MSE (Maxillary Skeletal Expansion) and MARPE (Miniscrew-Assisted Rapid Palatal Expansion) in Arlington, VA, Including the Surrounding Washington Metro Area

If you are a child that is very narrow and has sleep disordered breathing that is affecting their well being I will do MSE if patients wish as early as age 6. But normally MARPE/MSE Is my go to expansion if child is 10-13. I will discuss pros and cons of other options and we decide together.

All males 25 or older and female over age 30, I use the Piezotome cube instead of corticopuntures Thin bone is an automatic customization and piezo for me. Thick bone w bicortical engagement is a good thing and if patient prefers and female I will try without Piezo if they prefer. Male over 25 needs to get Piezo.

Age is not the deciding factor. MSE is useful for young patients with

1. High angle
2. Midfacial deficiency that required bone-borne protraction
3. Nasal airway obstruction
4. Class 3 occlusion
5. Bimax retrusive
6. Narrow maxilla
7. Wider width of mandible

We consistently get more than 8 mm protraction with good cooperation in growing patients. We have observed about 3-5 mm in mature patients

Often I need to use another MARPE design like a superscrew for initial expansion and switch over to MSE as a second expander if second expander is needed for more expansion.

The posterior bone is often thinner than 5 mm but still works most of the time. Other factors should be considered as well…bone density, bone morphology, special relationship between force vector and resisting structures, We use Partners dental studio that merges our CBCT with the intraoral scan of their mouth with their software to make a custom design placing the tads exactly where we will have enough bone. Some tads are shorter some are longer just to make sure we get bicortical engagement which we know we will since they use this software to get us precision removes all guesswork.

No we use 3D printed bands that sit on top of the molars so we do not need to add spacers before we place the MSE

Yes, it may not work. We will try to design a custom marpe for this patient and we can try, I have seen thin bone work many times. Many doctors had a higher failure rate with thin bone which is why we cose to do always custom MARPE. We have become pretty creative with our designs since using this software sometimes if the entire palatal bone is thin, I use the lateral implants with or without acrylic pads.

Now that we are using the software with Partners dental studio we know that we are only penetrating 1 mm beyond bicortical so I can confidently say this is not an issue. However in the past before the software this could happen with no negative consequences.

I prefer to do MSE in patients with inactive TMJ, although others have used MSE as a TMJ treatment modality. I have done personally and the TMJ improved but it is really on a case by case decision.

Any expander that produces a V-shape expansion will widen the nasal alar base. Since MSE produces a parallel expansion, it is less of a concern. But patients should not be doing MARPE case for cosmetic reasons. I always tell patients if you do not like how the nose is looking we can always turn backwards. It is reversible if we do not allow suture to fuse.

Position the jackscrew perpendicular to the septum rather than adapting it to the canted palatal vault. But now that we have the software we can angle the lumen where the tad enters in different angles and depths to correct the canted palate in the custom designed MSE/ Marpe

In children after placing the MSE, I wait 1 week and start turning and start using the reverse pull face mask, followed by one turn a day until it splits. After it splits we turn every day for 2 to 3 weeks and if wearing a face mask we go to 3 turns a week. Adults is the same but we start the turns the day we place in mouth turning 4 times followed by once a day.

Only when it is through the second cortical layer… but often the patient may not feel anything. If we use a lot of anesthesia nothing is felt.

We use a sleep image ring that you can learn more about at Sleepimage.com It is FDA approved to check for sleep apnea in children over 2 and adults. We use it to give us a baseline to start and we can repeat after three months of starting treatment. It is inexpensive and easy but nothing is as good as a sleep lab. We own the ring and you borrow it and just pay for the reports. This allows more than one night to give us more accurate results in case you have a bad night……and it makes it easy to test throughout treatment to see positive rerduction in fragmented sleep and apneas.

Yes, before placing the tads we use a pilot drill that is the same size as the lumen so that we are assured correct angle placement of the tad since the tad is more narrow than the lumen it allows easy access direct to the pre-drill hole when we enter with the tad.

They promote parallel expansion, and having four reduces the strain per implant during the expansion. Sometimes due to age or thickness of bone we will add more tads. It is on a case by case basis. .

One theory is that there is bone on the medial side of the roots…no different than retracting the canines into the extraction site immediately after extracting bicuspids…taking advantage of the regional acceleratory phenomenon (RAP). Another theory is to wait for 2 months once you stop turning the upper to start closing space. The options will be discussed with patients.

Vomer is a very thin bone housed inside fibrotic sheets. As the hemifacial structure rotates downwards and outwards, the vomer moves inferiorly little. It generally stays within the sheets which splits at the bottom as the PNS split.

The child patient I like to see one week post op to be the one to turn it for the first time and introduce the reverse pull facemask. After that I see everyone every 4 weeks. However, every Sunday Dr Roca likes the patient to text her photos of the marpe expansion, bite, and diastema directly to my cell phone.

Yes if you have a large tori it makes no difference we just go deeper in that area with the piezotome.

We are not moving teeth we are opening the bone in the suture so it would not change anything. You may however need to replace the crown on the implant after Invisalign is complete so the new crown fits properly into the bite. The only problem occurs if you have anterior implants we will not be able to close the space with Invisalign and we need to get very creative how to handle this hurdle.

I recommend waiting till after the MARPE/MSE is finished to see how the breathing is feeling and after that you may want to correct the deviation if it is bothering you. We have never made nasal deviation worse up to now but often remove the need for surgery.

Every expansion with any device is asymmetric. No one is symmetric and reciprocal force will produce asymmetric expansion. It is difficult to predict which way the expansion will go because there are too many variables involved. However, the best way to encourage symmetric expansion during any treatment is with routine work with the Posture restoration Institute (PRI) – Physical therapist or cranial osteopathic physician that help us keep your cranial sutures loose to promote symmetric expansion.

We cut off the arms to the MSE and Leave the jackscrew with implants for 6 months but start the orthodontic treatment immediately.

The midfacial structure rotates forward with the fulcrums near TMJ area.

Everyone has studied with different mentors and finds what works best in our hands and with their patient pool.

We were able to do it with no problems.

Any facemask will work we give you one included with your treatment but you can purchase others if you prefer another one.

About 500g each side for growing patients…but 500-1,000g for mature patients.

Dr. Roca has not had an MARPE or MSE fail but it does happen. Since Dr Roca uses the Piezotome in her adult cases she has never had one fail and does not expect one with the intense custom planning she does for every case. She has found working so closely with the lab that uses the software to merge the CBCT with intraoral scan of the teeth we can prevent failures. However, since adult skeletal expansion is not a natural process we never know on each patient what will happen. If the patient does not have a space between their front teeth, what we call a “split by 3 weeks time – we check TADs. If they are not tipped we keep going for one more week. If still does not open we will take a new CBCT to check. If position or the TADs is good but it failed – usually because the placement is too posterior in a thin bone – we turn all the way back and remove the remove MSE, let tissue heal and do a piezo if it was not done or remake the MSE and move it either more forward position or add extra custom TADs. Again, with all our planning, Arlington Smile Center track record is all cases have split.

I like to limit xrays whenever possible so I will not order a new CBCT unless the patient wants one or treatment dictates that I need a new one. However, throughout the process I take one small periapical xray of the two front teeth to track the split.

My mentor, Dr Lipkin had a 64-year-old male… now using the piezotome much easier. My oldest has been a 56 year old female and 54 year old male.

Can we attach the supporting arms to dental implants?

I have yet to see any negative consequences yet but it is bound to happen.

We usually use the soft arms on the MSE cases but more rigid arms on the custom MARPE cases.

One option is to cut off the arms on the over-expanded side and compensate or add a turbo (composite resin filling) on the lower molar of the side that has not expanded to unlock the sphenoid and temporal bone.

Expansion force will be the same. Protraction force can be anything since any force is orthopedic (it is a bone-borne protraction). Heavier force and longer duration are more efficient.

Simultaneous protraction is better; 14+ hours will produce a great result (it has to be more than 10 for any positive progress); I do not like to use Class III elastic (it causes lower dental compensation) if patient is a good cooperator with Face Mask.; Face mask protraction promotes a forward and downward movement of maxilla; Class III elastic tends to rotate the maxilla in a counterclockwise direction (not good for a high angle case).

I prefer to expand first and then de-rotate after cutting off the arms. You can also band another tooth. we have found it does not matter so much which teeth you band as long as you have one band on the first or second molar.

We leave MARPE in for 6 month after completing the expansion; if protraction case we leave in usually for 8 months. Sometimes I leave MARPE it in place and use it as an anchorage for various tooth movements.

Generally harder as we go beyond late 20’s (male) but age is not the only factor. I have successfully treated many older patients. Using Piezotome with every patient is the way to go to increase success.

You see the implants severely tipping or cutting through the cortical bone, the jackscrew falling apart, the arms bending and impinging against the tissue, etc. The screw not advancing.

With expansion, the midfacial structure moves anteriorly with a larger overjet. Generally, the original incisor position is recaptured after the space closure; however, the oral volume is gained by the increase in width. If the incisor position after the expansion is desired to be the final position, then you can cut off the arms and protract to the entire arch…but this will be a rare instance.

The limiting factor is the lower arch. You can expand the upper basal bone as much as required to accommodate for lower decompensation and tongue space. Most of the time, the lower jaw is not narrow but the dental arch is because of the lingually collapsed lower posterior teeth. BEFORE, I would estimate the projected lower buccal surface (after the decompensation) by taking the width from the buccal points adjacent to the furcation of lower first molars. I expand until the narrowest area above the maxillary first molars becomes wider than the estimated lower buccal surface. This allows a full decompensation of both upper and lower posterior teeth. However, in very narrow upper arches with not enough buccal bone of the lower teeth we will need to stop expansion when the lower molars are uprighted or we will need to SFOT. NOW, Invisalign has a new feature that allows us to merge the CBCT 3d xray data with the scan of the teeth so there is no more guessing we know exactly how much we can expand each lower tooth. This new feature has really decreased the need for SFOT.

Watch this video I prepared that explains this.

While MARPE has a high success rate, its success is dependent on several factors which include your ageand bone density. We cannot guarantee that the MARPE will be a success, and we have alternative options that we can propose if the MARPE does not work.

I have heard that there is a rare chance of optic nerve complications / changes in vision with this type of expansion. Is this true, and if so, have you experienced such complications?

Dr Moon did an extensive optic study and found that No functional change was observed. The optic nerve comes through a part of sphenoid bone, and an expansion has no impact whatsoever.

Always a possibility but we know how to avoid this.

Usually lasts for 5 days.

This can happen at anytine during the process but we normally only see this in the first week if piezo was done, we just avoid it by giving antibiotics to prevent infection if Piezo procedure is used.

This can happen as the MARPE expands everyone reacts differently usually we see improvement in breathing within a couple weeks.

Mini screw might unravel and we may need to take it out.

We do not like to do a marpe on a Patient allergic to metal or nickel to avoid this complication.

If a tooth is not healthy before the MARPE is placed we can not control what happens during treatment which is why Dr Roca tests all teeth before she places marpe.

Dr. Roca has never seen this in her patients but it has been found but in older patients

we watch this very carefully and go very slow so we can always reverse turn if necessary. We work closely with the PRI (physical therapist) to avoid assymnetry.