Two weeks ago I had a coaching call with an adult male client who just had a Custom MARPE placed by one of the top orthodontists in America. The pain and discomfort was so bad that he wanted it out immediately.
He could not even fathom patiently waiting weeks while he cranked the appliance and hoped for the split.
Even if he got the split, there was no guarantee it would be symmetric or aesthetic.
And even if it was a clean, beautiful expansion, the more he turned the appliance, the more time he would need to spend in braces or Invisalign piecing his bite back together after MARPE spread everything apart.
This is the barrel of the gun that MARPE patients look down.
MARPE is a painful, uncertain and slow process. There is the stress of having TADs screwed through your palate, the anxiety of not knowing if you will split and the fear of asymmetry. And on top of all that, the cost in dollars and time to go through this multi-year process.
Considering all this, it’s no wonder that patients want to leap-frog MARPE and go right into jaw surgery, which can be completed in a matter of hours.
Here are five instances where I think it might be okay to skip MARPE and consult with a jaw surgeon instead.
Jaw Surgery Disclaimer
Keep in mind that one reason MARPE is so appealing is because jaw surgery is so terrifying. It can be incredibly dangerous.
Often the way to mitigate the dangerous part is to work with an experienced, well known surgeon, but often they are out of network with insurance companies, and so now you are facing a surgery than can cost $50-100K out of pocket.
With jaw surgery there’s always a risk of infection, permanent damage to your nerves and joints, and a chance you won’t like the way you look.
With MARPE, change occurs one fraction of a millimeter at a time. With jaw surgery, you go to sleep and wake up with new face. Don’t take that lightly.
1. Your Nasal Breathing is Fine
When people skip MARPE and do jaw surgery, it’s the lack of nasal breathing improvement that they often regret. Imagine you have a constantly stuffy nose, and you go into jaw surgery counting on it to solve this problem. This is where MARPE-skippers get burnt.
Jaw surgery often does improve nasal breathing, but it seems to be hit or miss whether or not that improvement is sufficient for any given patient.
The safer play for patients who present with distinctly poor nasal breathing is to do MARPE first. MARPE splits the roof of the mouth, which is the same bone as the floor of the nose, and send expansion all the way up the midface in the shape of a triangular prism that reaches the inside bottom corners of the eyes.
MARPE is the only way to dramatically increase nasal volume posteriorly and superiorly, where relief can be felt around the turbinates, sinuses, deviated septum, Eustachian tubes, and everywhere that typically gets blocked in an underdeveloped patient.
Also, it is a forced error to skip MARPE in favor of jaw surgery only to find yourself seeking MARPE after jaw surgery. Trying to get a clean, symmetric midfacial expansion after a double jaw surgery, especially a segmental Lefort, is a gamble.
The proper sequence is to do MARPE before jaw surgery.
2. Your Side Profile is Primary Pain Point
Some clients are driven to jawhacking out of a desire to alter their side profile. Full stop. They have a weak jawline when viewed from the side, and they want to correct that.
MARPE is primarily a transverse expander. It will have limited impact on the side profile. That impact won’t be zero, but it will be an order of magnitude (literally 10x) less than what’s possible with a double jaw surgery.
With a double jaw surgery, it’s possible to move the upper and lower jaws together a centimeter or more — AND change their angulation (upswing them via “counterclockwise rotation”).
3. You Have a Tall Face with a Gummy Smile
MARPE not only expands the face in the transverse (left/right), but it also advances the midface in roughly a 5:1 ratio of transverse:advancement, and also heightens the midface.
That’s right – MARPE can make the face taller.
So if vertical maxillary excess is already present, usually manifesting in the form of a gummy smile, then MARPE stands to exacerbate this excess.
If a patient has terribly poor nasal breathing and seeks the functional relief of MARPE in spite of the potential aesthetic compromise of worsening vertical excess, then so be it.
But such patients should be informed that they stand to look worse after MARPE. At a minimum, they should be heedful about the magnitude of expansion, doing the minimum viable dose needed to achieve their nasal breathing goal.
Meanwhile, jaw surgery can actually fix a gummy smile via an impaction and counterclockwise rotation where the excess maxillary bone that is causing the gummy smile is removed.
4. You Have a Large Pre-existing Asymmetry
MARPE is a dumb appliance. It operates on basic Newtonian physics – turn the jackscrew, and it goes left/right according to the vector that it’s been oriented inside your mouth.
It does not contain any sensors like your car, that give it feedback on how things are going. If one side is expanding more than the other, it has no way of throwing a code. If it’s been placed crookedly by the doctor, you will not get a notification via an app alerting you.
Given its brute, simplistic nature, MARPE can be an asymmetry risk even in patients that start out with excellent symmetry. Unless it’s designed and oriented perfectly by the doctor, it will create an asymmetry where none existed before.
The situation becomes nigh hopeless when there is a pre-existing asymmetry of any significance. What we have seen over time is that MARPE tends to make existing asymmetries worse, not better.
This can be mitigated by trying to design the appliance so that the vector of expansion counters the asymmetry. But such maneuvers are only attempted by the most experienced providers.
Run-of-the-mill MARPE providers are more likely to just blow out the existing asymmetry by refusing to factor it into the appliance design.
5. You Have Small Teeth and No Crowding
MARPE increases maxillary arch length. That is to say, the bony arch that houses your teeth will get longer when you expand, since you’re adding several millimeters of bone to it between the central incisors.
So if you have small teeth, but then proceed to make your arch significantly bigger, then you may end up with the very unaesthetic situation of having teeth that appear quite small compared to a much larger arch.
This can be mitigated with restorative dentistry that reconstructs the teeth to make them bigger. But that is an added cost and level of invasiveness that patients should be informed of prior to proceeding with treatment.
What did I miss?
In conclusion, there is no universal right answer as to whether or not someone should do MARPE or jaw surgery. Every patient needs to consider their own starting situation.
Patients with distinctly poor nasal breathing should definitely consider doing MARPE first.
Patients who are happy with their nasal breathing have more leeway to consider the finer details as to whether or not MARPE fits into their cosmetic goals.
If you’d like feedback on your own situation, you can get 1-on-1 access to me inside The Joint, my private coaching space.
