upper and lower ALFs, tongue tie release results

Thanks for sharing your story! Your maxillary arch definitely looks wider. You said that your mandible has protruded, but do you think that your maxilla has had any forward changes? Are you sleeping better?

Maxilla has come forward a little, but I think 90% of the expansion has been transverse. Some of this was by design (the dentist did transverse-only adjustments for the first 8 months), but now he is trying to shift the maxilla forward and it is just...really slow going, even with proper oral posture.

Yes, sleeping much better! I haven't had a second CT scan yet but my dentist thinks my airway has approximately doubled. Other benefits: jaw never clicks anymore, can open to 50mm (previously 30 mm), can lay on my back with chin tuck and tongue in "the spot" and breathe out of my nose, and lifelong post-nasal drip disappeared.

I attached a current pic of my bite with mandible in relaxed/forward position.

@therose would love to know where you’re currently at, since 2 years have passed since this result photo was posted. 

My mandible is very narrow and I require significant lateral width expansion. I’ve read threads saying the ALF won’t give me this. I’d love to know what you have to say.. 

Fortunately this story has a happy ending 🙂 Everything I complained about earlier did end up getting fixed, though it was slow. I've had my ALFs off for 16 months, and in total I had them 2 years 9 months. My molars did erupt a bit, upper front teeth moved out a few mm, and my bite is fine. I still have some gaps but it was my choice not to continue with Invisalign to fix them - I hate Invisalign, it feels "compressive" rather than the expansive feeling of ALFs.

I also ended up getting CATS cranial chiropractic treatments which I feel were more effective at releasing the last remaining maxilla tensions than cranial osteopathy. I can breathe great now and have no more headaches, jaw pain, sleep problems, or trouble breathing. Overall ALFs were amazing for me, my life is changed. If you can't breathe, life sucks.

One last thing I want to mention is that I often read people criticizing ALFs by saying that they "only tip teeth" but when I was at the ENT about a year ago, without my mentioning anything about my ALFs, the ENT looked in my mouth and said "oh, I see you've had palate expansion surgery." I told him it an appliance from adulthood and he was pretty surprised. Anyway, if all ALF did is tip teeth than I don't think the ENT could have made such an observation.

@therose

awesome to hear the good news! I’m on my second adjustment of ALF plus close to a year of mewing and I’m seeing results, my Face is starting to look how it used too. 

Yes ALF takes time but from what I’ve seen from Dr. Bronson (the same doctor you and I see) the maxilla really does expand with minimal tipping. I believe Dr. B is the best ALF practitioner on the planet hence why he is hard to get in with. 

Did you have any neck pain before treatment? If so is it resolved. My neck pain is my only issue pain wise.

Was your initial treatment time projected at 2 years 9 months? Mines only 18 months.

Did you see a myofunctional therapist?

Posted by: @therose

I also ended up getting CATS cranial chiropractic treatments

Can you briefly elaborate on what the CATS treatment entailed? The information on it is very scarce.

@robbie343 so you and @therose are both seeing Bronson in VA?  And are both adults?

That’s good to know - I’m very near his offices.  I did start down a path with a DNA provider in the DC area but if ever I were to feel I needed to switch out of that then ALF would be what I would look into. I kind of regret not going and at least getting a consult with him before getting started with DNA (not that I find anything wrong with DNA).

@therose - if that chiro is near Bronson’s area anywhere, I’d love to know who that is you’re working with.  Right now I have an osteopath, but am always keeping my eyes open.

@toomer

I am 33 and see him in Santa Cruz California, he flys out once a month to see patients here. 

@Robbie343 I think all of my pain was in my jaw, head, and upper back actually. My projected treatment plan was 18 months, too. That was the reason for my original post - I realized I wasn't anywhere near done at 2 years in and started to panic. My upper front teeth were just so stubborn about moving forward but they finally did enough to accommodate my released mandible position. Dr. B made it happen 🙂 I went to Kathy for myofunctional via Skype, if you're in Santa Cruz she may be local to you?

@toomer I was 33 when I started and I saw Dr. B in Charlottesville, VA where he goes twice per month. The CATS practitioner I traveled to see for a 2 week intensive session in White Lake, Michigan. CATS started in Toronto and it seems like all of the really experienced chiros who adjust facial bones are in Canada or the upper Midwest.

@progress CATS adjusts bones in the skull and face with force. Most American chiropractors don't believe the bones of the skull can be moved let alone American MDs, but for sure they can be. CATS isn't like craniosacral or cranial osteopathy - it was so high force I often wondered "how the heck is she doing this with nothing but bare hands?!" but it feels soooo good. CATS level 1/2 practitioners don't adjust facial bones, though, so you need someone very experienced to work around the maxilla. During my 2 weeks of CATS, I had 3-5 adjustments per day. They take about 15 minutes each. I believe the vast majority of people who go in for CATS are complaining about headaches that have developed from concussions/accidents. I believe I had two untreated concussions under my belt when I showed up, both from accidents as a teenager.

The most surprising part of CATS for me was how it straightened out my nose. I broke it badly as a teenager and had a corrective rhinoplasty about 6 months later, but even after ALF I couldn't breathe well out of my nose which is why I visited the ENT a year ago. The ENT said I had complete nasal valve obstruction on one side and compensatory valve collapse on the other. He was very hesitant to do another surgery because the cheek parts of my maxillary bones were so asymmetrical - he said it would be like "building a house on a bad foundation" and that my wonky maxillary bones are why the original rhinoplasty failed. During my time at CATS, I probably had about 15 adjustments on my nose in which she moved the nasal bones ever so slightly each time. I was terrified prior to the first one, but it didn't hurt at all, and by the end of the two weeks I could breathe easily. I wish I could stand on rooftops and yell "hey broken nose people, don't bother with surgery, go get CATS!"

Anyway, if I may get philosophical for a moment, I should mention that when I began this journey for airway improvement, I believed that ALFs were the ticket and that tongue tie/lip tie release and manual therapies would solely function to support the ALF. But in retrospect, I see ALFs, tie releases, and CATS as three legs on a stool, and the stool fails if any of the three aren't there, at least for my situation. I was born with severe cranial asymmetries in the back of my head, something that won't apply to most of you so who knows which legs of the stool you'll need. 

@therose

yes I’m seeing Kathy. She’s a wealth of knowledge. She explained to me exactly how I my problems started and they pretty much line up to everything I’ve read on here and by the Mews. Glad to hear your pain is gone. 

Dr. B also told me to be prepared for longer treatment time if necessary. 

@therose Thanks for sharing your story, very interesting. Do you have any advice for finding a CATS practitioner? I'm located in Illinois. It seems awfully esoteric and difficult to find in the area.

@pizzaman500 When I was looking, I called/emailed about 10 chiropractors based on how prominently CATS was featured on their website. It was not easy to find someone. You could try asking Dr. Turner (the guy who created CATS) but I believe he retired.

Posted by: @therose

I attached a current pic of my bite with mandible in relaxed/forward position.

So in that mid-treatment photo, it looks like you have a posterior open-bite, you're tip-to-tip on the incisors, and you have maybe a little bit of a maxillary cant?

And all this got resolved by the end?  That's awesome.  It isn't 100% clear in the current photo you published because we can only see your upper teeth ... but if all of that got sorted out by ALF, I'm really encouraged for my case as it closely mirrors yours (with the exception of the cant).

@toomer No, the cant (and underrotation) are still present. In the pic I just snapped below, my mandible is in the same position as in the mid-treatment photo. Since that mid-treatment photo, my 4 upper front teeth were moved forward with my second set of ALFs until I looked like an AGGA person - I had a gap of about one tooth length between those teeth and premolars/molars. Then ALFs came off and he pulled my premolars/molars forward slowly with Invisalign. Originally this last phase was supposed to happen with TADs but at the last minute there was a switch to Invisalign.

Even though the cant wasn't corrected, I suppose the important part was getting the upper arch forward enough to accommodate the released mandible. Hopefully I can get someone at their office to give me copies of my CT scans to share here, I think those are more useful than cell phone pics. I was told when my final CT scan came in that my airway expanded from 3mm to 10mm in diameter. My IMW was never officially measured, but I kept track of it and the last night guard I had before starting ALF showed width of 29mm, and my last Invisalign tray 36mm. I measured from center to center of my upper 1st molars. 

I do still have an overjet too but that is unavoidable because my lower arch is way smaller than upper. No fixing that now, but doesn't matter to me because I no longer have pain/discomfort/sleep problems and that's "good enough". A long time ago I ordered a Starecta and if the motivation ever strikes me, might try that as I think some people have had luck correcting maxillary cant with it.

@therose

Thanks so much!  That really gives me hope!  I'm in the "mandible in forward position" stage right now, but my mandible came forward 3-4mm (according to my regular cleaning dentist) which pretty much ruined any/all hope of occlusion for the time being.  So it's been a bit anxiety-inducing so far.  So it's so great to see that you eventually got the forward growth and got your upper teeth back in front.  Honestly, it's a great looking arch -- I wish I'd stopped in to Dr. Bronson's office to speak with him.

I'm with you, functionality over all else!  I just want to be able to breathe and sleep normally.  If I ended up with a little bit of a cant, or a slightly off-center bite, or some gaps ... as long as everything works well ... I wouldn't care much about how it looks.  The good news is that I had another airway scan recently from a different provider, and the lower 1/3rd of my upper airway looks wide open now.  So now we just need get to the middle 1/3 and upper 1/3rd (nasal area) opened up with working on the maxilla ... and then maybe I can take a sledge hammer to my CPAP machine.

How long did it take to haul the molars forward with Invisalign?  Seems like that would be a somewhat lengthy process given that they've got some serious roots.

The Starecta scares me a bit.  I think it should only be attempted in partnership with both a dental and postural specialist or osteopath.  I was reading their website, and part of the instructions seemed to be "stand up straight, in good posture, and then register your bite" ... and given everything I know about all of this now, I have to say that seemed a little bit scary to me.  Although I wasn't looking into it for correcting cants, I was reading a bit for a friend who has scoliosis.

@toomer Sounds like you're in the "oh shit, how am I going to eat?!" phase of TMJ decompression 😆 But it will get better! Dr. B put composite on my molars and/or premolars pretty much every adjustment at this phase which helped me chew with the weird bite.

I think I had 10 Invisalign trays and wore them for 2 weeks each, so something like 5-6 months? This stage was surprisingly short. Maybe when Robbie gets to this stage with Dr. B he can enlighten us on how it actually works because it seems like there's nothing to anchor against.

Starecta scares me too and if I were to give that a go I'd do it while checking in with Dr. B. I actually showed it to him when I first got it and asked if I could raise my bite height with it instead of/in addition to composite...he said not while in ALF because Starecta locks everything in place while the whole point of ALF is to let things move. Which makes sense, so I dropped it. 

@therose

So just to make sure I understand your outcome fully - I assume you do not have build-ups on your molars or pre-molars anymore now that you’re done?  That your bite is 100% your own teeth?

it would be hard to imagine doing Invisalign over build-ups I suppose ... but yeah, I wonder the same thing, how do they haul those molars forward with their dual roots, without causing any retraction in the front?   Interesting...

@toomer Correct, no build-ups now and none during Invisalign. The composite served as a temporary bite opener when my mandible first released during mid-ALF. When my ALFs first came off and I started Invisalign I had fairly different mandible positions for "rest" vs. "chew" and those positions slowly merged as I went from tray to tray. Nowadays I do not htink my molars are optimally extruded but they did extrude some through the ALF/Invisalign process.

Posted by: @therose

My IMW was never officially measured, but I kept track of it and the last night guard I had before starting ALF showed width of 29mm, and my last Invisalign tray 36mm. I measured from center to center of my upper 1st molars. 

Been pondering this point a bit ... and I find if interesting for a couple of reasons:

1) You measured from the center, which is probably as good as you can accomplish for an at-home measurement.  Some critiques of these appliance strategies (which I think are fair comments to make) is when providers measure from "cusp tip to cusp tip" on an x-ray or a mold ... because then you could just tilt the crowns outward by pushing on them and show a patient a few mm's of "improvement" ... but the teeth haven't actually moved.  Measuring from the center is probably a little bit better as you're closer to the CEJ which is a more traditional measurement point of bone growth (worth adding into the discussion, CEJ is what Vivos uses in its Airway Intelligence Reports for patients ... not cusp tips).

2) Since you got a net of 7mm of expansion, and assume it's not due to tilting ... if we assume it was roughly equivalent expansion on each side that means the teeth were moved 3.5mm outward.  This is an important consideration IMO because critics of a lot of these appliances will also say that it just moves your teeth out to the edge of the alveolar ridge, or potentially too far and out of the bone.  While I am absolutely not a trained medical expert ... I do not think there is 3.5mm of alveolar bone in front of each tooth to move them out into.

3) ALF is a permanent appliance, but there are opinions out there that more on-and-off protocols that cycle the body are better at bone growth.  Dr. Ben Miraglia in NYC is using "modified Schwartz" appliances for adults, and advocates an overnight wear plus on-and-off an hour at a time (as much as possible) throughout the day.  Based on his research and talking with orthopedic surgeons he says he believes it is the "cycling" of pressure and tension off and on in the jaw which leads to the most bone growth.  But providers that follow this approach typically aim for 1mm expansion per month advancement schedules (for example, Vivos DNA default approach is usually one turn which is 0.25mm every 5-7 days).  

Did your doctor ever give you any clues in terms of how fast he was trying to expand you?  I think there's an interesting question to ponder on how much the body can absorb and adapt to with a permanently in-place device, vs. a removable one.  If I just do some basic math on your case, you were in for 35 months and got about 7mm of expansion ... so that's roughly 0.20 - 0.25mm per month. Definitely very slow, but maybe that's also within the realm of what the body can tolerate on its own and expand naturally under constant (instead of intermittent) force.

All great stuff, thanks again for coming back and sharing your story!

Great thoughts.

Not sure if I mentioned it on this thread yet, but to me one of the biggest arguments against ALF "just tipping teeth" is that ALFs rest on the gumline, they aren't centered on the tooth applying force like traditional braces. And they are sooooo flimsy, when holding them you just don't get the sense that they could brute force anything to move anywhere like braces.

My dentist didn't give me numbers or time frames, but by my perception, I got all of my expansion within the first 8 months. After that, tongue tie and lip tie release, and after that began the glacial forward march of my upper incisors to catch up to my released mandible.

Regarding expansion speed, I can't remember who said this exactly, but one of the airway dentists once stated that in adults, faster expansion encourages the cheekbone part of the maxilla to "come along for the ride", whereas slow expansion does not. The number that pops into my head for what he considered fast expansion was 1 mm per week. He said the reason dentists expand typically at 1 mm per month in adults has more to do with convenience (since many patients travel far for adjustments) than with physiological limit. I don't recall whether fixed vs. removable appliances were part of this particular discussion.

And I also can't remember who specifically said this but I do remember on a podcast or something one of the dentists saying "just about any of these appliances can expand adults. It's not hard and can be done even with appliances that have been around for 50 years. It's sagittal movement that's the hard part." If anyone recalls who said any of this stuff, please let me know 🙂

Posted by: @therose

My dentist didn't give me numbers or time frames, but by my perception, I got all of my expansion within the first 8 months. After that, tongue tie and lip tie release, and after that began the glacial forward march of my upper incisors to catch up to my released mandible.

Oh, interesting.  So your lateral expansion was more or less done in 8 months ... which actually would work out to more like 1mm per month.  And then all of the remaining 2 years of time was just for the forward development of the maxilla to occur, and subsequent reductions of the build-ups on the molars?  Was your provider still adjusting your ALF at all, or was it just static in-place at that point to make sure there was no relapsing while your tongue was doing all of the work?

@toomer

Let's see, the first 8 months was expansion and the last 6 months was Invisalign. That leaves around 1.5 years in the middle of bringing the upper incisors forward. I should've had ~18 adjustments during this time but I ended up having only around a dozen because I missed adjustments when my upper appliance broke (twice!) and had to go back to the lab for repair each time, plus a few other emergency cancellations such as snowstorms. Each time I missed an adjustment I'd have to wait a whole month because I was out of the satellite office. During the times my ALFs were out for repair, I never relapsed - they fit perfectly even after being out for a month. The forward adjustments were just really slow compared to the progress rate of expansion.

@therose And with the forward expansion phase, I assume he was reducing the molar build-ups each time?  If so, how long into that 1.5 year part of the process did it take before he was no longer adjusting build-ups in the back any longer ... that he had adjusted them back down to just your normal teeth?

I guess in addition to lateral and forward expansion, I’m trying to overlay the timeline of the vertical - when did the molar build-ups go on, and when were they effectively gone?

@toomer He didn't have to reduce them, regular chewing would wear down the composite. I think he had to reapply it several times actually. Eventually I didn't need it anymore, but that was very late in the game. I do remember asking if there would be a permanent solution to applying the composite because I complained "my molars are too short to touch each other." He said I wouldn't need permanent build-ups and the molars would eventually extrude on their own. I don't remember exactly when within the 1.5 years but I wanna say the vertical dimension was the last thing to happen. Perhaps even during the Invisalign phase. 

Did your ortho measure how much skeletal maxillary expansion you got? Or did you mostly have dental alveolar expansion?

@therose

Can you describe your mandible decompression? When did it happen? How? I’m guessing some muscles had to be unwound? That’s my big issue now I desperately need my mandible to decompress. 

Also, any changes to your neck posture or pain? 

@Hyperintake

No, he didn't measure it at all. I measured 7mm myself taking the difference in IMW between an old pre-ALF nightguard and my final set of Invisalign trays. Is this something that could be deciphered from my before/after CT scans? 

@robbie343

I had been reading Ken Leaver's blog (he took it down later I believe, I don't remember what it was called) which contained an entry about the cascade of effects through the body caused by poor maxillary development. One of the effects he mentioned was legs that turn inwards from the hip joint, something I had really badly. When I went to my Rolfer/CST gal after my next ALF adjustment, I asked if she could untwist my legs. She did, and the change was so drastic that I took one step and nearly fell when I got off the table. It changed my gait, and the change has stuck to this day. The mandible pop happened shortly after untwisting my legs. I can't remember if it was that day exactly, but within a couple days. My Rolfer/CST also worked directly on my jaw joints after each ALF adjustment so I can't say for sure whether the leg rotation induced it or whether that was just coincidental and it was her CST on the jaw joints that did the trick. I also had achieved decent expansion by this point, so the mandible jump might have been associated with hitting X mm of expansion. But for some reason I've always associated the mandible jump with untwisting my legs.

At the time I thought my neck posture improved a lot with the mandible jump but it was minor compared to how much my neck posture improved after tongue tie release, which was 6+ months later. 

@toomer. Can I ask who you are seeing for your DNA? I am currently doing research to decide between ALF and DNA and am located in the DC Metro area. I saw Dr. Bronson for a consult and am now looking for the best DNA options in the area to get a consult.

@zendog74 Sure. Feel free to direct message me.