand, there is going to be more resistance.
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Often times, when the suture is thicker, so are the zygomatic bones, so are the other sutures. So, in general, patients like this are going to have more resistance. So, that's part of the equation, I'm sure. Also, um, they told
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me the type of expander they had was essentially a toothborne exa expander turned at a very slow rate, once a week or once every two weeks. And you can see here that the teeth are still perfectly housed within the middle of the bone.
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So, it's not like the teeth just tipped out and now they're right out here at the edge of the buckle plate. These teeth and the bone surrounding these teeth has translated outward. U, but the problem is, you know, now we're looking
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at this scenario that we have here. Well, the lower jaw is normal. This is at a cross-section at the level of the first mers. So, just to orient everybody, this is the brain. These are the eyes. This is the middle of the
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nasal cavity. These are the sinuses. This is the upper jaw and the floor of the uh the the uh the upper pallet, the floor of the nose. And then this is the lower jaw cross-section. So, this is at
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the six-year mers. You know, kind of normal or average distance between the middle of the bone at the lower jaw is about 43 to 46. So, the lower jaw is right in the range of normal. Now, we look at at what the upper jaw is right
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now, 55 mm. So this is significant because we have to understand what ideal is before we can really measure or grade like is this good is this bad like what is this? So Ron have we talked about or
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or do you know you probably do like what is considered ideal when it become like the upper jaw width compared to the lower jaw width at this cross-section here like what would be considered ideal?
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>> Um maybe the upper jaw being you know 2 to 5 millime wider >> 100%. Yeah, typically about 3 to 5 millimeters wider. And the reason for that is we want the upper teeth to fit on the outside of the lower teeth. And
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we want those roots to be upright in the bone. So if the upper teeth are going to fit on the outside of the lower teeth, then the upper jaw needs to be a little bit wider in order for those teeth to be
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upright within the bone and basically have, you know, the the the walls over the foundation, so to speak. So So the bone is essentially the foundation of the teeth, and the roots are like the walls of a house, right? So now you can
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probably get a house to fit if one's bigger, the other one's bigger. I mean, you can get the structure to work, but is it going to be structurally ideal?
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No, it's not. And so, we look at a case like this where the upper jaw is 11 mm wider than the lower jaw. Now, can I get these teeth to fit together? Yeah, I probably can. I can probably scoot this
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out a little bit more in the bone. I can probably tip this tooth out. I can tip these in. But, is this an ideal scenario? No. And did the patient get ideal sutral expansion to have the other added benefits of having increased nasal
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volume, reduced nasal resistance? You know, likely not. Again, I can't say that definitively because I only have one image at one time, but but this is the type of pattern that we see in patients that undergo dental ovular
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expansion that really probably needed some type of sutral expansion. And if we could pause briefly and just look at this patient's nasal anatomy, I mean, it doesn't look that clear. There's not a lot of nice black cavernous pathways for
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the air to pass through. He's got a little sinusitis in the left sinus. Um, but he definitely could have benefited from from uh uh nasal basil bone expansion.
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>> Yeah, certainly. I I would agree. And and definitely, you know, nasal breathing if nothing else. And so, yeah.
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And so, this is the kind of thing that we see all the time. And and again, patients, a lot of patients just don't know like they go to their practitioner and they say, "Oh, we're going to expand." That's the only word they use.
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Yeah, we're going to expand. Like, they don't know what they're going to use to expand. they don't know what type of expansion, you know, that they're getting. Um, and so it's so important to become educated. In fact, we're we're
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doing a whole entire video on this soon on on the Vegas Orthodox YouTube channel. So, you know, stay tuned, subscribe, and and and it'll be out soon. But basically, we're going to go through all of the different types.
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We're going to name all the different types of expanders and the type of expansion that they typically produce.
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Hopefully, in an effort to help patients, uh, understand, you know, the goals of the type of expansion that they're getting.
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>> How would you have treated this kid, Doc? >> Yeah. you know, it's really hard to say because I don't know where he started, but assuming he started with a jaw size discrepancy, I would have treated him with uh in at this age group in what's
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called a bonded RP. Uh, and it's a very, you know, these have been around for years and years and years and years and years. Um, a lot of practitioners don't use bonded RPEs because there's kind of a big learning curve with them and they
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come with a set of um, practice management challenges to put it nicely. Um, but the reason that I use uh bonded RPEs is because the way that they work is they encapsulate 360° multiple teeth.
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So, it basically hugs the tooth. And again, this is the same conversation that we're going to have later about dimensional stability. So, in order to have dimensional stability in a toothborne expander, you have to have dimensional stability of these roots. If
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your expander is designed in any way, shape, or form where it's just pushing on these uh teeth, but it's not uh having any forces that help keep these roots upright, then you're going to be way more likely to have this type of
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expansion. And so, when we think about like, you know, a normal hierax, so a normal hyrax um is a metal expander that goes over the teeth. Typically it's banded on the first mers but on the teeth in front of it it's usually not
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banded or sometimes it is but a lot of times it's not and it's just pushing on those teeth in front of it. So so basically one tooth has good dimensional stability the first mer and the band is holding it to some extent um you know
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because it's encapsulating you know 360° but it's still not even encapsulating the top part of the tooth. So again, the only way to encapsulate 360 degrees of the tooth is to cover the tooth entirely. And that's what a bonded
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expander does. And so, you know, basically in in my experience and in my opinion, it it allows us to keep those roots upright within the bone, providing the best sutral expansion possible.
Speaker A
>> Why wouldn't you just treat him with some kind of custom harpy instead and and and forget about all of that dental bonding?
Speaker A
>> Yeah. You know, here's the thing. I mean like in in kids that are, you know, like I think the only the youngest patient I've done a MARPY on is probably like eight or nine years old and it was a
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syndroic patient uh that had just a huge discrepancy and there was no way possible that we could do it with the traditional expander. Uh marpies are great and they provide the highest percentage of sutral expansion possible.
Speaker A
Um but every child does not need a MARPY. And so if if the discrepancy is say let's between you know three let's say the discrepancy is between three and and and maybe six millimeters uh sutral meaning the bones need to widen 3 to six
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millimeters in order to get to ideal that can be very predictably treated in let's say most 11year-olds or younger by doing a traditional expander. Now will you have some side effects that you have to deal with? Probably yes. So, if I
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need to get 6 millm of sutral expansion, then I'm probably going to be turning that expander at least 10 millimeters depending on the anatomy, maybe even a little bit more, maybe even closer to 12 millimeters. That's going to push these
Speaker A
teeth way out and you will have some dental ovular bending, but you can recover from that later, right? When they're older, when all their permanent teeth are in, you can tip these upper teeth back, and the net result is still
Speaker A
sutural change to the amount that you needed. And so I I would say it's a little aggressive to um to put, you know, basically have a patient have to be anesticized, put the TADs in, you know, for seven, eight, nine, 10 year
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olds. Most of them can be treated traditionally and get the same outcome. Um it's just a different method and and you might have to expand a little bit more. Is it wrong?
Speaker A
>> Is that the only disadvantage? Is that the only disadvantage to treating them with the MARPY is that it's scary?
Speaker A
>> Uh yeah. Well, there's risk, right? So, anytime that you're doing uh something that involves anesthesia and and you know, something that involves, you know, piercing the soft tissues and the bones, there's risk, right? And especially in younger kids, for instance, infection
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risk, right? So, kids are inherently not as good at keeping things clean as adults. Um, and so it's like, yeah, you maybe you use a MARPY instead of a toothborn expander. Well, if either one can do the job, there's just less risk
Speaker A
with the toothborne expander. And so, you know, if you're going to get to the same end result, like you want to minimize the risk, right? The first thing we look at is is how do I get to the ideal result? Now once I know what
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the ideal result is, well now I can backtrack and say how can I get to the ideal result with the least amount of risk possible. And and that is where so many adult Marpy cases uh are finding this this kind of sweet spot because
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there's a subset of patients who used to need uh MRAPY expand or who used to need jaw surgery for their upper jaw but really it was like one jaw you know mostly widening maybe advancing a couple millimeters would get them to ideal well
Speaker A
those patients can now ideally be treated without jaw surgery. So when you look at the risks associated with jaw surgery compared to the risks associated with MARPY, I mean there's no question, right? And so again, you have to define
Speaker A
that ideal result and then work your way backwards to the safest and and the least risky uh type of procedure that can get you there. Fair enough. If in your own child, if you had an 11-year-old who needed, you know, 6 mm
Speaker A
of sutral expansion, you knew he was a relatively hygienic kid, would you use a custom marpie in your kid or would you use a toothborne?
Speaker A
>> Yeah. So 6 millimeters in an 11-year-old like let's just Okay, it would let's assume in this 11-year-old he has all of his permanent dentition. Okay, I would have the conversation with him, right?
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Cuz all the permanent dentition, if you can anchor to that in an 11-year-old, you can you can probably get a 6 millimeter uh width pretty good. All right, and I would just explain it to him and and let him make the decision
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knowing that I can monitor this very closely. I can monitor the hygiene. You know, it's not there's not going to be surprises. the patient's not going to disappear and come back in four months and and they had an infection going and
Speaker A
now there's like loss of bone, right? So, I would give them the option. Um, you know, and I do the same thing with my patients, right? My job as a practitioner is not to tell you uh what to do, right? My job as a practitioner
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is to uh educate you and to inform you of of of the outcomes and the risks. And so yes, there are 10 and 11 year olds where we uh where we choose where the patients choose MARPY, the parents
Speaker A
choose MARPY uh because they understand the risk compared and they don't want to be in, you know, treatment for 2 years or 2 and 1/2 years when we can, you know, not have to blow the teeth out and
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then bring them back in. Uh so if it was my kid, I I would honestly give them the option. If they're like, "Oh yeah, let's just do the screws." I'd be like, "Cool." If you're like, "Oh, no. These
Speaker A
screws are like, "No, no, no, no. Let's just do let's just do it the other way." And you'll be surprised when you ask patients, they do have an opinion, almost all of them. And so you know bottom line is define what the the ideal
Speaker A
result is and then give the options to the patients and let them choose. >> And at what age do you say that the the uh toothborn expanders are just inappropriate and it's going to be purely dental alvolola or dental?
Speaker A
>> Well certainly uh well that's a hard one. So inappropriate it's a really hard one. I would say the majority of patients who are let's say 14 or older >> who have a discrepancy of 5 mm or more
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>> I'm going to be talking to them a lot about Marpy expansion you know because because at that point it's like you know yeah can you get again it becomes the predictability issue you know could you get 5 millimeters in a 14-y old yeah you
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can do it um will you get it every single time no can you accurately predict exactly what times you're going to get it and exactly what times you're not. No. Um, does it depend on the patient's compliance a lot more? Yes.
Speaker A
Uh, because like, you know, depending on how they turn the exp with a MARPY, right, if they don't turn it, you know, you still are anchored anchored to the bone. If if you have a patient that is turning a traditional expander more
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slowly than they were supposed to or maybe they took a few weeks off. Well, again, those that that that system is dynamically changing all the time. And so, you might be getting some, you know, some dental or some dental alvolar
Speaker A
bending that you didn't want just because the patient's compliance wasn't what it needed to be. So when we get into that unpredictable area, that unpredictable age, then yes, we're going to lean more toward MARPY when we need a
Speaker A
significant amount of sutral expansion. >> And what do you think about this business of uh expanding kids that are 2, three, four years old?
Speaker A
>> Yeah, it's interesting. So I don't expand a lot of two, three, and foury olds. Uh there are some um that that uh that that I will expand mostly if uh they have documented sleep issues and of course documented jaw size
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discrepancies. um you know the the the behavioral management side of of of expanding kids at that age is very challenging. Now I think that an area that does need a lot more attention is how can we we need more research on how
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we can expand these kids in less invasive ways. So we know we can expand them with expanders that are you know bonded or fixed expanders and we also know that things like you know like healthy start my brace and you know all
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these other appliances that again get pitched as quote unquote expanders um don't tend to produce a significant sutural expansion differences over time um even with good compliance uh we do see a lot more tipping we see a lot more
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dental ovular bending and so we don't have a good answer for how to get predictable sutral expansion even in these younger kids besides traditional type of expanders. I think a lot more research needs to go into that area
Speaker A
because if we could come up with some type of a system that these kids could tolerate a lot better um then then that would be ideal. Um hopefully after our conversation today um anyone with a 2, three or fouryear-old is going to
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rethink some of their uh lifestyle and home habits uh to hopefully you know to hopefully get some more natural growth and and at least set their child up for more success just by the decisions they're making at home. But that's kind
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of a like a topic that we'll dive into a little bit more in just a few minutes.
Speaker A
>> Okay. Fantastic. >> All right. So now we're here. We're here. Skeletal orthopedic expansion.
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Okay. >> Ah [laughter] you can see here we do have a diastma. Right. So how do we define it? true widening of the maxul uh the basil bone uh through and through separation of the mid palatal suture uh and you have uh
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separation or remodeling of the circumaxillary sutures and we're going to talk about that producing orthopedic change in the transverse dimension and as we'll also learn the AP dimension and the vertical dimension um rather than just the repositioning of the al uh the
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alvial uh of the teeth. So mechanism, we use RP in kids that are young enough. We use MARPY and SARPY. Although that's another conversation. I don't know that SARPY will be around forever. My guess is that it won't. Uh I can't remember
Speaker A
the last time I sent a patient for Sarpie. Uh the result >> in 20 seconds. What is Sarpie compared to Marpy in 20 seconds?
Speaker A
>> So basically, yeah, SARPY is surgically assisted rapid pallet expansion. It's been around forever. And basically, it's a toothborne expander uh that's put on an adult's teeth. uh and the adult goes to surgery and the surgeon cuts the
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upper jaw in half basically and cuts it from the top part and sometimes even separates the tergoid plate. So basically mobilizes the maxel like they would in jaw surgery and then cranks that expander open. Often times they'll crank it open you know four, five, six
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millimeters on the table and then a lot of times they'll crank it back and then and then they'll do you know they'll do turns trying to basically simulate an orth like the type of orthopedic expansion you would get when you were
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younger. um it comes with a lot of risk specifically black triangles uh devitalization of teeth um and of course an unnatural expansion pattern. So again um you know Sarpie is is not something that uh that that I have recommended in
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in over over 5 years maybe even 8 years um since we've been having more success with MARPY. Even dome I think will eventually go away almost completely.
Speaker A
And dome is basically uh Sarpie but you use a MARPY instead. So basically you have a marpie expander in most of the time they won't crank them open you know five six seven mm on the table they'll just do the cuts and the idea is you
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reduce the resistance and then you have a marpie that you know is better anchors and you can get expansion on on cases that used to fail. So we we would send patients for dome a lot after we had
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failed marpies. Uh but now failure is so uncommon um that that uh that again I I don't know a lot of practitioners even doing a lot of dome um you know except for surgeons. though.
Speaker A
>> Yeah. >> Mhm. >> And is the big problem with Sarby besides the invasiveness that you're basically pushing too low uh on the teeth and so the kind of the whole uh the whole segment kind of tips out uh
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because you're pushing so low instead of spreading from at the top of the pallet.
Speaker A
>> Yeah. Absolutely right. There's there's nothing in a Sarpie. There's nothing, you know, assuming that the surgeon actually has mobilized both halves of the upper jaw, which you know, talk about unpredictability. There's a huge factor right there. Not every surgeon's
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sharpie cuts techniques are going to be the same. So you may have, you know, great mobilization in one patient or you may have great mobilization on one side and not the other side. So it introduces a lot of room for air. But to your
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point, assuming you have good mobilization of both the upper, you know, pieces of the upper jaw, yes, you're pushing from the very bottom of those teeth. And so as you're pushing outward, those segments, those bony segments are going to have the, you
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know, the the tendency to tip outward. Um, additionally, you know, you are limited in the uh expansion to where the surgeon cuts. So, typically those cuts are done at the floor of the nasal cavity. And so, you're only expanding
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the maxul uh um inferior uh at the very bottom portion of the nasal cavity. And so, you're not getting a lot of uh you know, nasal uh opening reduction in nasal resistance, anything like that doing that as well. So, again, for all
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those reasons, we tend to shy away from it. And to your last point, that's the same problem that uh uh segmental lfort has in terms of improving nasal breathing outcomes when you expand during a double jaw surgery.
Speaker A
>> That's 100% correct. >> All the expansion occurs at or below the leffort cut, which is right about here.
Speaker A
>> That's correct. So, you know, and a surgeon, you know, they might talk about, oh, well, we do a high leaf for okay, cool. Like, you know, you might have a high leaf for they can cut a little bit higher into the nasal cavity.
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But, I mean, if you want to know, just look at the before and after CBCTs. you can very clearly see what movements happened and you know even these patients who consult with me like after double jaw surgery they kind of want to
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know the result or they have a question about you know x y or z part of their treatment you know we superimpose these uh these 3D images and and maybe the cut was you know another even centimeter higher than the floor of the nasal
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cavity but when you look at where the bones ended up they're essentially approximated I mean like there's almost no expansion in that area and then additionally you have this um this unnatural part Like so let's say that you cut it halfway up the nasal cavity
Speaker A
and you actually do expand it. Well, now normally that nasal wall is intact, right? So you've cut it and then you've disapproximated the bones. You've moved those bones outward. Well, now you kind of have a hole on the nasal on the side
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of the nasal wall which is going to affect, you know, the turbulence of how the air comes in. Is it going to be a problem? I don't know, right? But it's certainly not um the way that mother nature built it initially, right? So,
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you know, we'll talk about that more later. But yeah, it's it's definitely uh in my opinion a problem and and again, we start from ideal and work our way backwards. I I'm not uh I I I love what
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surgeons can do. I work with surgeons all the time. I they're amazing. Like like I'm so glad we have them in our profession. Um but when a surgeon comes back and and you know and sends a patient, they're like, "Yeah, yeah, they
Speaker A
don't they don't need MRAP. Like I can do everything surgically." I'm like, well, I agree that you can get the bones approximated and get the teeth to fit together and eliminate the jaw size discrepancy surgically, but unless you're doing a Lefort 3, which none of
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them are doing, unless you're some like a syndrome patient or something because, you know, that's that's basically cutting all the way up into the orbit, um, which again, no, nobody does, the risk does not uh warrant it. You're not
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going to have that increase in change in nasal volume like you would if you do a successful MARPY.
Speaker A
>> Do you know the difference between God and jaw surgeons? >> [laughter] >> I do, but I'll let you say it.
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>> God knows that patients with bad nasal breathing should do MARPY first. >> Oh, there you go. That's actually better than the one I was thinking. So, that's good. [laughter] >> All right. So, yeah, orthopedic expansion limitations, of course, you
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know, the older the patient, uh, makes it more challenging. Again, uh, this limitation is becoming less and less and less for a lot of the reasons that we're going to be talking about today. Uh, how this becomes more and more predictable.
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again multiple tads, different types of expanders. Uh so this can be used to correct, of course, dental issues. The top three reasons people seek out MAP.
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Um one is function, like they cannot function, their teeth can't fit together because their jaws are mismatched. Um two is aesthetics. Uh you know, basically they want a wider smile or maybe they want midface enhancement.
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They want a broader cheeks. They want to change their facial shape. Maybe they feel like it's too square or too round and they want to make it more oval. Um or three uh they they and this is probably the one why most people seek it
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out is airway improvements. They're not sleeping well. They have sleep apnea and that's you know obviously we can do a super deep dive into that. I talk more patients out of expansion than I talk into it because so many patients come to
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me and they're saying hey you know I have sleep apnea or I'm not sleeping well like I need to expand my jaw and and maybe they don't even have a jaw size discrepancy or maybe we're scrolling through the anatomy and and
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there's no constriction anywhere. Uh the external nasal valve looks good. The internal nasal valve looks good. there's no inflammation of the turbinets, you know, and we're going through this like, hey, this is not likely the cause of your apnea, like we need to do
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additional diagnosing. And so those are kind of the three reasons in general though, airway function and aesthetics that people seek this out.
Speaker A
>> Mhm. >> All right. So, let's look at a case skeletal orthopedic expansion. So, here we are before we can see this is a growing teenager about 13 years old. To your point, like you know, do we use a
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MARPY? Do we not use a MARPY? Well, in a case like this, we're chasing two things. So, one, we have the transverse problem. You can see already that these teeth are tipped out. You can see uh the teeth in the front. They're not super
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flared, but maybe a little bit flared forward. Uh and and and at the bottom line is that this tooth is supposed to be way up here relative to the bottom tooth. So, we have a big AP or front to
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back problem that needs to be addressed here. And so, you know, could you address this by moving the teeth only?
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Maybe. you, you know, maybe you could distalize all these teeth back, tip these teeth back till they're touching the tongue here, and flare these teeth forward till they're like pretty much looking straight at you. You know, I would not recommend doing that, right?
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So, we start with the problem. The problem is that the upper jaw is too small and too set back compared to the lower jaw. Um, also, it's it's vertically insufficient, right? You can see here that when he smiles, um, you
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know, he's not really showing a lot of the teeth, about half of the teeth and and not much of the gums. All right? So we have kind of like a problem in three dimensions which is usually the problem
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that we have. The maxul develops downward and forward all right and outward and it broadens right so when the maxul is underdeveloped a lot of times we will see it underdeveloped in all three dimensions. So it's wide I
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mean it's narrow it's set back and it's set up higher. Okay not in every case but in in in the probably the vast majority of cases that's what we'll see.
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So we look here and now we've we've done you know our skeletal orthopedic expansion. Now we've gotten to the finish line and you can see here that even still like you know uh like maybe we could have used even a little bit
Speaker A
more expansion. Um but I want to show you again like going to this comparison we look at these jaws before and after and if I just show you these photos uh like how much does it look like he
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expanded? >> 6 mm. >> Okay. Yeah. I mean, I think that's a decent guess and that honestly that guess is probably u because you're so involved in this space and you're a little more educated than most. Um I
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presented this to a bunch of dental residents and orthodontic residents and pediatric dental residents and most of them thought like 2 to 3 millimeters total, you know, a millimeter and a halfish per side. Uh and part of the
Speaker A
reason is the same as I showed you in that other photo. These photos are not um uh magnified to the proper amount. So you can see that the teeth look bigger uh on the photo on the left side of the
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screen than they do on the right side of the screen. And so if I show you this, you know, I could probably tell you, oh, we expanded 2 millm, we expanded 3 mill.
Speaker A
And you'd probably believe me if you didn't know a lot about what you're looking at. If I were to actually magnify that side, you would see the actual or you'd see more the actual extent that we expanded. But at the end
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of the day, really, the proof is in the pudding and that is in the CBCT. So let's look through and see how much we actually expanded. All right, this is the actual 3D superimposition of that Marpy expander and you can see almost 10
Speaker A
mm all right over 9 mm of bony change about 5 mm on the patient's right side about 4 millm on the patient's left side. So you can actually quantify and look at the changes within the nasal cavity itself. Um look at the changes in
Speaker A
the cheekbones. You can see these cheekbones the midface advancement the whole orbit remodels the the internal portion of the nasal cavity remodels.
Speaker A
So, so this is what we see when we're doing a true sutral expansion. But if we didn't actually put these images over top of each other, we would have never been able to know or quantify what we actually did in this case.
Speaker A
>> So now my question Ron, what is the best type of expansion? >> FME [laughter] >> between dental, dental, alviola and sutral. What is the best type of expansion? Uh I mean probably the answer is it depends what you're trying to do
Speaker A
but I think my gut is to say skeletal suture. >> So 100%. So so yes it absolutely depends on the case right. So there are going to be cases where dental expansion is appropriate and is the best option.
Speaker A
There are going to be cases where dental alvolola expansion is appropriate and is the best option. Um a but the vast majority of the patients the best type of expansion is sutral expansion and that's the one that's most often needed
Speaker A
when we talk about patients who need expansion. But the best best best type of expansion normal growth >> right?
Speaker A
>> So when the jaw grows normally and it grows as wide as it should all right like our ancestors grew almost always that is ideal expansion. All right. So, knowing that we have a standard now to compare what we're doing against you.
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All right. So, now we're saying like anything that we're doing clinically, we want to mimic or get as close as possible to natural human ideal growth.
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Okay. So, now we have a target. So, once we have a target, we can start uh talking specifics. So, you know, our caveman ancestors, they had, you know, they had a lot that wasn't going on great for them, right? You know, food
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was hard to come by. You know, sleeping on rocks, whatever, that may have been a little bit difficult. But one of the things they had great was they had great bones, right? They had great maxulas.
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They had great faces. And you can see that most skulls 500 plus years ago, the maxul was 3 to 5 mm wider than the mandible. And because of that, uh dental crowding was was a rarity. Uh wisdom teeth, they they came in and they had
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room for them. A lot of times there was even spacing between the teeth. All right. So this this uh this problem of everybody needing their wisdom teeth out and and everybody has crowding and everybody needs braces. like this is a
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modern-day problem and so we do have to beg the question is why is this even happening and and and of course we could t spend you know 5 10 hours talking about that but I want to I want to I
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want to go through at a more high level with you Ron and really dig into you know making sense of of of why this has changed in such a relatively short amount of time. Okay. So to understand why you have to understand what factors
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are at play. uh you know if you ask uh most residency and dental programs dentists like you know what's the biggest contributing factor to growth uh you know they're going to tell you genetics. All right so that's kind of
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what a lot of people are taught meaning like you know hey growth in general yeah there's so much you can do environmentally but yeah it's mostly genetics. Okay we we'll we'll dive into that. All right there's also things like
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lifestyle and environment uh there you know there's things like tongue posture oral habits breathing and airway function diet and chewing. So lifestyle environment meaning things like allergies and whatnot. Um, so these are kind of like the five broad categories
Speaker A
of things that can affect the upper jaw development specifically development as a whole of course, but specifically the midface and the upper jaw development.
Speaker A
Okay. >> So yeah, go ahead. >> So Dr. Mu gets in trouble for saying this stuff in England, but we're allowed to say this stuff in the United States without being shunned by the main the mainstream dental establishment.
Speaker A
>> Well, so I I have said nothing that is not very well documented in the literature. Okay. So you can find literature that supports that every one of these things affects facial growth.
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This is not an argument. Okay. Now the argument comes what percentage of these things really has the biggest difference and if you intervene in these different areas how big of a difference will it make or will it not make? So in general
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you know most clinicians most researchers are going to agree that all of these things have an effect. The question becomes how big of an effect?
Speaker A
And so >> where do you put genetics? Where do you what do you where do you put genetics?
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30 40%. >> I'm going to tell you soon but uh but but I want to get your take on it first actually. So so so let's let let's look at this. Well let's define it first. All right. So what is genetics right? So
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genetics genes provide the blueprint right. So this is basically saying you know you know the environmental affects how the genes are expressed but basically the genes themselves have a pre-programmed predetermined you know uh amount to it. Right? So I'm going to
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grow to be 5 foot 10 tall. I'm going to grow to be 6' 2 tall, whatever it might be. We know that genetics has a huge role in that. If you get two 7 foot parents together, you know, they're
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probably not going to have a 5ft tall child, right? So, we know that genetics has a big part to do with it in in all factors. The question is, you know, why does it, you know, does genetics have as
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big of an effect on the upper jaw specifically? We know things like height. That's not really in question.
Speaker A
We even know things like lower jaw, like the lower jaw anterior growth. I mean you look at different populations and you see more or less forward anterior growth or forward anterior growth in these populations based on solely the
Speaker A
genetics. But what doesn't make sense is even identical twins can have differences in their maxula larger differences than you see in other parts of their body. So that begs the question of why. Of course that's the environmental factors in some way. So
Speaker A
let's look at lifestyle and environment. Okay. So these are things like allergies, chronic inflammation, um you know asthma, obstructed breathing, you know, bottlefeeding versus breastfeeding, uh head forward posture, like all these things like you know people we talk about these right books
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have been written about these and this is where you know people start like raising the red flags like hey don't listen to that guy like he's crazy uh you know like like this is all this isn't proven like blah blah blah blah
Speaker A
and and that it's true like we don't know exactly how much of a difference this makes but we do know it makes a difference. So let's go on to the next one. tongue posture, oral habits. All right, the tongue is a natural expander,
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right? You can even get some argument with that. But we know that what's not in what's not in dispute is we know that force placed on a bone over time in a growing child changes that bone. All right, so that is not disputable. Okay,
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[snorts] so the only question is well, how much force and over what period of time? uh you know if you have a [clears throat] resting tongue posture that is on the roof of your mouth you are essentially besides when you're
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actually talking you're having that force at least you know while you're awake so you know minus 8 hours 24 hours - 8 hours 16 hours right while you're awake pretty much is that force is going to be there you're swallowing 600 plus
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times a day that force is going to be there if you have a proper swallow so that is a significant amount of force in an environment that is significantly able able to change meaning a growing child. Okay. So, so, so this is going to
Speaker A
have an effect. Okay. Now, how big of an effect? We'll talk about that. Breathing and airway function. All right. So, mouth breathing versus nasal breathing.
Speaker A
We know that if you mouth breathe versus you nasal breathe that the development will be different. This has been shown in twin studies as well. There have been cases where some twins have grown like longer faces uh genetically identical uh
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you know based on you know based on on on being a nasal breather or not nasal breather meaning like you know maybe one either developed an allergy or had you know more restrictions or just was naturally a mouth breather and then had
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you know swelling of the tonsils and adoids. Something happened uh so that they they ended up breathing through their mouth more than their nose compared to the other and it had an effect. again. Now, now the haters would
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say like, well, that's not that big of an effect, right? But, you know, if if you if you believe that this um has the opportunity or the potential to actually make a big difference when you add all these things up, well, then that's
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something that you're going to pay attention to, right? And say, okay, well, well, maybe it's not the hugest effect, but it's an effect. Well, if we add up all these and effects, it can really become a big effect in my
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opinion. So, the last one is diet and chewing. Okay. Now, this uh is basically what it what it amounts to. And and this is my my question for you, Ron. We talk about diet, you know, everybody talks about, oh yeah, have you know, we used
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to chew hard foods. We used to be ripping meat off of bones. We used to be having uncooked vegetables like all those things. So, so why uh why do you think that the diet and chewing demands um has any effect on the maxillary
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growth? Like what are your thoughts on that? Uh my thoughts on that are that uh well I would say first of all nutritionally in order for things to grow you need the right building blocks. So I think that
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high higher protein uh foods such as meats and other uh you know animal products that need to be chewed. I guess that would always be meats u regardless of the force load that's going into the jaws. I think I think just nutritionally
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supports more more robust bone density bone structure. >> Okay. uh the same way that it's important for adults to eat nutritious foods in order to gain muscle etc etc. I would say also just uh the force load that chewing puts on the jaws stimulates
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them to grow bigger. Um and then I think when you're chewing your food, you have to breathe through your nose. So chewing your food is also a good way to train nasal breathing.
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>> Okay. Yeah. I think I think that those >> I'll start there. >> Yeah. I think those are all very solid reasons why this may have an effect. All right, so this chart is not gospel. It's not true. It's not, you know, even even
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my opinion entirely. This is what I threw into chatbt and I asked it like, hey, what do you think like what amounts or factors do you think has on growth?
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Right? You know, pulling from all the resources that you have like what do you think has the biggest effect? All right?
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And this is the pie chart that it came up with. So, it said one of these things, you know, was 40%, one was 30%, one was 20%, one was 8%, one was 3%. So, I mean, I'm just curious, Ron, like when
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you look at this, like if you had to guess the high and the low, like which ones would you guess would be the high and which one would you guess would be the low? So, this is kind of like a how
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well do you know chatbt? [laughter] >> I would say genetics is either the 30 or the 40%. Um I and and my reason for saying that is my two children of course anecdotal they were born with a certain
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palatal arch shape and that shape has pretty much stayed the same over the course of you know a year and a half.
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>> Um >> and I also just I think genetics sets the ceiling and the floor for what's possible in terms of someone's facial development. I think that all of the stuff beneath it uh just is what's in between the ceiling and floor set by um
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by genetics. I think well I I consider all four of these things lifestyle and environment that that are below genetics. So I I'm not sure I would really separate all of that. Um but I think that um I mean tongue posture and oral habits,
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how do you really separate that from breathing and airway function? Right. >> Yeah. Uh but I would say genetics is going to be one of the big ones. And then I think uh you know nasal breathing habitually is going to be another big
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one. I think that I think diet and chewing demand is going to be on the lower end.
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>> Okay. >> Um now I'm just spewing Why don't you go ahead and show us?
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[laughter] >> Well, this may surprise you. Yeah. So So let's look at it. This is this is what it came up with.
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>> Okay. Oh, wow. really surprising, right? So, it had diet and chewing demands at 40%, breathing and airway function at 30%, tongue posture, oral habits at 20%, lifestyle environment, you know, things like allergies, uh, you know, chronic rhinitis, things like that. Uh, and then
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genetics at 3%. Now, do I think that this is 100% accurate? No. But this did give me pause and it made me think about this for a little bit. Now, when you when you think about this chart, what do
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we treat most frequently? We treat >> as a society what do we treat? We like basically we treat lifestyle environment. We treat the asthma. We treat the allergies. We treat you know that that is what we as practitioners
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you know doctors they spend the most time treating the lifestyle stuff right and and then there are some you know practitioners out there that talk about tongue posture, airway function, all this kind of stuff. But by and large you
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know we're spending a lot of time treating you know the lifestyle and environmental factors. And again, we're treating them anyway, right? I mean, there's other quality of life negatives.
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This chart, just to be clear, is specifically for transverse growth of the maxul. So, we're not saying growth as a whole. We're not saying facial development as a whole. I asked it specifically transverse growth of the maxul. Okay? And this is in my opinion a
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very important distinction because I do see differences in the amount of growth that happens or the amount of change that happens in the maxul to a much greater extent than I do other bones mandible included. All right, we so so
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you know if I ran this same chart with the mandible, I think you would get an entirely different uh breakdown. Okay, so let's just assume for a minute that chat GBT is right and that the diet and the chewing demands does have that big
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of an effect on the maxillary growth. Well, we have to ask the question, how would that even be possible? Like how could you explain that something like diet and chewing demands could have that big of an effect on the maxillary
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growth? And to answer that question, I want to show you this superimposition. All right, so this is an actual patient.
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Okay. So, I want to ask you a couple questions about this actual patient. All right. So, this is showing the before and it's showing the after. Okay. So, my first question is how old do you think this patient is? And my second question
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is what do you think was done? >> Uh I think this patient is in his 30s.
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>> Okay. >> And I think that a uh maxillary skeletal expander was done. >> Okay. um which uh brought the maxilla forward and down and widened it and then I think the mandible repositioned inside of the joint. It's it it slid uh couple
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millimeters forward. >> Okay. Now, uh let let's quantify it a little bit more. If you had to guess, and I don't have measurements on this screen, but if you had to guess just looking at this animation, how far
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forward does it look like that upper jaw retracted? >> 4 mm, >> I would agree. Yeah, probably somewhere around four at least. All right. So, now how how is that possible, right? How is it possible to protract a a jaw forward
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4 millime without because you didn't mention any surgery, right? You just said some type of marpy, right?
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>> Mhm. >> Yeah. You didn't mention any cuts. You didn't mention So, so, so how is that possible if the maxul is attached to so many other bones in the skull?
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I think that uh circumaxillary sutures are being uh distracted or are changing in response to just the widening of the maxilla because of course the pallet can't be seen as a standalone bone inside of the face. The the maxilla is
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the entire midface really. So when you spread the pallet wide it's going to have a chain effect on all of the bones of the midface. And if you do enough of that, the little connection points, the sutures between the various bones that
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compose the midface are all going to kind of be changed. And and you know, all of the resistance is superior and inferior. I'm sorry, superior and posterior as we discussed in our podcast last year. And so when those sutures
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are, you know, loosened, the tendency is going to be for everything to kind of fall forward and down.
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>> Absolutely. So look at these circumaxillary sutures, right? Uh this patient was in his 40s. He had an FME um and an FMA. All right, so this is one of the three patients that has had that. Um now, uh I don't know exactly how much of
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the expansion was due to the expander versus the you know the protraction device versus uh you know another part of this treatment which was uh jawline gum. Okay. So now if you think about we need to your point we need these
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circumaxillary sutures mobilized in order for this jaw to translate and or move significantly. All right we need them to move. We need them to remodel and we really need them not to break.
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Okay. So this is where the delicacy comes in because if you go too hard too fast then you risk breaking at one of these points which then causes a complication where you essentially cannot continue with expansion. And a
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lot of times you have to back turn in order over overcome that. But when we think about the the next question I want to ask you is you know well let's look at this. So so these this kind of shows
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for for for your audience that may not know exactly where the maxul goes. So this green bone here is the maxula right? So here you can see it up against the zygoma. Here you can see it up against the nasal bone the frontal bone.
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Uh you can see it at the floor of the orbit here. And what you can't see in this image is the terragoid plates which of course connect back here. Um so this is the bone and we know that we're going
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to split the bone in the middle. So once this is split, then these are all of the sutures that we're talking about that have to remodel in order to be able to have translation and movement of that jaw. So now my question is, what is the
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biggest difference between a child's jaw or skull and an adult one? Uh well the fact that of course in a child uh the whole thing is just growing three-dimensionally continuously but also are the sutures looser in a child.
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>> They're open. They're open. Yeah. They're basically completely open. And the younger you are the more open they are. Right. So when you're born like that's like the most open they are. And as you continue to grow they get a
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little more fused, a little bigger, a little more overlapping. Like like that process continues to happen. The bone gets a little more dense, a little bit harder to move. And so like there's this process of the resistance of the maxula
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increasing as you age until you reach adulthood which is where ideally your jaw would be ideal and it would be hardened or solidified so that it stays there. Right? So, you want this mobility while you're growing. And as we know
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now, while you're changing the upper jaw, but you don't want it afterwards, right? After you have the jaw in the right place, you want it to be as solid as possible so that if you get hit in the face or you fall down or whatever,
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like get in a car accident, that you're the least likely to, you know, disrupt that perfect system which has been built if that makes sense. So when we talk about you know any type of marpy expansion and trying to get or midface
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expansion maxillary sutral expansion we have to take into account these circumaxillary sutures and so you know Ben what are the ways that we can reduce the resistance of the circumaxillary sutures. So what are our options in a non-rowing patient?
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Um, of course, Marpy is a great option. Uh and >> but think about this because we put a MARPY on. There's there's a lot of different ways you can use a MARPY, right? You can turn it three times a
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day, you can turn it once a day, you can turn it every six days. Um, you can turn it back and forth. Like, >> so even just the MARPY itself, there's a lot of variability, right? So when we
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talk about things like you know FCPC functional polyyclic cycling basically expanding and then contracting expanding and then contracting and basically it would make sense that those circumaxillary sutures might remodel and get a little bit more loose. When I was
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first introduced to that concept it was published um in Europe actually. Uh, I was seeing these cases that they were treating over there and and and I'm like, "Wow, you're using less tads than I'm using." Um, and and you know, you're
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getting success with less tads and you're not even connected to the teeth. I'm like, "Wow, that's really interesting." So, that made me do a lot deeper dive into why this might have such a big effect. And and that's
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essentially the the results or the conclusion that I came to is that as you do you know functional polyyclic cycling expanding putting pressure on these maxillary sutures and then relieving it pressure and relieving it you're essentially mobilizing or loosening
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these circumaxillary sutures. And when you do that you are essentially making them more like they were when you are growing. And we know that the more like they were when you were growing, the looser they are, the more expansion we
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can achieve, and the more translation of the maxul we can achieve. So one thing we have control over is the turning of a marpie. So we have control over how much of the bone we anchor to, how many tads
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we use, uh, and how we turn that expander. Okay. So what other ways can we reduce resistance of the circumaxular futures? Uh full disclaimer, I'm not sure I believe that this is the case, but I've heard that uh things like
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osteopathy, craniosacral therapy, or even uh so-called thumb pulling, in other words, adding uh forces on top of the MARPY in addition to the MARPY uh manually uh to to uh put more force up into the into the face during the
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expansion process. So, literally taking fingers and uh putting them around some of the more critical sutures that are actually accessible with your fingers inside of a patient's cheeks and pressing and releasing or otherwise massaging those areas or potentially
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really tough chewing during an expansion process or perhaps pulling uh with a protraction device or with your thumbs.
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Probably more realistically a protraction device. I don't know, maybe this is where you're headed with this is with a protraction device. Um, but yes, some sort of additional force during expansion on top of the forces of the expansion. So, so yeah, we can basically
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yeah, loop that into extra force like any way that we can come up with to put additional force on these sutures.
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Again, not overwhelming force, but force enough to affect the suture uh at a timeline that is increased. Right? The problem with turning too fast is yes, you get more force, but the timeline does not allow for remodeling and and
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also the pressure itself is in one specific area where when we think about something like, you know, yeah, the cranial osteopathy, again, I'm not an expert in cranial osteopathy. I'm with you. I'm not 100% certain how um helpful
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or not it is. I haven't seen uh truthfully any before and after CBCTs of patients who have undergone osteopathy.
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My my guess is that you probably wouldn't see a ton of change on an X-ray. And and I hope there's some cranial osteopathy people out there that are like, "No way. This is crazy." Like, I'm going to show you. Please do. Like,
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I would love to like join the conversation because like I like I promise you there's not a lot of people out there that know what you do well.
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And if we can see and understand what you're doing on a 3D image and we can see those structural changes in the bone, you better believe that, you know, I'm going to be referring every patient to you. So, so again, I'm not really
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sure how how much change they can affect in the bones themselves, but the thought process is yes, any amount of change or is good, right? So, if you can do some exercises and maybe they're trained by the osteopath how to do those exercises,
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you know, daily or multiple times a day where they're adding, you know, where they're adding pressure, but what's something that we're all doing every day anyway that might have an effect on how much force gets placed on these sutures
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and these circumaxillary sutures? >> Eating. >> We're eating, right? we're chewing, right? So the foods that we select, right, can have an effect. And now we have things like jawline gum, right? So we can literally be stressing these
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maxillary sutures. And I say stress in a good way, right? We can be placing force, maybe lateral forces, maybe vertical forces. We can be placing, you know, circumferential forces all over these sutures every single day. Now, can we say definitively that that yes, it's
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proven if you chew jawline gum for x amount of hours per day, you're going to result in this much mobilization of these circumax sutures and you're going to get this much more expansion. No, but I think that's where we need to go. I
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think that's the research that needs to be done because we're in a situation where we're now able to have forces be placed on these circumax sutures. We're able to have them remodel in ways that has never been possible before. Right.
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With before Marpy, the remodeling of the midface in a non-growing patient was not possible. It was thought to be impossible. And the only people who could move the midface was surgeons, you know, with all the limitations that come
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with surgery. And so now that we know that we can move those bones, the next step is how can we move those bones better? How can we get those bones to move again toward the target? How can we
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make the expansion look as close to natural normal growth as possible? Well, in order to do that, we have to be able to mobilize these circumaxillary sutures. And so, the other way that we haven't talked about yet is of course
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like actually surgically. You could go in there and you could cut every single one of those sutures. You could cut the maxul every single place it connects.
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Now, obviously, we don't do that. There would be a ton of risk and a ton of impredictability, right? And so, you know, that would not be the ideal way to do it, but that would be another way to
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reduce the resistance of the circumaxary sutures. So, this is a video that I did on that. If you're interested, you can check it out. And then there's a description that has some of the research out of Europe that uh
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introduced it. Um, so I've modified the protocol a little bit just to make it easier for patients to understand and so I don't have to send him home with a force gauge. Uh, but the idea is the same. Uh, and so now I want to talk to
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you about a patient uh who found me and had a specific concern. Uh and now that we have the groundwork laid for um for this uh this this this moving of the bones um conversation, I want to talk to
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you about a patient who had not normal movement of the bones. Uh which resulted in a complication. Uh and this is the only one of its kind that I'm aware of.
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Uh there may be others out there. Uh but I want to do a deep dive into you know what this complication is and how it happened and again maybe have a discussion about well what are things that we can do or what are things that
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your audience can do if they're undergoing max expansion maybe in order to limit the possibility of this happening to them. All right. So, so this patient, we'll just call him X. Uh, you know, basically, you know, X wanted
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expansion. And so, he went through, you know, the whole process doing all his research and whatnot and, you know, to decide what type of expansion, how he's going to get that done. And so, he decided uh first that he wanted to get
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his wisdom teeth out. And Ron, you could probably speak to this better than I can because I guess there's a lot of conversations about wisdom teeth uh on on the internet amongst patients that that we're not really having as as
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orthodontics and dental practitioners. So, so what's what's the latest buzz on on wisdom teeth that you're hearing?
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>> I mean, I think the buzz is that if if you don't need to get your wisdom teeth out, it's better to keep them because maybe they serve as placeholders for mandibular or and or maxillary bone. And once you get them out, it's possible
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that everything sinks backwards. Perhaps they they function as sort of, you know, foundational footings to the the jawbones. Um, and I think uh something I've mentioned in the past is that, you know, a lot of Eastern European people
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uh they they just don't see orthodontists as kids. And so they might have really crooked teeth, but they have all of their teeth. And so, you know, even though their teeth are a little wonky, which is to say crooked, they
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have really nice uh sort of profiles. Um so yeah I think uh the the buzz in the looks maxing space and uh you know on jaw hacks let's say is uh remove wisdom teeth only if necessary for example in
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preparation for a jaw surgery or if they're causing some sort of problem or you know look like they're going to cause a problem in the future such as if your teeth look like this.
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>> Absolutely. And and I would agree with you completely and you know you know my oldest two kids uh one of them still has their wisdom teeth. The other one we did have problems and so you know at the at
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the we didn't have problems with all the wisdom teeth but we had problems with one of the wisdom teeth and then also one of the teeth in front of the wisdom teeth. So we went ahead and got those
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removed at the same time. But uh this patient decided to get their wisdom teeth removed. But again you know before we opine too much on you know what's happening let's look at what actually happened. And so this is a
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superimposition from age 19 to 22 uh before and after wisdom teeth removal. So the first thing that you're going to see is that you know there is uh some growth. We've superimposed this on the cranial base there. So you're not going
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to see any change there but you can see like from before and after there is a little bit of growth from even from 19 to 22. And patients ask all the time like you know when should I go get my
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implant or like when is it safe to do jaw surgery? Well, just know that yeah, we're not seeing a ton of growth or movement uh in this superimposition, but there is some downward some forward growth and and that's something to be
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aware of. You can also see the changes in the airway there as the tongue posture changes and that rolls back between those two images. Um so, let's fast forward here. We're going to go and we're going to look at the actual level
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of the um of the mers here. So, let me move here and we're going to go to here and we're going to go back to the area of the wisdom teeth here. All right. So, we're going to scroll over. Now, we're
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looking at where the wisdom teeth were. This is the after you're seeing because you can see there's no wisdom tooth there. All right. So, now we're going to look, well, what happened in that specific area. All right. So, there's
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the before. All right. And there's the after. You can see the lower jaw translate forward and you can see the teeth moving forward with it. All right.
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So, again, it's kind of hard for me to to say like, oh, well, the whole entire mandibular dentition is is distalizing.
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I mean, it seems to be moving forward with normal growth. You can see the uprighting of the maxillary mers as well kind of keeping pace so to speak with with the lower jaw as it continues to grow forward. And when we look at the
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condile just to just to kind of rule out like well is this just like the patient was postured forward a little bit more um in the initial compared to the final.
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Well, let's look at that. We can see that here again there's not really a ton of change in the condular position um on that side. And I think we might have the other side as well. Let's see. Oops.
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Hang on a second. So, are you basically making an argument that removing wisdom teeth does not cause uh uh retraction in mandibular mandibular bone?
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>> Well, I I think that I think that it's hard to say that it's it's probably like a a huge primary driver. Again, well, and again, I'm not saying that it doesn't happen. I just haven't seen enough evidence, right? This is one
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case. And I think if you're going to make claims like that, you need to look at this evidence and you need to do superimpositions on patients who have and have not. And ideally, if you could throw a few identical twins in there,
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that would be awesome, right? Like taking genetics off the table completely. Um, you know, that's the kind of research that we need now that we have the capability to look at threedimensional images. And and now with AI, this gets a whole lot easier,
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right? Cuz we can train a robot to look at a thousand of these, right? And we can we can train it to read the chart history and and make comparisons and find things. So that's where I think research is going. The amount of
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research that we're going to be able to do with AI assistance in my opinion is going to be like nothing that we can even imagine right now. Um, >> do we have that data on preolar extractions?
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>> Uh, so yes and no. The short answer is no. We do not have uh a lot of substantial three-dimensional super imposition analysis. Now, we have a lot of data in general about AP changes, about transverse changes because we've
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had sephs and and PAFs for years and years and years. And so we have a lot of data as it relates to you know some of the bigger dimensions but as far as three dimensions no we don't have a lot
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of uh good data on that yet but can we say that having preolers removed as a seventh grader uh you know in predicts that your uh jaw development will not be as good uh you know five or 10 years
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later as it would have been if you didn't have those preolars extracted or can we not even say that? So I would say that you you you can't say that definitively yet. But what you can say that especially if you have preolars
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extracted and and nothing else done. Uh it's not managed in any way with like you know let's say tads to protract everything in the back that you will have you know clo you know movement of the back teeth forward movement of the
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front teeth backward. Um and that certainly does affect the position of those teeth which affects your profile because your teeth support your lips.
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And so that in in my opinion you can you can say now that's not to say that you know you could extract and you can control the where the teeth are orthodontically right you can do that with tads you can do that with different
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types of mechanics so it's not um not overcomeable so to speak um but I really am curious like I would not be surprised if when we do get this data that we do show some direct correlations to growth
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but to my knowledge there is not any definitive well-accepted data that says hey I got preolars extracted and it made my jaws grow 1 millm 2 mm less than they otherwise would have. I do not think you can definitively say that based on the
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current research that we have. >> So it's primarily a dental change that occurs with preolar extraction not a basil bone change.
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>> That's correct. The evidence that we have so far and again there's lots of robust evidence on transverse on AP because we've had sephs and PAFs for a long long time. um it does not show a definitive difference you know in those
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dimensions of the actual >> do you do you do you do a lot of preolar extraction >> I do almost none so I probably extract you know uh just in general any teeth you know maybe maybe well I could count
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it on less on one hand you know a year so like you know this year I maybe extracted on two patients I don't know because sometimes it is a dental problem right sometimes the bones are right and there's just been so much space loss
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that I mean yeah could you push all the teeth back and put the tooth back in.
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Sure. But it just doesn't make sense at all. The vast majority of of of traditional extraction patients, you're basically treating the symptom, not the problem. The upper jaw is small. If the upper jaw were wide and the lower teeth
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were tipped out, there's room for the teeth. So, you know, primarily like my my my uh favorite way to treat is expanding. If there's a jaw size discrepancy at, let's just say between the age of five and seven, right? That's
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my favorite time to expand is actually right before the permanent first mers come in. um anchored to uh baby teeth which are very solid at that age. Uh and at an age when uh the the bones are again the circumaxillary sutures are uh
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less uh less dense, less resistance. Uh hold it out there for a while and and and and then you have all of that time because now we can identify these discrepancies at that age. Before, you know, 30 years ago, we couldn't really
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tell what the discrepancies were in a 5-year-old. All right. Now we have long-term growth studies. We know if we do nothing on average how much development and growth that child's going to have. So we can just add it to
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the number. We measure the jaws. We say, "Okay, you're 5 years old. You're going to have whatever five more millimeters of growth of the maxula. So all right, minus that off cuz we know, you know, not know, but we're likely going to get
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that later as you grow." Well, now how much of an underlying discrepancy is still left? Well, now we can use the types of expanders that we have. And in kids, you know, five and six, before their six-year mers even come in, I
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mean, we're talking 60 70% uh skeletal expansion uh compared, you know, to the expander versus the actual bony change, the level of orthopedic expansion is much much better. So, and in addition to getting what I would consider is a
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higher quality of expansion, meaning that, you know, again, the the looser those sutures are, the closer you're going to be to mimicking what nature would have done when you expand. um you know so a you're getting a more quote
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unquote natural type of expansion b you are giving mother nature time to use that expansion before the teeth have already come in over overlapped crowded ran into each other impacted absorbed all those things and so you're reducing the risk and this is well documented in
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the literature if you expand at an early age before the permanent teeth erupt the permanent teeth will erupt straighter in general and you will have less incidence of things like root resorption and impaction of teeth so that's not
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disputed all right now the argument becomes like well I I mean, the incidence of those things is so low anyways that just wait till they're a little bit older, wait till they're seven, wait till they're eight, you know, whatever. The patient can tolerate
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it better. And there's some truth to that. Like some five and sixyear-olds, they they, you know, it would be traumatic for them to have an expander.
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Not because it's actually traumatic, but in their mind it is. Maybe they've had previous dental trauma trauma and they can't sit in a dental chair, you know, maybe they can't lean back, you know, maybe they can't tolerate having things
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in their mouth. There's a lot of reasons why it may not be a good idea to expand in that age of a child. Um, but I expanded all four of my kids. And the more I learned about Maxer expansion,
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the younger I expanded my kids. So my oldest daughter had her expander at I think eight and then it was like seven and then it was six. And my youngest son he had is at five. And if I could go
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back and expand all my kids at five, assuming that, you know, they were on board and able to tolerate it and not, you know, it wasn't going to be a traumatic thing for him, that's what I would do.
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>> I love that. Yeah. So five sounds like the sweet the sweet spot. I have a 2-year-old who is has a high vaulted pallet. Uh, and I'm trying to get a timeline for how I'm going to intervene on that. And five feels right. You know,
Speaker A
three probably feels too young. Four, I have a nephew and a niece that are, you know, older than four, so I've seen what it's like at that age, seems a little young. Five seems kind of like just right. Yeah, I think for a lot of kids
Speaker A
it is. I think for a lot of kids, it is like, you know, right before those six-year mers come in, the sixyear mers don't compensate. So, they come upright within the bone. So, then you don't have to like, you know, tip them out and tip
Speaker A
them back in. they erupt in the right spot. There is compensation of the baby teeth. So, the baby teeth do tip outward and sometimes that can cause like bite instability issues or you have to add like ramps to support the bite. But
Speaker A
again, they're baby teeth so they're coming out eventually anyway. Uh and so you can manage the bite during that time period um and still uh put set them up for a position where the permanent teeth can erupt within the middle of the bone
Speaker A
and they don't have to compensate to fit together correctly. >> Right. And with regards to the mandible because you know you had argued earlier that uh uh environmental factors mostly affect maxillary transverse development.
Speaker A
So you're saying if you just expand the maxilla that the mandible will kind of just grow naturally to to fit it after expansion. Is that what happens?
Speaker A
>> Here's the thing and and that's another one of those things that uh that has a lot of debate about it. So the question is like you know if I expand the maxul early enough or wide enough will the
Speaker A
mandible grow forward more than it otherwise would have and if you look at most of the current studies you have the answer is no like basically it it's like you know mostly the mandible is going to grow forward however much it is
Speaker A
predetermined to grow forward and and when we talked about genetics remember like I think I agree too I think that there's a much stronger correlation genetically to the mandib the mandibular growth grow than there is to the maxillary growth. So, will it result in
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the lower jaw growing forward more than it otherwise would have? At this point in time, 2025, I don't know. All right.
Speaker A
Um, but I do know that I'm setting up the maxula for the teeth to come in as ideal as possible. I'm getting uh the the most ideal uh quality of expansion that I can. Uh, and I'm setting the
Speaker A
maxula up in a position where the lower jaw will fit best if it is forward, if that makes sense. So, will it actually result in an overall length of change in the mandible? I don't know. Um, we know
Speaker A
that the direction of growth can be altered. And so, you know, if they're maybe if they're nasal breathing now and and expansion help to facilitate nasal breathing or maybe they're lip taping or they're naturally keeping their lips closed at night, we're going to see more
Speaker A
of a forward direction to that growth. Even if the overall length isn't the same, if it's directed forward, that's a net positive. So, so in my opinion, there's a lot to um to consider when you think about the benefits to the lower
Speaker A
jaw of expanding the upper jaw. But as far as a definitive like, hey, you expand and you're going to get an extra millimeter, like we don't have that data yet. Um I do >> but on child number four, on child
Speaker A
number four that you expanded at age five, did you did you intervene on the mandible at all or did you just let it do its thing?
Speaker A
>> I didn't I didn't intervene on the mandible on any of my kids. And now granted, my kids uh are not uh class 2 retrodnatic mandible. Like that's not genetically, you know, that that's not where we are. are I mean typically uh
Speaker A
we're a little bit if anything a little bit prognathic tendency class 3 that's why I wish I could go back in time and and and expand my own jaws um but no we didn't intervene in the mandal we
Speaker A
basically just expanded the maxul and then held held those teeth there for a while gave the mandible a target and then let them continue to grow uh and that was the only intervention we did at at a younger age is expansion and then I
Speaker A
think two of my kids wanted braces when they were younger the older two uh and so we did some partial braces I think on both of them at least one of them uh and then uh the younger two we We didn't
Speaker A
intervene phase one with braces because again, we'd expanded so early that those teeth came in pretty good. So again, if I could go back and do it again, um, you know, my older kids wouldn't have had the crowding that they did because we
Speaker A
basically let the crowding happen and then we expanded. >> Mhm. Roger. >> All right. So, let's go back to patient X here. All right. So, he did his research and he decided to go with uh the ease procedure and he so he got a
Speaker A
TPD. Uh, for those who don't kind of know what that looks like, it looks something like this. uh where it has a component that connects to the bone and then it has a screw that pushes the two halves of the bone apart. Okay. [snorts]
Speaker A
So >> doc, maybe we should just uh def define ease endoscope assisted surgical expansion I think.
Speaker A
>> Yeah. And end endoscopy assisted surgical expansion. Basically they're going in with a camera um into uh the the nasal cavity and then you know potentially the back of the throat and and the idea is that you have a complete
Speaker A
separation surgically of the maxul. um you know debatable whether or not they they cut the terragoid plates off as well. Basically detaching the the posterior portion of the mandible at each of the maxula at each side. And so
Speaker A
the idea is you surgically eliminate all of the resistance um the midline resistance of the maxul and you surgically eliminate some of the lateral resistance of of the maxul is the idea with with that surgical procedure and then you couple that with the device
Speaker A
that's purely bone. >> What's your understanding of the role of the endoscope? Are the cuts actually occurring top down through the nose into the mouth or is is the endoscope just putting eyes on a cut that's occurring at the uh roof of the mouth or a chisel
Speaker A
down the ANS? >> Yeah, unfortunately this procedure is not well published as far as the as the details of how it's actually performed.
Speaker A
So you'd have to talk to surgeons who are actually doing it. But from my understanding uh and from what I hear most of the cuts are typically done from the mouth side and then the the the uh the endoscopy portion of it helps to
Speaker A
visualize you know where that tip of the burr actually is in relationship to the bone and like you know is it at the at the very end of the soft tissue. I think a lot of this is done with pzo. So, PZO,
Speaker A
as you may know, is really good at cutting bone, but it doesn't tend to puncture through soft tissue very easily. And so, if you're looking up in the nasal cavity and you get through the bone, you might see that soft tissue
Speaker A
start to move. And then, you know, okay, I'm all the way through the bone. That that's my understanding of it. Again, I'm not I'm not the best person to opine on that because I've never done this procedure. I'm not a surgeon. I don't do
Speaker A
this procedure. Um, but uh but but that's kind of the idea as I understand it. But as someone who's done lots of uh midline paso cuts from the mouth side, could you imagine uh the endoscope helping you do a better cut, a pazo cut
Speaker A
from the mouth side? >> So my my biggest question with it, you know, and if I was talking to somebody who did a lot of these procedures, what I would want to ask is like how do you see it? Because like, you know, the
Speaker A
midline uh the nasal septum is is quite broad in most patients and there's a significant amount of soft tissue like right in the midline. So ideally, you're cutting right right in the midline. And maybe that's not maybe they cut a little
Speaker A
bit off of the midline in order to be able to visualize it more. But if you're cutting right in the midline, I would imagine you could be pretty high up into the nasal septum, you know, maybe before you notice the soft tissue moving. I
Speaker A
don't know. But that would be my question is with the nasal septum being so thick. And again, there's cartilage in the nasal septum, so it may not move as easily, like, you know, how how easy is it to actually see when you're
Speaker A
through? And they may say, "Oh, totally easy." Like you do one of them and you'll know what I'm talking about. And and and fine, great. You know, like again, I I uh I I don't think this is the direction that that Marpy is going.
Speaker A
I don't think this is the direction that uh that skeletal expansion is going. I think we're going to be moving away um from from the surgical uh techniques of reducing resistance. I think in general uh for two reasons. One, patients don't
Speaker A
want surgery, right? In general, patients want as the minimum amount of surgery possible to get the maximum amount of benefit. So if there are two ways to to mobilize a suture and one of them involves surgery and one of them
Speaker A
doesn't, most patients are going to pick the way that doesn't. Okay? So I think that we will see a shift away from these surgical type procedures, ease included.
Speaker A
Uh that's my opinion. Again, you can talk to ease people and they may talk all day long about the you know like oh we get the posterior expansion more blah blah blah blah. Well, I've seen plenty of uh ease before and after cases at
Speaker A
this point, and I've seen plenty of MARPY and and customarpie and MSE and FME, and we're going to talk, we're going to get into the weeds of the quality of expansion. I do think it's important. It doesn't fall on deaf ears
Speaker A
that we should be paying attention to how parallel the expansion is. I just have a disagreement on what is the best way to get to that level of the most parallel expansion, the most quote unquote natural expansion possible. I
Speaker A
don't think it's going this direction. the statement you just made about getting away from cuts though. I mean, last year we talked uh on our podcast and you said that you still like to do midline PZO cuts for a lot of your adult
Speaker A
male patients. Are you falling away from that and going more into the Mariana Evans Audrey Yun camp where you're doing just different appliance design and less PZO cut surgical assist? Yeah. Even even less than the appliance design. Yes, to
Speaker A
some extent the appliance design, but to more extent that turning protocol um I'm seeing more and more mobilization of the circumax sutures. I mean like a and a and opening of the midline pal suture without osteotomy. I think I did two
Speaker A
osteotoies last week. It's not like I don't do it. I still do it and and again I educate the patients and let them decide. Right? So, if they have if they're an adult male and they have dense uh maxillary bone and I'm looking
Speaker A
on their CBCT and I don't see any sort of separation between the two halves of the max, it looks pretty much like one bone and in addition to that, it looks extra dense in the midline pallet. Uh, is that a patient that I, you know, I'm
Speaker A
going to say, hey, you should probably not do a PZO. No, I'm going to say, well, if you want the most predictable way to get this split, I would consider doing a PZO for these reasons. Now, if you want to try it without a PZO, cool.
Speaker A
Like I mean you know the risks. The risk is that we don't get the expansion. We can always go back and do the paso later if you want, but the risk is that we're turning turning turning turning and it
Speaker A
doesn't open up. Okay? And so if you're okay with that risk and you're okay with doing a second expander, then great, don't do the surgery. Um if you want the most predictable expansion at this moment in time based on your anatomy,
Speaker A
then it might be wise to do the PZO. But to answer your question, yes, I'm doing less PZO. Um, and and and I'm paying a lot more attention to what the anatomy on the CBCT looks like, specifically the
Speaker A
midline suture anatomy. Uh, and two, I'm relying a lot more on the the way that the expander is turned uh and the force levels that are placed on the expander and and utilizing stretching turns both morning and night going along that FCPC
Speaker A
type of protocol uh to mobilize the sutures that way. Uh, you know, and as I continue to learn more about this, I mean, it's like, you know, maybe we start to incorporate more things like jawline gum. Now, I mean, that may not
Speaker A
be the answer for everybody, but if you know, if you can chew jawline gum for multiple hours a day, that's a significant amount of time where you're putting force on this suture, which could potentially, again, this is not
Speaker A
definitive, could potentially help to mobilize those sutures and get you a higher quality of expansion. I think that that's some of the things that we need to pay attention to, right? If there's the potential for a lot of
Speaker A
benefit and there's not really a huge downside to it, I mean, you know, if you're chewing gum all day, yeah, you might get sore jaws or something, but that's something that can be monitored, right? you're probably not going to mess
Speaker A
anything big up by chewing jawline gum. So, it's it's a pretty lowrisk intervention for a potentially um highv value reward if that makes sense.
Speaker A
>> I think two two comments and then a question for you. Uh comment one, I personally could not chew gum like that because, you know, with my TMJD issues, chewing gum pretty much for me is the number one predictor of if I'm going to
Speaker A
have a headache the next day. I think that and then I I question, you know, if if the Marbby is disrupting occlusion and basically creating not great occlusion during the process of expansion, do we really want to kind of
Speaker A
lean into that with heavy lifting with jawline gum with poor occlusion? Because to me, that's like doing, you know, heavy squats with bad form, although I think you're right, it can just be monitored and managed. And maybe I'm
Speaker A
particularly sensitive. I mean, I mean, I know that I am particularly sensitive much more than lots of other people.
Speaker A
Second comment, Dr. Noaz told me with his FME, he thinks the only reason he got so much midfacial change is because he was biting down so much during expansion. In fact, he would go out of his way, not even with gum, but just
Speaker A
just bear, you know, bear back, just clenching down on his jaws during expansion. He didn't want to mention that in the podcast cuz I think he didn't want to necessarily encourage other people to do that. And to be
Speaker A
clear, he is not necessarily encouraging other people to do that, but he did credit that with why his midfacial uh circumaxillary sutural uh change was so significant. Um so to to your point actually, right? Um he he would I think
Speaker A
agree with you. And then my question for you is who needs PZO more? Is it people with really thick bone or is it actually people with really really thin bone where the screw drag uh becomes the bigger issue?
Speaker A
>> Yeah. So in my opinion is thick bone uh you know so so here's the like I think you know you have an anchorage problem you have a resistance problem so so resistance problems in my opinion are the ones that are best suited for uh a
Speaker A
resistance solution which is uh cutting right so when you cut the midline when you do a paso on the midline you are reducing the resistance so you're correcting a resistant problem inherently now can you lower the resistance to kind of get through an
Speaker A
anchorage problem yes you can right because now the anchorage requirements are lower because you reduce the resistance. But ideally, if there's an anchorage problem, I want to address address that with anchorage, meaning more tads, meaning maybe incorporating some of the teeth. You know, I would
Speaker A
rather address that via an anchorage problem. Oh, yeah. Or both, right? I mean, like but but my my go-to starting point is like if it's an anchorage problem, address the anchorage. If it's a resistance problem, address the resistance. Uh but you could do both for
Speaker A
sure. Going back to your point about TMD patients, I think it's a really good point. Like if you're actively having jaw symptoms, jawline gum is a terrible idea, right? I mean that would be like the last thing that you want to do. If
Speaker A
you've had a history of resorption of your jaw joints due to, you know, parapunction, jawing gum is a terrible idea. All right. So, but if you have healthy jaws, healthy joints, you're not at a high risk factor for either of
Speaker A
those things, then and you know, potentially you have possibly a bone expander, uh you can there's a couple benefits. one, you might get the mobilization of those circumaxary sutures, which could again potentially help the quality of your expansion, but
Speaker A
you also get the benefit of your teeth are trying to stay into occlusion. So if you have a bone born expander and your bones are moving and perhaps you haven't started like clar liner therapy or braces or something like that well the
Speaker A
act of clenching because of the inclines on the teeth can actually potentially help to start moving those teeth >> before you actually you know get into active tooth movement which could potentially reduce your likelihood to have a diasta during the turning or to
Speaker A
make that diasta smaller could also help to potentially upright those lower teeth as those forces continue to push outward. So, in my opinion, there's kind of like two decent reasons. And one more thing to mention is that, you know, when
Speaker A
you talk about like, well, putting excess force on on on a bad or on an unstable bite, you can stabilize the bite. We can throw bite ramps on the teeth to where you're hitting a flat surface on on multiple teeth, maybe four
Speaker A
teeth, maybe six teeth, maybe eight teeth. You know, you can build up as many teeth as you want to transmit that force in a more vertical way, which which I think is a decent idea. I use in what are called in-mouth bite splints in
Speaker A
my TMD patients anyway. So if their if their bite has caused a jaw issue, the first thing we do is get them off their bite. We build up ramps essentially on the second mers and usually the first preolers if they're accessessible and if
Speaker A
that works. Uh basically we build a splint in their mouth and we literally bond to these four teeth and and we have a support and then we dial in the occlusion so that they're hitting evenly on, you know, two spots on the right and
Speaker A
left, forward and back. And that essentially stabilizes their occlusion so that their jaw can then relax and it's not being forced into any certain position. you know, you could do that on more teeth if you wanted even more
Speaker A
stability uh in order to be able to transmit the forces of of occlusion and of chewing um you know, to the jaw while you're doing expansion. So, there are ways to manage that is all I'm saying.
Speaker A
>> Touche. Touche. uh and uh uh around the question of a uh thin bone screw drag problem versus a thick bone sutral resistance problem. Would you say that uh custom MARPY and this is a little bit foreshadowing into our discussion of
Speaker A
custom MARPY versus FME which I think will occur a little bit later but do you think that custom MRP because of the transverse TADS and you know tooth anchorage is often a better solution than FME which purely has more midline
Speaker A
anchorage at least in the current version the 4.5 uh uh for for those you know Pringle thin potato chip palatal type patients do you like the custom harpy better >> I do yeah for two reasons so One, you
Speaker A
can find the bone. All right, you can you can place a tad wherever the bone is. Uh, two, you can incorporate the teeth. So, I mean, this this doesn't get said enough in my opinion. Like, everybody's like, "Oh, I don't want to
Speaker A
be on the teeth. I don't want to be on the teeth." Okay, you can be on the teeth at least for a little while while you're getting that initial split. Like, if you've got plenty of bone and you can
Speaker A
afford a little buckle movement of the teeth. Now, if you've got recession on the facial of all your teeth, okay, maybe you don't get on those teeth. But if you have support, that that's, you know, that's four teeth or more roots
Speaker A
that can be helping that bone to overcome that initial midline resistance. Again, the resistance is highest until we overcome that midline resistance. So, to answer your question, yes, you can incorporate teeth. Yes, you can put tads wherever you need them. Uh,
Speaker A
and for an anchorage problem, I think that that's a better solution for an anchorage problem. Yes.
Speaker A
>> Thank you. >> All right. Perfect. Okay. So let's look at okay go back to patient X. All right this is uh the actual uh TPD that was placed and this is the actual expansion that he achieved. So this is the
Speaker A
superimposition showing the before and the after. What are you observing? >> A small split.
Speaker A
>> Okay. We see a small split in the midline. We see a little bit of change in the zygoma maybe a little bit more on the left side than the right side. How would you describe the dimensional stability of this particular expander in
Speaker A
this particular case? Yeah. What I'm seeing is on the patient's right, I'm seeing the uh am I seeing a little bit of dental alvolola sort of bending and then the appliance is sort of no longer uh uh straight with the bite line
Speaker A
anymore. the appliance is kind of uh uh twisting up uh or or following the dental alvolola bending so that if the expansion were to continue the left side would would come down and the right side would sort of not move or would would
Speaker A
sort of um not go up because there's nowhere for it to go. But uh this would lead to an asymmetric expansion potentially.
Speaker A
>> I I I I definitely think yes. I think it would lead to an asymmetric expansion.
Speaker A
Now, the part about the dental ovular uh bending, I I'm not sure that this appliance was in there long enough to cause a significant amount of dental ovular bending. So, when I think about dental ovular bending, I'm thinking
Speaker A
about this whole area here like significantly bending outward. And when I look from before to after, like I'm not seeing a ton of bending. I'm actually seeing a little bit of uprighting of the tooth, which could be due to two reasons. One, it could be a
Speaker A
little bit of expansion and then, you know, the forces of the cheek move it back. or maybe more likely. We can see what looks to be a little bit of um anchorage failure here. You can see that where the TBD is placed initially on the
Speaker A
bone is further away from the tooth and then where it is at the end, you see it almost pushing into that palal root of that tooth. It's a lot closer to it. And so, you know, maybe pushing on this root
Speaker A
caused that tooth to move um because the expander kind of pushed through the bone in that area, if that makes sense.
Speaker A
>> Great. When you look at the force that's applied here and you compare at the beginning and you compare that to the force that's applied here as that expander changes those forces are different and if you have a different
Speaker A
force placed on the same jaws the movements that you get are going to be different. So to your point yes I think you are at a high risk of asymmetric expansion uh in addition to potentially dental problems uh tooth problems uh
Speaker A
root fracture problems things like that if you continue to turn that expander. And so um so that was uh their initial expansion there that happened with the ease procedure. So then um patient decided okay well I'm going to get an
Speaker A
FME and and we're going to see you know now that uh everything has already been cut hopefully the resistance is taken care of um and we're going to get an FME and we're going to expand and and that's
Speaker A
going to be um what happens. And so that was the idea. Uh ideally the FME is more dimensionally stable. We're going to talk a lot about that. And so that was what this patient did. Uh but something interesting happened to this patient. um
Speaker A
they had a a a side effect that dealt with their eyes after they had the FME installed. And what happened is they actually went a little crosseyed uh and they were having uh trouble with their vision uh with their balance. A lot of
Speaker A
people don't know that vision can be related to balance. Uh it can also be related to even things um uh like like uh like tonitis and also your perceptual awareness. And so um a lot of patients don't rule that out. So, he started to
Speaker A
have vision problems immediately after the FME was placed and he's like, "Well, that's weird. Like, what's going on?" Um, and and and he didn't know at the time. So, he just, you know, he waited.
Speaker A
He saw his eye doctor and they they were kind of just waiting to turn to see like, "Okay, well, let's see if this gets better." Um, and it didn't. But, his his eye started to go crosseyed a little bit and then like he'd had
Speaker A
trouble looking in mirrors. Um, a little bit of just trouble with perceptual ability in general, like his vision was just off. Uh, and and his eye was slightly crosseyed on the left side.
Speaker A
>> Okay. So fast forward he was able to get a definitive diagnosis via an MRI and an opthalmologist of cranial nerve four palsy or the trolear nerve pausy. Okay.
Speaker A
So what is cranial nerve 4? All right. So cranial nerve four originates in the brain stem and goes forward. This is of course the top of the skull. It enters the orbit through the superior orbital fissure which is kind of like what
Speaker A
you're seeing here. Okay. >> So basically they're saying that there was some type of paralysis of that nerve. Now, this was the first case that at least his eye doctor had ever seen or heard of where this complication was
Speaker A
associated with maxillary expansion ever. Okay? >> So, so you know, by the time that we're talking about this, uh, you know, like like you know, he's asking my opinion is well, well, could how how could this have caused this? Like, and I'm like,
Speaker A
well, I don't know. Like, let's take a look and see what we can see, but let's understand a little bit more about what we're looking for. All right. So we have of course the optic nerve that's coming through the round hole here and then you
Speaker A
have a cluster of nerves one of which is that trolear nerve here um which is going to be innervating uh some of the muscles uh of the eye uh which can affect uh basically where the eye sits and the rotation of the eye okay I'm not
Speaker A
an eye expert so that that's my basic understanding of it so this would be where the optic nerve enters and this would be the superior orbital fissure here where the other nerves would enter in there so when we look at this and we
Speaker A
look at that in relationship to the upper jaw Like the upper jaw is not even touching this bone, right? I mean, but the upper jaw is touching bones that are touching bones that are touching that bone. So, is it out of the realm of
Speaker A
possibility that that could happen or that there could be some change in this area um with maxillary expansion? No, it's not out of the realm of possibility. Now, what we're thinking and what we know now is like, hey, well,
Speaker A
the more mobilized that these sutures were before force levels were increased, probably the more likely that they would have been to move at these earlier areas and sutures versus ones that are potentially further back. So, we're going to look at the superp positions
Speaker A
and see if we can like opine what might have happened. All right. So, again, here is that superior orbital fissure there and this is in relationship to the terragoid bones here. So, and then this is like cell pituitary gland. So again,
Speaker A
we're trying to figure out was there a change here? And I'm showing you this image here because this is kind of like the picture of what we're going to be looking at when we look at the superimposition to see what changes
Speaker A
happened. So So this is that superimposition and this was taken immediately after the FME was placed. So there's a there's a PFME and then there's an FME activation. So the way that this was done is that um the
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practitioner placed the FME uh and then they activated the FME on the table and we can look and see like how much that was activated. Um so let's play through this here. So when we look at uh the
Speaker A
changes that actually happen. All right. So first we will look at the volutric view here. And this is again how this is done. You're first going to orient the images. Uh and then what I want to do is
Speaker A
I want to just get a sense of uh what uh what is the overall level of expansion between those two things like how much did it actually expand. So we're going to see here as this starts to play.
Speaker A
These are the changes. You can see that opening up just a little bit. So this expansion was done at at one moment in time. Okay. So you can see the extent at which the expander was activated. Before there's no expander and then after the
Speaker A
expander is in there and it's activated. So you can see the change. And we tried to measure it out probably somewhere between a half a millimeter and 1 millimeter. But remember this is happening at one moment in time. So this
Speaker A
was basically while he was having the procedure done. Right afterwards they activate it and this was the amount of change that they saw. So you can see here again the diasma change. This these images were taken the exact same day.
Speaker A
Okay. So roughly 3 to six turns of the FME at the time of the surgical release.
Speaker A
>> I I I it's hard to say exactly how many turns because again the bones won't always move the exact amount of turns, but probably my guess is probably 3 to six turns. Uh coincidentally, you can see his mouth was hanging open in in the
Speaker A
after image, just so you know. But now we're going to scroll through right here and and and follow me here because we're going to try to find that same area in the skull where that tlear nerve would be entering into the orbit and we're
Speaker A
going to see if we can see anything different. But first let I mean we can see here the cross-sections okay maxilla widened a little bit you can see even movements of the cheekbones again like all of the bones are moving right so so
Speaker A
so we know that you know skeletal orthopedic change is happening uh and probably not a lot of remodeling at the circumaxularary sutures because this is one point in time. So follow me here we're looking at the the the canal that
Speaker A
has the optic nerve down here and then the superior orbital fissure. Now look at these two kind of like halves of the bone. This is the best view I could get of it uh to try and demonstrate like
Speaker A
like is that moving or not? And this is the patient's right side and this is the patient's left side here. So that's what we're going to focus on as we look at those superp positions to see like is
Speaker A
there some explanation here. So when we look at that you can see this is the after this is uh and then and then the before these two bones do appear that before after do appear to be slightly uh
Speaker A
closer together on the left side and actually slightly further apart on the right side. You can see here they open and here they kind of close. Now again, this is the the first uh uh superior orbital uh superp position that I've
Speaker A
ever done. Uh so so so is this reliable? Is this accurate? Like you know, I don't know. But it does appear that it looks like this area is a little bit more constricted and this area is if anything
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a little bit more expanded. Here you can definitely see the expansion happening here and it appears to be the opposite on this side. Now why why did that happen? I don't know. I mean, going back, we saw more expansion of that left
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side in the very beginning. So, did that have something to do with it because that side was more mobile and like this whole part of the maxul was kind of able to rotate or or or you know, kind of
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counterclockwise rotate in this view kind of causing this to to can't or tilt a little bit or because that left side was further down, did this kind of drop and this kind of move in? I don't know.
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But the diagnosis was that basically something was pinched in this area. And and so again, like unless you can go through and see, I mean, this this evidence doesn't definitively say this is what caused it, but it does at least
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provide some sort of it adds up, right? It's like, okay, well, they said something was pinched in this area. The two bones that make up this area appear to be a little bit closer together in this area. Yeah, that kind of makes
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sense. Okay, so again, this wasn't discovered until later. So, what do you do? All right, he waited a few weeks and then he decid he still wants his expansion, right? So then he decides to turn the expander and and then you know
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hopefully the symptoms don't get worse, right? So he turns his expander. So now we're going to see the superimposition of him turning his expander. So when we look here, uh we see again the expansion that happened. So I'm going to actually
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fast forward just a little bit through here. Okay, there we go. All right, so again, this is after all the turns were completed. I think he turned for about two or three weeks only. All right, so we can see here the changes again. A
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little bit more expansion on the left side than the right side. Uh and you can see that kind of moving a little bit more more mobilization. Again, this is the reason why I think mobilization of those sutures is so important because
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the more mobilization there is in general, the closer it becomes to kids who have mobilization at every suture.
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Right? So here you can see the additional split from from when uh from before it was placed until after it was fully activated. You can see a little bit more than in the activation um before. Uh and and while he's turning
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the symptoms weren't getting better and they started to get just a little bit worse. Okay. And so um and so at that point he was like, you know, very concerned. Again, he's meeting with his his his eye doctors trying to figure out
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what's happening. But you can see the definitive uh more movement on the left side compared to the right side. And as we >> point that out, doc, point out the movement on the left side where we think the culprit nerve compression is
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occurring. >> Well, okay. So here here it's harder to tell. They look more symmetrical at the level of the teeth. Um, but yeah, the nerve the nerve won't it hasn't showed up quite yet. Let me uh let me get to
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it. Yeah, let's see. Uh, let's fast forward here. That's just jaw joints. Uh, let's get all the way forward. Okay.
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Well, this kind of shows you a little bit. Uh, you do you see how much the cheekbone moves on the left compared to the right?
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>> Yes. Yes. That's a great great you can see that clearly. All right. So, now let's get to our trouble point here. All right. Optic nerve and then superior or orbital fissure. So, we're back here where we started, right? And this is
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from before to full activation. Right. So again, there's the two halves of the of of the of that bone or that plate.
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The best view I could or the section I could get of it. And again, so we go before and after. Before and after. You see that compression on the um on the left side but not on the right side. And
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so again, it becomes uh uh a little bit confusing. So at this point since >> put put your scroller around the fissure and again the fissure is basically the hole in in the skull where the nerves are emerging from the brain into the
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eye. opening is is in this area right here. Yeah. So, basically this area right here and this area right here.
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Yeah. >> Got it. So, those are the areas that are either, you know, compressing or moving.
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And so, again, we see this unusual, you know, pattern of of expansion happening with one side doing something different than the other side. So, what did he do?
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He decided he's going to unturn the FME and then he had it removed. So, he back turned it as much as he could until he got to the point where it was kind of like, you know, you're going to be
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compressing stuff if you turn it anymore, which was not completely unturned, but mostly unturned. uh and then he had it removed. Um did his symptoms go away? Well, some of them did. Uh some of them didn't. The way
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that it was described to me, and again, I'm not an eye doctor, so I don't know exactly how this works, but essentially, uh he he was uh basically has to do physical therapy for his eyes now. And so something about the way that the
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nerve intervates the muscle and then it causes a paralysis and then essentially there's like a memory like you know, we have memory mastication and it takes a minute like when your bite is changed to to restore your masticatory function.
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same idea I think but related to the eyes. Uh so so he still has a little bit of crossey a little bit of difficulty looking in mirrors but it is better. Uh and and then we went through and looked
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and we don't have to spend all the time in this but long story short when we looked uh through the the the sections afterwards uh what we we didn't really see a huge change back to where that opened up. It kind of just stayed where
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it was for for lack of a better description. So this is you know after the expander came off and then turning back you can see the bones moving back there now in this image here. And again, I I won't, you know, go all the way
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through it just because, you know, in the interest of time, but uh we I didn't see a big uh reopening of that area. It sort of just looked like it stayed the same to me. Okay.
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>> So, up in the eye, you're referring to the area in the eye where the nerve compression occurred.
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>> So, so the last superp position we'll look at again is from from when he, you know, before he did any of this until after he did anything. So what was like the net result change before he did
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anything to after uh the FME you know the ease and the FME were done and both were removed and I believe they removed about 3 months before this image was taken. All right. So could there still be change after this point? Yeah. So he
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did achieve some skeletal expansion there. You can see some dental expansion on the lower. And to your point about or the point we made earlier about mastication, I mean those lower teeth uh moved out to some extent and he didn't
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have any braces or aligners on them. So, you know, there's something to that. Uh, so let's, uh, scroll forward just a bit here. And I want to get to, let's see here. All right. So, you can see a
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little bit of the, uh, forward movement of the jaw. Now, this can be uh, deceiving because uh, when when you look at forward movement, you're looking at a different lateral area front to so if you have any type of expansion, then the
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the the portion of the jaw you're looking at, this stays static and so the portion is different. So, it's going to appear that you have more protraction than you actually do in this section view, just so you know. Um, but
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basically, you know, not a ton of movement of the jaws. Uh, uh, a little bit of expansion. You can see here again, a little bit of there definitely is what looks to be like some a little bit dental alvolola bending or
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remodeling where this is getting closer to this sinus wall there um, versus this whole apparatus moving, if that makes sense. But, you also do see some definitive orthopedic expansion as well with both sides. And when it was all
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said and done, it kind of looks like, you know, the right and left side to some extent expanded about the same, right? So when we're seeing here, it looks like the cheekbones are have expanded out roughly the same. When we
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look at the volumetric view here, we can kind of see it looks like, okay, it looks like they've expanded roughly the same. Um, and so did we Yeah, we'll take a look. We'll take a look one more time
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here. And again, this is from all the way before and all the way after. So again, this is this is the two parts of that bone when we go from be uh before and after here. So there's before and
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after. Before and after. Before and after. You see there still is a little bit of constriction on that side. So again, I don't know [clears throat] like I don't know um what that means that this side there doesn't appear to be
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much change between those bones at all. And then on the left side there appears to be a little bit more. So again, this is this is one of those areas that we really don't know a ton about. And and
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now we are finally to what I have actually been most excited about uh to talk about this entire time which is dimensional stability and what we can do about it. Okay. And this talk are are we are we going to circle back to what the
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lessons from that case we just looked at are as part of the dimensional stability discussion or should >> let's do that. So so honestly the biggest lesson that I learned from that case is that uh you don't want to go too
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too fast uh uh or too too much force too soon. Uh, and that's something that we've kind of all learned over the last decade or so. I mean, when a lot of us were initially taught maxillary expansion, uh, like like Juan Moon, I
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mean, I love what he's done for our profession as a whole, he's really put a spotlight on um, skeletal expansion. Um, but the initial turning protocols, I don't know what he's currently recommending, but the initial turning protocols were very aggressive, four to
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six turns per day. Uh, you know, with the idea being, you know, really break that suture open. Uh, and that's just not safe in my opinion. and and we've seen a lot of of major complications, many of which have had to be corrected
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with jaw surgery. And so, you know, the takeaway from this is is is a similar takeaway that I feel like we've been learning over the last, you know, decade or so, which is, you know, uh slow is predictable and predictable is good,
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right? So, uh you know, but but again, there might be too slow and we're going to talk about that in a minute, but there is some sort of a balance and we need to continue to focus on that
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balance. And in general, if you if you try to get a lot of movement all at once, you are more likely to have bad things happen. I think that's my take away from it.
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>> And and your basic overarching theory about what should ideally happen with the circumaxillary sutures is that they should be subjected to a much slower turning protocol so that they and you used this word earlier so that they
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remodel rather than snap. Is that the idea? >> Correct. That's that's correct. Yeah. So anatomically biochemically whatever you want to call it, there's a distinction between a sudden break of a circumaxary suture versus a slow and steady remodeling of that suture, which
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presumably is a some sort of cellular biochemical process. Is that right? >> That's 100% right. And let's like, so if you're listening to this podcast and you have had a a fracture, a diagnosed fracture due to Marpy, throw it in the
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comments if you want. If you don't want to share, that's fine. But like I I'll bet you'll have a bunch of comments that talk about um just that like oh my gosh I was turning and then one day I I felt
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this snap. I heard this snap. I was like what was that? Um this you know this happened a lot when expansion was more aggressive. Uh and so I've always been a little bit more on the cautious side as
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far as the turning protocols go. Um you know thankfully I I don't know of any um you know actual fractures in any of my cases. Um that being said I look at my cases a lot more closely now than I ever
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have before. the more I've learned, the more I' i've learned that I needed to have uh a closer eye on things. Um, but as far as I know, I don't know of any cases that that I've had that have had
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actual fractures where we didn't want them. Um, but there are plenty out there. And when you talk to these people, um, that's what they say. It's like, "Oh my gosh, I was turning, then all of a sudden I felt this snap." And a
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lot of times it it's like immediate pain. Sometimes it's swelling in the area. So to answer your question, yes, there's a big difference between breaking a suture uh compared to having uh mobilization of the suture where you have essentially what I would call some
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type of functional remodeling um where you know basically slower pressures, maybe more frequent over time but less pressure overall results in this area of bone activity uh that can result in allowing those bones to bend and remodel to some extent versus snap
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And uh like hisytologically like if we were to look at the tissue that's at the at a suture at the joint between two bones at the suture is it >> different at the cellular level than the than the the basil skeletal bone that's
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on either side of that suture and whatever that cellular composition is. Is it more predisposed to being able to actually be changed even in an adult under slow steady pressures?
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>> Yeah. Yeah, I mean I'm not a bone scientist but the way I understand it is yes. So basically you know most of the sutures have an interwoven property to them to where you have basically the bones are fitting together to some
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extent like puzzle pieces. Now they may be microscopic puzzle pieces. They may be bigger puzzle pieces like is the case with the maxillary suture the midline suture but basically to some extent these bones are approximated and there's some level of mechanical retention due
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to some type of interlocking between those bones. And if you turn too fast, you essentially snap that interlocking completely and you lose pretty much the entirety of the resistance in that area, which is why you see a jaw fly forward
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and down or whatever. For instance, in in in the instance of a frontto maxillary suture fracture or nasol maxillary suture fracture, which uh I didn't put in the in the presentation today, but I had one come in recently on
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on uh on my uh coaching platform where literally one side of the maxula expanded and this is not an exaggeration. We actually measured it out 8 1/2 millime uh and the other side expanded 1 millimeter. So almost purely,
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you know, and really no great explanation for it except for it wasn't even that aggressive of a turning protocol. about two turns per day uh initially. Uh so again like that that you know compared to the four and and uh
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and and and six and eight turns that were recommended a decade ago. You know two turns per day again I I do like one swing which if you're talking about a tiger screw is like one half of a turn
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um per day. So so that you know two full turns could be a little aggressive but that's the only thing that accounts for it. There wasn't like a tad misplaced.
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The design of the expander looked uh good from what I could tell. Um but obviously the expansion was uh was very asymmetric. Now luckily this practitioner caught it u you know before it had been eight months or a year where
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where you you know can have a very difficult time back turning and recovering from something like that. And those are the cases that need surgery right if you you push it out you break something you don't notice the asymmetry
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until later um and then it's been you know 5 6 7 8 9 10 months uh and now you can't back turn because you back turn and and there's already stability at that new location >> and so yeah that that you know it it is
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important it's worth discussing. So the way that I understand it is like when we put forces on these uh circumax sutures, we need enough force to mobilize them in some extent. Like we need those puzzle pieces to get loose, right? We need them
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to start having the ability to, you know, fit in more ways than one, if that makes sense. But we don't want to break the puzzle pieces completely, right? We want just like, you know, it's basically like you want one edge of the puzzle
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piece a little smaller than the recepted end. Like if you pull if you try to pull it straight out, it's not going to come all the way out, right? But you can kind of move it a little bit and it still
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fits within that in that cutout. Does that make sense? >> Yes. >> Yeah. So that's the way that that I think about it. Okay.
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>> And in terms of in terms of patient X, before we move on from patient X, >> yeah, >> the pat patient X essentially had a perfect storm for a circumaxillary suture fracture. Uh and did I mean did
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he have a circumaxary suture fracture? I don't know. But he had some sort of essentially catastrophic movement of a circumaxillary suture really high up in the face. And was that because of a perfect storm of really really strong
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appliance, really really deep surgical assist with ease and a lot of turns all at once? In my opinion, yes. Like if if someone said, "Hey, you have to come up with the best explanation for this." That would be what I would explain. Do I
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know that for a fact? No. I mean, like I say, I'm I'm opining based on the evidence that I see in front of me. Um but yeah, I don't have all the evidence.
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So So I really don't know 100% for sure. But that that was what makes sense to me. Uh you know and and and circumaxary suture fractures are very hard to detect. Um especially in the beginning stages of expansion like 1 millm 2
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millime you typically won't see it on an X-ray. The patient may or may not feel it. He didn't report feeling anything off. So it could have been a fracture that was just not really detectable on the X-ray or that we couldn't find on
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the X-ray. Or it could have been just like a hypermobilization of you know certain sutures but not other sutures if that makes sense. And and for whatever reason, the way that the resistance formula worked out, it it caused the
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maxul to rotate in a way that caused that one side to pinch and the other side not to.
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>> Yes. Yes. And and and from a historical perspective, if we look at the trajectory of the skeletal expansion field over the last, let's say, 7 years since I discovered MSE in 2018. Back then, like you said, Dr. Juan Moon's
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protocol was just when you think you should stop turning, you should turn more. I mean, when I did my MSE type 2, the idea was five turns per day, right?
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And I had actually a pretty wonky expansion right? >> Uh, back then, appliances were pretty weak and flimsy. MSE type 2, I mean, compared to say an FME looked like looks like a paperclip, right? Uh, and back then, maybe the idea was we really need
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to compensate for the weakness of the appliance and the lack of PZO cuts with lots of aggressive turning cuz maybe we fear that we can't break the mid pal suture otherwise. Since then, we have stronger appliances. We have things like
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paso cuts. We have things like ease. And now to take that same aggressive turning protocol into an era of strong appliances and surgical assists is dangerous. And hence the transition from MARPY to MASSPY. Maybe it's worth mentioning that distinction now as it
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came up in the first ever Marpie Symposium that you guys hosted back in April. there was this discussion of uh renaming Marbby to masspie which is to say you know micro microimplant assisted slow palatal expansion instead of microimplant assisted rapid palatal
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expansion right >> can you comment on that >> yeah I mean I do think truthfully I think that's a more appropriate name I mean even at like a half or one turn per day that's still considered rapid by
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most of our standards so I I don't know that we have to go change the name because at least initially um for for many patients it will be quote unquote rapid even if they're turning like you know three times a week that can be
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considered rapid you know, slow is typically associated with one turn per week or less. Um, so so it's kind of hard, but you know, so you know, but but definitely it's a lot slower than we initially thought we
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needed. Uh, and and and you know, turning it, you know, two or three times per week after that midline suture or maybe even once per week in certain instances, uh, may be more appropriate, uh, than, you know, than than every day
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going on forward and forever. This is why I am as so excited and and uh about the results that we're seeing with a more of a functional turning approach.
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So essentially like not even having I think ideally we don't even have a set prescription. The challenge is like every patient's different and you have to explain whatever turning protocol you're going to do to the patient that you're talking to and and every patient
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has a a differing ability to understand what the heck you're talking about, right? So we try to systematize and standardize our turning protocols so they're as easy as possible but yet also make them in a way that you know that
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that that they hopefully will produce the best quality of expansion possible. So currently what I recommend my patients do who have MARPY is you know they'll they'll start out with but well they'll do stretching turns and forward turns. That's how we break it up. So the
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stretching turns are always just as many turns forward as they are back. So you might turn uh you know two forward and then wait 15 minutes and then turn two back. And they're going to do that um twice a day and they're going to wait at
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least 15 minutes in between those turns. Right? So the idea is you're putting pressure on the suture, you're letting it sit there for a little bit and then you're turning it back. But I don't tell them, okay, you have to do two, you have
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to do three, you have to do six, you have to do seven. I basically say usually some, you know, somewhere between two and six is appropriate. But you're going to feel it like when you feel that pressure like that's what you
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want to feel. You know that it's doing its job. You're going to feel the pressure in the sutures. Like you're going to feel it kind of in your head basically. You could probably describe that feeling better than me since you've
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experienced it. But you you basically >> feels like getting punched in the nose. I felt a lot of pressure here.
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>> I wasn't expecting it, but it felt like I've been punched in the nose. It felt like getting punched in the nose.
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>> There you go. So, when you feel that getting punched in the nose feeling, that pressure on those sutures, that's when you're going to let it sit. And then, you know, 15 minutes, you're going to unturn it. And what you'll find is as
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you do that now, in order to get that same punched in the nose feeling, so to speak, you might have to turn it three turns, you might have to turn it four turns, you might have to turn it six
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turns. And so I usually have them go somewhere between two and six turns. Um, usually at least at this point if you're doing, you know, six forward and six back, that's plenty of mobilization. I mean, that's, you know, basically with a
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tiger's group because really they're half turns. I mean, that's, you know, close to 3 mm of mo or I'm sorry, close to a half a millimeter of mobilization, which is, you know, quite significant when we look at, you know, uh,
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mobilization of as little as, you know, when we looked at that patient, that initial mobilization was 1/2 to 1 millimeter. It was within that range.
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So, if we're mobilizing a half a millimeter, doing, you know, six half turns forward, letting it sit, and six half turns back, to me, that is significant enough. Now, will we find out later that we can actually do even
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more on the stretching turns? Maybe. But I'm kind of in the camp where it's like, if you're doing up to six, like that's quite a bit. That's almost a half a millimeter of of uh of of actual movement of the bones during those
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stretching turns. I think that's plenty. >> Yeah. I wonder if we should stop thinking of bone as stone and start thinking it of it more as a metal or as wood, right? Because with with wood, we take for granted that it's not wood is
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kind of this complex material that can be sort of bent and manipulated with heat and with uh with with um you know uh back and forth. You kind of loosen it up. You can wet wood and get it to
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behave differently, right? Uh and there's a whole multi,000-year-old tradition around sort of refining those techniques to get wood to do whatever you want it to do to bend it into a circle if you want. Right? Metal similarly has a kind of memory where if
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you bend it back and forth, its properties change uh as a result of, you know, memory of having been manipulated in a certain way. Whereas with stone, you know, stone, you bang it with a hammer and it just fractures. Stone
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can't really be manipulated in the same way as wood or metal. Yeah. I wonder well what are your thoughts on that?
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Thinking of bone as as kind of more of this complex sort of living material uh that requires a kind of art to to to dealing with it.
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>> Yeah, spoiler alert. We're going to we're going to talk a lot about that when we get to the animations. Uh but basically I view it almost as a very dense putty on the inside. Uh followed by more of like a wood shell on the
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outside would be the best way I describe it. And when I say a dense putty, I mean I'm talking like, you know, the densest putty possible, but still movable, right? Still movable in some way on the inside and then the outside of the bone
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being more like wood where it is, you know, bendable up to a certain extent uh but uh but but pretty hard overall if that makes sense. And so yeah, when we look at I'm going to show you some act
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I'm going to show you a patient who actual superp positions. Then I'm going to show you an animation that actually um kind of opines on what we might have been seeing in the mouth uh and try to explain it with a cross-section of the
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bone. So I think you'll like that. >> Cool. Awesome. All right. So let's talk first about dimensional stability, though. So here we are. We have and we're going to compare an MSE with, you know, with a tiger screw custom type
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design with an FME. And all I'm looking at what we're going to do is we're just going to kind of play around with it.
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Now, I'm I'm not saying any one of these expanders is better than the other. I'm not saying that you should only do one type of expander. I don't speak for any companies that are that make any of these products. I don't have any
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investments or dogs in this fight with any of these. Okay? So, we're just kind of like throwing out a conversation. All right? And just kind of like seeing what the differences are and then we can talk about what it means just so we can start
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the conversation. All right? So, this is 0 mm of expansion and this is kind of like, you know, I'm just playing with the expander and trying to see like how mobile is it? like how much ability is there within that expander? How much
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play is there uh within the expander itself? And we're just kind of looking, right? This is at 0 millimeters, right?
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Here we go. Tiger screw. Now, one of the differences you'll notice right away is that there is not rotational stability with a tiger screw, right? So, either side of of a tiger screw can rotate.
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Same with the TPD. You saw that happen in that case I just showed you, right?
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So, that means that you have to be extra sensitive. And of course, here is the FME. And and you can see again, we're at 0 millimeters here. And this is uh this is it looks like a 3.5 because the
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plates don't even extend over the anchor bodies in this uh version. Okay, so we have our FME, we have our our our Marpy, our custom MPY kind of tiger screw, and then we have our MSE. All right, so
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that's at 0 millimeters. Let's jump to and I'm going to take you through all the time. Have we have we already seen even in the 0 millimeter expansion demonstration that the FME has the most stability?
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>> I mean, I don't know. You can see you can have your listeners apply throw in the comments. Did it look very different in in 0 millimeters than it did at 4 millimeters? We'll see what they say, but we're as we get wider, I think that
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you're going to see a little bit more of the differences between them. So, let's go through 4, 8, and 12 mm, and then let's have a discussion about what we think we're seeing overall. So, here is our 4 mm of expansion. And again, you
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can see here, okay, I mean, what does that look like? Does it look like maybe those pieces can move a little bit more?
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Can they maybe shift a little bit more compared to where they were at 0 millimeters? Is there more possible movement between those two sections of the jaw? I don't know. We're going to keep looking and we're going to see
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maybe when we get to eight millimeters, does that change? So, that is our MSE.
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Um, you know, quote unquote stability at uh 4 mm. Now, we're going to jump to our custom MARPY here in just a second. Let me see. I have to speed it up because I'm impatient. All right, here we go.
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So, here is our custom MPY. And again, rotational stability we we know is not going to be there. All right. So, I'm trying to just look at besides the rotation sort of the uh flexural ability of the expander. Right. So, I'm trying
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to >> Does rotational stability matter? >> Uh I do think it does, but I'll I'll I'll pause that conversation and we'll have it once we see like I want to show you everything so that we can have the
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complete data before we opine too much on it. But 100% I think it does. Um >> Okay.
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>> But maybe it's not as as much as as you might think it does. Okay. So that's our uh that's our that's our 4 millimeter expansion with our um tiger or with our tiger screw there. And then of course
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with our FME here, right? So this is 4 mm expanded FME. And again, this is I believe the 3.5 version. Okay. And I'm trying I'm trying to put like the same amount of force on each of these while
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I'm doing it. So I I don't have a force gauge. I'm not perfect, but like my intent in doing this was to put the same amount of force on the expander to see how it changed. Now, is that force level
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the same as in the mouth? No. way less, right? The mouth puts way more stress on this. So, I'm not saying that this is what you're going to get in the mouth.
Speaker A
But again, I just I want to have this conversation because I think it's important to have and I've never heard anybody have it yet. Okay. So, now we get to 8 millm of expansion. All right.
Speaker A
So, now we're here and we're looking. Okay. So, again, still like we have rotational control with the MSE, right?
Speaker A
Because we have those those arms, right? So maybe we're starting to see possibly even a little bit more wiggleness as we get a little bit further out on that screw. Maybe a little bit more potential for one side to move potentially
Speaker A
different than the other side. Let's jump to our custom RP here. All right. So again, tiger screw there. All right.
Speaker A
Obviously the rotation. >> Yep. >> Now that rotational instability is kind of scary. >> Yeah. Well, we'll talk about it again. I mean I mean I think that I do more custom RPS than I do FMES. Uh, I
Speaker A
probably honestly do the most MSE because they're great for teenagers. Um, but uh, but yeah, I mean like it doesn't scare me away from them, but it does make me a lot more aware of what I need to be aware of when using them. And
Speaker A
that's what I want to talk about once we get through these videos here. So, let's jump to the the FME one again. And and I'm trying to use approximately the same amount of force on on each expander type
Speaker A
that we're looking at here. So, so this is the FME again. And let's take a peek here and we'll see. Okay. So, I'm I'm wiggling it like I'm trying to wiggle it the same kind of way I was wiggling the
Speaker A
other ones. >> Okay. >> Mhm. >> And then we'll let's look uh Yep. From here, trying to wiggle it about the same. And you can see some movement.
Speaker A
There's definitely some movement for sure. Okay. >> All right. But seemingly noticeably a lot less movement. Let's jump all the way out to 12 mm of expansion. Okay. So, now we're kind of at the end of our ropes with, you know, MSE like 12 mm is
Speaker A
pretty much at the end of the rope there. Okay. we start to see a lot of instability at 12 millimeters, right?
Speaker A
This is very apparent, right? Because, and it makes sense, right? Those guide rods are probably not even all the way through those lumens anymore, right?
Speaker A
They're halfway through the lumen. So, when you're at the very very tail end of the turns of your expander, you would expect additional, you know, instability there, if that makes sense. So, now let's look at our our tiger screw here.
Speaker A
Again, we can see a little more wobbliness as as that gets further and further out, but you know, maybe a little bit more dimensional control from, you know, from this view than than the MSE in my opinion. Uh, all right.
Speaker A
Obviously, the rotation we're going to talk about. And then again, let's look at the uh FME.
Speaker A
And again, I'm trying to apply the same amount of force to it. Again, these >> Jesus, man, the the FME is a beast.
Speaker A
Well, and and again, like I I want to be very careful to to insinuate that this is the same as you will see in the mouth. These forces are astronomically lower than you would experience in the mouth. But again, I think it's a
Speaker A
conversation worth having. So now I want to show you what this looks like if you just set it on a table. All right. So if you set it on a table and you just wiggle the pieces. All right.
Speaker A
>> Oh god. >> Yeah. So that's again 12 mm. You're at the very tail end of the MSE there. All right. With the tire ju for just a brief second, have you heard of a potentially a a new MSE type
Speaker A
3 that's in the works or is that just a rumor? >> The the the latest MSE I saw was at the AAO and it had the ability to basically add composite and then uh expand further. So that would be a great like
Speaker A
if I had that that would be another great dimensional stability test um is is uh is uh is doing that adding the composite to it and then seeing how much dimensional stability it actually keeps.
Speaker A
But that was the last one I'm aware of. There might be something else in the works that I don't know about yet, but uh but yeah. So again, again, this is a benchtop demonstration, but I think it sparks the conversation. So now go ahead
Speaker A
and let's talk about whatever questions you have. >> Well, why don't we play this video one more time cuz I interrupted it.
Speaker A
>> Yeah. No, let's play it. Yep. Perfect. All right. So here we have 12 mm MSE.
Speaker A
Okay. >> Yeah, that's a soggy biscuit. >> Yep. All right. And now we have 12 mm Tiger Screw.
Speaker A
>> Not great either. less soggy, but definitely a little soggy, right? Again, trying to do the same exact force, same exact way.
Speaker A
>> I mean, you can see it move a little. >> Yeah, a little bit. Little bit. FME is starting to get pushed to the limit, >> right? Yeah.
Speaker A
>> It's just more leverage on that, right? Basically, >> and this is basically FMA 3.5. So, 4.5 covers the the anchor bodies here. It sits over top of this and and then I'm going to show you what the pro is, which
Speaker A
is uh you know, ETA before the end of the year. So, um I'm excited about that.
Speaker A
>> That's the FME Pro. >> Yeah, the FME Pro ETA is before the end of the year. So, >> and then next year we'll get the FME Pro Max.
Speaker A
>> Exactly. Right. Yeah. Something like that. Pro Ultra. They'll have to come up with the name, I'm sure. See, as we're getting closer and closer to what will probably eventually be the final design, you know, the names are moving away from
Speaker A
numbers. Now, we're starting to name it, you know. So, it'll probably end up something like FME Pro Max Ultra V2 or something. And then we'll be good. And then we'll we'll get like space gray and we'll get like you know the titanium
Speaker A
blue or whatever. >> Exactly. Exactly. Okay. Any questions on on this before we move forward? Any Oh, you talked about rotational stability.
Speaker A
Okay. Does it matter? All right. Here's my opinion about this. Um it ma So if you don't have rotational stability, the resistance is going to matter a whole lot more from a vertical asymmetry standpoint than if you do have
Speaker A
dimensional stability. that another way. Like if I don't have rotational control, I need to be very sure that where I'm lining up that screw is going to be pretty darn close to the middle of resistance of the bone. So that it's not
Speaker A
going to trigger a a rotation of one side of the maxullet compared to the other side. Just like we saw in that TPD example, right? We saw that happen. It expanded, one side of the expander went down, the other side didn't. it caused
Speaker A
an asymmetry. Like there was probably a difference in resistance because I mean as far as I could tell it was placed normally. Maybe it wasn't like maybe one side of it was placed forward, one side of it was placed back and that's what
Speaker A
started the whole cascade. I don't know. But you have to be very careful how you place that. And that's why when I hear like you know like like people talk about the problem of asymmetry with custom marpies. I think that most of the
Speaker A
asymmetry problems that you see are not because something actually broke. I mean that does happen. you do have things break sometimes they turn too fast a suture breaks you have a big complication but I think most of the
Speaker A
asymmetries the mild asymmetries that we see that we end up correcting dentally um either with braces only or maybe elastics or maybe tads if it's like quite large um is happening because of the differential movement between the bones and that's happening in part due
Speaker A
to the dimensional stability of the expander itself and you know I see less of that with my MSE patients than I do with my custom RB patients so that's not I said you'll use custom >> MSE MSE or FME
Speaker A
>> both MSE and FME. So both have those guide rods, right? So both have good or better rotational control. Right? Now again you can you can argue about the MSE the the the sturdiness of it the strength of it is noticeably less. I'm
Speaker A
not going to you know say otherwise um but again when it comes to developing an asymmetry like if I put an MSE in a patient and again I mostly use these on uh teenagers right? So if I put an MS on
Speaker A
a patient, a teenager's resistance areas are pretty uh even usually uh the the circumaxary sutures are pretty um uh moldable uh pretty movable at that age.
Speaker A
Uh if I design the MSE correctly, I typically don't have problems with asymmetry at all, right? Um whereas like sometimes in adults even if I design it correctly you can still have uh problems and and when you have prior surgeries
Speaker A
nasal surgeries that's why you know like prior surgeries to MARPY is a contraindication that doesn't mean you can't do it but you are affecting the resistance in some way shape or form you know cuz unless whatever surgery you had
Speaker A
resulted in the exact same cuts on both sides and that's assuming you had symmetrical resistance to start with like there is going to be a difference in the resistance from one side to the other and that force is going to be
Speaker A
pushing into the bone into those resistance areas. Uh, and it's going to play out like it's going to play out to some extent. The more dimensionally stable your expander is, the less ability it has to play out in a way that
Speaker A
moves the bones differentially and the more of that uh unwanted force is absorbed by the expander itself, so to speak, in the >> So, are you saying >> Yeah. So, are you saying that custom marpies are generally designed very
Speaker A
perfectly? They're designed to be symmetric and for the expansion vector to be symmetric and they're placed symmetrically. The lab is doing everything it can possibly do to orient the appliance correctly, so is the provider. It's just that as forces are
Speaker A
added during the expansion process or we should maybe say emerging because of skull anatomy and maybe differential uh skull anatomy on either side the appliance twists as a result of forces that are introduced later in a way that's
Speaker A
impossible to predict during the planning stage and that's where custom harpies tend to fail. So, I think it fails at all of those points, but I think that is one of the parts that fails that I haven't heard a lot of
Speaker A
people talk about. So, I do think it fails by the lab. I do think it fails by the doctor. I do think it fails by the anatomy of the patient. Uh, and it can also fail by the cooperation of the
Speaker A
patient, right? If they if they if they do something they're not supposed to and they go rogue and they, you know, turn it 20 times in a day, obviously, it's becoming unpredictable at that point.
Speaker A
Um, and it can and it can fail due to failure of the appliance itself. force levels get too high and the dimensional stability of that specific expander even though normally the dimensional stability would have been fine. Uh it
Speaker A
didn't in that case because the force were too high. We a lot of early FME failures uh you know I would put in that category cuz you know design-wise it would have looked just like you saw here but function-wise uh because the forces
Speaker A
were so high at that level of expansion you know something something gave way. That's why we have so many versions of the FME. When something gives way they take it back to the drawing board. So, I don't know if you guys know that
Speaker A
company's been around for 9 years. This is a medical device company. This is not like a, oh, let me pop up and, you know, try to capture all this market share.
Speaker A
Like, these guys are serious about finding the optimal expander, about designing and creating the optimal expander. And they're heavily invested in doing that. And so, it's like I love that they're in this space. Again, they're not there yet, right? They are
Speaker A
not there yet. I mean, I mean, we could probably there's been less than a thousand for sure FME patients in the world, right? Probably less than a few hundred. And so like you know there is they're still in the development
Speaker A
process. All right. So if you want an FME just know like yeah we we know what we know about it but there's still things that we don't know and as we learn the design changes the design changes the design changes which in my
Speaker A
opinion is very good. Now, uh to your point about like, you know, the the doctor or the lab messing it up, like if you don't believe that, talk to any new lab that's been in this space, uh you
Speaker A
know, like there is a learning curve, right? And so that's why a lot of practitioners use labs in this space who have been doing this for a little bit longer because they do learn the hard way things that can happen uh when when
Speaker A
the screw is set wrong. But the promising part about this is now I'll actually set the screw intentionally um asymmetrically in order to correct an existing asymmetry. Right? So if we have a caned maxula or uh then we can
Speaker A
actually set one side of the expander lower compared to the other in in an attempt to actually correct the can and we are doing that somewhat predictably.
Speaker A
Now the hard part is again resistance is not the same in every patient. So, you're not going to always get it perfect, but even if you get it close, you can manage the rest uh with uh basically um you can manage the rest
Speaker A
with uh with with dental movements and tad movements. Okay. >> Okay. So, just uh yeah, wrapping up wrapping up this point about dimensional stability on uh the rotational stability of the tiger screw of the custom. Um two questions. Is that rotational stability
Speaker A
an issue when you have the frontal maxillary suture fracture and you have that notorious uh dropping of one side where you get that stepwise kind of asymmetry uh in the in the vertical dimension? Is that occurring because the
Speaker A
tiger screw is is the is the pallet actually doing this as a result of that lack of rotational stability or is that not actually the case? Well, so so so the force that is is coming that's that's causing that rotation is caused
Speaker A
because there's a change in resistance, but the expander doesn't um prevent that from happening, right? So the force would be there either way. As soon as the suture breaks, you're going to have that force of things wanting to move
Speaker A
away from the resistance and move more downward and forward. But the expander itself, the tiger screw, does not have a mechanism to absorb that force in any way that slows down that movement. And so yes, you tend to see more changes
Speaker A
after a fracture with something like a custom RP than you would after a fracture of an MSE or an FME in my opinion.
Speaker A
>> Have you ever seen an FME cause that step-wise drop on one side of the pallet as opposed to the other?
Speaker A
>> I that's a great question. Um I I would say not more than about a millimeter or so. Um no, not not ever not ever like uh like more than I would say more than a millimeter. And again, I don't know. I
Speaker A
actually I I to truthfully, I have not seen a frontal nasomaxary uh suture uh break on an FME. I don't know that they're they may not be out there. Um uh that would be a good question for docs
Speaker A
who other docs who have done them. I've not had a nasomaxary fracture in any of my FMEs. Um and I've not seen one. So, so for that specific complication, I don't know, but I have seen um especially in earlier designs uh
Speaker A
asymmetry up to about a millimeter of of one side, you know, moving moving down more than the other. Um but but again usually yeah I would say even less than a half a millimeter I've been and that's why I I' I've I'm using more and more
Speaker A
FMEs because again the more I use them initially it was a question of am I going to get the split right? We had failures early on and so it's like, you know, we tried and it's like, okay, well, let me be a little more cautious.
Speaker A
Let me, you know, maybe use this on on on kids. Let me look at some more superp positions and see what's happening. Uh, and I definitely don't want to, you know, have it fail, right? I don't want to, you know, at the end of the day, I
Speaker A
want to get the expansion going. But now that things have been beefed up a little bit, I'm using them more and more because I'm seeing again a better quality of expansion and the predictability of expansion is is much
Speaker A
much higher at this point as well. So, what I want to walk you through now, Ron, is a hypothetical example. And I put that on there because I don't want people to like watch this and be like, "Oh, this is what happens." And he's
Speaker A
saying MSSE is terrible. No, this is a hypothetical example based on what we saw from the dimensional stability of those expanders that that could potentially play out um with expansion.
Speaker A
So, what you're seeing here is what happening is one side of the jaw is dropping for some reason. And as the expansion continues, you'll notice that that side continues to move down more compared to the other side, which makes
Speaker A
sense because once that bone starts to move and once that expander angulation starts to change, well then uh it can continue to change. And then this is an example from an AP standpoint of if that starts to get off, how that can continue
Speaker A
to shift. So from the back here, again, you can see u like the more it tilts, the more likely it is to tilt. And again, this is an animation, so I'm not saying that this is happening or is
Speaker A
likely to happen in a lot of patients, but hypothetically based on the design alone, these movements are possible, if that makes sense. Okay, >> so that's what we're talking about when we look at the MSE. Now, when we look at
Speaker A
the tiger screw, going back to the point of the uh of the uh uh uh super screw part of it or the tiger screw part of it, right? So this ability to rotate and have that anterior portion drop down
Speaker A
more as you see here is higher because we don't have any arms that prevent that if that makes sense. And so when we look vertically the potential for that vertical change to be even higher than it would be in an MSE I believe is there
Speaker A
right and this is assuming again not even a frontal max suture fracture just uh something starts to get off in the angulation of the expander could be due to the resistance could be due to a number of things but it can cause more
Speaker A
of a vertical effect because of you can more likely have that rotation because the expander screw itself is not controlling for that. Right? So again sticking with the hypothetical here if we're looking at an FME and we're saying
Speaker A
well how might that expand? Well, again hypothetically uh if you maintained perfect dimensional stability if the forces were to overcome then of resistance then what would happen is you know either you wouldn't be able to turn the expander or the expander would
Speaker A
actually fail through the bone essentially pressure necrosis basically put so much force on the area where the tads are where the tads fail the bone starts to attack it and and basically the bones uh the the pins translate
Speaker A
through the bones. Now, up to this point, I haven't seen this happen. What I've seen happen is the the appliance does actually fail and the anchor bodies start to tip inward and you actually see tipping of the tads. Uh, and so I've
Speaker A
seen that. Again, I haven't seen that with FME4.5, but I haven't done a lot of FME4.5s. And hopefully with with with the Pro, uh, we'll see that even less and less and less. But hypothetically, that's the goal is to have so much stability of the
Speaker A
expander that it can overcome those forces and one of two things will happen. either the the bone where the expander is attached will fail or the expander screw will fail, but it won't allow the bone to move in a way that you
Speaker A
don't want it to move. Okay. >> It's a kind of built-in safety. >> Exactly. Builtin built-in safety for the for the direction of expansion. So, this is an actual superimposition. Um and and uh this is with a um uh this should be a
Speaker A
custom marty here. Although, you know what? Actually, I'm going to skip this because I think this is a different superp position. I think I put the wrong one in. Okay, we'll skip that. But basically, I'm going to show you in the
Speaker A
animation anyway. But u this is an example. Again, this is a hypothetical example. And this is why I describe the bone with putty uh on on the inside and then maybe like a wood-like exterior, if that makes sense. So, as we expand, you
Speaker A
can see here like do you see the the teeth dropping down and the bone almost remodeling but nothing changing to the outside. So, this is an example where the uh resistance increases for some reason. So the circumaxularary sutures
Speaker A
lock up. You get to a point where you just can't go any further. And what we tend to see is this boowing of the appliance uh with the screw coming down like this as you see here in the image.
Speaker A
But that you do continue to see vertical change. So even though the um the the the orthopedic side of the expansion has stopped, you start to see vertical change actually continue. And and the way that I explain it is like it's like
Speaker A
it's almost like the inside of the maxul is dropping relative to the outside of the maxul and the teeth are following whether you are connected to the teeth which I think if you are connected to the teeth this will happen more um or
Speaker A
you know whether even if you're connected to the bone when that starts to fail and those bone starts to uh to the tad start to move we tend to see a little bit of rotation and vertical change even after um you know we're not
Speaker A
really getting any any uh lateral expansion as well. And you can see the same thing happen on the tiger screw. So when we look at that uh again, we can see that uh uh maybe we cut the arms off
Speaker A
and we're only connected to the bone. Uh and that's a superp position I thought I added earlier, but I didn't. So we'll have to circle back on that maybe on the next one. Uh but basically I've seen superp positions uh with MSE with Tiger
Speaker A
Screws where this phenomenon takes place where basically uh we're not really getting much lateral expansion but we're still seeing vertical change of the level of the teeth as they continue to turn uh and turn and turn and turn the
Speaker A
expander. And again, this is this is something that hypothetically or in theory, if you have a dimensionally stable expander, it's not that you couldn't get to the point where the resistance is too high, but when you do get to that point, it should maintain it
Speaker A
should absorb the unwanted forces and then you either one can't turn it because the force is too high. uh or two um you know it basically causes uh the TADs to fail and and and and maintains its parallelism which again I've not
Speaker A
seen an FME design be able to take this much force and not distort but hopefully that's what they're going for that's the goal right so that's what they're trying to do um so I don't know how much time
Speaker A
we want to spend on this uh FME planning guide but I know that like you know it's kind of nice to take a look at the backside when we plan an FME um how that process works and what we get back from
Speaker A
the lab and what we approve But basically this is what it looks like. Uh so this is like you know up to a 10 tad FME. You can see here like a six TAD would be the blue and 8 TAD
Speaker A
would include this light blue. And then if it was a 10 TAD you would have two more posterior tads here. This tells you the length of the TADS. These are the different selections, the design of the appliance. P standing for protraction if
Speaker A
you were you know looking at doing FMA whenever that becomes available. Um and then uh and then the medial tads on the 4.5 version here which means that these front two will angle out a little bit here. So, as we walk through this, I
Speaker A
mean, the first thing you're going to see is kind of the overall design. This is showing us where the FME is placed relative to the midline suture. You can see here in this particular patient, the nasal anatomy is quite off. It's quite
Speaker A
caned. And so, you wouldn't want to put this FME and tilt it the same direction as the nose. That's going to exacerbate um that discrepancy. So, we're going to go ahead and use other skeletal landmarks to uh achieve symmetry here,
Speaker A
which I'll show you in just a minute. The red line is indicative of roughly where that midline suture is. I mean, obviously the midline suture is not straight. This red line is, but you can see here it's roughly going through PNS
Speaker A
and ANS, even though in this particular suture, it kind of veers off to that side a little bit. And this >> Time out, doc. Doc, time out, please.
Speaker A
>> What I want to know is who is doing this analysis and making these decisions? Is it you or is it Face Genics? And where I'm going with this question is lots of, you know, orthodontists are popping up
Speaker A
and taking courses like yours or Dr. Dr. Lipkin's course or Dr. Ting's course and they're starting to do MARPY custom MARPY. Uh, and so patients that are looking for a local provider, right, maybe through getexpanded.org are how can they be sure that the
Speaker A
provider that they're finding is designing the appliance with all of these things in mind? And one thing that I've fallen back on is that if face genics is doing all of this landmarking and deciding on uh appliance orientation
Speaker A
with respect to existing asymmetries, that's a kind of safety for patients who want to avoid getting asymmetric expansion. So my question is is partners doing this sort of same analysis? Is it provider dependent? Uh is face genics doing this?
Speaker A
>> Who's doing this? >> Yeah. >> So hopefully any lab involved in this space is doing this. Hopefully any lab involved is looking at skeletal landmarks, is looking at the forces that need to be applied to the bone based on
Speaker A
the anatomy. But at the end of the day, the lab is always going to do what the doctor tells them to do. So to answer your question, like if you're a new doc and you just send out, you say, "Hey, I
Speaker A
want a custom," you're basically relying on the lab to do a good job. Like if you don't instruct them as to what to do, and they send back a case and and and you just approve it, well, hopefully the
Speaker A
lab did a good job, right? And that's honestly how a lot of docs start because they just don't know. They don't know what to ask for. They don't know what to look for. Uh they don't know what is
Speaker A
good, what's not good. And so, you know, that's why, especially if you're new to this game, it behooves you to use a lab that has some experience uh in this space because uh you know, you are going to be more likely to have success uh in
Speaker A
a lab that has had a 100 doctors call them and say, "Hey, this is what happened to my patient." And they're like, "Oh, shoot." And then they go back and look. They're like, "Maybe that's why that happened." So, this is a team
Speaker A
effort. We learn from the lab. the lab learns from us and and you know so when I send in a prescription I'm going to tell the lab what I want okay so maybe I want it more anteriorly placed maybe um
Speaker A
maybe I want you know even even a a counter action to an existing maxillary can't that I want to correct a little bit uh maybe I see bone on the x-ray that I want them to involve and so I'll
Speaker A
instruct that to them or maybe I send it off and when I get it back I see something I don't like or I do like so both of those things are happening but you as a patient you don't know you
Speaker A
don't know what the lab's doing you don't know what the doctor's doing. And so you are basically trying to pick a doctor that has uh enough experience and hopefully they use a lab that I mean most most patients don't even know what
Speaker A
lab their doctor uses, right? It's like you go in for a MARP, it's like you go in for an MSE, there's there's 50 labs that make MSE, you know what I mean? So it's like you don't even know. Um so
Speaker A
really you just need to find a provider that you can trust hopefully that has a bit of experience. Um you know, and if you have questions, there are options available. I mean we we do uh consultations for patients typically who
Speaker A
have questions either before they are expanded. So, we basically dig through their comb beam and we look a lot at a lot of these uh analyses and we say, "Hey, look, when they design your expander, you know, maybe consider
Speaker A
talking about X, Y, or Z. Um, or unfortunately, you know, when it does go south, you know, we look and we and we determine like, well, what went south?
Speaker A
Why did that happen?" Um, you know, I would say probably the vast majority of of what I know about expanders um have not come from my own complications. I've learned a lot from my own complications.
Speaker A
Don't get me wrong. I've learned a lot from my own complications, but I've learned a lot more in networking and partnering with labs and seeing doctor's cases who've had complications even more, you know, severe than the ones that I've experienced. And so, uh, this
Speaker A
is a a group effort. This is a team effort. We're all still learning. Um, you know, we want to provide the best quality of care possible. But, yeah, it's going to be a combination between what your doctor asks for, what the lab
Speaker A
produces, and then and then what what is said or the feedback that's given after that. Okay, that's all well and good, but hypothetical situation. I want you to be as non-politically correct in this answer as possible. Patient in some
Speaker A
random American city, let's say Bloxy, Mississippi, okay? Goes on getexpanded.org finds a provider uh in Bloxy, Mississippi, goes and that provider can either do a custom MARPY through let's say Partners Dental Studio or they can do an FME. and that provider
Speaker A
has no idea how to orient an appliance for an asymmetric skeleton like this patient that you just showed. Who's more likely to orient an expander in accordance with that asymmetry to counteract that asymmetry? Would it be Face Genics or would it be Partners
Speaker A
Dental Studio? >> Yeah. So, so truthfully, and I'm not trying to be politically correct, I don't know which one is more likely to orient it correctly. I feel like the orientation is is is good. um in both but but I if I had to pick between the
Speaker A
two I would pick the FME if that were the option if the provider like you know basically what you're saying is the provider doesn't know what they're doing which one should you pick the reason for that is not so much the orientation
Speaker A
although that's important the reason for that is the dimensional stability right so even if your orientation is is perfect if you don't have as much dimensional stability then the potential for unwanted movement can happen and so in that exact circumstance I would pick
Speaker A
FME over over custom MPY Um, but still I do a lot more custom harpies than I do FMEs. I mean, they're they're quite a bit less costly. You know what I mean?
Speaker A
So, we can we we can manage this. We can set it up correctly. I'm by no means saying you shouldn't do a custom RAP.
Speaker A
But, yes, there is, to your point, um, a benefit in going with a more dimensionally stable and and and properly positioned appliance um, if if you happen to be working with a provider that maybe doesn't have as much
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experience. >> Let me ask the question a different way if you would allow me. If you were to send in a prescription to both labs, Face Genics and Partners, and you were to tell them you want to orient this
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jack screw parallel to that asymmetric pallet, >> Uhhuh. >> would would Partners Dental Studio abide by that and actually send you that appliance and would Cameron at Face Genics do the same?
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>> Almost surely yes in both cases. Um, and but if they ever see anything that they know may not be a good idea, they'll probably call the doctor and at least have that conversation with them. Um, I know that Partners has called doctors
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before um because they've called me to ask if they should call a doctor. And so, like, you know, like I I I I know that this happens and I think that's I think that's wise. I think that's important. They're not trying to tell
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the doctor what to do, but they have a lot of experience in this space. And as a doctor, I mean like I mean the best thing you can have if you're going to jump into uh expansion is humility,
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right? The best thing you can have if you're going to jump into skeletal expansion is humility. None of us know everything, right? We are all still learning. I learn something new every single week, every single month. Uh and
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so like we are all still learning and and any information you can get from any source that's going to help you to make better treatment decisions, um I would I would take that. I mean I I've learned things from new labs that are getting
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into this space that I've collaborated with, right? I mean they don't even have a lot of experience but I learned something from them. Maybe they have a different way of designing it. Maybe they have a different software. Maybe
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they have a different uh you know like uh orientation technique or whatnot. So so you can learn something from everyone. Uh and that's my takeaway from that.
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>> Okay. All right. Thank you. >> So yeah. So orientation here. I mean they're going to be lining it up uh with you know basically with with the skull and and I don't want to dive into too too much details as far as uh the
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different landmarks because that will I know turn into a very long conversation. But if you guys want to circle back on that, we can go into skeletal landmarks in detail. Um I just don't want to do it a disservice. So just uh know that we're
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looking at multiple skeletal landmarks. Uh we're meaning the lab and as a doctor confirming that these landmarks are correct in order to orient this expander. Uh and then these views are going to give you a view of the depth at
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the cross-section. You can see this is the bone. This is the soft tissue here.
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This shows you how much those uh tads are projected to be by cortical. Uh this shows the cross-section directly through that angular lateral tad. So you can see the actual length there. This shows the other side. So, we're looking at the
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patient's right side here. So, these are the back three tads. This is the uh the front tad here, cross-sectioned at that level. So, you can see how much bone engagement there is. It looks like 9 and a half millimeters there. And it's
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extending past 2.1 mm when it's fully locked into the anchor body there. Um this is what it looks like when it's oriented to the skull as a whole. Um uh and so like this, this shows you the screws protruding and those angulations
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that are there. Uh this is a closer up view of the you can see the uh medial uh lateral angulated um tads in the front and then the straight ones in the back.
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This is from behind showing you the level at which it's set on the pallet both the soft tissues and then you can see it going through the soft tissue into the bone there. Uh and and again um how that looks relative to the actual
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pal tissue itself. And then this is basically looking from inside the nose and you can see that midline pal suture.
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In this case you can see that this suture is a little bit thicker. It comes up in the middle there. So all of this resistance has to be overcome in order for this patient to expand. Uh and then
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they go through, this is just the parts list. Uh it tells you the diameter of the tads, the length of each of the tads, and then what it does is it goes through each and every tad and it shows
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you three different cross-sections of that tad. So you can look at these in as much painstaking detail as you want.
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It's going to go through each eight or 10. And at the end of the day, if you plan this out right, when you uh get the expander and you place it in the mouth, it should look pretty darn similar to
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how it did on on the setup there. So that's the goal. >> All right.
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>> Okay. So, >> and and obviously you have the surgical guide to make sure that you get it dead dead on, right?
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>> That's not shown here, but yes, I mean, we can go if we want to go through we can do a whole another thing on uh placing anchor bodies and the surgical guides and the steps that are involved
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and locking the heads and the tads and placing the screws over top of that.
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Yes, there are multiple steps involved in the actual delivery of the FME appliance that ensures what you planned actually ends up in the mouth where you planned it. Um but but yes, at the end of the day, through all of those systems
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in planning and execution, you should have an FME that's right where you planned it. All right. So, >> and when people say when when people say, "Why not just do an armless custom?" What I say is, "Well, how how
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the hell do you place an armless custom if you don't have arms going to the teeth to orient it?" Because the custom doesn't have a surgical guide, >> right? Yeah. So, so that's exactly correct. And you can place a custom
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MARPY with some type of Essex or guided splint. they can make those for you if you want to. But I feel like the teeth do actually provide a level of dimensional stability as well in addition to the tads, right? Because
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you're connecting to hopefully the same amount of teeth on the right and the left side, approximately the same AP distance, right and left. Um, so that should provide some additional dimensional stability while you're attached to them. I know you're not
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going to be attached to them the whole time, but at least while you're overcoming that initial uh midline resistance. uh in my opinion that can help especially with a type of expander that doesn't have inherent uh you know
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dimensional rotational stability uh to begin with. >> Okay. But that's that's an argument as to why arms are actually useful, not an argument as to how you can get away with doing a custom RP without arms.
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>> Right. Right. That's correct. But just know that you can if you wanted to, you can do a custom MPY without arms. There's there's multiple ways to do it. Some people place the TADS. Uh they do it a
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lot in Europe. Uh the benefit system is a popular one. uh you can look that up, but basically you place the tads first uh and then you scan and then the appliance is made over top of those tads
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and then you deliver that in the mouth. So there's multiple ways that you can do a non-toborn MARPY besides Face Genics.
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Uh so so that's not impossible. Um but for the reasons I just talked to you about like I I choose not to do uh non-toborn expanders in general.
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occasionally um I will do an MSE uh that is not toothborne or that I use the uh the teeth to place and then immediately cut the arms um when when I have severe dental tipping already and I know I just
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need to move the bones out and again it's in a teenager where where the risk of asymmetric expansion is much lower.
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So I probably do I don't know maybe a few of those a year. >> Got it.
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>> Yeah. Okay. Perfect. So, let's wrap up because I do want to talk about the FME Pro and I'm sure people are interested and and for many people this will probably be their first look at it. So, I just want to point out a few of the
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the design features. So, FME 4.5 I mentioned added this plate that goes over top of this anchor body. So, before it's set into the anchor body FME 4.5 now it goes on top of the anchor body.
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FME Pro, they are now adding a basically a sleeve to lock it in both the outside and the inside as you'll soon see of the anchor body. So now you have this screw basically having rigid metal pieces that
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extend past the flange of the anchor body on both the outside and the inside of the FME again to hopefully provide the most stability of expansion possible so that those anchor bodies cannot move except for parallel to each other like
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we showed in those ideal animations. And so this is another look at that here.
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Here is the screw and you can see the portion of the FME screw itself that is uh extending onto the uh lingual side or the or the the medial side of the anchor body here. So you have this on the
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inside and you have those little arms here or these little wraparound design here on the outside. And the idea is this is locked onto those anchor bodies and again adding two more layers of dimensional stability to where this has
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to fail and this has to fail in order for the dimensional stability to be lost. Now, can it fail? I don't know.
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That's why it's only FME Pro. It's not FME Pro Max. I'm sure. I mean, I'm not sure, but likely there will be a patient it fails on. And then what's going to happen is, okay, we're going to go back
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and we're going to look, well, where did it fail? And then and then again, maybe they'll redesign it again with hopefully even more dimensional stability. So, um, any questions on that? Yeah, I think that we we made it, Ron. We made it. So,
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any questions on that? And, uh, and then and then I can I can wrap you up with, uh, some ways if people want to stay in touch.
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>> Yes. Uh my question is I guess I'm having a hard time visualizing how the FME Pro uh is an upgrade. Uh uh I'm having a hard time orienting myself around what exactly is going on with it.
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Can you maybe try explaining it to me like I'm a four fourth grader? Okay.
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Yeah. So first off, we're we're looking right here at the anchor body. Uh so here are the anchor body. Let's see. The pink is the anchor bodies and the blue is the screw that goes on top. I think
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the biggest challenge is I don't have a picture of just the anchor bodies. So you can see what they look like before the screws placed on it. But if you can imagine this um this little piece being gone and you could just see the pink
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piece underneath. It's basically a piece of metal here and a piece of metal here.
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And then this screw kind of sets into it. Okay. A and this is an FME 4.5. So that FME 4.5 screw sets into these two anchor bodies. So it's a separate piece and it has separate screws and it screws
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not into the pallet but it screws into those two anchor body metal pieces. So, these are screws that go into the pallet uh that that traverse through the anchor body here. These screws screw this FME piece onto the anchor body here. So,
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what you'll see in the FME 4.5, there is no extension past the anchor body. I can't really blow it up, but this is the uh this is the FME screw. The anchor body is right here. They are flush. So,
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this does not o overlap at all. It sits on top of it. Okay. Mhm.
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>> So, so, so basically when we get to FME Pro, what we're seeing here is now instead of sitting flush on top of it, it's still sitting on top of it. This is the screw. This is the anchor body, but
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we have this added area of metal here that actually goes down and overlaps the outside of the anchor body. So, instead of just sitting flat and then sitting inside of the uh of the anchor bodies, now on this is the outside of the anchor
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bodies, there's a piece of metal. So, if this anchor body were to try to move toward us, like it moving out of the screen toward you as you're watching this, the these little flanges right here prevent that to some extent from
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happening. So, this blocks it. So, if this tries to wobble, for lack of a better description, this helps to decrease the chances that that will wobble. Now, if this were like all the way this big, that would decrease the
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chances even more, right? So, you know, this is a small piece, but that's the idea behind it is that it overlaps this surface at least to some extent. So, if this ever tries to bend, this is like locking it in. It's basically a U. It's
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like here, and then you go to the inside and and the other side there's a metal piece, too. So, it's like a U-shape.
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It's like a U fitting on top of this. So, this really the idea is that it can't wobble. Does that make sense?
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>> So, are there specific types of asymmetry that this would prevent? >> Yeah. Well, any any type of asymmetry that that that wobble would be introduced. So, so wobble, we're talking about like this, right? So, if the expander can wobble, then just like in
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those animations, it has the potential for the inside of the bone to move down and for vertical changes to happen. All right.
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>> Oh, it's the it's the bulging effect that we saw when the when it bulges off of the pallet downward.
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>> Yes. So, basically, if it wobbles, then you have this screw going out, but you have the anchor bodies bending. Those screws are attached to the bone. So, then the bones bending and it's almost creating this, you know, basically force
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where you're having more of a vertical effect. and it's essentially pulling the expander away from the pallet but taking the bone with it and the bone is bending and we see vertical changes but not as much lateral change. So this idea is to
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prevent that to where if you get to that point and it might the forces might be too high you'll either a not be able to turn it or b if you do turn it it's going to just basically keep going this
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way and and and jackhammer its way through the bone but not move it um versus actually bend or move the bone if that makes sense.
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>> I I get it. I get it. Wow. >> Wow. Impressive. >> Yeah. So again, and this is I believe they will continue to innovate until they have probably I don't know 50 patients that they don't have any
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failures on, then they'll launch it. I mean that that that's what what I think.
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Um but yeah, I mean I know we're shy on time and so if people want to stay connected obviously make sure you subscribe to the channel. We put a ton of content uh both expansion related and not. If you want to check out that um
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force control polyyclic turning protocol and read some of the research on that, you can check that out here.
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>> That's the Vegas Orthodoc YouTube channel. >> Yeah, that's the Vegas Orthodox YouTube channel. That's correct. And then this is the Vegas Orthodoc website if you have questions about your own case and you want to upload your records onto
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that site. Um that is now available. So uh we've had a number of patients take advantage of that. So you can check that out if you're interested there at vegas.com.
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>> How does that work, doc? That's uh they submit their information and then they get the pre-recorded video from you uh giving them a kind of a download of what's going on with them.
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>> That's correct. So, basically, they'll send in a CBCT, they'll send in photos, they'll send in a a history, they'll send in their concerns. Uh, and then I'll I'll dig through everything and send them a video of my thoughts on
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their case, and if they're a good candidate for X, Y, or Z type of expander, or if they're having trouble with sleep, like maybe offer some solutions that they hadn't thought about yet. And a lot of times it's
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conservative solutions, doesn't involve expansion at all, just things that, you know, had never been brought to their attention or mentioned to them. Uh, so basically whatever their concerns are, I try to uh address them to the best of my
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ability, send them a video back, and then if they want to connect further, we can schedule a live Q&A call where we talk about anything from the video or or anything else that you might not have mentioned that you want to talk about.
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So that's kind of how that works. >> Got it. Sounds good. >> Yeah. This is for my my practitioners out there, the orthodontists, dentists, oral surgeons, periodontists. Uh, come out and learn more about expansion. U, you know, many of you, especially
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orthodontists, know who Steu Frost is. We're doing a course together. This is uh the first time I have offered an in-office hands-on course um uh ever.
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And so I I partnered up with Stu Frost to do that. We're going to be talking a lot about Marpy and skeletal expansion, but we'll also be talking about um TAD mechanics and advanced aesthetic uh options, gummy smiles, uh reverse gummy
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smiles or what we call undercover smiles. Uh and then creative ways to use tabs, uh TADs to solve other problems.
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will have pig jaws there so you can um actually get experience working with a PAZO unit and also um actually screwing TADs into bone. So a lot of practitioners have never done that, right? So we'll go through all of that
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and equip you hopefully with as much as possible to put you on your way to success not only with MARPY but with TADS. Um of course we have to give a plug for the symposium that's happening in April. Uh and so we are super excited
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this year we have a periodonist coming and we also have an orthodontist who's well versed in SFOT coming. Uh so any of our docs out there or other uh uh health professionals that want to uh learn more about the latest and greatest in all
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things MARPY SFOT uh and research go ahead and and get make sure you get signed up. Uh we already have >> any surgeons any surgeons at this year's conference.
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>> Last year we did surgery. This year we're doing uh pererryio surgery. So we have a periodon actually two periodonists coming. Uh Mandelaris George Mandelis is coming and he's going to be talking. He's basically the the you know the father of SFOT for lack you
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know basically. Um and so he's going to be coming and talking about that procedure uh specifically and some of the newer research that hasn't even published yet on it. So we are super excited to have them out. Um in addition
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to Rick Robbley, uh he does a ton of Marpy and also SFOT as do his two boys.
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They have a course in November which I'm actually attending myself. Like I say, we are all still learning. So I haven't taken their course yet. So I'm excited to take that in uh in November out in Arkansas. So, if you guys want to join
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me in that, hit them up and I would love to I would love to be there with you to learn with you. And of course, I have an online MARPY course for those of you who have a harder time getting away from the
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office. Uh you can email info at Vegas Orthodoc for more information about that. It's about eight hours of uh of CE there that goes through all the different types of expanders uh and also uh kind of airway uh and and expansion
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physiology. How the diagnosis of it like how how do you diagnose if you even need to expand? How do you decide how much to expand? How do you analyze these records? How do you do 3D superpositions? We cover it all um in
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that course. >> You forgot one other thing, doc. Besides the book, we'll get to the book in a sec. You forgot if people want to talk to you, they can also uh sign up for the joint, the Jaw Hacks joint, the Jaw
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Hacks coaching portal where you where you'll be coming in to do a live event with joint members sometime in the next uh 30 days.
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>> Yes, I am super excited. I mean, at these events, we get some of the [laughter] best questions that are asked possible. Let's do it. I'm on the books.
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Let's let's schedule it. We get some of the best questions uh from um your listeners that have done such a deep dive in so many different areas. Um honestly I get a sometimes I get better questions at those type of events than I
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do at Dr. CE events truthfully. So >> well the joint is uh it's a powerful powerful uh group of people all extremely highly intelligent uh all people that have um you know spoken with me. Uh I'm I also learn from my clients
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more than I learned from anywhere else. And so uh what we found so far is that all of the live events in the joint are the best jaw conversations and airway health conversations that a lot of these people have ever had. and in a unique
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format, right? Usually people are used to having these sorts of conversations on Discord or on Reddit where it's just a thread where you don't actually see the people or speak with them synchronously. Uh and in the joint, it's
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a it's a live video call with people like you plus a lot of really awesome uh highly intelligent experienced members that have gone through some of these procedures or are thinking of going through them. So yes, it's going to be a
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great conversation inside the joint when you come in. >> Amazing. I am super excited. So we will do it. Uh and then lastly, um so I do have a patientf facing uh book coming out by the end of the year. Uh so the
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details are here. So if you want to pre-order it. Basically this book, my intent with this book was to hopefully dispel a lot of the myths that are out there about maxillary expansion in general on both sides of the aisle. It
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does work, it doesn't work. Try to bring some science to the arena. But honestly, mostly what I'm trying to do with this book is help patients to find what they need to do to get better. So we go
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through a number of patient experiences from start to finish and where we ended up. Sometimes it's expansion, sometimes it's, you know, inspire, sometimes it's myofunctional therapy, sometimes it's nasal dilator, sometimes it's lip taping, uh, you know, sometimes it's PT.
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You know, there's all sorts of these different practitioners that can help people. And and as you learn to network with these people, you learn a little bit more about what they do. And so we'll go through stories, we'll go
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through symptoms, and we'll go through like real world experiences. And my hope is that if you read this, you can find yourself if you're struggling.
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Hopefully, you can't find yourself. Hopefully, you find nothing and you're just like, man, it sucks for all these people who are are struggling every day.
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But if you happen to find yourself in that category where you are struggling on a daily basis and you feel like you've like left no stone unturned and you don't know like what what do I even do? I've tried everything. Hopefully,
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this book will give you some hope and and be able to steer you in some type of direction that will actually lead to meaningful change within your life. So, if you want to check that out, again, the book should be out by the end of the
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year, but we're taking pre-orders now. >> Awesome. Dr. Manueli, thank you so much. Thanks for your time today, and I look forward to the next one.
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>> Thanks so much. Appreciate you. Have a great day.
Topics:FMEmaxillary skeletal expansionskeletal expansiondental expansionorthodonticsadult expansionFME Proorthognathic surgeryairway analysisorthodontic devices
