Got MSE today; DOME next week; protraction experience anyone?

Where would you connect the elastics for extra-oral traction? Typically there will be J hooks off of the molar bands on an MSE if protraction is indicated. Also, do the TADS on your MARPE have bicortical engagement, extending from the roof of the mouth to the floor of the nose like an MSE, or are they relying on the surgical release to reduce the resistance making that less necessary for lateral expansion? I could see TADS tilting forward if you're connecting elastics to the molar arms or elsewhere and there's not bicortical stability.

@apollo There are hooks on the molar bands (see attached photo), and thankfully the screws are indeed engaged bicortically (this was something my ortho discussed).

I'm also going to get bollard plates on my mandible, between the lateral incisors and canines, for anchorage, so that I can have almost constant protraction via elastics.

You can probably tell from the photo that I need quite a lot of transverse expansion; it's possible that the first MARPE appliance isn't enough and I'll need another one after maximizing the first one.  My lower IMW is over 50 mm, as measured between the inner cusps of the first molars

Nice! So the Dome procedure will release the midpalatal suture and the lefort 1 zygomatic buttress cut. Will it also release the pterygomaxillary junction? I wonder if your providers are worried about the extra-oral traction inducing a traumatic fracture and excessive maxillary mobility. I guess they wouldn't have put the protraction hooks on if they thought that was a real risk.

I did try adding facemask with my MSE, but my separation was facilitated by only midpalatal cortipuncture. If I got any sagittal displacement it was modest. I would have liked to try bollard plates, but that wasn't something my provider offered.

@apollo No, there won't be any surgical pterygomaxillary disjunction; just the midpalatal and buttress releases, like you said.

My ortho said to expect maybe a couple millimeters or more of forward protraction; the surgeon performing the DOME said "don't count on" any protraction but he wouldn't be surprised if I got a couple mm (I guess he's more skeptical).  It can't hurt to try, of course.  My ortho did say something about how the transverse expansion may induce some loosening of the pterygomaxillary junction just based on the transverse movement, so we'll see

Ok, DOME is done, and the turning hs begun (total of 1.5mm so far).  I should be able to begin the elastics very soon; you can see part of the bollard plates in this picture:

@mr_man can see more of a central diastema already!

@apollo Yes!  It's bigger now of course; I'll eventually be putting more pictures up.  That's one of the advantages of DOME -- not having to wait for the diastema, because the orthodontist turns the screw while you're under anesthesia at the end of the DOME procedure, to make sure the diastema appears

Happy 4th everybody! 

Here's where I am with the turning; I'm less than halfway through but you can already see a ton of transverse progress.  In the forward direction, it's hard to guess how far I've moved but I'm guessing 1mm so far.  It's also difficult to tell how much forward movement is affected by the intraoral elastics vs simple geometry of the upper jaw expanding, but either way is good

For reference, here is CBCT snapshot from about a year ago of most of my face (left side).  You can see why I need much transverse expansion, as well as any upper forward displacement I can get.

Also notable are the plates and screws (which were put there during the DJS 25 years ago).  During the DOME procedure I had a couple weeks ago, most of the lefort plates/screws had to be removed for obvious reasons

Hopefully I'll be getting more CBCT scans or xrays soon, so that I can see the new progress on a skeletal level

Has your breathing improved from this procedure?  Is your expansion symmetrical?  

My breathing is slowly getting better in my left nostril (which had usually been rather blocked before); my right nostril was already fine.

The expansion seems to be symmetrical so far.  I do have a bit of asymmetry to begin with but the expansion thus far has appeared to expand evenly on both sides, so the initial asymmetry is just maintained as is

FYI, this is how it looks now:

Do the bollard plates on the mandible feel to you like they're pulling back, or putting too much counterforce, on the mandible itself? I've heard this as a concern before while researching bollards for maxillary protraction. 

@grow-your-face   Funny, Ron Ead asked me the same question within his youtube comments.  Here is my reply:

reply to @Jaw Hacks  I see what you mean. I do feel a little bit of force pulling back on the mandible. I don't have TMJ or anything like that so the force on the mandible doesn't bother me.

The force is pulling on the upper jaw forward but also downward by about 30°. I think in my case this works, because although my maxilla is somewhat recessed, it's pretty far upward (i.e. it's already counter-clockwise enough, perhaps even a little too much). Combine this with my substantial lower jaw (I'm not afraid of inadvertently moving it back a little), then I think the orthodontist's and surgeon's plan makes sense for me.

Doing the same for [other people] might not work due to [others] potential need for counter-clockwise rotation that I don't need and my substantial lower jaw.  But if it results in maxillary protraction, then it still might be worth the issues it could possibly cause with the lower jaw. 

If my apparent forward maxillary movement did in fact work (I'll hopefully find out for sure when I get the next CBCT), then the elastics did indeed work as intended, and will have resulted in maxillary protraction without having to use a facemask

It's been quite apparent to me that my nasolabial/paranasal area of my face has become more prominent (kind of like a lion or any other cat).  Of course, some of this may be due to swelling, since the bone along the lefort 1 line is still healing, but I can feel when I tap on this part of my face that the underlying bone is also more prominent than it used to be.

This is a good thing, in my opinion, as that area of my face used to be kind of flat or even sunken in.  Plus, when I smile, my nasolabial folds are less noticeable.  Since I'm 45, those folds (a.k.a. smile lines) used to be quite noticeable.

Here's a before pic:

 And after:

 I wish I had a before pic with the same lighting/angle, but this should give an idea what I'm talking about. 

Also, here's how my teeth look now with the progress of turning the MARPE: