MSE vs EASE. Which is the best option for palatal expansion?

Posted by: @bushido

Hi,

 

I see a lot of people talking about MSE in Reddit, Youtube and here, but I rarely see people mentioning EASE (with Dr. Kasey Li) as an option.

 

At first sight it seems like EASE is a better option because:

1) Successful suture split guaranteed

2) Less risk of asymmetrical split (MSE's split is often cone-shaped, wide anterior and narrow posterior)

3) Dr Li says how MSE expansion is 50% skeletal and 50% dental, whereas EASE is mainly skeletal.

 

Am I missing something? Let me know which do you think is the better option and why.

Depends on your priorities. EASE is expensive, requires hospitalization, and is only offered by one doctor. It does seem like a more reliable way than DOME or MSE with surgical assist to ensure suture separation and open the airway while minimizing asymmetry and dental stress without cutting the zygomatic buttress. However, the aesthetic changes are often minimal with EASE. If your demographics and/or the grading of your suture suggests a low failure risk, then MSE with cortipuncture facilitation might be the most straightforward way to achieve midface skeletal expansion.

Hey guys, 

It sounds like I might be one of the few (maybe the first) to have done the EASE on this forum. Happy to share my journey and experience here with others.

After 3 years of dozens of consults and multiple visits with MSE providers, I settled with the EASE primarily for three reasons:

1. I have thin upper maxillary bone (the bone area where the TADs of the MSE are drilled into). Dr. Audrey Yoon suggested that with an MSE,  there would be a high risk that instead of the screws pushing the two halves of the maxilla apart, they would just drag across the bone because of how thin it is (even with cortipuncture). There wouldn't be enough anchorage because of how thin my bone was. I also didn't want to worry about the TADs bending upon turning the MSE. With EASE, the anchorage points are on the side walls of the maxilla instead of the top (for me, this was better).
2. As part of the EASE procedure, Dr. Li does some conservative bone scoring on areas that are known to have great resistance to lateral expansion from the midline suture. I'm not entirely sure of ALL the areas that he scores but I think the pterygomaxillary junction and the midline suture are two of them. This facilitates easier expansion with the device.
3. Finally, it appears that the device used as part of the EASE (a KLS Martin rapid palatal expander) is stronger and the placement of the distractor is such that the two ends are anchored onto the side walls of each half of the upper arch, instead of the roof as with MSE. This allows the vectors of force that are applied from the device to the bone to be in the same direction as the mechanism of lateral telescoping (expansion) of the device. You can read more about the device here.

Those three points really just tie into my overarching goal of choosing a procedure that had the highest chance of both ensuring a successful suture split given my age and particular bone structure and making future expansion easier. 

On top of that, as you guys may already know, Dr. Li also has some 30 years of experience with surgical solutions for sleep apnea and has studied and published with Dr. Christian Guilleminault, who I consider to be one of the pioneers of understanding sleep-disordered breathing.

One other note, Dr. Li may have changed the way he does this because when I got it done (about a month ago) I did not require hospitalization - it was done in his office. But as Apollo mentioned, it can be prohibitively expensive and I understand that will be a blocker for many. 

I'm still thinking about the difference in aesthetic changes between EASE and MSE. Will post more on that soon.

My vote would be for EASE.  I got MSE and had plenty of complications, both functional and aesthetic.  I wish I had gotten EASE instead and regret getting MSE.  

Posted by: @grow-your-face

One other note, Dr. Li may have changed the way he does this because when I got it done (about a month ago) I did not require hospitalization - it was done in his office. But as Apollo mentioned, it can be prohibitively expensive and I understand that will be a blocker for many.  

It's that cut at the pterygomaxillary junction that has high bleeding risk and why I thought it couldn't be performed in an outpatient clinic. You said "scored" so maybe Dr. Li is just cutting through one cortical layer of bone but not the other, minimizing the risk of penetrating through into the artery for some or all patients. My understanding is that EASE  leaves the anterior, premaxillary portion of the midpalatal suture uncut, whereas SMARPE/DOME chisel from the front below the anterior nasal spine between the roots of the central incisors, potentially risking their vitality/stability. So if the separation isn't parallel, EASE would tend to have more separation at the back with less of a diastema whereas SMARPE would follow the more traditional pac-man pattern. My cortipuncture-facilitated MSE also seemed to separate more at the back than the front. We think my posterior nasal spine opened a little more than my anterior nasal spine. This might reduce the impact on midface volume if the two halves of the maxilla are swinging apart from the back more than the front. EASE also doesn't provide anchorage for extra-oral traction, if you hope to increase forward displacement, but I think using the facemask had a pretty meager effect in my case.

Posted by: @apollo

It's that cut at the pterygomaxillary junction that has high bleeding risk and why I thought it couldn't be performed in an outpatient clinic. You said "scored" so maybe Dr. Li is just cutting through one cortical layer of bone but not the other, minimizing the risk of penetrating through into the artery for some or all patients.

I think you might be right here. From his description on his site, he says "With endoscopic assistance, very conservative bone scoring is then performed to facilitate expansion of the upper jaw" 

And:

"EASE is dramatically less invasive compared to other surgical jaw-widening techniques. Instead of making lengthy incisions inside the mouth as is done in other jaw-widening surgeries, EASE involves making a very small pinhole incision. Since no saw is used, EASE minimizes patient trauma, pain and swelling."

Makes me wonder if it's some sort of ultrasonic or piezoelectric blade then? 

For the split pattern, it's supposed to be parallel from ANS to PNS like below:

But we'll see at the end of my treatment what the shape actually ends up being. I'm only 3 weeks in with 2-3 months left to go.

Posted by: @apollo

EASE also doesn't provide anchorage for extra-oral traction, if you hope to increase forward displacement, but I think using the facemask had a pretty meager effect in my case.

Yeah, that was one of the things I had to plan ahead for haha. For forward displacement, my tentative plan is to take care of that during the consolidation phase - after the final length of the distractor has been achieved, you have to leave the device in for another 3 months to solidify the bone. During that time, I'd get braces to align the teeth and I'm planning to work with an airway-focused, forward growth orthodontist in the Bay Area named Dr. Sandra Khan. She's using something called the Bow, which is a new take on reverse pull headgear, on some adults and seems to be getting decent results? So I'd attach elastics from that to custom hooks on the braces. I'm skeptical as well on how much forward growth a fully grown adult male can get but I figure better something than nothing at all ¯\_(ツ)_/¯

For reference: https://www.forwardontics.com/bow.html  

I used the BOW during sleep and a traditional facemask during the day. Since the MSE protraction hooks attach to the molar bands which attach by malleable metal arms to the framework with the TADs anchored in the bone, the degree of skeletal and dental anchorage is debatable. Sounds like you'll be relying on dental anchorage. Maybe with the EASE cuts, you'll get better displacement than I did if you start before the bone heals. I wonder if the distractor used with EASE is more or less obstructive to tongue posture than the MSE.

Yeah, makes sense. As I continue thinking about this, I wonder if I can talk to her about finding a way to get pure skeletal anchorage. Maybe have two TADs placed directly on the maxilla on each side, maybe somewhere above the molars, on the buccal side? And have the elastics secured directly to those TADs instead of the braces? I'm theorizing at this point. 

Posted by: @apollo

I wonder if the distractor used with EASE is more or less obstructive to tongue posture than the MSE.

I think it depends on each individual's distractor placement. He has a strategy around how far up the vault and how posteriorly he installs the distractor based on that person's specific needs (any existing asymmetries, crossbites, etc). For me, it feels like it's definitely more obstructive than if I had the MSE because it's a bit lower in the arch and blocks the normal arc of my tongue during a swallow (stops it halfway). I also have a fun little lisp for certain words (ironically, the hardest word for me to say is ease lol.)

@grow-your-face Would you mind sharing the cost range for the EASE procedure please?

Posted by: @apollo

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However, the aesthetic changes are often minimal with EASE.

What do you base this statement on, @Apollo? If EASE is mainly skeletal expansion, how could this possibly translate to minimal aesthetic changes? It seems to me that it would be the other way around.

Posted by: @loliboly

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Posted by: @apollo

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However, the aesthetic changes are often minimal with EASE.

What do you base this statement on, @Apollo? If EASE is mainly skeletal expansion, how could this possibly translate to minimal aesthetic changes? It seems to me that it would be the other way around.

 

My understanding is that because the midpalatal suture is cut through the nose from the posterior nasal spine forward toward the incisive foramen but stopping short to protect the nerves and leaving the anterior maxilla including the anterior nasal spine uncut, there's more bending and stretching that occurs to achieve the lateral displacement at the front so there might be a smaller diastema and less risk to devitalizing the upper central incisors as compared to a typical surgical approach that would separate the maxillary halves from the front with a chisel. So the increase in the posterior, internal volume around the nasal airway might be more profound without any of the expansion lost to bending and tilting of the appliance while the total expansion is still pretty conservative so it might not appear as dramatic just to look at the face front on. In other words, it's a functional procedure to improve the nasal airway rather than a cosmetic procedure to improve facial form.

@apollo 
Hm, I guess that makes sense in theory. However, have you been able to compare visual results between the procedures? I am opting for EASE myself, since I am over 25 and male. But I will have to discuss your point with the provider I am consulting with. I will report back and share whatever he tells me about it.

Posted by: @loliboly

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@apollo 
Hm, I guess that makes sense in theory. However, have you been able to compare visual results between the procedures? I am opting for EASE myself, since I am over 25 and male. But I will have to discuss your point with the provider I am consulting with. I will report back and share whatever he tells me about it.

I had brief email communication with Dr. Kasey Li and reviewed some of his articles and lectures, which include some imaging of results. Ultimately, for logistical and economic reasons, I decided to try MSE with cortipuncture as a man in my late 30s. Luckily for me, my suture successfully separated. I get the impression that MSE providers now using a piezo corticotomy are regularly achieving success with older men, but that's still not widely available. I'm not trying to dissuade you from EASE if it makes the most sense for your case. There's a guy on youtube called @GrowYourFace who documented his complicated EASE treatment. Keep us posted!