14 Takeaways from My Dr. Gunson Podcast

Last night I posted my podcast with renowned maxillofacial surgeon Dr. Michael Gunson. So far this interview has the highest average view duration of any video I have ever made.

Here are 14 lessons I learned from Dr. Gunson about double jaw surgery:

  1. Arnett Cephalometric Analysis
    Dr. Gunson credits the beauty of his surgeries to the “Arnett Cephalometric analysis.” This analysis takes a different approach by focusing more on facial features than just cranial references. 0:06:35
  2. Be Careful with the Term “Normal”
    Dr. Gunson cautions against overusing the term “normal” in facial analysis. He believes it can push surgeons to treat patients according to a standard that might not be best suited for their unique anatomy and functional needs. 1:07:25
  3. Risks of Over-Advancing the Jaw
    If the jaws are advanced too much, it can result in lip incompetence. That’s why it’s essential to fully understand the patient’s anatomy and functional needs in order to strike the right balance between esthetics and function. 1:14:30
  4. Impact of Connective Tissue Disorders
    Conditions like Ehlers-Danlos syndrome, which affect connective tissue, can have a big impact on the outcome of jaw surgery. It’s crucial to ensure patients are fully informed and that the surgical approach is carefully customized. 1:52:10
  5. Waiting on Rhinoplasty
    Dr. Gunson prefers not to perform rhinoplasty at the same time as jaw surgery. He believes that the nasal structures can change significantly based on how the jaw and lip positions shift, so it’s often better to address nasal concerns after the jaw surgery is complete. 2:07:10
  6. Measuring Lip Space for Upper Incisor Placement
    Dr. Gunson shares that instead of relying only on cephalometric analysis, he physically measures the space behind the lip to figure out the ideal position for the upper incisor. This way, he can better balance both esthetics and function. 2:25:02
  7. Don’t Push a Surgeon Out of His Comfort Zone
    Dr. Gunson advises patients not to ask surgeons to use techniques they’re not familiar or comfortable with, even if those methods have a reputation for being superior. The surgeon’s expertise and confidence in their approach are more important for achieving successful outcomes. 2:28:00
  8. Concerns with Custom Plates and DICOM Data
    When it comes to custom plates for jaw surgery, Dr. Gunson raises some concerns. He points out that inaccuracies can arise from the DICOM data and the challenge of ensuring the patient’s physiology matches the planned surgical movements. 2:33:59
  9. Manual Plate Bending for Accuracy
    Dr. Gunson prefers to manually bend plates for jaw surgeries. His expertise with the techniques allows him to achieve precise results, which he believes are more reliable than custom plates. 2:41:50
  10. Preference for Hard Tissue Solutions Over Fillers
    Dr. Gunson tends to favor hard tissue solutions to tackle facial aesthetic issues such as cheekbone implants. He believes they offer a more lasting and structural result compared to using soft tissue fillers or fat grafts alone. 2:47:09
  11. Mandible Issues: Short vs. Narrow
    Dr. Gunson suggests that developmental issues with the mandible are more commonly due to it being too short rather than too narrow. He rarely finds situations where multi-piece mandibular surgeries are actually necessary. 2:53:29
  12. Caution with Multi-Piece Mandibular Surgeries
    Dr. Gunson is cautious about performing multi-piece mandibular surgeries. He feels that, in most cases, the mandible grows quite well, so the focus should be on restoring what the anatomy should have been, rather than making drastic changes. 2:56:15
  13. Maxillary Deficiency and Cheekbone Implants
    Dr. Gunson estimates that around 75% of patients with maxillary deficiencies end up needing cheekbone implants or grafts to maintain facial esthetics after jaw surgery. 3:15:49
  14. Conservative Isn’t Always “Non-Invasive”
    Dr. Gunson points out that the most conservative option isn’t necessarily the least invasive one. Sometimes a more comprehensive treatment plan that includes jaw surgery is needed to ensure the best long-term results for the patient. 3:25:56

Will Ron Have a Double Jaw Surgery?

A Pre-Jaw Surgery Experiment

I have decided to run an experiment to see if I myself am a candidate for double jaw surgery.

For the next several weeks, until October 1, I am going to mimic post-jaw surgery anatomy by sticking my tongue out as I go about my daily activities.

Michael Jordan often stuck out his tongue during play

If this results in a significant improvement of my headache symptoms, then I am going to commit to pursuing jaw surgery for the purpose of permanently giving me more tongue space.

You’re Having Headaches Again?

As many of my subscribers know, I have had a bad summer of headaches. The worst in many years.

Almost every other day for the past few months, I have been incapacitated with headache pain centered on the back of my neck that radiates to my eyes and temples, and causes lots of burping and indigestion. My symptoms jive with a diagnosis of occipital neuralgia.

Occipital neuralgia anatomy

And this has resulted in inconsistency of YouTube posting, as well as delaying the writing and publication of parts 5 and 6 of the JawHacks ebook.

Now that I have a wife, a 10 month old daughter, and another baby to be born in March, I simply cannot afford to be a slave to these headaches.

When I was living in a Sprinter, the pain sucked but at least the fallout was contained to me alone. However it’s not just about me anymore.

Headache Hypothesis

I have a working hypothesis that the reason I continue to get headaches is because of my tongue being cramped inside my mouth, like a folded accordion.

The posterior part of my tongue being kinked back is causing excessive pressure on the muscles at the back of my neck, causing those muscles to strain and impinge my lesser occipital nerves on both sides.

person carrying accordion
Photo by David Vilches on Unsplash

I have been meditating on the phenomenological experience of having my distinct type of headache, and two nights ago I made an important (re)discovery.

I call it a re-discovery because it’s actually something I figured out 10 years ago, which drove me to seek jaw augmentation in the first place.

And that realization is that when I allow my tongue to relax and fall forward out of my mouth, outside of my teeth, the tension in my neck immediately releases.

For example, last night while doing my evening workout/stretching, I switched back and forth between doing pull-ups with my tongue in (and my teeth gently together), and then with my tongue flopping out about a centimeter in front of my teeth.

It was unmistakable that the tongue-out pull-ups were much easier, involving almost no neck tension at all. And as soon as I bit my teeth gently together, forcing my tongue back into its “normal” retracted position, I could feel the occipital neuralgia symptoms percolating.

I did the same with dips, and then seated meditation, and then reading my Kindle on the couch. And the next morning I went for a short jog, also with my tongue out.

In all instances, releasing my tongue forward out of my mouth resulted in being able to engage with these activities with none of the usual neck pain.

But Didn’t MSE Fix My Headache Problem?

This tells me that maybe the root problem of my remaining headaches is the fact that I never achieved forward advancement of my jaws.

This excellent image is the cover of Dr. Felix Liao’s book (Source)

Yes, I expanded transversely with MSE back in 2019, and at that time I did experience a profound improvement in my headache symptoms. To this day, my headaches are much better (even at their worst) than they were prior to MSE.

As of recently, my headache frequency has been high (equal to my worst periods from the pre-expansion, pre-migraine surgery era of 2018-2019).

However, their severity and duration are down.

Before, my typical headache was a 7/10 or 8/10 with nausea and vomiting. Now my headaches are 4/10 with no vomiting. And they are easily aborted with triptan medications.

However, having a 4/10 headache multiple times per week is still a terrible nuisance and is preventing me from being as present and functional for my wife and daughter as I need to be. And of course, the financial pressure on me is at an all-time high.

So I really have no choice but to keep hunting down this headache problem and trying to put another big dent in it.

The MSE helped decompress my tongue somewhat, and did improve my symptoms. But I never actually achieved jaw advancement. Maybe that’s what’s missing for me.

If I could do a double jaw surgery, and allow my tongue to permanently park ~1cm farther forward than where it is now, maybe that nagging pressure in the back of my neck will be forever relieved.

Due Diligence Before Jaw Surgery

I am currently in my 9th straight year of orthodontic treatment (not including my 2 years of childhood extract and retract ortho).

And to say I am suffering from orthodontic burnout is an understatement. Since July 2016, I have had failed tooth-borne expansion, an MSE, Invisalign, regular braces, BRIUS lingual braces, Invisalign again, SFOT, and now more Invisalign.

My teeth are in rough shape and my mouth and mind have been through a lot.

And so now I am supposed to pony up and do a double jaw surgery, one of the scariest elective procedures on the planet?

It would be a travesty for me to do the jaw surgery and have no relief of the underlying headache condition. So I need to have some assurance that my “cramped tongue causing neck pressure” theory is not totally kooky.

man with burning hair portrait painting
Is my theory insane? The tongue experiment will give me data to help decide. Photo by Thiébaud Faix on Unsplash

Toward this end, I am going to run my tongue-out experiment for the next month. If I can reduce my headaches and neck pain over this period, I will strongly consider requesting the services of one of my jaw surgery colleagues.

Limits of My Experiment

Of course, sticking the tongue out of the mouth doesn’t perfectly mimic jaw surgery. To begin with, it’s very uncomfortable as the teeth bite into it. And that also puts excess pressure on the front teeth, which is not ideal for me, given my orthodontic history.

And it’s not possible to eat or talk with the tongue out, so those two activities will inevitably pull be back into the kinked-tongue / strained-neck position.

And then there’s the elephant in the room — sleep. I can’t sleep with my tongue out either, and so each night my experiment will be shut down, and bad things will probably happen to my neck while I am unconscious.

But I hope I can gather enough data during the day to be able to make a confident decision about jaw surgery.

My Chiari 1 Malformation

You may be wondering: “Ron – if you’re theory is correct, why doesn’t everyone with small jaws experience occipital neuralgia and chronic headaches like you?”

It’s possible that the key feature in my case is my Chiari 1 malformation. This is something I was diagnosed with back in 2011, but never really gave much thought until this year’s exceptionally bad summer of headaches.

A Chiari malformation is sort of like small jaws, but at the back of the skull. It is an underdevelopment of the back of the skull which results in a traffic jam of the cerebellum and the brain stem as they emerge from the foramen magnum, which is the hole at the base of the skull.

Chiari malformation
Source: Dr. Eric Baron

My Chiari malformation is not severe, but that doesn’t really mean much. As with sleep testing and sleep apnea, there is not a 1:1 relationship between AHI and severity of symptoms.

Similarly with Chiari, a small compression can be very symptomatic for some patients, and that may be the case with me, especially since I am a notoriously sensitive person.

My own brain MRI from June 2017 showing a mild Chiari 1 malformation

My current theory is that the Chiari malformation is causing a central compression of my occipital nerves and other nerves of my neck and upper back, resulting in these nerves being “on edge” all the time.

By “central compression,” I mean that the nerve impingement is occurring at or very near to the brain stem and spinal cord as they emerge from the foramen magnum.

Since the nerves are already on edge, the excess muscular pressure and strain at the back of my neck being caused by my kinked tongue is causing these nerves to boil over, resulting in occipital neuralgia.

What About a Chiari Decompression Surgery?

The primary symptom of a Chiari malformation is constant cervicogenic headache, just like what I have. And many Chiari patients describe an experience that mimics that of occipital neuralgia patients, just like me.

So why not treat the Chiari malformation instead of the jaws? There is such a thing as a Chiari decompression surgery, in which a part of the skull is removed in order to relieve pressure of skull/brain/brainstem traffic jam previously described.

Surgical decompression of Chiari malformation (Source)

Whether or not I proceed with Chiari decompression will depend on the success of my tongue experiment this next month.

If I find that decompressing the tongue allows for my Chiari malformation to become asymptomatic again, then I would rather not do the very invasive neurosurgery involved in Chiari decompression which results in surgical exposure of the brain.

Doing the jaw surgery as opposed to the Chiari decompression also affords airway benefits. If I do the jaw surgery, and my headaches are still bad, at least I might have gained the ability to sleep on my back without choking (currently I struggle to breath in supine).

Are the Headaches Caused by Diet, Lifestyle and Stress?

It’s true, in some ways as a new husband and dad, I am more stressed than ever. For example, my sleep is very interrupted, and my morning fitness routine which I have long depended on for health stability is often disturbed by parenting duties.

But stress is definitely not the whole story here. I would tell you if it were, I’m not ashamed to admit to my mental susceptibility to the difficulties of life.

And with regards to diet, I went strictly carnivore about 3 weeks ago, and while symptoms have been reduced, there is still this distinct, localized pain in my neck that must have a mechanical source.

brown and black chocolate cake
Photo by Justus Menke on Unsplash

Additionally, I quit nicotine, cut way back on caffeine to one cup of tea per day, and use no other illicit drugs. I simply don’t know what else I could do to purify my biochemistry and lifestyle.

I have also tried to eliminate the sleep disordered breathing variable by returning to my old practice of sleeping with a backpack filled with balloons to force me to sleep on my side, where I never snore and choke.

If you have any other lifestyle suggestions that I should try prior to jaw surgery, please comment below.

What About My Migraine Nerve Decompression Surgeries?

Yes, I have had three migraine nerve decompression surgeries. An initial surgery in December 2017 with Dr. Ziv Peled to excise the lesser and third occipital nerves, and decompress the greater occipital nerve.

My own nerve decompression surgery with Dr. Peled in 2017. This image shows was a compressed vs. a surgically decompressed nerve looks like.
My own right lesser occipital nerve branches during surgery with Dr. Peled in 2017

A second surgery in April 2018 with Dr. Peled to decompress or excise the nerves in my eyebrows, temples and forehead.

And then a third surgery in January 2021 with Dr. Jay Austen to further investigate residual pain I was having in the area of my right lesser occipital nerve.

These surgeries were all helpful and definitely contributed to the enduring reduction in my headache severity.

But I believe what is happening now is that the nerves are being re-compressed by the excessive pressure being caused by my cramped tongue, likely the same pressure that has been compressing them since my childhood.

And in the case of my excised lesser occipital nerves (on both the left and right sides of my neck), I believe the nerve stubs that remained after Dr. Peled cut them are being irritated in the muscle where they were buried.

In fact, most of my current neuralgia pain occurs at the sites of my excised lesser occipital nerves, and I believe that those nerve stubs are directly irritated by the muscular pressure caused by my cramped tongue.

Fat Grafting for Nerve Pain?

If I do the jaw surgery and get a major improvement of my headache symptoms from the tongue decompression, but I still have some small amount of residual pain around the lesser occipital nerves, I would consider going back to Dr. Peled to do fat-grafting on these lesser occipital nerve stubs.

Dr. Ziv Peled is at the forefront of peripheral nerve surgery done to treat occipital neuralgia. In recent years, he has begun adding fat grafting to his arsenal of surgical tools that can be used to quell damaged nerves.

The fat grafting provides cushioning of the nerve, protecting it against the surrounding muscle. It also introduces stem cells to the area which could promote much needed healing of those nerves.

This fat grafting procedure would be like icing on the cake of this whole experimental headache treatment process.

Stay Tuned

That’s it for now. I will let you know how the “tongue-out” experiment progresses over the next month.

Dr. Newaz on FME vs. Custom MARPE

Part 2 of the talk by Dr. Zubad Newaz, DDS at MewCon 2024

Below is a lightly edited transcript from the second half of the talk by Dr. Zubad Newaz, DDS at MewCon 2024 on August 17. All images shown below are from Dr. Newaz’s MewCon 2024 slideshow.


The Rise of Custom MARPE

All the patients shown so far have been treated with what we now view as perhaps a more primitive form of an expander device [in reference to MSE type 2, see previous week’s post]. They have worked well for younger people and females.

But now…we didn’t used to be able to look at somebody in the face, if you’re a 40 year old male, you come to the office, you’re seeking skeletal expansion. I couldn’t really look at somebody straight in the eye and say “we will be able to expand your palate.”

But with the advent of custom MARPE, where we can superimpose surface data with a 3D scan and be able to identify which parts of the bone and where exactly and how we want to place the expander’s anchorage. It was game changer.

And this was also a game changer because now I’m not stuck with a particular predetermined orientation of a pre-fabricated expander.

Image of a Custom MARPE

CBCT Planning of Custom MARPE

So the 3D guided MARPE fabrication relies on your CBCT scan planning, the placement of the screws, and we instruct the lab on a lot of different parameters in this kind of case, such as location and number of the lumens (the little holes for the screws). We have as much control as we want on that issue.

Also, accessory arms.

It helps to have a workflow where we can adapt the underside of the expander body to a patient’s individual anatomy. That is what has made custom MARPE be our staple tool for predictable adult expansion.

But it does have its drawbacks. Expansion as it exists in 2024 is not perfect, but it has been a very good tool to help people of all ages gain real estate in their mouth, nasal breathing and so forth.

Armless MARPEs?

We can instruct the lab on accessory arms. Where do we want, or not want, tooth anchorage. We do toothless versions of these all the time as well, where we will make it with an armed framework to seat it predictably as planned, and then immediately proceed to cut the arms off so that the expander is toothless.

You may do this for an individual where you really are concerned about or want to minimize, to the best degree possible, any sort of unwanted flaring or periodontal effect on the teeth.

Even though we anticipate the expansion to be mostly coming skeletally, it doesn’t always end up being 100% skeletal, that’s just the honest truth of the matter. Anyone who tells you otherwise is not being totally honest.

And that’s okay. It’s okay to have a little bit of hybrid-style expansion, as long as you know what you’re getting, how you’re doing it, how to see what you’re getting, and how to see whether that’s appropriate for the individual patient.

Arms for Intrusion, Protraction

Then, of course, it’s easy to put on whatever accessory arms or whatever you want for protraction or intrusion.

Intrusion is a very common thing that we end up using with bone anchored expansion, because it is what allows the lower jaw to auto rotate into a more forward position after you have gotten some of the natural forward outward rotation of the maxilla as a result of doing this style expansion, where expansion tends to pivot about this *points to zygomatico temporal region*.

So we have these trinkets that we can put on our expanders for a number of select applications.

Intro to FME

This is another expander that we use now, and as of just a few weeks ago we were the only practice doing this. It is the Facegenics Midface Expander (FME).

Facegenics Midface Expander (FME) with 6 TADs

Dimensional Stability of FME

Basically what this is, is an evolution from some of what we have now learned are shortcomings in the dimensional-stability-forgiveness built into other kinds of expanders.

We have all learned now that bone anchored expansion comes with its drawbacks. Asymmetry is the biggest drawback. Lack of dimensional stability of the expander body is a big drawback.

I talked to another participant here today, where we shared the experience where sometimes you’re cranking that MARPE screw, and then enough tension will build up into the device, even if the palate splits that you can’t turn the screw, it kind of gets stuck.

Why would that happen in a mechanism where you have a telescoping barrel, where things are supposed to come out of each other in parallel. Well, something must not be parallel if it’s getting stuck right?

Locking TADs

This particular team of individuals (Faccgenics) who started this company, they’ve been working on this expander for a long time to try to overcome some of these physics challenges that exist with bone anchored expansion, to make the expander body as unforgiving to twisting/rotational/shearing forces as possible.

And one of the ways that they’ve been able to do that is to lock the TADs into the body of the expander where there’s zero play between the screw in the palate and the expander body.

Being able to do that at least confers some level of predictability of the dimensionality and direction of your expansion.

But this is super early. We don’t know if, for example…maybe, between the screw and the screw housing, we have a perfect relationship — but maybe between the screw and the native bone, we don’t have a perfect relationship. We have to see what the effect of that is going to be as far as this appliance’s propensity to drift or rotate.

We have to now see if [the FME] performs a little better than other things we’ve had in our hands these past few years.

The field of bone anchored expansion is rapidly changing and evolving, so we’re trying to stay with it.

Detachability of FME

What you just saw in the prior slide [above] was a 6 screw version of FME. It has 4 holes on the top, but those actually are not the screws that go into the palate. Those are the screws that lock the expander module onto the little plates that connect to the palate.

8 and 10 TAD Facegenics Midface Expanders (FME)

And having it be detachable is good, because you can reload your expansion without reinstalling the whole thing.

You can also dismount the expander if you have a clinical problem beneath your expander. With other expanders, right now say you have an oronasal fistula, a bone problem in the center palate, you can’t necessarily see or access that.

But with FME I can just take this top piece off so that the clinical condition underneath the expander can be evaluated.

So I think that this has been also a nice upgrade into the world expansion.

FME vs. Custom MARPE

I say “upgrade” not to mean that FME is categorically the best expander, but rather to say that is has the potential to overcome some of the limitations [of other expanders].

But I still find that custom MARPE is perhaps a bit more predictable, at least in my hands today, since I have only installed 9 or 10 FMEs.

Also, some of the characteristics of custom MARPE are better for some individuals for whom we may need to work with irregularities in the native anatomy.

“Composite Bone Anchorage”

FME fabrication is in large part very similar to custom MARPE. It depends on the use of surface and 3-dimensional imaging data radiographically to plan the positioning of the appliance to maximize your composite bone anchorage.

“Composite bone anchorage” is a word I like to use to describe the fact that the success of adult bone anchored expansion is directly proportional to this composite bone anchorage — putting 6, 8, 10, whatever amount of screws we’re putting in, we need a high quality screw to bone interface, and we need it well-spread out across an axis that will allow for a dimensionally favorable expansion.

So all of that is the phenomenon I call composite bone anchorage.

FME Installation

This is some of the process of delivering the FME, where everything is surgically guided.

FME installation guides for pilot drill, anchor body placement and TAD placement.

We don’t have any tooth attachments [with FME], so how do we deliver it in a predictable position, exactly where we planned it?

It’s using these guides.

We put the plates that are going to house that expander and actually screw it into the guide so it doesn’t move when you’re bolting it in.

FME Fabrication and Key Points

  • Impression of upper arch with whole palate
  • CBCT scan
  • Locking TADs
  • Rigid expander body
  • Detachable expander
  • Anchor plates placed first with TADs then expander mounted on
  • Titanium construction
  • Does not tolerate bending and twisting forces
  • Armless
  • Surgically guided installation

Dr. Newaz’s Talk on Bone-Anchored Expansion – Part 1

by Dr. Zubad Newaz, DDS at MewCon 2024

Below is a lightly edited transcript from the talk by Dr. Zubad Newaz, DDS at MewCon 2024 on August 17. All images shown below are from Dr. Newaz’s MewCon 2024 slideshow.


Facial Structure and Health

I know it’s end of the day, everybody’s looking to get socializing again. So I’ll try to keep this as brief as I can.

Basically all of us here have something in common. I think we’re all asking certain kinds of questions that are not typically asked and we’re all here because, by definition, we claim not to know all the answers.

This is a oft evolving profession, and just like Mike [Mew] said at the very beginning, we’re just scratching the surface, right?

We’re here because we all share an appreciation for making the box bigger.

And the box is so important because it is the framework that houses and fits the tongue, the lower jaw, the airway…and our whole facial structure is the underpinning of good health and good function.

And I think we believe that, and it’s very important not to be dogmatic in any of our approaches on how to achieve that. Medicine is very individualized, and maintains the view as a community that one particular type of treatment modality is not for everybody.

So see what I’m presenting today as merely one of the tools in the toolbox to help “make the box bigger.”

Dr. Newaz Had Extractions

I’m here on this stage today because my own experiences have shaped me into what I’m doing now.

I had extraction orthodontics as a teenager. And by all orthodontic standards, I think my treatment was done very well. And then, of course, I started seeing different kinds of disturbances. Thankfully, I’m not suffering as much as many, but I still do feel the progression decade after decade, of the downstream effects of some of these things.

Dr. Newaz Getting His Own FME?

We may be starting the project to reverse that tomorrow. My partner may be installing [an FME] in my mouth. I’m very excited about that. And it’s good to know what you’re doing to people.

Dr. Newaz’s Training as a Oral Maxillofacial Radiologist

My own experience with orthodontic treatment was one thing, and then the other is before I became an orthodontist, I was a oral and maxillofacial radiologist, and I continue to practice that.

I really enjoy that part of the profession, because it is what connected me to people’s airways and diagnostic questions on a level that I was not otherwise trained as a clinician to do. So I feel like it’s been very helpful for me in this particular space to have the diagnostic background as well as a clinical background.

Dr. Newaz is New to Social Media

Some of you can know that I run a very inefficient business because I travel between three states. And also I have been brought onto the social media wagon by my beloved colleagues [Dr. Jaffari], and Bailey who’s somewhere lurking in the shadows here.

They both got me. I’m very shy, not public facing. So it has been good to start to get some of our message out there in ways that we try to do everyday with our patients.

Dr. Newaz’s social media channels: YouTubeInstagram

Jaw Structure and The Central Nervous System

Everything that’s on this slide is pretty much the same thing that’s been repeated every lecture today, right? We’ve been talking about the box and some structural generalities about the jaws and the airway and so forth.

And I think it’s all about these last two things. We’re trying to improve the anatomic constrictions that contribute to airway compromise.

We know that there are a lot of those types of constrictions in the area, and we’re all trained to treat the diagnosis. And we are looking to improve the freedom from the mandible, and hence the tongue, the mandible itself and the joint associated with it.

The central nervous system doesn’t tend to like when things are compressed, there are a lot of intricate nerve endings and things like that in our face. And when the structures are constricted…we had a great talk this morning by our osteopathic physician [Dr. Tasha Turzo] about the role of the central nervous system in these kinds of issues. And again, how all that stuff relates…we don’t even claim to know the beginning of it. We just know that it does relate.

I think we will find out a lot more in this 22nd century of medicine, where we now are going to have all kinds of modeling and computerized data that we’re going to crunch, and as a community, we are going to have the answer to our contrarians, because that’s what we need, so that we’re not seen as a fringe.

We want this to be what is normal, what is the future of medicine.

Dr. Newaz on Myofunctional Therapy and Tongue Posture

While stability of expansion has been studied and reported in the literature, there is little to no emphasis in the profession and in the research about the role of tongue posture reeducation and optimization as it specifically pertains to holding expansion (and general orthodontic) results.

I give most of my patients a simple myofunctional regimen or guidance and if more sophisticated training is needed, I refer them to a myofunctional therapist.

And all studies right now that comment on the the efficacy and stability of expansion fail to mention tongue posture as a possible biomodulator. Not a single study today mentions that. And when you have the very scaffold that has been mentioned in all of these talks we have heard today, housing and supporting the structures of the face, it is senseless to make any conclusions without looking at that.

How in the world does anyone think expansion is going to be stable in the long-term if the tongue is not acting as a scaffold against the palate to hold and protect it?

Evolution of Bone Anchored Expanders

So we’ll talk a little bit about some of the evolution and different varieties of bone-anchored expanders. A lot of you are familiar with these designs already.

Credit to Dr. Won Moon, Intro to MSE

Lots of credit to Dr. Won Moon who has popularized and made it easy, reduced the barrier to entry, for those of us who are interested in having a solution to expand our patients’ maxillas, especially those who were either in a later stage of growing or non-growing.

(Because we have a lot more latitude and lot more options in growing patients than we do in non-growing patients.)

So this was a boon to those of us who felt we had our hands tied behind our backs without a relatively easy way to address it.

You’ll see some of the components of that particular expansion system here [MSE type 2].

[The below photos] are showing the concept of bone anchored expansion, and the skeletal effects it can have. We’re splitting not only the mid-palatal suture, but we’re also targeting other circummaxillary sutures higher up than simply just the mid-palatal suture.

10 years ago, the only way you could expand an adult palate would be to go to the operating room and have an osteotomy, the same kind of cuts that Ronny [Ead] was talking about for purposes of moving the jaw forward.

We would have to make similar cuts, along with a midline cut to be able to skeletally expand an adult palate. That is no longer necessary.

Case Studies and Patient Transformations

And this is a quick smile photo of a patient that had done some standard MSE and Invisalign. You can kind of see how some tension was relieved in the face.

The smile is a little bit more relaxed. The area under the eyes looks a bit more relaxed and not retruded.

And you can see from the tone of the masseters, this patient’s primary concern was that of a clenching. Expanding the maxilla was, indirectly, the tool that we used to help provide more of a house for the mandible and the lower teeth, and resolve the lower crowding and upper crowding at the same time.

Expansion with Protraction – “Good Alone, Better Together”

Many of you know we’ve talked about the value of protraction. And I think, actually, protraction and forward movement of the jaw has the potential to be most transformational.

I think having increased access to expansion for all ages has been extremely transformational. But I think what will be more transformation is actually when we as community figure out protraction of all ages.

See the Potential Goodness in Your Face

This is a quick reminder to the youngsters out there watching, perhaps not limited youngsters, who may be so fixated and worried about the downstream effects of their suboptimal facial structure that they also fail to see some positives within it, or perhaps some of the opportunity for this to easily switch and go positive.

We as a community have grown good at pointing out shortcomings in people’s structures. But it’s also important to point out merits in people’s structures as it pertains to overall well being. We’re not only “structural improvement” doctors and functional doctors, but we are doctors of mental and emotional well being as well when you do this kind of work.

Comments on Scolopendra Case

Some of you who frequent certain talk spaces may recognize this individual. This is a very good case to show the facial effects of protraction orthodontics in adults — that it’s indeed possible. This person expanded beyond a level that was customary, and beyond what I would have customarily allowed.

But we had a few unique things. There was some lax facial soft tissue and it took a large amount of expansion to fill out his buccal corridors. And I’ve been reprimanded on some of these talk spaces for allowing the patient to do this.

But me and the patient alike saw a pathway to be able to put this back together—because, of course, the lower jaw now is looking like it belongs to a different person. This is work in progress.

The lower jaw — we had a good presentation today by Ronny [Ead] that shows us that we have a lot of possibilities for enhancing mandibular structure and function. And basically it took a degree of fearlessness and mutual trust for us to pull this off.

But as a result, even though he has very little functional coordination right now, he is very happy with the amount of expansion and protraction he got. He almost got a Lefort 2 or 3 style protraction because of how profoundly his midface came forward.

So this is, again, is just to show the possibilities. This is non-surgical bone anchored protraction. This is not upper jaw surgery.

But you can see how obtuse that nasolabial angle was pre treatment. And then you can see that it’s about a right angle, or maybe slightly acute, after.

This patient actually very compliantly, religiously wore the bow designed by Dr. [Sandra] Kahn, especially in the height of his suture loosening. He’s been a model for being able to show that the adult protraction does indeed work. And he’s not the only one. I think you’ll find a lot of other evidence online that this is actually a thing.

Next Post

Next week, we will cover more of Dr. Newaz’s MewCon talk, which includes a discussion of the Rise of Custom MARPE, a technical explanation of the Facegenics Midface Expander (FME), and more.

5 Ways to Make Your Jaws as Big as Humanely Possible

My MewCon 2024 Talk

Ron gave this talk at the first ever MewCon in New York City on August 17, 2024.

Introduction: What is Airway Maximalism?

A big part of what I do is maintain a 12,000ft view of the airway world. Since I am purely a consultant, and do not offer any treatments of my own (since I am not a healthcare provider of any kind), I have the luxury of being able to keep a very broad, disinterested view of all airway treatments modalities.

In this talk, I want survey 5 approaches to maximizing three dimensional jaw augmentation that I am seeing done, and that clients regularly ask me to help them compare and contrast, in terms of pros and cons.

First of all, what do I mean by 3 dimensional jaw augmentation? By this, I mean both widening and advancing the jaws as much as is reasonably possible for a given patient. Think: make the box bigger, in every way.

3 dimensional jaw augmentation is something generally sought after by what I call “maximalists,” which are patients that want it all – the full monty of jaw reconstruction. As one client aptly put it when explaining his case to me last week: “I need everything,” he said.

This particular patient was a 36 year old army veteran with long brown hair and jaws so small and so recessed it looked like he had a permanent frown on his face. This man was worn thin, and desperate for air and for sleep.

To quote the TV show True Detective: I could see his soul bleeding out the edges of his tired eyes.

2 Types of Airway Maximalists

Generally I find that airway maximalists tend to fall into 2 categories: 1) desperate airway patients who are approaching death’s door, such as the man I just described and 2) bold biohackers who are doing pretty good but want to be doing great, and they have the money and the balls to try and make that happen.

These are the type of people who are willing to just “go for it,” doing extreme, unconventional things with their time and with their bodies in order to have great experiences in life.

A good example of the latter category is a client who I spoke to recently who was a 29 year old, wealthy digital nomad who spent almost 2 years on a waitlist to have a famous New York tattoo artist sleeve both his arms, and who called me from the Philipines where he was “geomaxxing” with a group of friends.

This means he proactively sought out a country where his American dollar was more valuable and his European appearance was rarer and more appreciated, in order to maximize his chance of dating success. Clearly this guy was a serial optimizer.

He had a visibly narrow palate and recessed jaws, wanted to solve his breathing troubles, fix his TMJ pain and, of course, look better. And he wanted to do it quickly and without compromise. He wanted a path forward that was fast and maximally effective, and his tolerance for more invasive procedures was high.

Foreshadowing: he was interested in the fastest, most invasive and most effective treatment to be discussed below. Option #5.

Perspective

Now, not every airway patient is a maximalist and I’m certainly not saying that they should be. But I’m also not going to stand in judgment of maximalists either, especially if they decide to pursue these treatments armed with full understanding of the potential risks, costs and pitfalls.

And if maximalism is not your particular interest, I think there is value in understanding the airway maximalist modalities.

Regarding the treatments to be discussed below – this is it. They are the final frontier of jaw augmentation, at least for now. You are about to reach the edge of the Milky Air-way Galaxy.

If nothing else, this discussion should give you perspective on where your own, more conservative approach to treatment falls on the full spectrum of all possible jaw augmentation modalities.

5 Approaches to Jaw and Airway Maximalism

And so, here are 5 paths of treatment presently being considered by many airway maximalists.

What all 5 paths have in common is that they are primarily bone-borne approaches, and whenever dental augmentation is used, it is used only as a complement. In other words, the bone-borne modality is the meat, and the tooth-borne expansion is the sauce.

OPTION 1 – MARPE + SFOT + Dental Expansion on Upper and Lower

A partial image of Dr. Yousefian’s MAPES appliance, that provides skeletal widening of the palate and some anteriorization of the upper front teeth.

The first treatment approach is MARPE + SFOT and Dental Expansion on the Upper and Lower. Of the 5 paths to 3 dimensional jaw maximalism that I will be discussing, this is the only one that does not include orthognathic surgery, although it does include SFOT which is a kind of surgery, and not a very pleasant one at that.

Dr. Joseph Yousefian in Bellevue, WA has an interesting take on MARPE + upper and lower SFOT. He calls it MAPES (Microimplant-Assisted Protraction Expansion Surgery).

It involves a MARPE with arms that extend forward and attach onto the 6 upper front teeth. Those arms have their own jack screws, one on each side, and those screws can be turned to push the upper front teeth forward using the MARPE as an anchor.

With the support of SFOT, this anteriorizing of the upper front teeth is relatively safe as compared to toothborne expanders like AGGA. And with anchorage to the MARPE, you don’t get the upper molars being pushed back at all due to Newton’s 3rd Law such as we saw with AGGA.

And with the support of SFOT on the bottom, dental expansion can be used to get the lower arch to match the upper in all dimensions.

One of Dr. Yousefian’s many MAPES cases. (Source)

All things considered, this is about as good as it gets for 3D jaw augmentation for those that are dead set against the Lefort and BSSO cuts that come with orthognathic surgery. Although of course the magnitude of advancement that can be achieved with MAPES and SFOT is not in the same league as that which can be achieved with a true jaw surgery.

OPTION 2 – MARPE + Facemask + Lower Jaw Surgery

The second treatment approach to 3-dimensional jaw maximalism is MARPE + facemask + a lower jaw only surgery. I will call this approach theoretical for now since I don’t know anyone who has actually done this.

This approach involves a MARPE to widen the upper palate, and to loosen the various sutures of the face, which paves the way for a protraction device. With enough compliance, the facemask can be used to pull the maxilla and entire midface forward, far ahead of the mandible. Which then forces the patient into a situation where the mandible needs to be augmented to match.

A DIY bed-mounted facemask built by an ambitious patient and his father.

Sure, dental expansion could be used to buy you a few mm of anteriorization of the mandibular teeth, but that approach would set very underwhelming limits on how far the patient could go with the facemask.

However with a lower jaw surgical advancement, the facemask could be used to its full potential.

This would allow the patient to avoid the scary Lefort cut on the upper jaw, and potentially pull the entire midface forward rather that just than just the maxilla, as occurs with even a high Lefort cut.

Although disadvantages to this approach include 1) its dependency on patient compliance with the facemask, which many find to be miserable, 2) inability to have a predictable rotational upswing of the jaws, also known as counterclockwise rotation, with the facemask, and 3) the potential for post-surgical numbness, which is almost always worse on the lower jaw, which is the jaw which would be operated on in this approach.

Dr. Sandra Kahn’s Forwardontics Bow Facemask (Source)

It would take a very special kind of patient to attempt this approach – notably, one who is very curious and interested in experimenting with a facemask

Ron with Dr. Sandra Kahn at MewCon 2024

OPTION 3 – MARPE + 1 Piece Maxilla and 1 Piece Mandibular Surgery

A third approach to 3 dimensional jaw maximalism is MARPE followed by a simple, standard one piece upper and one piece lower jaw surgery.

This approach is great for those who aren’t sure if they are true maximalists, because they have the option to bow out of the jaw surgery if the MARPE gets them what they’re looking for.

That could mean enough nasal breathing improvement and tongue space to go on living. Or maybe from an aesthetic point of view, they are happy to have a wider, more Hollywood smile, and sharper cheekbones, and can do without the killer side profile.

But if they feel like the MARPE wasn’t enough, and they still want the surgical advancement, now they can take a simplified approach to surgery by doing a 1 piece upper jaw surgery, which is simpler, harder to botch, and has less risk to the health of the teeth. Also a lower infection risk as it means less surgical plates, which are often the site of post-surgical infection. A once piece upper jaw surgery is also a faster surgery, which means less tissue jostling, less anesthesia, etc. which translates to an easier recovery.

Finally the last advantage of this approach, and perhaps the most important, is that the MARPE may give certain nasal breathing benefits that orthognathic surgery simply cannot.

Specifically, it can expand the nasal volume vertically along the y-axis of the nose, because the it spreads the nose basically all the way up to the base of the eyes, as opposed to jaw surgery which only expands the nose up to the height of the Lefort cut.

This is a partially complete EASE case by Dr. Kasey Li. Notice how expansion occurs all the way up the nose, and not just at the base. gif by Shuikai

Higher Lefort cuts as part of a segmental Lefort may approach the effectiveness of the MARPE in achieving nasal volume expansion up the vertical axis of the nose. But patients who present with distinctly poor nasal breathing should strongly consider this benefit of MARPE when weighing their treatment options.

OPTION 4 – 3 Piece Maxilla, 1 Piece Mandibular Surgery + SFOT

The fourth approach to 3D jaw maximalism skips MARPE altogether. It involves a 3 piece maxillary segmental osteotomy to both advance and widen the upper jaw, a BSSO to advance the lower jaw, and later SFOT and dental expansion to widen the lower arch.

This is a surgical plan from Dr. Alfi which shows a 3 piece segmental on the maxilla in anticipation of SFOT and dental expansion on the lower. Notice how after surgery, the upper teeth are much wider than the lower.

This approach hinges on the fact that orthognathic surgeons are quite proficient in doing multi-piece upper jaw surgeries, to both widen and advance the upper jaw. Most of them offer this as an option.

But multi-piece lower jaw surgeries are much rarer, which means dental expansion is still needed to get the lower jaw to match.

This MARPE-less approach appeals to those interested in speed and efficiency, as they can get a MARPE-like result without going through a multi-year orthodontic process.

For example, many patients have bites that suit a surgery-first approach that allows them to go into surgery immediately without doing any preparatory orthodontics.

So why would they seek out a MARPE, with its cost, known risk of asymmetry, difficulty in splitting adult males (which, of course, often requires its own surgery), and two years of associated orthodontics, when they could go into surgery tomorrow and get an arguably more precise, more predictable expansion in 3 hours?

Sure, the segmental Lefort does not provide the desirable zygomatic enhancement that MARPE does, since the lever arm of the expansion is severed at the site of the Lefort cuts, beneath the zygomas. Although this can be ameliorated with malar implants, such as those done by Dr. Gunson.

And as mentioned before, theoretically, MARPE does have the potential to expand more of the nose, up the y-axis.

But are these reasons enough to warrant the time and hassle of MARPE? More and more patients are asking this question.

OPTION 5 – 3 Piece Maxilla, 5 Piece Mandibular Surgery

The fifth and final approach to 3D jaw maximalism that I will discuss today is a 3 or 4 piece segmental maxillary surgery combined with a multi-piece mandibular surgery, such as Dr. David Bell’s 5 or 6 piece mandibular surgeries. Other surgeons do this too, but not many.

This image and all images below show a before and after case of maxillofacial surgeon Dr. David Bell. The gifs were created by Shuikai. (Source)

This is complete and total reconstruction of both jaws in one day. Widening, advancing, re-angling. The whole, 3-dimensional shebang.

Specifically what is unique about this approach is the mandibular skeletal widening. The type of widening that Dr. Bell performs is not at all like a mandibular midline distraction, also known as MSDO. MSDO widens the front of the jaw, but does not widen the proximal segments, which are the back of the jaw, at all.

There is no other treatment modality on earth that widens the mandible in this way. gifs by Shuikai
A rendering of the actual visible change from this case by Dr. David Bell. gif by Shuikai

Shuikai has argued that MSDO is an unnatural kind of mandibular widening that has very limited airway and aesthetic benefits if at all, along with a greater risk of TMJ complications.

But Dr. Bell’s manner of expanding more closely mimics natural mandibular growth. He widens and arranges the proximal segments in a manner that produces better aesthetic and airway outcomes, and without stressing the TMJs.

Of course the downside of this approach is the recovery. That’s a lot of bone cutting and a lot of plating. And more plates means increased risk of infection. Soft tissue draping into the site of the bone gaps can also be an issue.

But if you could wave a magic wand over your own head and wake up 6 months after a surgery like this, and having had it all go well, that would be some result, wouldn’t it?

A remarkable airway transformation for the Bell case shown above. gif by Shuikai

So, now that we have reviewed 5 approaches to 3D jaw maximalism, I will leave you with one question: who’s ready to have their jaw cut into 9 pieces? 

Thanks!

Ron with Dr. Mew, Koko Hayashi, Dr. Newaz and Jawley having a Persian feast in Manhattan the night before MewCon 2024.