[Music] with like a yeah we are so gnarly we are so hary she like a Harley like I she she we on well I can't think of a better intro than Bailey freestyling so Bailey thank you for that. Uh, this is the second podcast of the day. We just shot a podcast for your channel, which let me just pump that right now. What, what's that channel? That is the Jaw Complex YouTube. The Jaw Complex, correct. Okay. Uh, will this be, will that be the first video posted on the Jaw Complex? The one we just shot with my wife? It will not. Uh, we've had a few, uh, videos. Uh, we've had some discussions and some clips and and one or two silly little things on there. And, uh, just trying to, we're, we're new to it. I'm very new to social media as, uh, these two young men know, uh, very well. Um, getting me, uh, yeah, getting me out in front of the camera, sitting here, uh, was a big leap. Are you ready to become famous? I am not. I know. Nor, nor do I have any intention to. So what's the purpose of that channel? Like, what are you trying to accomplish with that? I think that might be a good question for Dr. J. Yeah, I think that, um, we have a lot of things we can offer to our patients. I think that, uh, you know, obviously you guys have a history before, um, my introduction to expansion came basically. I told you this before, I saw one of our patients who had gone to Dr. Evans and I brought up to him immediately. And what I started noticing was that a lot of his patients were getting a lot of benefit, relief, TMJ pain, airway, sleep, etc. Um, and then what I kind of started realizing is that this procedure that we do is more than just orthodontic. You can change somebody's life. Um, and, you know, airway, breathing, apnea, oxygen. And so kind of like where we started noticing that if we brought this more mainstream, rather than just being an orthodontic solution, a healthcare solution. And so I think that this would, this is our first foray into making that more mainstream, making more from just a dental orthodontic to actually medical health. That's kind of where the Jaw Complex is our way to kind of bring that more of a health solution to people. And you said this procedure that we do, what are you specifically referring to? Expansion. Right. Um, specifically, but I mean, just the overall way we look at things. Um, you know, as orthodontists or dentists, we kind of look, look at the teeth, the jaws. And as medicine, we kind of, medical doctors or kind of focus on their specialty. And I'd say, you know, what we're trying to focus on is, is that person alive? Are they breathing well? Are they sleeping well? And then kind of look at it top down, right? So what are the necessities of life? And then kind of bringing it down to the, the micro level. And that could be whether it's the tooth or the jaw and things like that. But if the person's not sleeping, you know, getting oxygen, that affects, obviously, you're not alive, but affects everything else. And then is a person sleeping? Are they eating well? Are they drinking well? Are they allowed, are they able to take nutrition in, right? And then do they have infection? Are there, is everything that the, the mouth and the airways a portal to everything in the body from here to here? And so, is that in a functional capacity doing its job as well as possible? Mhm.

So the audience of my channel is well aware of expansion, the benefits that come with it, the need for it, basically all throughout, you know, our society and and probably most societies across the world. We have this underdevelopment sort of epidemic where people's faces are not growing to their full potential. And that causes this oxygen problem where people just, their air intake is too small. I've been using the automobile analogy a lot recently, um, which is to say, you know, combustion engines function similarly, sort of, to the human body. And that, you know, they require air, fuel, and spark. And a vehicle, if it's not getting sufficient air, immediately you see that it's sputtering out or it simply won't start. It's, its sensors will throw codes, right? Um, but for some reason, and any old, you know, average Joe knows when his car isn't functioning well and will get it taken to the mechanic and get the air intake fixed if it's an intake problem. But when it comes to our own bodies, so many of us are walking around with poor oxygenation issues, and it's affecting our metabolism, and we're just functioning suboptimally in a million different ways. I've been sort of looking at expansion more and more as a biohack recently. In other words, it's not the, it's not the solution capital T capital S. Just like any biohack, you sort of have to stack them, and they, they all work together to get you more optimal performance overall. But I've been trying to figure out like a way to bring this concept to the public in a way that's more palatable. And it's hard because there's no real good buzzword that captures it well. It's like, there's people use airway a lot, #airway, but if you hash airway, it like brings up American Airlines or some, you know, um, mew is another common one, but obviously that has like, uh, looks maxing and sort of not incel undertones, but it is what it is. Like mew is tongue posture, it doesn't really encapsulate the whole space. But I think maybe if we look at it as a biohack, cuz people are into biohacks, like specifically the Joe Rogan circuit of podcasters, they're all, you know, framing things in terms of biohacking. What do you guys think about maxillary expansion as a kind of biohack?

I think that's actually a fairly good character, you know, characterization of what it is. Because in, you know, I think the biohack, you know, kind of captures a few different things. One of them is the bio, obviously, like we're, we're doing something to affect a system in the body and the structure to support that system. And then we're also hacking is not essentially like natural, right? Like if we take a bunch of supplements for example, to hack our performance, right? That's not inherently so natural. But we may do it for per, you know, performance enhancement. It's kind of the same way that maybe mechanically kind of splitting the skull is not particularly the most natural thing you can do. But it is something that we nonetheless can do to improve structure and breathing and things like that. And of course, you know, we can later get into the excellence and, you know, um, pros and cons of it. But, um, it nonetheless is a tool that we have to improve structure in a somewhat unnatural way. Um, but so that what results from it is natural structure that we can then use to support better space for the tongue, better room to house the lower jaw, better, uh, nasal breathing and and so forth, right? Um, I think that, you know, and then if we think about those few things, it's just one of many tools that can be used in that space, right? So expansion isn't, and in my opinion, shouldn't be thought of so, you know, I guess like as like a singular thing. Like, hey, I or we are all about this, right? And that thing is expansion. Like this particular brand of expansion. No. Yeah, it's, uh, I think very silly to really think that way. I, I think it's more understanding like, hey, you know, we have an individual. This individual has some sort of, you know, uh, structural, anatomical, functional, you know, maybe systemic, molecular type of problem, right? What is that problem? And then what are the appropriate hacks or solutions to offer for that person, right? And of course, expansion just happens to be one thing in a really wide sea of other things, um, to throw in that mix. Mhm.

Although we can sort of draw some distinctions when it comes to discussing what is better or worse expansion. For example, in my ebook published on Substack, I just started my chapter called Chapter 4, How Not to Expand: The Limits of Tooth-Borne Expansion. So expansion is not all created equal. There's dental expansion, then there's, you could say, a second category of expansion, which is skeletal expansion, bone-anchored expansion. And then within skeletal expansion, of course, you have more distinctions that need to be drawn, which is particularly what I want to talk to you guys about today because you are offering, I want to call it the latest and greatest, uh, certainly the most hyped as potentially becoming the latest and greatest skeletal expander that exists, which is the FME, the Facegenic Maxillary Expander. Can you, um, I guess before we dive into what separates the FME from, let's say, an MSSE type 2 or a Parnes custom MARPE or a TPD that comes along with Casey Lee's ease, uh, which we, that's really, uh, the crux of what I want to talk to you about today is technically what makes the FME different. But can you just speak, uh, to how skeletal expansion in general, splitting the suture, has changed our ability to make the box bigger, so to speak?

Um, I think by definition, it's of course broadened that scope, um, quite a bit, right? You know, I think cases that used to be the only way that you could navigate a solution around that case and treat it comprehensively was to have a surgical orthodontic treatment plan, right? Where, and, you know, for those viewers who are wondering what I mean by that, um, you know, when you can move teeth with teeth moving appliances like braces or Invisalign, then you can basically, you know, move them into a bite or you can just move them within themselves to be straight for then a surgeon to then align, uh, however, which way is suitable for that patient's face, bite, airway, whatever, right? And so, um, you know, surgical, um, you know, surgical orthodontic treatment plans, you know, once upon a time were the only way to overcome perhaps, uh, larger discrepancies or problems not otherwise fixable or camouflage with traditional orthodontic. When you say a surgical orthodontic plan, does that mean just prepping a patient for an orthognathic surgery? Yes, that's at least what I mean for it to be in this context. Okay. You're not talking SARPE? No. Okay. Okay. Even though SARPE, I guess, fits in the cocktail of surgically facilitated procedures, um, to overcome certain problems. So, you know, of course, before the advent of bone-anchored expansion, then you did have SARPE as one of the, you know, um, tools, um, in a, in a toolbox of trying to correct different malocclusions, right? Um, and of course, your classic, you know, transverse, uh, deficiency was, you know, one of those things where, you know, then you have to make a decision. Am I going to do a two-piece Le Fort? Am I going to do a three-piece Le Fort? Or am I going to do a SARPE, right? Um, and, uh, and that was, those were pretty much your cocktail of options, uh, if you had transverse maxillary deficiency in the past. Now you could have transverse. Oh, go ahead. Just briefly. You seem to be speaking in terms of malocclusion, but are you also talking in terms of airway correction? Or are you just talking traditionally, this is how orthodontists, surgeons have approached expansion was purely from the perspective of occlusion? Generally speaking, it was. And that's why my answer is sort of sounding a little bit more like that now. We may be happening to correct an occlusion problem when we are also primarily treating an airway problem, right? Um, and so even if it's taking the same occlusion and just simply moving it forward in the face, right, it's still correcting an occlusion. It's still, you know, so it's, um, you know, so by saying the word occlusion and, and this is another thing for the viewers, and especially your viewers, is that when you hear certain buzzwords, don't think that there's like ignorance or, you know, kind of, um, you know, that two things can't be true at the same time, right? You know, what that thing called Schrödinger's cat? Yes. Have, uh, you know, that, you know, maybe we were talking about and focusing on one thing, and maybe something that seems to be contradictory to it, you know, it's not that that thing also can't be true, right? Um, so conversationally, and a lot of us, right, especially now that I'm like, for the first time in my life, kind of in a little bit of a public space, I'm going to say one or two things and then people are going to go on the talk space and say, oh my gosh, Noah said this, doesn't care about, yeah, right, you know, because they'll hear one little clip of me talking about malocclusion, not understanding that inside the computer that, you know, is all of our brains, really, you know, that all of these things can be true at one time. So that's just, you know, and, you know, this is also a, a message to your viewership, not to really do that to anybody, not just me, um, but really to anybody, because then those are the very things we have to waste our time answering when patients come to us for consultation, right? Right. Um, and, and that's a, again, it's a fair thing. I mean, we tend to be the office or the doctors to go to to handle those types of inquiries, um, but this is just so, you know, like critically think, people, you know, what I mean? Like understand that, you know, it's possible that, you know, we could be talking about a lot of things and that, you know, perhaps there are situations, uh, that might call for a little bit of, um, you know, deviation from what we usually say or usually do to treat that individual circumstance correctly. Sure, sure. I just went off on that tangent because I think your your question, um, was, I think positively triggering because it actually got me to think about, you know, again, you know, we're thinking about ways to make our communication with our patients more efficient and effective. And this is one of those things that we actually confront every day in practice is that, like, you know, like, you know, we, we have certain, um, I think there, there are certain buzzwords that kind of float around the echo chambers of this space, you know, right? Whether it's jaw hacks or Facebook or, you know, mewing or Discord or whatever, right? Um, you know, there's, uh, and there's just a lot of things. I think that, um, there are certain assumptions that are made, um, when talking about and deconstructing these issues. And really, our whole purpose of existing is to help patients de, you know, defragment some of that information, make it make sense. Not to go too far down the rabbit hole of occlusion versus airway, but it's one thing I've been doing a lot more of recently is trying, trying to distinguish between different types of orthognathic surgeons in helping patients choose what is the right, which surgeon should they talk to and consider. And one of the differences I'm finding is that, so I think, and please correct me if I'm wrong, but historically, orthognathic surgeons and orthodontists don't treat airway at all. They treat occlusion primarily. So in your training, you probably didn't hear much about airway. You heard about correcting bad bites, moving the jaws into a certain configuration such that the bite is now appropriate according to some standard, correct? Okay. And presumably, that standard is well, understood how the teeth should be in relation to each other. Can be perfect while the airway still be small? Absolutely. You could pull the perfect bite backward or pull it forward, as you mentioned. But so to my point though, um, I'm finding that some of the more popular surgeons, and I'm not going to mention any names, but they still seem to be more occlusion-focused and less airway-focused. And so less believing in the idea that making the jaws, moving them forward and making the whole thing bigger has any impact on airway and less willing to treat toward that end, just because that's not what they do technically. So that's the only reason I bring attention to the airway-occlusion distinction because, um, still, I think most providers out there really are only thinking about occlusion. I think that, um, you know, there's a lot of research that came out. I think University of Alabama did a lot of research on advancement of the mandible and MMA surgery on how it affects Le apnea and it's very evident that doing double jaw surgery can literally solve for most patients the VAPnea and airway issues. And so I think that kind of what you're saying is that classically trained, you know, a lot of it was probably occlusion-based, but I think it should start transitioning into that we can actually do surgical interventions to correct breathing issues. No doubt. And I think that, you know, going back to, you know, the medical realm, it's easy to give a band-aid treatment, whether it's a CPAP or mandibular advancement device, not actually look at where that obstruction or where that problem lies from the beginning of their nose all the way down to their, you know, airway, right? And so if you can figure out where that obstruction is, whether it's in the nose or hypopharynx, wherever that is, if you can figure that out, you could potentially solve it permanently, right? And that's where this conversation can be had as well, too. And I think it's all about establishing some hierarchy to the paradigm, right? All of these things are important, right? Teeth, bite, face, airway, all of them are important. But what's, what's first, right? And, you know, I think many of us in this space contend that airway's first, right? Right. And then of course, while you're doing airway, you know, of course, respect the face. And then when you've figured out the face and airway equation, then where can your puzzle pieces then fit to, uh, you know, reasonably match that goal, right? And, and the way that, um, I, and, you know, here's the way that, so there's a prominent periodontist, Dr. George Mandelaris, you know, when we work together on patients, right, he'll, you know, I like some of the language that he uses in, in saying like, hey, you know, like, if that's where a patient's teeth need to be for their airway to function optimally, then put them there, and we can do whatever supportive procedures are necessary to put them there, right? That really captures this illustration of this paradigm that I'm talking about, right? That airway first. And then obviously, for, you know, for that thing to be true, then, you know, maybe the teeth or the jaws or the bones need to be somewhere. And then now how do we get them from where they are to where that place is? And there may be a cocktail of different treatments, um, you know, to get them there. That's kind of, you know, thinking like that is really, in a way, a nutshell of this whole space, right? For sure. Yeah. And we've discussed how, uh, skeletal expanders can be part of that equation in terms of, um, airway construction, um, and also, you know, having a major impact on occlusion as well. Being able to widen the maxilla to fix, would it be called a, um, bilateral crossbite when the maxilla is just too narrow for the, as compared to the mandible? You can fix a crossbite at the level of the bone. That would be the occlusion perspective. So not to, don't want to go too far down that rabbit hole, but I want to start talking about FME now, basically, as what I'm saying. Um, tell me about your history in the different expanders you've used and how you've arrived at the FME, and just try to make it sort of a historical perspective on maxillary skeletal expanders.

Yeah, that's, that's great. And actually, just to kind of touch on something that you were saying too, I think it's important also for the viewers to know that, yeah, you could have a bilateral crossbite, even just if we're just speaking in terms of occlusion. You can have a bilateral crossbite that requires expansion, you can have a unilateral crossbite requiring expansion, you can have a crossbite that requires expansion of both jaws are narrow, right? Um, and then of course, if if the maxilla is narrow, you could either have a lower jaw that fits within it, fits on one side of it, or fits on both sides of it. That's basically, you know, that you can have all three types of crossbites or lack thereof and require some sort of skeletal expansion or have a transverse, uh, deficiency, uh, of the maxilla. And so really, that's actually a decent segue into, um, kind of what comes next is as far as like the, my sort of historical relationship with expansion in general. Um, a lot of this comes from, you know, and then I'll get specifically into the bone anchor part of it, but just like a brief, you know, sort of two-minute history on sort of where, you know, this all started for me. Um, you know, I, um, you know, I had orthodontics as a teenager. I had, you know, four premolars extracted, and so forth, and things were brought in, pulled back, and whatnot. And, you know, by orthodontic treatment standards, my treatment was done quite well. And, you know, I've not really gotten complaints about, you know, sort of my, you know, like, you know, your teeth look good kind of thing. I mean, that's, you know, again, the orthodontist did a very good job. Um, and, um, and then I kind of, you know, uh, grew to then, of course, study dentistry and then go into radiology first, and then orthodontics, right? And so when I was training, um, as a radiology resident and then later, um, practicing radiology, of course, we're trained to look at the airway, we're trained to look at the facial bones, we're trained to look at the interplay of all those structures. I think that was probably one of my, uh, core foundational influences that then when I became an orthodontic resident, I'm taking this background of reviewing, you know, medical and dental imaging to study airways, study noses, study jaw joints, and think about the connections that may exist there. And, um, and take that into, you know, sort of my clinical training as an orthodontist. And then it's then when you start seeing and then you start getting some real world practical experience and seeing like, okay, this is how my non-extraction cases are coming out, this is how the extraction cases are coming out, these are where the patients are more comfortable, these are where the patients are less comfortable during treatment, those kinds of reflections, you know, kind of started to all sort of connect, um, when I was in training as an orthodontic resident. Um, and I was very fortunate, again, I'll say this on, you know, pretty much every time I talk about this, I was very fortunate to have a program director and a leader in my education who was supportive of me kind of thinking a little bit outside the orthodontic box. Um, and so, um, you know, and I was the only one out of eight residents and six faculty members who themselves had premolars extracted. And that's why I did my residency thesis on that subject, like, hey, do orthodontists who've themselves had their premolars extracted, do they think differently about, you know, are their attitudes about premolar extractions different than those who haven't had? I had mine out, and it definitely influenced the way I think about this stuff. Absolutely, right? So I think that, you know, altogether, that's kind of where I became, you know, a little bit of a more expansion-focused provider. You know, we're now thinking of ways to make the box bigger, not smaller, because you're thinking about airway, because you're thinking about trapping the jaw joints, because you're thinking about, you know, the aesthetics, right? And just seeing that, you know, just the extraction cases just didn't look as good, right? You know, or whatever. So, um, so then I go, uh, you know, I graduated orthodontic residency, and then I, I kind of went on a tear of sorts, uh, for continuing education and kind of consumed as much of the cocktail as I could. Meaning, I took Juan Moon's MSE course, I went to, uh, you know, Clifton, New Jersey, took Barry Raphael and Mark Cruz's Airway mini residency, and then I took a Myo-Race course, and I took a this and that. I went to go see Bill H in Vegas. I did like a lot of these things. And, you know, of course, I'm seeing the same people at all the same meetings, be at all these different meetings around the country, because it was at the very, at the time, kind of a small group of people who were just kind of sort of following this little track. And obviously things have, uh, blown up quite a bit since then. That was like six years ago, right? And then, um, and so I take, you know, of course, that sort of cocktail of training and stuff, and then I start implementing it in practice, right? Just, you know, to the degree I learn something, and then I'm kind of trying new tools. I have the same philosophy of treatment. I know I kind of want to go this way and that way, right? You know, I want to go outwards and forwards. But, um, you know, I'm just trying to basically pick up more tools to do it right. And of course, I think perhaps the most influential of the things that I learned about was bone-anchored expansion. And A, that it was possible, B, that it was, you know, biologically, I think defied what we were taught in residency, and it actually works, right? There's actually evidence and papers and this and that to suggest that this is an actual physical thing that can happen. Well, we can also see it on the CBCT. You can also see it on the CBCT. So in picture, don't lie, right? The diastema doesn't lie. The diastema doesn't lie. Um, and that even that may be a somewhat, um, you know, uh, dissectable topic, but we'll save that one, uh, because there, there's something that some people think are fake diastemas because of hybrid expansion pushing the teeth and the bone, and you don't know where. But anyways, that's, uh, that, but that actually is going to become an important point of, you know, now talking about different kinds of expansion. And so some people might have a big skeletal expansion and get no diastema or a little diastema if it's more posterior, potentially. I think that that's, um, you know, at least the diastema, maybe becomes a little bit less conspicuous if it's more posterior, or it's just that the methods now used for quote unquote posterior expansion, right? You know, classically FME and E, or whatever, will be done so slowly that it's really just simply a matter of the interpalatal fibers and the teeth, right? There's, there's currently no type of expansion that current, uh, that exclusively expands the posterior. And so if you have posterior expansion that unzips its way to the front, and you get a successful full split of the midpalatal suture, you will get anterior and posterior expansion. I think the question lies in to what proportion, right? Is it one to one? Is it, you know, just all anterior and no split at the posterior nasal spine? And I think that's where some of the, you know, uh, divergence between different kinds of expansion patterns, um, is talked about. And then what is actually true, and what we've actually observed, is that you can have the device matters so much less than people think it matters to achieve those patterns. It's more about how the expansion is planned and carried out, and where, you know, the doctor decides to put the anchorage, and also how that individual's bone in the whole physical equation, right? You have a subject bone mass, right? And then you have some kind of center of resistance in that bone mass, and then you have a force application. You can either apply that force with vertical screws, or you can apply it with a, you know, lateral bar. It doesn't really matter how you do it, but the physics of those two things are different. So to also talk about those things like apples and apples is is also wrong. But, you know, but let's say that you have all these, you know, things at play, then that is what influences the pattern of expansion, right? So you have to know that the device you're using, applied the way it's applied on the particular subject bone mass that you're applying it to, will result in XYZ pattern of expansion. That's really the way to think about it. And that's, I think, you know, so as excited as we are to talk about and let the world know about, you know, what we think are some great things about the FME, this remains my ethos with expansion even today, right? That, you know, you can get parallel or anterior expansion with, you know, or posterior expansion with any kind of expansion medium. Um, and sure, there are certain factors that may promote expansion pattern to be this shape or that shape or whatnot. And I think we're seeing that. I think we, as an expansion community, are starting to more critically and scrutinizing that issue more. And then as far as the actual clinical significance and universal application of like, you know, these, you know, like, of course, you know, there, let's say that one type of expander or expansion pattern, right, is a little more anterior, right, or results in a little more anterior expansion pattern. Then, is that clinically significant from a full posterior expansion? I think often times it can be, because if you're not getting sufficient posterior expansion for somebody whose problem is posterior, then obviously that's not going to be really addressing the primary problem. But a lot of people may have their primary problem being more in front. Can it be said universally that nasal breathing problems are always posterior? No, absolutely not. So this generalization that the more posterior the expansion, the better the nasal breathing result is incorrect. I think it's incomplete at best. Um, and I think it's, um, it's incorrect to, you know, say that in an absolute sense. It's, it may be generally correct that you were going to get a more excellent nasal result if you also get posterior expansion, right? I think that's safe to say. But to say that, um, you know, uh, that posterior expansion is categorically better than anterior expansion and to separate them and to, you know, think about device patterns doing this or that is somewhat, uh, of a, you know, uh, futile debate, uh, really in my opinion. Because even those of us who are obsessed with posterior expansion, right, what's one of the anatomical structures we talk about? We talk about the nasal aperture, right? And we talk about the nasal aperture's width, as a, which is to say the front of the nose. Well, it happens to be the front of the nose, right? It is literally the measurement of the opening of the nose anteriorly as you enter the skull, right? And so just above the, uh, anterior nasal spine, generally, yes. Yep. And it's kind of like an oblique structure, so it may be situated, you know, either right, uh, above or, you know, a little bit forward or backward of the anterior nasal spine. Um, and so we're talking about posterior expansion being God's gift to mankind when we're using an anterior structure to define it, right? So I think that's where people need to start, you know, kind of being a bit more diverse with their thought patterns about, you know, anterior and posterior expansion. Of course, for those who are educated about expansion, that is. But, you know, our primary role as clinicians is, you know, our patients are coming to us with a problem, right? We have a solution for the problem. And in most people who aren't necessarily seeking a theoretical, you know, sort of advancement or benefit with a particular type of, um, Oh, is that? Well, I was asking, you want me to close the door? No, it's all right. Yeah, yeah, yeah. Close if you want. Close the door. We hear the baby crying. The baby's home. And, uh, we can hear her bringing some life to the house. Yea. Definitely bringing some life. But we're two floors up and, uh, she's definitely landing in my headphones. So, um, but continue. Yeah. So, um, so basically, um, you know, I think that, um, I, I think that anterior and posterior expansion can both be important, right? So us as clinicians, right, we can see, you know, I usually like to, in my imaging analysis, um, walk the patient through, you know, the front of their nose all the way to the back part of the airway, right? And so we see using a CBCT, using a CBCT, right? And so you can scroll through a stack of coronal or frontally facing slices of the CBCT, and you can start to appreciate the nasal tip, the nostrils, the nasal valves, then you pick up the nasal aperture, start to get into the bone-bearing part of the nose, and you can see the septal, you know, uh, you know, configuration and thickening and deviation and whatever. You can see turbinates, you can see adjacent air spaces, you can see the sinuses, you can see the osteomeatal complexes, which is basically a little conduit between the sinuses and the superior part of the nose. And, and then you're walking back, and then you get into the pharyngeal airway. And so you look at all those things critically, because, you know, you can see that people have different levels of resistance in different parts of the nose. Sometimes it's before you even get to the bone-bearing part of the nose in the soft tissue of the front of the nose, right? And sometimes that's somebody's bottleneck. Sometimes that's their biggest bottleneck, right? And so thinking about those things, and then also thinking about, you know, different skeletal, you know, deficiencies that people have. Some people have vertical maxillary excess, some people have vertical maxillary deficiency, some people have, you know, um, you know, a deficiency of anterior projection of the maxilla, right? And so when you're kind of thinking about, like, if you think of like a really, really short maxilla that's also narrow and pulled back, right? And then you're thinking about, okay, now you've got more of like a bulldog bite kind of pattern, wouldn't we think that it would be beneficial to bring this person's maxilla down and forward, right? So it's like, if you think about, and then of course, and maybe the teeth are so jumbled up that, you know, to simply create space for the teeth and create more room for the tongue and perhaps to deflect the maxilla, anterior part of the maxilla, down and forward, may be of some benefit to treating that particular patient, right? And then somebody with a vertical maxillary excess pattern with a really deficient mandible, well, then maybe now we want to think about, you know, letting the patient know that, hey, you're going to need surgery after we do this skeletal expansion, if we happen to do skeletal expansion, um, but, you know, this is what the expected result of the expansion is going to be, and perhaps may make, you know, the gumminess more prominent. And so we just have to understand the effects of our treatment. And of course, you know, as we get deeper and deeper into understanding different kinds of expanders and where to put the anchorage and this and that, and the actual skeletal, uh, expansion patterns that we see from those choices that we make, then that helps us make better decisions. I mean, you know, with respect to, and I think this is an evolving science. I think, you know, I mean, this is something that, um, you know, you have to do a lot of these to know what, you know, some of these variables even are. And you have to do enough of these to, you know, with a, you know, somewhat questioning mind, to understand what is actually the effect of our expansion. Because somebody who's simply seeking nasal breathing gains from expansion, almost everybody will get some variety of that. If you've successfully expanded the maxilla, you will probably get, you know, at least in 98% of patients who seek expansion, some sort of measurable objective or, you know, subjective report, like, hey, I can breathe better through my nose. And, you know, many non-expansion seeking patients are happy with that and don't need a lot of expansion, and you put the bite together and so forth, right? And so it's like, when we do the same thing for, you know, individuals who really kind of think a lot about these things, then it brings up a lot of this discussion. I think it's a very healthy discussion. I think it's discussion that really has made me actually, you know, question, like, you know, of course, here I am sitting talking about like, hey, well, you know, better nasal breathing, we're giving you better nasal breathing, what else matters? But a lot of else matters, right? Thinking about how the pattern of the skeletal expansion is unfolding, and also the risks associated therein. I think these are very, um, you know, I, I think these are very important topics to think about and talk about. Um, yeah, I mean, that's a lot to unpack there. You, you're sort of bringing a whole different perspective to the space rather than thinking in terms of these sort of dualities of anterior, posterior. There's obviously more to it. Can you talk about the tough lessons that you've learned using these sorts of expanders over the past five or six years, and how the technologies have evolved to keep up with the challenges that providers have faced in where we're at now with the state of the market in terms of technologies available and limits of those technologies? And maybe incorporate FME into that sort of conversation.

Yeah, definitely. Because I think FME is, is perhaps a direct response to a lot of the challenges or shortcomings I'm about to mention, right? Um, so, um, I think a, a big part of it initially, right, um, was just the, you know, there are variables in seating a bone-anchored expander. If you're using traditional, you know, bands and other things, and you're pushing this thing on and off the teeth, and trying to get the thing aligned, and then you got to, you know, check, you know, to stand behind the patient and kind of, you know, and stand in front of the patient and check. And then, you know, you have to, might, you know, rotate or reposition your appliance to make sure it's not kind of cockeyed in the mouth, right? Like, and then even understanding that that's important. Where with tooth-borne expansion, you just got to push the teeth out, sort of as, you know, they're basically just, you know, going along for the ride in the expansion. You get a little skeletal, and then, you know, you put the teeth wherever you want to put the teeth. It becomes, you know, when you have now a rigid bone-anchored expander, it becomes more sensitive to, um, you know, uh, basically inequalities in all three dimensions of space, right? Roll, pitch, yaw, all of that, right? And so now, now we've started to kind of learn that, oh, okay, you know, now expansion can be tilted. Now maybe I don't want to put this expander conforming exactly to the patient's anatomy because the patient's anatomy itself may be slanted. Um, maybe I don't want to try to overcorrect for that thing because maybe that means another structure affected by the expansion could go the wrong way, even if something's going the right way. And, you know, what I'm talking about in particular, let's say somebody has, you know, a slant or something, right, or a cant, and, you know, maybe the left side's higher than the right, let's just say. But let's say the left orbit is lower than the right, you know, and then now you're thinking, okay, well, you know, I can expand and the structures are going to behave one way. If I try to correct for the occlusal pre problem, am I going to make the orbital problem worse? You know, these are, it's just basically that, you know, we have to think about all these things when we're doing expansion. So I've learned to basically have to think about all these things and whether the planning of the expansion is going to indeed predictably, you know, um, do what we want it to do. And then how do we do it in such a way where, um, you know, we can maybe intercept things if it's not doing what we want it to do. Um, and what are some ways to correct or adjust for that, right? Um, so I think learning all of that, obviously, it's led me to, so now just kind of making the simple bullet points, it's led me to go super slow with expansion. It's led me to be a little bit closer with monitoring with expansion. And it's led me to understand that probably expansion's number one problem as it exists today is symmetry problems, right? And symmetry problems is a result of Newtonian physics where one side must push off of the other side in a structure where you may have differential amounts of bone resistance in the face, right? When you do that, then if you know, generally early on in expansion, these things are not really much of an issue at all, right? You know, the tension required to split the palate will eventually be overcome, palate will split, and then expansion will propagate. And then perhaps at a certain point, you know, of course, suture disarticulation happens progressively, right? So you'll have mid-suture, mid-palatal suture disarticulate first, right? And then you may have other sutures start to kind of give out. Well, if some of the sutures on one side are giving out a lot sooner or a lot easier than the other side, well, there's your differential bone resistance. What are some of those sutures? Yeah, so some of the sutures are the pterygomaxillary suture, that's in the back, right, connecting the maxilla basically to the skull base. Then you have your zygomaticofrontal sutures, you have your zygomaticotemporal sutures, you have your frontonasal suture, right? So you have a lot of these different, um, you know, um, so you have a lot of these different sutures that, you know, let's say zygomaticotemporal, as described by Dr. Juan Moon, who's studied a lot of these things, is perhaps the fulcrum point or the rotation point about which, uh, expansion, uh, occurs in skeletal expansion, right? And so, um, you know, so we may see cases where, let's say, particularly that which, let's say, if it's the pinnacle point or suture of, you know, involved in expansion and it disarticulates early and much more than the other side, well, then that's one reason why you might have one cheekbone start flying out a lot more than the other, right? Um, and, uh, and then you might see frontonasal, right? You might see that's why one side drops more than the other, right? You just have all these different sutures that maybe have different significances in terms of what we've kind of seen to be complications with expansion, and how much of these asymmetries that happen with skeletal expanders are are a result of asymmetric placement of the appliance? Maybe that was something that happened more early on in the early years of of these expanders, 18, 19, 20, let's say, versus how much of it is just biological variations and asymmetries that pre-exist? Yeah, I think I think it's a little bit of both. So I think, like, for example, your case, right? Like your case, expander went in, you know, straight, but, you know, again, you kind of put certain forces on the skull, and then the expander starts to behave a certain way, right? So the resistance and the, um, you know, rotational control within the expander mechanism itself is important. Your case taught me that, right? Your case also was a big lesson to me on speed of expansion, right? Like you were kind of the first case that really kind of, you know, like with really, really aggressive turning for a while, right? And then, you know, we see, yay, the suture splits, and now we want to carry it, we want to try to get the biggest maxilla, right, we can, right? That's so was kind of like, and so, and I want to be candid about this talking to your viewers, because, you know, you know, we all know that, you know, I did your expansion, and, you know, that that expansion happened several years ago, and you've been on a quest to kind of correct your occlusion and other things since then. And so, you know, I think that, um, in those earlier years, expander placement was an issue. Also understanding the effect of expander dimensional stability as you activate it, right? You remember one thing that happened to your expander, it started looking pretty ugly at a certain point where like one bar was here and another thing was there, and it just, it looked like it was coming apart. It looked like it went to war. It looked like you went to war, right? And, uh, you know, you turn it 26 times in three days, it's going to, that's going to be a little bit of a start of a war, right? And so it's like, you know, so some of these things happen, and then that promotes the expander, um, to drift, or it expands the, you know, it promotes some things to drag or be more.

susceptible to those things, right? And so I didn't—I can't necessarily say that I really firmly understood that, right? At the time that, you know, like because we were following Juan Moon's guidance, right? Early on, right? Four to six turns a day, whatever. Then we all learned, those of us who were doing a lot of these, learned individually in our own ways and through each other that that is not at all the way you want to do skeletal expansion, right? Because it's ultra-aggressive. It promotes all kinds of risk and failure and this and that, right?

Then now, let's evolve to the, um, you know, era of CBCT-guided, you know, expansion planning, right? Specifically TAD placement. TAD, tell us what that means. Yeah, so, um, you know, of course, you have, um, you know, so you can have a pre-fabricated expander body, like the classic MSE. And you can actually even plan that, right? Like you can, you know, you can have the lab have a digital object of that and superimpose it on the impression and superimpose that impression on the CBCT, and then you can plan how long the screws need to be and where might be a good position to place that particular object because you have that object in your digital library for purposes of planning and diagnosis.

Could you take that MSE, the actual MSE type two, I think it was type two, right? And actually adjust whether it was going to be flush to the bone or flush to the bite plane? Like, could you do all sorts of different customizations with it like that? Well, I think, um, so inherently, no, because, you know, all your screw holes and everything will move as you tilt it. But you could still, like, let's say I want this MSE here in space, and that results, because of asymmetric undulation in the palate, the need to weld things to the underside of the, uh, MSE or otherwise, you know, to make it flush so that you don't have an air gap when your screw goes through the hole. Then those are the types of adjustments we would have to make. Or that if it did need to tilt, well, now you have to think, well, you know, my screws are going to tilt with it, right? And is that appropriate for the situation?

Well, you know, at least having CBCT helped us better understand, you know, because if you can see the orbits, you can see the cheekbones, you can see the nose, you can see the nasal floor, uh, you know, undulation, and you can see the palate undulation, and you can see the occlusal plane, you can see all those things and make a decision how you want to tilt your expander, right? Or not tilt it, right? And then if you're making it flush with the palate or flush with the occlusal plane, what does that mean for the skeleton? And what does that mean for where you may already have too much prominence on one side of the face versus the other, right?

So the advent of uncoupling, because see, the expander screw is embedded in the MSE device, right? In the MSE type. So the MSE type two's TAD holes are going to, uh, you know, tilt or rotate in, you know, in direct response to where you place it, right? Versus with a custom MARPE kind of workflow, you can uncouple the orientation, twisting, tilting, you know, whatever, of the expansion screw component from where the TADs go, right? You can put the TADs wherever the heck you want in the palate. You can design the underbody of this custom hardware however you want. You can place them paramedian, you can place them alveolar, it doesn't matter. But you are the boss, right? You pick where that anchorage goes and how much of it you want and how to angle it. You're not predetermined to strictly parallel. You can maybe do a little better than parallel. And I'm talking about the paramedian TADs. And what I mean by paramedian is, of course, the TADs that are on either side of the midpalatal suture, not even those side TADs or alveolar TADs. I'm just talking about the central TADs, you know?

And, you know, this is an example I've given to a lot of patients that, you know, the palatal bone, right, is like a little bone sandwich. Right? You have the oral side, you have the nasal side, and you have a thickness of spongy bone in between, right? And so you engage that in parallel, well, you're engaging actually the minimal possible surface area that you can engage. Then maybe you get, you know, of course, one of the problems with, um, you know, MSE, you're putting a 1.8 mm screw in a 2.3 mm hole. You have a lot of engagement and tipping of the screw just to engage with the side walls of the expander. And so you're, it's, you're kind of burning out some of your expansion potential with these screws bending. And of course, if your suture doesn't split easily, well, then the TAD heads diverge, you know, more occlusally, right? And the tails stay together. That means you didn't really get much expansion at the tails, right?

So if you could orient these TADs not just parallel, but better than parallel, right? Now you've got the tails divergent, right? And you're engaging in an oblique surface area of bone. Yeah, you're toenailing it. Toenailing, right? And then you can do that, and now you have a little bit better bone anchorage. That's why we see more efficient results of expansion with custom MARPE as opposed to MSE type two. And the custom MARPE, was that all coming out of Partners Dental Studio, or were there different labs doing those custom MARPEs? There were different labs, of course. Uh, I think Partners definitely quickly and easily took the top spot because of how, um, because of how predictable, I think, and how robust the planning was. And then they've developed a reputation and they got very comfortable with certain things, like, of course, technically any lab with a digital library can do and metal 3D printing and, you know, access to the little expansion screws can do what they do. But I think they had a knack for designing these things and understanding, oh, you know, well, these providers are mostly using the MSE ratchet, well, we got to make the window where, like, they're actually thinking about what tools the clinician has to use in that, you know, individual's palate and whether them using those tools in that area is going to actually work to deliver those screws in the holes, right? And then, you know, they make those holes 1.85 mm diameter so that there's, you know, at least a much more minimized amount of screw to screw housing play in this, right? And that is a very important aspect of making expansion more efficient. We're going to get to how that, you know, goes into some of the FME stuff, um, but that was an important, I think, advancement, you can call it, right? Um, and there are other labs around the world. There are many labs in Europe and South America that do digital 3D planning similar to Partners on MARPEs, on MARPEs, on MARPEs, you know, and, um, you know, shout out to OrthoDigi in Turkey. They do some great, you know, digital MARPE planning and stuff like that. Um, and there are just some other.

Have you worked with them? You know, I've, um, I've had some conversations with them. I haven't done a case with them. I know some of their capabilities because of, you know, some collaborations that I've had, but I haven't ordered an appliance from them. I think we've, uh, found maybe some logistical issues with the timing of getting appliances and this and that and whatever. Wonder if that's who Aisha Chamila uses? Probably. She's in Turkey. I think there's a good chance that she probably. She does a nice MARPE, she sure does. Um, so I think it's very possible that they are the lab, um, that that she uses. So I haven't used their, like, I haven't ordered an appliance from them, um, but they do some really cool stuff. Check out their Instagram. Cool, cool. So, but, uh, in general, these, the, the second MARPE type two or Phase 2 MARPE 2.0, was this, these custom MARPEs that where you could decouple the TAD placement from the actual orientation of the expansion screw, and as well as having the tighter socket that the screw sat in, so you didn't have as much play in the between the screw and the the housing for it? Correct. Are there any other key features of that custom planning that was part of the evolution, the continuing evolution of these expanders? Uh, well, as far as the planning, I think just really being able to make CBCT such a central, uh, element of the workflow, whereas, you know, in the past, we used to pre-diagnose, still look at things on the CBCT, or when we didn't have access to CBCT, and we just had two-dimensional images, we would do our best to make skeletal diagnosis from the images at hand, and then basically, in the real-time clinical situation, manipulate or, you know, ask our labs to manipulate things to where we thought they should be. Of course, you can see that doing it with the images as part of the design workflow take a lot of the guesswork out of that, right?

I'm not sure I understand that point. Yeah, can you just give me a practical example of the, the better way of doing it by integrating the CBCT and how that informs the the appliance manufacturer? Yeah, absolutely. So basically, there is overlay of surface impression data, that's your STL or digital impression, right? So you have surface data, right? You scan that's like your iTero scan, right? I scan, Trios scan, and all that. That's the, the camera when it goes in your mouth and takes a photo, your teeth and your palate and stuff, correct? Actually lots of photos and then stitches them together, essentially. Absolutely. And then you have your digital imaging, right? Your CBCT, right? And then of course, the two are superimposed. There are certain anatomic landmarks, of course, usually just the teeth and the, you know, uh, surface anatomy of the gums or whatever, that are captured, that are used to register those two things on each other. And is it a separate software where you superimpose them on each other? Yes. And labs will have access to different softwares to do that purpose. Um, you know, so there are different softwares out there for that. Um, and, and, and again, these are softwares and technologies, commonly used in digital implant planning, right? Like Dr. Jafari uses those things as part of daily practice, right? Where you have a surgical guide to place an implant, you make a surgical guide using the data in your imaging data set. But that imaging data set then has to result in you having something in your hand that you can put in the mouth and guide your implant placement. So the custom MARPEs essentially are the surgical guide generated from overlaying these things together and then seeing what thickness of bone, how do we maybe thread the needle between these roots, right? We have tooth roots on the side, and sometimes you'll see in, you know, um, custom MARPEs, right, we'll sometimes put pads in the side, right, that thread the needle between the roots. Well, that's certainly not something you want to guess or do blind, right? Like, and sometimes while you're doing it, it's like, am I really threading the needle between the roots? You know, but you have that confidence, and you saw the planning yourself, and you yourself, as the provider, are being asked to approve that planning, right? So you're seeing that, and then, and then you have that confidence that, okay, if this thing seats on the palate, on the teeth, the way that it was planned to sit, then you know that we all trust the holes. I can trust the holes. Exactly. Similar in a way to Dr. Alfie's, uh, pre-printed surgical guides and plates for the way he does his surgeries. You have to, you go all in on the planning phase. Yeah. And then you trust what comes out the other end. Absolutely. And you basically follow the holes and follow the cut lines. All right. Yeah, yeah.

So, um, continue though. So, uh, this workflow, yeah. So that workflow basically, you know, then, then basically they, so your MARPE, your custom MARPE is the guide. Mmm. Because it's seated on the teeth. So then you cement that, and then now the holes are already digitally planned, then you place the TADs through the digitally planned holes, and the lab tells you and shows you, you know, provides the TADs that are pre-sized for that particular hole, and you know, they give you a little map saying this TAD goes there after we've already approved it and and created that plan. Now, as part of this, uh, new workflow, is it the case that immediately in the wake of these custom MARPEs, we started getting more anterior-biased placement of these expanders to overcome a common problem that was happening in the early days, which was posterior placement with the off-the-shelf MSE type 2, and the bone is just too thin back there? So people just sort of, was there a reactionary period where people went the other way and they went toward the anterior nasal spine and anchored in the big, fat, hard bone up there? I think so. Can you talk about that? I mean, that's what I did and do. Um, because, you know, again, you have to understand, you know, we have had a lot of failed expanders back in the day.

How bad was that? Like, what was that, what was that actually like? Like, would you get an adult male come in and you'd be like, well, man, we're really essentially doing a coin toss as to whether or not this is going to work? I think, I think so, to some degree, we would have to kind of look these people, uh, in the eye and say, like, you know, we can't really predict whether you're going to get successful expansion. We may need to do two or three rounds of expansion. We may need to do this and that. Like, we had a whole spiel that we would have to give because it was unpredictable. It was maybe made to be predictable with other forms of surgical assistance, and we'd have to lean on our colleagues to then do surgical cuts for these people to then make them good candidates for a predictable expansion with more primitive appliances, right?

Then we got to a point where we saw, okay, you know, like, you know, when we're engaging the bone anteriorly, well, again, it is not the anterior engagement of bone that causes anterior expansion. It is again, how the physics of the expander plays out in the subject bone mass when the expander is being activated. So you can have something anchored in the anterior, but having an effect, right? Like, you take a pair of weed whackers or something, right? The expression of the force is different than where the application of the force is, right? So if you have expansion that, you know, perhaps primarily is in the place where you, you have the most mechanical resistance, at least in a vertical screw-oriented appliance, right? Then you have, um, then you have to know that if the palate splits there and unzips to the back, right? Then you have expansion in the front and the back. But what are some of the ways that we help it be more equal and not just anterior? Well, you got to spread your anchorage around so that your axis screws is perhaps long enough to engage posterior and anterior bone, right? You, and then in other words, you, you make sure you add some TADs in the back too. Absolutely. In addition to the more solid ones up front. 100%, right? And of course, TADs in the back are shorter because the bone's thinner. TADs in the front are longer because the bone is more, you know, uh, thick, right?

And then, and then the other assumption or, uh, condition for expansion to be relatively parallel, right? Is for the expander to remain dimensionally stable throughout the expansion, right? Of course, if you have an expander whose mechanism is prone to buckling or twisting, then that may affect the parallelism of expansion, perhaps like yours, right? You need the appliance to maintain its form. You need the appliance to maintain its form, even. And so let's say you now have these barrel-type screws, Tiger or Super Screws, as opposed to to the MSE type two little hex. So you got this big, strong barrel thing, but then as it telescopes out, right? TPD, and you know, custom MARPEs both use telescoping expansion screw systems, right? What that means is that you've got basically, um, things compressed into a barrel, and then you're pulling the two tubes out from one another, right? As you do that, you need the whole axis of the tube to stay straight, right? Whether it does or not depends on the strength of the tube mechanism that you have at hand and whether the resistance in the subject bone mass has allowed it to buckle or not. So, right now, just to be clear, you're not talking about the TADs that are in the bone, and you're talking about the expansion screw? Yeah, the, the, the screw that, uh, is parallel to the bite plane, correct? Yeah, or not, if you intentionally don't want to put it parallel to the bite plane, because you don't want to exacerbate an asymmetry, right? It looks almost like a piston. Yes. Correct. And so you have this barrel, right? And then of course, if that barrel stays dimensionally stable, you're calling that a barrel now? Yeah, okay. I just, especially conversationally, I think it makes a lot more sense, right? You look at this thing, it looks like a big gun barrel. Yeah, there you go. Yeah, yeah. And, um, and then you pull this thing, as the police, and so you pull this thing out from itself, right? And then, you know, there are times in our custom MARPE cases, right, where again, a lot of resistance in the palate, and maybe you're activating this thing, it mostly stays straight, but maybe later into the term, you'll see it kind of give out a little bit, right? As it gets longer and the lever arm gets bigger, essentially. Exactly, exactly, right? Um, but assuming that it stays dimensionally stable, your expansion should be generally parallel, right? Um, and, uh, and so that's, that's, I think, some of what we have to look at with the performance of these things. Um, and then the, um, you know, as, as to whether, um, you know, as to like how much activation, when do we start to see, you know, failure of the barrel to stay really perfect? Um, that I think remains to be studied in maybe some, some bit of detail. I think, um, I think that's something missing from the current, you know, research on expansion. And I think that, um, you know, it's important to understand, um, that as, um, you know, as you're expanding, um, and then let's say you get four, 4 mm anteriorly and 3 mm posteriorly, or let's say, you know, four and two, right? What is the clinical significance of that, right? For that individual? So I think that needs to be studied, right? And I don't think, um, it's been perhaps properly studied with current tools. I think those who say they've studied it and say they have the only solution in the world to overcome the post-lack of posterior nasal expansion problem are perhaps living a little bit in the past when comparing them to other methods of bone-anchored expansion from a few years ago or prior, right? I think now with custom MARPE, FME, all these other things, right? I think we, we have to revisit that conversation, right? Because I, and again, and if we revisit it, what will we find? Well, I think that we're going to find a nuanced, um, you know, again, I think a set of new research questions, right? A, what is the clinical, like, to what degree is fan or reverse cone expansion clinically significant? You know, how important is parallel expansion? I think we all sort of inherently believe it to be important because you want expansion in the front and the back to expand the whole nose, right? I think it's common sense, and that's why we want to get expansion in the back, not just the front, right? Um, but I think it's important to understand the clinical significance of that, um, and I think it's important to understand, you know, what other factors as far as, you know, like, let's say, how far off of, you know, the bone mass does your force application nut have to be, you know, to then not start seeing other kinds of fan-shaped expansion, you know, or dropping of the, you know, like there's all these concerns out there. Um, but are you, are you suggesting, are you suggesting that maybe if we somehow test nasal breathing differences in patients with all sorts of different expansion patterns, that it's not as crystal clear as yes, some purport it to be that the reverse cone is categorically the best for nasal breathing? Correct. I think we're not going to find that to be true. Research to be done, right? How would you even study something like that? Using rhinomanometry, I think that would be one of the things that you could use. You know, yeah, because basically, you would need to see some sort of measurable nasal airflow dynamics to to know that for sure. Um, but yeah, measurable, um, you know, nasal gain. So I think you could kind of couple the objective imaging kind of changes with subjective stuff, and of course, with other objective clinical stuff not related to damaging, like rhinometry, right?

Okay, maybe we should now transition into FME. Transition into FME. Yeah, and, and I think we'll all chime in here, but, um, you know, including Bailey. Including Bailey. Yeah. Bailey, tell us about how you developed the FME. So first, I, uh, no, I'm just kidding. Um, so we're talking about, this is actually a great transition point because I think the number one strength of FME, um, is is its ability to stay dimensionally stable throughout the whole expansion process, right? We saw more prototypical versions before that look like, hey, how's that thing going to stay stable throughout the whole expansion, especially in an adult male? But with these recent iterations and the current generation of FME, it's like, how is this thing going to buckle? Right? And, um, you know, we have gotten to know the people who have founded the company, and they're extremely passionate about expansion. They've spent years, um, testing and researching this stuff in a, in a lab setting, and then, you know, before even kind of starting to think about, you know, clinical. Full disclosure, do you work for these people or anything like that? We do not work for them. You're independent of them. They're simply a supplier to your independent orthodontic practice. That's correct. You're not a partner or an investor or anything like that? Only in a, I guess, only in the sense that we are now, I guess, the only providers, um, that may change in the coming weeks, but for right now, we're the only providers. We are the ones who've been giving them feedback, um, and, you know, sort of experience. No, we have no financial interest in this. We do not have any. But you got the most experience with FME? I'd say, I'd say, um, so far, our experience with FaceGenX has been really positive. Extremely detail-oriented, extremely passionate. Then every, every time we deliver a case, we give them basically an after-action report, and, um, every feedback we have, they implement it immediately. So each, each delivery has become even better, more smooth, more accurate, more precise. Who are these people and why did they become interested in solving this particular problem? I've, I talked to Cameron about this. He's, he's a patient, has a Class III, and I think that he wanted to apply for himself and he's seen that there was a problem with the generation of, um, expanders and he wanted to come up with a solution. And pretty much he wanted to use it for himself, and he's doing that. And he figured out that it has to be really detail-oriented and you just can't just throw, um, something against the wall and make it stick. So that's why everything is so precise, so meticulously planned out, 'cause he saw a need for himself and he wanted to bring that to the population. Was he like studying the last five years of expansion cases and identifying the particular shortcomings of other appliances, or did he sort of start from scratch on a pad with a pen and paper and say, hey, how can I make the best possible expander? Do we know? I think, I think a little bit of both. I think as part of answering that question, I think he, you know, kind of, um, you know, had to take a little bit of a survey of different methods of expansion and what the, uh, protocol issues are, what the design issues are, and basically tried in real time to develop a product that overcomes some of those challenges. This is essentially one man who kind of began this by wanting to make it the best possible expander for himself. Him and his brother? Yeah, but for for him, yeah, definitely. And so I would say that it's so far, I mean, our experience has been a patient like he's a patient himself and in the future and he's seeing how it could apply in a very, a calculated manner that's predictable. What's, what's his background? Is he an engineer or is he just a kind of a savant who's? He's an engineer. Yeah, I think so. I'm not sure, um, if if he's not an engineer, he is an engineering savant. He's a, he's a de facto engineer. He's a natural. Yeah, he knows his stuff. He does know his stuff. Um, so he may actually indeed have a background in engineering, but I don't know. But if I think I think he may have mentioned that to us. It's a possibility. And when when he went about creating this appliance, and you're saying that the sort of the key thing about it is that, how, how did you phrase that again? It's dimensional stability. Dimensional stability. So that means as you're entering the, let's say, the seventh and eighth innings of expansion, it's preserving its form and it's not distorting and leading to asymmetries and other types of failures? Correct. And part of, uh, also in the planning process, right? You know, again, the planning depends on, you know, interplay of, you know, the doctor's prescription and, you know, the planning on the end of the lab, right? Let's say with this, right? They have, you know, what they, uh, call kind of like a mid-facial alignment protocol, right? So they're looking at different structures of the face. They're looking at the orbits, they're looking at the nose, they're looking at what should be the mid-sagittal plane and other cranial structures and kind of determining a mid-sagittal plane. And they're making sure that the FME in the planning is perpendicular to that plane. Okay. If the FME is perpendicular to that plane, then basically the only variable, uh, is, you know, where to place it anterior-posteriorly, right? And then again, that variable is then an interplay of us and them, you know, kind of saying, hey, this is bone quality and this is this and that, whatever. But in, so in layman's terms, that the mid-sagittal plane is that essentially the theoretical midline of the whole facial structure? But if, if there's discrepancy between the teeth and the bone and and pre-existing asymmetries, how do you decide what to prioritize in drawing that line? I think that's a very good question. I, I think so. Um, you know, sometimes when appropriate, you'll use the interorbital axis as reference. Sometimes it doesn't make sense to use that as reference if the orbits themselves are misaligned. So you're looking at other cranial markers, right? But not the teeth. Not, not necessarily the teeth. The teeth can be moved. The teeth can be moved. The teeth is perhaps the last thing to look at when you're planning a mid-sagittal plane of the skeleton, right? Um, and so, yeah, so, but you're looking at, you know, maybe anterior and posterior nasal spine. You're looking at, and of course, but if you can see a clear evidence of yaw in that person's face, right? Then maybe you're not assigning the mid-sagittal plane as anterior, you know, ANS to PNS, right? Um, but doesn't this sort of speak to an inherent shortcoming in all of maxillary skeletal expansion, which is dealing with pre-existing asymmetries? I think so. Mmm. I think so. Yeah, absolutely. I, I don't think that there's a perfect science here. I think, but the fact that we have to now assess and analyze all these structures and that there is a call to do that is progress from where we were as a community just a few years ago. I mean, I remember asking certain orthodontists just a few years ago what they thought about MSE symmetry and they said, oh, there's no such thing. Mmm. And it turns out to be the biggest problem in MSE. It was clear to me that it was the biggest problem, but I, I still can't explain how they could have uttered that phrase. But, but maybe they meant something different. Maybe they meant like, it's the result of screw-ups, like, yes, it happens, but it only happens if someone messes up, a user error, so to speak. Anyway, I mean, six years ago, they didn't think MSE was possible to expand palates and so some people, anyways, fair enough, right? And so I think it's an evolving science and I think that a lot of orthodontists are indoctrinated, like some people are still putting up premolars, right? We're clearly on the opposite extreme of that. We don't take our premolars for anything, for sure. You know, you know, going back to the stability of the actual FME body, I mean, that's something we should probably talk about because it is pretty, pretty sturdy. Yeah. Should we take a look at? Refresh the page, if you could. So we're not screen sharing yet, but let me, uh, let me get a visual. For maybe I'll do a screen recording while he's figuring that out, if I might add and ask you a question, Dr. Rax. Yes, sir. Have you seen an explosion in popularity or patients coming to you asking for expansion over the past, let's say, three years? I wouldn't call it an explosion, but I, I mean, there's definitely, I think, I mean, my career is is young enough that my whole career has been the explosion, right? So I don't know what to compare it to. It's all I've ever really been known for or did. Um, but I think that, um, you know, again, as these things become better understood, I think that we may see, and especially if we see a broadening of the applications, a better understanding of the aesthetic part of it. I think that's really important because aesthetic outcomes are very variable, right? My my question was with people like Ron in the space, pioneer of, you know, putting everything on onto the platforms, FaceGenX, this could have come in a year or two if it hadn't been brought to the attention of someone like the gentleman who started FaceGenX. Like I think that's an an important thing to keep in mind that this is a progressing field and the more eyes and the quicker it will evolve. Absolutely. So thank you, Dr. Rax. Oh, thank you for making FME possible. Thank, thanks for the shout out. You know, uh, but we still got a long way to go. There's a, you know, just, I feel sometimes I feel like it's, that's it, we get it now. It's like a good, a good expansion and then a good jaw surgery and, you know, maybe some soft tissue stuff to put some icing on the cake when all is said and done, and that's it. We figured it out, you know, like everyone can go home now. We know how to fix airway stuff. But it's like, no, we're just getting started. And I think that right now, like, you know, you know, if you read, like, a lot of books about like how MA got popular, it's like a very cult-like following. I think that in this space, it's a very, um, the people that know, know. But bringing this out more mainstream and seeing what benefits it could bring to the general population is, I think, where the true beauty of all that's going to lie. Yeah, no doubt, no doubt. Um, all right, let me start this screen recording. I think it started. I hope it started. All right, uh, as a hedge, I'm just going to get this going too. This will also help us sync it in post. And this is actually a good time to just kind of give, um, you know, uh, like a quick intro into how we even became introduced to FME, you know, because, you know, I saw that, you know, Dr. Ting had done a couple cases and, you know, was teaching it and I saw a couple pictures of it and all that kind of stuff. This thing is interesting. Um, and then that was kind of that. And then we got really comfortable with our custom MARPE workflow and this and that. And then I had a patient, a young man, um, you know, international patient, um, who, um, you know, probably one of the smartest 17-year-olds I've ever met, who came to me and said, you know, like, hey, you know, like, this is why I kind of want this new expander. It's called the FME, and, you know, we know that, you know, about it. I just kind of want to, you know, like, this is some of the reasons I'm pursuing it, and, you know, I think it'll be good for my case, especially given that, you know, now we've demonstrated that, of course, you know, really pure forms of skeletal expansion are possible, and I think that would be good for my case, plus protracting, uh, the maxilla a little bit, and this and that, and I think FME will kind of lend itself well to my own clinical goals. So here is the phone number for the savant engineer that we're talking about, and, you know, contact him and see about getting hooked up with FaceGenX. He's, you know, familiar with my case, so if you just reach out to him and say, like, I'm so-and-so's orthodontist, then he'll, you know, maybe try to kind of get you onboarded or whatever, right? So I contact this guy, and then, uh, this guy, you know, refers me to his brother, who's kind of more the business manager of the operation, and the business manager kind of goes over some basics with me, sends me a training kit, I kind of get a chance to sort of put my hands on it and play with the, you know, the the FME, just on a tooth model, on a typodont, and, and then, as you know, as we kind of got a little deeper into, um, you know, seeing a few more patients who had voiced interest, and FaceGenX was getting closer to actually releasing what, you know, was going to be their FME 2.0, if you will, um, you know, those things kind of collided around a time where, you know, we were kind of, we had our little sort of basket of very early FME patients, right? And of course, that's now translated into a few installs and quite a few more on the books. Okay. Yeah, let's take a look at it. Let's do it. What iteration of this appliance are we on? How long has this thing been under development? Like this one right here, for example? Yeah. Well, actually, I would encourage you to, uh, back out of that page. Go to the, go to the one that is all the way to the right. Should I go to Baba 23? Yeah, this is Dr. Jafari's Instagram page. Go to this one. Yeah, go to that one. What, yeah, buddy. Um, and I don't know if there's a way to pause that reel or whatever, but, um, if you look at, yeah, okay, so if we look at the, okay, well, let's talk about it. Yeah, let's just let it, let's just let it do its thing. So you're just seeing basically an opened and closed version of the same expander. Um, and, um, in the, in the closed one, you can basically see there's four little holes there and screws. Those are what's called the retaining screws. They hold the detachable expander module in those little plates. So like the border thing that you see housing the expander module is what is pinned in. See, why don't you, uh, why don't you use the scroller to illustrate your point? Yeah, buddy. And then actually, do we have a static picture of this? Six TADs? I just took one. Oh, yeah, buddy. Okay, yeah. Where did that go? Yeah, I guess I didn't just take one. No, that's the recording. I got you. Well, let's, I mean, we could even just look at this picture in static and at least, Oh, there you go. Yeah, it's not static. If you go back, just go back to Instagram. Sucks, huh? Oh, to the page and just zoom in. You zoom in. Facts. Yeah. All right, so let's just keep it there, right? Or you can use the one on the F. Go, go, go to the left. The middle one. You can talk about it from the back side too, if you want. Oh, I think because those are eight and ten, I just want to talk about the six. Go, use the scroller. Z because there's six, eight, and ten, right? And so you have, so this expander body right here, this is the FM6. Right? What all FMEs have in common are the four retaining screws that just holds the expander into this sidewall stuff, right? Those are the plates. We call those anchor bodies, right? So the expander bolted into the anchor body, but the anchor body is bolted into the palate with the TADs. And that's where, if we look at these things over here, the TADs not even visible in that photo. They're not. Where are they? They're so they're hanging out under, under here. So this is the underside. That's the chassis that's touching the palate. Yeah. And how do I? Oh, there we go. Okay, so now as I go over here, right, you can kind of see the little holes are where the TADs go. The big holes are these right retainer screws. Okay. So, um, the FME body, right, in a, in a six-screw thing, it's just the anchor plates with the three TADs on each side, and then the expander modules bolted onto it. In the eight-TAD version, the expander, there's two additional TADs, uh, on the front part of the body. And in the 10-screw version, there's two in the front, two in the back. Now, is, and the 10 is on that, that side, and then this is, that's the 10 fully assembled. That's the 10 fully assembled. Now, is this, go ahead, Bailey. I was going to ask a question. You know, when you put nails in a board, and if you put them too close together, it kind of messes up the wood. Could that happen with the bone? That's a, that's a good question. I think that these are spaced out strategically enough for that not to be a concern, um, because, yes, theoretically, right? And then you have kind of just weak bone in between, right? Um, so I think that the level of spacing in these is, um, you know, I think, uh, there's, you know, because it looks like there's a lot of holes here, but if you look at the center one and the back one, there's, there's quite a bit of space between there. Also talking about, so the bigger holes are not the TADs? No. And are, is there air between that thing? Looks like it's three-dimensional. It doesn't look like, is there air between those holes in the palate? Well, that is a big part of the planning, right? So there can be air between that and the palate if that is what is necessary to align that thing in the person's skull where you want to put it, right? That guide here, right? So this is, you can see, you know, registration of teeth and everything here, right? This is kind of like a little partial retainer, right? You put this thing on the teeth, it has little seating windows, right? There's like little cutouts. I'm going to move the mouse, right? You can see that there's little holes in the teeth part of that, so you can see that your guide went down all the way flush when you put this thing in there, right? So if you see that the guide is flush on both sides, it means that those anchor bodies are going and being delivered to the palate in space where you planned them, right? And then to put the anchor bodies there, of course, in a very flat, broad palate, those are going to be pretty much flush to the palate. And if there's some teetering of the palate anatomy, then those things will still be straight, you know, according to themselves and according to the planning. And then because that, you know, these anchor bodies, they're not just floating this plastic, they're bolted into it, okay? And they're torqued in. So by torquing and bolting it in, you basically don't allow any migration deviation of those bodies when you're now bolting it into the palate, you're bolting it into the palate with it secured in the planned position. That's the whole premise of FME, right? Put it where you planned it. But how is that different than what the Partners custom MARPEs do? I thought those are all similarly pre-planned and correct. So, you know, going back to what you said before with the oral, oral surgery planning, this, you cannot, you cannot even place this if you are off. If you're doing this properly, this will not be seated unless it's done properly. Are there certain dimensions in that the custom MARPE can't be, can be seated if something is off, if there's a little tilt in it, or is there more, there's more play in the custom MARPE? Well, I think it's important to say this, the custom MARPE similarly, right? You can be confident that's where you put it if the bands fit flush around the teeth and you know the little wings or whatever. So similarly, like this, it's, it's really firm. So it's not that custom MARPE isn't, it's just that FME is, um, extremely unforgiving, right? Meaning it's, you know, it's only going to go in one way, right? And if you bolt these things in, as long as the guide is seated properly, right? Then those bodies are being put in space exactly where you put them. Of course, those guides may otherwise be floating, right? But this is necessary to overcome one of what I now think will be, you know, maybe something that evolves with the FME is that the underside of that thing is not customizable to a person's individual anatomy. That's okay. But the way, so that's why you have to, you know, what I mean? Like, and even when it becomes maybe possible to do that, if it should be advantageous to do that, then, um, basically this thing, right, you know, it's still bolted into the guide, but is there some air between this and the palate? There could be, right? So, and does that air matter, right? Of course, one of the things that we always tried to avoid void with other types of expanders was the air gap, right? The air gap means that you're going to be less likely to have a successful expansion because your expander body is, you know, off of the palate, giving it, gives you an unnecessarily long lever arm, basically. Exactly. So how do you then overcome that problem, right? And how did Fenics overcome that problem? Because there's always going to be an air gap if you have a predetermined expander body, maybe placed in space in a customized way like this, right? So you overcome that problem by really making, so of course, you have your locking TADs, right? So there's no play between the TADs and the, uh, and the TAD housings. Yeah. What is the, what is locking TAD mean? It locks into the expander body. Yes. So it locks into the expander body. What does that even mean? It means that the head of the screws itself has threads on it that exactly correspond to the little hole that it sits in. So now it's not just threading into the bone, it's threading into the expander too. Yes. Threading into the expander, right? As opposed to just sitting really tight like a, like a cylinder in a cylinder? Yes, exactly, right? So it's threaded in, right? If it's threaded in, I can't believe Juan Moon didn't get that right. This is a first iteration, right? Or it's, yeah, no, don't, hey, don't get me wrong. I love, I love Dr. Moon, and he had, I went to one of his courses once, no charge, and I brought him a thing of vodka and dark chocolate from Russia. Uh-huh. And I love him, but I think that, I think he fumbled that one. Well, here's, here's what I'm going to say. Even, even an uneducated carpenter knows that you want a tight, you don't want, you don't want a gap between your fastener and whatever you're fastening, correct? However, I think some of the reason why that play exists, I mean, it used to be maybe clinically advantageous to

us to be able to kind of like tweak our, you know, you know what I mean, screwdriver a little, one way to try to make the screw tails a little more d. Right? Almost like when you, like on a TV stand, it comes with the, the wider screw hole so you can adjust it a little bit. Adjust it a little. Exactly, I get it. So there's some adjustability there. And also, um, there's, you know, locking screws have been around in orthopedic surgery for a long time. This is just like, we're talking about it like it's revolutionary stuff. This stuff is basic stuff, right? They are on the Discord, they act like it's like a godsend, like lock and tads are like the best invention to ever touch Earth. Crazy. Um, so, you know, they've been around orthopedic surgery for a long time. And, um, just on that point, very briefly, uh, you know, Dr. Alfie's whole thing about custom printed surgical plates, those have been around in orthopedic surgery for a long time too. It's just, they just, it's a new, it's new that they're being used in orthognathics. So they, it seems like orthopedic surgery is somehow on the bleeding edge of a lot of this stuff, and then it gets taken and applied in other parts of medicine. I think so, yeah. And I think a lot of it is workflows and softwares and this and that. And also just the uniqueness of working in the head, right? You know, I think it's a very different kind of place to work. And also research development money, things like that. Yeah, there's a lot of money in orthopedics, is that what you're saying? And more research and I think is more, more prevalent, maybe more cases, more mainstream. Yeah, right. Investments. Yeah.

So, um, so you could still talk about the differences in them too now. So the locking tads, they're the copper colored, uh, Y pieces there on the left, not the things that fasten, correct? The L's into the rest. So those are different colors. There's different lengths of the tads. And the other six are hiding under this. Right, right. Um, and then, um, and so the locking tads is something that basically, okay, if the tads are locked into the expander body, and then the expander module is locked into the plates, then the whole thing, the whole system must move together, right? And I guess telescope upon itself with no forgiveness, right? Like if the thing tries to buckle, bend, to rotate, then the expansion will fail. Like the thing will simply not turn, right? And that's what they've, you know, did on, you know, sort of, uh, um, outside the mouth testing, right? You can kind of see, right? So it is thought that the, you know, if you get bicortical anchorage, right? Um, you know, so it's basically going through the anchor body, the tad's going through the anchor body, locking into it, then perhaps through a small air gap, then approaching the pallet tissue, and then going through the pallet tissue into the oral cortical layer, and then the nasal cortical layer, right? They have. So in your, in your petal sandwich that you were describing earlier, there's two, there's two hamburger patties inside of the bun, so to speak. There's two layers of bone. Oh, no, the, I guess it's the bun that's the cortical. So it's the, there's one hamburger patty, but there's, there's, uh, the hamburger patty is the spongy bone. Yes. And then there's two harder layers of bone on either side of that. And there's two layers of mucosa on either side of that. That's correct. Okay. You want to pull up the, um, expansion, expansion GIF? Yeah, buddy. Um, there's like an X-ray. So that's pretty much. Is there any Chick-fil-A sauce in that sandwich? There better be. Don't, don't go, don't go to my history, bro. Please. In the South. He, I saw what you did. Yeah. Oh, what's, is this, this facegenck website? This is our website. Oh, this is your website. What are you, a pilot? Everything is backwards on this thing, man. Bro, with the. Okay. Is that good? You want to explain this? S was. Yeah, buddy. Um, well, basically what you're seeing here is, um, so this is a CBCT image, of course, of, uh, you know, before and after overlay, um, of, uh, you know, this FME patient. You can see good lateralization of the walls of the nose. Wow. That's a wonderful, uh, opening of the nasal airways. Absolutely, right? So you can see more black airspace around these gray structures, right? The middle gray structure is your septum, and then you've got the turbonet on either side, right? So this is, you know, just for those of you watching who are perhaps new to pallet expansion, this is why, you know, it's not just because you have a nasal septum deviation, you got to go get your nasal septum deviation corrected. Look, the nasal septum stays deviated, but there's a lot more black airspace around it, right? Who do you think breathes better, before or after? Right, right. And, um, so, you know, so that's the, that's the thing. I think this is, um, you know, it's important to kind of, you know, think about like, okay, you know, like, I'm not necess, like, I'm, I'm, it's basically more about, um, the impact on the airspaces. Scroll around the, the deviated septum, just so people know what you're talking about. Now, do you subscribe to the theory that septums deviate like that because the maxilla is grown too high in volved, and it essentially kinks the the septum like an accordion, or is that broscience? I think there could be, I think there could be merit to that, but you'll see deviated septums in people with vertical excess and deficiency. So I don't necessarily think that, um, that necessarily all the way tracks. M. Right? Um, and, um, you know, I do think that people with more well-developed maxillas tend to have straighter septums, but not, not that predictably. Does this guy have a little sinusitis too on the left? I guess you could call that mucositis, right? Like, so just from a radiology perspective, I'm calling that mild mucosal thickening in the bilateral maxillary sinuses. Um, that may be not clinically significant, right? It might just be some mucositis, not of clinical concern in the absence of symptoms, or it could be a, you know, mild form or manifestation of some kind of chronic inflammatory condition. It's always, it's always good to have normal radiologists on staff. Just a little shout out. He, he's probably one of the most, uh, intelligent people I know that specializes in both radiology and orthodontics. Intelligent, yes. Handsome. I've been, I've been stupid ever since I got my wisdom teeth out at age 19, though. So I'm just working with what I got. It was stupid of you to get them out. It was stupid. I mean, them things, I think could have survived. They could have. Yeah, they should have. But we're going to be expanding you in the next, uh, next week. Oh, yeah, that's right. You've got your own FME install coming up. Yeah, we're going to live stream that. That, that's what, that's what the consensus is. Yes. It's been planned and sent. And so we, we believe in it. That we're doing it on. Then I'm doing it on my wife too. Well, in all fairness, I, I res, I respect it. But also, you got to forgive me because at the same time, back in the day, all the AGA providers were doing AGA, and they were having their kids do it, and their wives do it, and their dog do it. And I, like, that was one of their big arguments. And that, that was catastrophic. And, you know, I don't want to say any more about that space because, you know, if you want to learn more about that, check out my book chapter about it. Right now. But so just, but I think it's, it's good to put your money where your mouth is, though, for sure. Dr. Noas, is it appropriate for me to bring up the front teeth thing? The front teeth thing. Uh, yes. In maybe in a minute. In a minute. Yeah. Because, um, that, that's something because that, you know, I'll keep it at the tip of your tongue. Bailey, right on. Okay. Well, only, only because now, are you just talking? If you were talking about the space, this is the result of slow expansion that the teeth stay pretty much together, even though the roots are diverged a little bit, right? So that's where your no diastema kind of comes from, right? Yeah. What are you guys talking about? Can you scroll to it? Z, is it right side? So you can kind of see how the edges of the teeth are still touching, right? So there is bone expansion, but the teeth aren't kind of going all over the place, right? This is not a tooth born expander. Um, and of course, now we see a lot of Marpe cases that look like this too, especially early on in the expansion, right? Before then, you know, let's say if your skeletal expansion burns out and then the teeth take the rest of the hit. Right. What, who, who, what do you mean by that? The skeletal expansion burns out and the teeth take the rest of the hit. How can an appliance that's not touching the teeth give the teeth a hit? Oh, no, I'm talking about Marpe. You. Oh, so Marpe. When I said that, not all Marpes have dental anchorage, though, do they? Correct. No. Yeah. And that's the whole thing. You could have a toothless Marpe. So it's also not like, oh, Marpes are, you know, tooth born. So you're specifically referring to Marpes with dental anchorage that the bone, the bone expansion wears out, runs its course, and then the rest goes to the teeth. Correct. Kind of like MSE with arms on it. Correct. And that's really any, um, you know, I think anything that's attached in a hybrid fashion, right? That has tooth anchorage and skeletal anchorage. Of course, the main force is being applied to the skeleton, but the teeth are going along for the ride until maybe they don't, right? And then, um, and then they are bearing the brunt of the expansion if the skeleton is no longer opening or yielding to the pressures in the expander, right? So what, what, so what happens with FME in that case? It just stops. You just, it's almost like a, like a rusty. To be honest with you, um, I think if I claim to know what happened at the end of FME expansions, I would clearly be a liar because our first FME patient has not finished expanding. So, you know what I mean? So we, we don't necessarily know the answer to that question. But like, if you look at the expanded form of this expander, right? You can kind of see that it requires that sort of expander screw. You know, also, I'll call it a little barrel, right? That little barrel has to be straight and contained in the, you know. Which little barrel? The one in the middle or the two? Yeah, the one in the middle. The jack screw. The jack screw. When the FME patient had, he had two different keys he had to use, right? The, the first one for the first few days, and then you had to switch to another one, is that right? Correct. Well, and that's just the, the thing to turn the barrel, right? Um, but, you know, yeah, so we're basically talking about like, you know, like in this, let's say that this expansion, like, you know, this, this, uh, you know, one side of it kind of drifted or rotated a little bit out or something, right? And then you see that barrel thing kind of getting strained, right? Yeah. So if the barrel thing is strained, then the appliance is not going to really turn that easily, right? Right, right. Or at all, right? Right. So it's going to burn out. And it's, but that friction force, what would you even call that? Yeah, I guess it's, uh, you know, you would generate enough friction to then make the turn mechanism fail, right? Because of rotational drift, right? Of one or both sides of your expander. So does FME prevent rotational drift, or does it just stop when rotational drift begins? Maybe the latter is more how I would characterize it, but that's still okay because at least you don't end up with catastrophe, right? I think it's very beneficial in that regard that it may help prevent some of those types of catastrophes. I think it's really to see whether it's capable of staying uniform to itself, but itself drifting in the pallet. Of course, there are protections built into the design of this thing that try to, you know, um, prevent that very problem, but it's theoretically possible, but I, we think that it's very unlikely. So you're suggesting that the weak link then becomes the, the screw to bone contact, and the whole thing will shift inside of the bone. Inside of the bone. Yeah. And that theoretically can happen, which is why no expander is perfect today. And is there, is there anything special about the, the bone anchorage in this? Are they, are they larger diameter? Are they somehow, you know, are they reverse threaded or some crazy that helps them not drift as much as a traditional MSE tad? Not in particular. No. Not in particular. You don't put Loctite in there. Uh, we don't put Loctite in there, but we put, we'd be putting that medical Loctite to close up the piezo split line. Nice. What's that? Some fairy dust. That's that peri-acryl. Uh, no, Dr. Alfie, he has this new product that he puts over the surgical site. It's like an antibiotic growth factor thing. He calls it fairy dust. Fairy dust. But he said it's got, uh, it's been helping his healing, his healing times, and reducing infection like dramatically. He swears by it. Oh, I mean, and, you know, just, yeah, one thing about seeing at least every one of his cases that I've seen, um, in person, you know, just the healing, uh, I mean, fantastic healing. Yes. No doubt. Fantastic. He, no doubt. Bring that baby over here. The food is ready. Bring that baby over here. The food is ready. But the podcast is just getting started. Are you serious? Serious. Oh, you guys are going to get cold. S baby. Jaw she has a great sff on it. It's hard to get a kiss on. See me get her. I got you. That's Dr. New and Dr. Jafari. He, mama, look at. Yeah, she's adorable. Con do part two? Keep going. Oh, yeah. No, we're not stopping right now. Hun. All right, well, I wish that the food was going to be hot. That's okay. Yeah, the podcast is hot. That's more important. That is super important. Thank you for making food. Thanks for bringing her. Replex. Okay, see you guys later. See you. Good baby. Huh? Beautiful. Very good baby. Maxilla baby. Oh, yeah. I mean, I would say that the one you put those tads in, and there's all, they're all anchored together, it kind of works like the unibody. So when some of the Marpes, because they're kind of individual, they, they still have the flexibility within themselves. So sometimes you could see some of those screws deviate more than others over here because everything's kind of locked in together. There's very little, if any, right? Like when you would take the tads and you would put one back here and one up here and one there, one, then they're kind, they could work independently together. But this is kind of when you're screwing everything, it's now. How come they're not leveraging the toenail effect of tad placement, especially since that's the weak link, to get more surface area? Is it just because it's FME 3.0? I mean, we're on already like FME 6. I mean, if you do the, those are just the tad numbers, not the, not the iteration. Well, the eight, the eight has a little bit of that factor in the front, yes, anteriorly. But medial laterally, yeah. Okay. Medial laterally, there's no. Okay. None of that, huh? I mean, what can you even really do to solve that problem, right? Besides, because if you start going bigger diameter, now you're, you're what Bailey is talking about, you're creating bone fatigue, right? And now, now you have a, you need to make the appliance bigger so that you don't just essentially create a big notch in the pallet with all the tad diameter, you know, it's a hard problem. It is. I would say, you know, something that we didn't talk about is patient comfort. Very minimalist. Very minimalist. Easier to keep clean. Easy on the tongue. Easy on the tongue. Speaking is a lot easier. Keeping it, you know, you get food, you know, it's a lot easier to clean food out. It's not affecting the actual teeth. You're not putting cement on the teeth with the, everything's rounded, rounded, it's soft. And so, you know, something that we didn't address is literally the person that has it in their mouth. This is a lot less cumbersome, right? Like it's just so much easier to use. Uh, I can almost see myself flicking my tongue on that thing like a fidget spinner. Seriously. It looks so Smet. That would take a strong tongue to actually be able to spin the freaking thigh. Um, no, for sure. And that's a huge factor. I mean, I'm five years removed from having something that big on my, my pallet, but I remember though, that I, my, my tongue would get cut on the screw heads on the hex, and I would have to plug it with, uh, wax for months. I did that. So this is, uh, very clever for sure. Very well constructed. And anytime we, like I said, we deliver, we, uh, do like an after action, and we literally give our feedback for the next one. It gets even better. Mhm. Mhm. Um, what are those arrows for? Telling you which way is back. Yeah. Yeah. Like, uh, that's like a tool go-and-day's checklist, right? You can never have too many check-check. Manifesto. Yeah, exactly. I mean, in, in Dr. Alfie surgeries, by the way, I was just shadowing Dr. Alfie. That's why all this stuff is on. Every screw is color-coded. Everything is like, uh, there's a million checks and balances to make sure stupid mistakes don't happen. So, you know, we have like a, basically like a heat map of how, you know, we're going to be placing each one in order. The length. So each, um, tad is color-coded for a length. And then we verify it on our plan before we start, right? So, it's, it's, it's very, um, precise for sure. All right, so I, I kind of get it. Um, what else? What else is there to say about this thing? I mean, what's protraction? We, we didn't talk about protraction. Yeah. How do you attach protraction? You want to pull up the eight and see if there's, even though you can't really see the protraction, you can't really see it. But what do you guys think about protraction? Protraction, anyway? What kind of cases? What kind of cases are you using protraction for, anyway? Just class threes? Or are you guys a little bit more liberal with it? I mean, I'm the most liberal. You're a liberal. Well, the most liberal with protraction, that is. Oh, I thought you were saying that you were voting for the Green Party candidate. I will not be, unless his name is Ralph Nader. F Lees. Oh, Ralph. Ralph. Um, so, yeah, tell me about that. Yeah. So the bottom one has the protraction holes on the white screen. Can, can you guys, uh, you can't really see it though. The bottom one. Yeah, there say eight. Oh, here you can't see that. Yeah. Well, but like, you got to go to the back of the r playing that, whatever is I was talking about like on the, it, the attachment is on the, the underbody. It's not on the. Yeah, because the underbody is what's bone anchored, correct? So that would make sense. Mhm. And is it, it's not these little, it's those, not those behind that you can't risk right there? It's in the shadows right there. Yeah, it's in the shadow. Yeah. If you play it where your mouse like just w, it's the black back wall. Yeah. Yeah. So what's there to attach to? There's, there's a hole there, and then there's a protraction wire that embeds itself in the hole, and then it kind of forms like a handle on the front, and that's what you're pulling from. But isn't that the back of the appliance? It is. So you're pulling from the appliance directly. But how do you pull from an appliance in the pallet? It come, unless through the diastema, unless it's through the diastema. You got to go around. So basically, there's like a little arch wire, right? Going from, you know, so now take any picture of any of those FMEs. Now picture the back surface. It's got the holes, and then the protraction wire is now going back behind the last molar and then wrapping around all the way to the front. Yeah. Oh, so you're still, you still have traditional hooks that come around the buckle side of the teeth, but they're not anchored to the teeth, but they're, they're only anchored to the anchor body. Just the elastic w s around. No. Uh, so there's like an actual wire that you clip into the FME body. That wire now serves as like the handle. That's kind of the best way I can think of it, right? So now think, where does it terminate outside of the mouth? M. Is it removable? Removable by the patient? Yeah. Wow. Really? How does? Yeah, you're not going to wear this thing the whole time, right? Right. Well, some of, some of these kids, yeah. Uh, but, but theoretically, and I think, you know, we saw, um, I think like a heat map of the way puts forces on the bone. So right now, we're traditionally using the U, the, the hooks around the first molars to pull. This is a lot more efficient in bringing the the maxilla forward. Why? Because it's less stress on the tooth and more direct force. Bone. Yeah. And is it hard for the patient to take the handle on and off? Of course. And an alternative way to get direct bone anchored protraction is baller plates, right? But if you're going to use the expander itself, of course, going straight from the expander module and or expander, I guess we'll call it the FME, right? Is is one way, right? Um, baller plates. Where baller plates? Uh, so the patients that I've sent for baller plates will typically get them, you know, an anterior and a posterior one, maybe sometimes just a posterior one. But if you're doing an anterior and a posterior on both sides, then you're going to put the anterior one on the lateral, you know, just lateral to the piriform rim of the nose, right? Just the opening of the nose at the corner. You're going to put one there, and then you're going to put one in this max zygomatic buttress area or zygoma, right? And then so you get some high skeletal anchorage in the back, you get some good skeletal anchorage in the front. And then maybe if this person wants to pull with some, some kind of control of the vector, you can maybe pull up from the front one and down from the back one, right? That was going to be my question. Is if that is removable, would you be able to go up and down with the force, or would it mess up how it's in, like, would it come out, or would it be like, do you, do you understand what I'm asking? I do. Like, what, I guess you would need baller plates if you want to go up or down or whichever direction, right? Otherwise, you're going to rip up into your gums, is that what you're saying? Well, no, the attachment could mess up or remove. Well, I think that, I think that remains to be seen. I, I think, you know, we're, we're just slightly a little bit early to see, you know, because there is diversity in the vector that you can pull from this handle. Like, basically, there's the FME that's in the pallet, then there's a handle that attaches to the FME, and then there's some kind of external force application, right? So that force application can still be applied to the handle in any which way you want. And how thick would the handle be? I can't imagine anything thicker than like a very tiny wire. Be. I'm thinking of a guitar string. Yeah, it would, it would it not bend? Yeah, that sounds it's got to be as stiff as hell. Guitar string. That's going to hurt your mouth. Pause. I mean, that's going to be, it's a rigid handle. Yeah. Yeah. So it gets popped in and out, sort of like it's a unit. So it wraps around the teeth. So it's like, kind of thinner in the front that way it's not, it's kind of like this. It's not like, I don't know if it's thinner in the front, but it wraps around. It's almost like a lip bumper. It's like, you know, it's sitting, it's not making any contact with the teeth, and it's only making contact with the inside of the lips and the tee. You'd have to get fitted for it. Yeah. Using your impression. It's custom wire for each individual patient. Wow. It's under development right now. It's, we should, it should be out pretty soon. Oh, it's not out yet. You haven't done one of these yet? No. Oh, we've just installed the expander that will accommodate it, but we haven't actually delivered this expansion, like protraction wire to anybody yet. And are they going to ship them all with that attachment so that people can improvise? And that's, that's predetermined by it. So we have to designate like FME 8 or FME 8p. Right. P for protraction holes. Would it be more expensive or not? Yeah, because it's a full apparatus that you're getting in addition to the FME. Ain't nothing free in this world. Yeah. Let me get that free lunch, though. Oh, exactly. Hey, um, it does sound to me though, like what you were just saying is that the baller plates are sort of the gold standard, though, for protraction, but it's a surgical procedure, right? You got it. General anesthesia or in office under sedative. You got to flap the gums, you got to see the bone, you got to fasten to the bone, you got to sew it back up. Do a little fork cut in there while you're at it, loosen it up a little bit. Unilateral. Yeah. You know, the maxilla, you know, it's, I think personally, I have seen successful protraction with, you know, just regular, you know, as long as the attachment arms are rigid, right? If you're pulling from the molar hook, that's kind of still my go-to, right? So these are great. These are great additions. One is of course incredibly invasive, which is the baller plates, but pretty effective. And then one is the FME, which is untested, right? It's not really that invasive though, if you think about it. No, it really is. You know what I mean? Like it's all, invasiveness is all of relativity. Absolutely. I mean, for a surgeon, this is bread and butter, walk in the park, 15 minutes kind of deal, right? 100%. It's like, you know, you make a tiny little incision, you just kind of get your access and visibility, plate this thing in, and then you close it up. 100%. I'd do that under local. Oh, yeah. I mean, I think, you know, it's, it's, it's pain is relative too. I think it's something that can be tolerated under local. I'll put it that way. Maybe most surgeons won't elect to do it under local, but I think it's kind of within the realm of what could be done with local. Well, local sucks for the provider because it just means you're going to get, it makes it harder for you to do your job. Providers love general, right? I think providers like some level of sedation, definitely when you're doing a little more, you don't want your patients to be aware of like, oh, wait, how close are you to eye? You know, put that the hammer come out. But I want to, I want to ask you more about protraction. Yeah. Protraction in general, because it's such a controversial thing. And, [Music] you know, I had Ethan on my podcast recently, and he's been protracting a lot, and I mean, his results look like almost like jaw surgery, almost. But the thing I can't wrap my head around is if you're just pulling the maxilla into infinity, what about the joint? And what about the mandible? Because you're not going to stretch the mandibular bone. How do you come to terms with that? Do you just plan for a BSSO, J drop surgery, or what do you do? You only do it on patients that are a little bit recessed in the joint? What, what do you do? Very good question. I think, I, I think it matters what your primary objective is, right? And then again, make all the other puzzle pieces fit however they need to fit, right? So if you will protract because your primary goal is improving nasal breathing, or improving, maybe for some people, a little bit of the protraction as an aesthetic thing too, right? Correcting the under eye deficiency of the mid facial bone complex. And, you know, let's say we're bringing this out, and it may happen to be what's needed to correct a facial balance problem, or it may exacerbate a facial balance problem if somebody's a little more class two, right? Or mandibular deficient. Totally. But does that mean that you shouldn't protract? Not necessarily, as long as you have a plan to then surgically correct the mandible. So, so basically, what I think about protraction in general is, I think it is kind of the next frontier of, you know, facial augmentation stuff, really. You don't think it's a fad that's had already had its moment? You think we're just getting started? I think we're just getting started. I think if we can figure out how to do it safely, effectively, predictably, all that, right? And it's, I think inherently a bit more safe than even expansion itself because it's so gradual. It's just distraction. You just discontinue if it's not like, you know what I mean? It's, it's inherently a lot less risky than expansion itself. In fact, I see protraction as the essential force modulator externally for the problems we see internally with expansion because again, Newtonian physics, one side must push off of the other, and there's no other place that you can apply control to that equation, right? Except extraorally. This is how we advance non-surgically. Yes. Is that what you're saying? Yeah. I felt the most breathing benefits when I was doing headgear. Shout out to Ron. You sent me the crane. That was very. I'm going to get in trouble for that now because I'm sending you medical devices. I don't know what talking about. Never mind. It, it must have been done with my prescription. Oh, yes, exactly. I mean, I must have told you to send him. Yes, he did indeed. Indeed. I think I recall you ordering that. I think I might have said something about that at some point. Well, I guess that question, the question that brings up is the market for headgear is trash. It's so trash. I've seen some cool stuff though. Oh, yeah. Me too. I've seen some insane DIY headgear stuff. I was, I was hanging mine from a rope on the top of my door, laying in my bed. Really? Yeah. Yeah. Damn, man. You had a rope hanging over your bed? Should we talk after this podcast? Yeah. I, I closed the door on some rope and made it just long enough so I could lay in my bed and it protract. And I was like, I'm going to sleep like this. But it didn't work like that. Why didn't it work? Uh, tossing and turning. If you go back even just like a few inches, it like pulls way too much. It's extremely uncomfortable. There has to be something that would be a part of you and could rotate and move around and it not change the force. At least from when I was wearing it, the crane was so uncomfortable, and you're biting weird, and I think just biting on one side more than the other could exacerbate asymmetry as well. I just, I believe that. So I think there's a lot to be done in the protracting. So what's the best, what's the best reversible headgear right now? The bow, I'd say maybe the bow and a modified crane from my experience. Coming soon. Coming soon. You guys didn't ask me if I wanted to invest. That's messed up, man. No, no. See, yeah, see what we was going to do is like, kind of internally prove the concept and then bring you in. Yeah. Yeah, right. That's what they all say. We don't want to bring you into a shitty idea. All right, well, you're going to need marketing, though. Well, but you guys are starting your own marketing wing. So I'm just going to be on the outs. That's whatever, man. Oh, but my marketing is better than yours. All right. I can take my, I can take, I can take my baby to the food kitchen. No, seriously though, I'm the worst marketer of all time. I concur. Well, that's where Borne comes in. Yeah, exactly. I agree with that assessment. Dr. Was, he just makes a rap song about your thing and then boom, boom, bam. By the way, you can't spell Brun without Ron. Hey, that's true. Yeah. And without bro. Oh, did you know Bro made this shirt? Yes. I, yeah, I can see by the graphics that that's style. That and the font and everything. The split. You see the split Y? Now, is that, that's a reverse cone. Wait, let me see that. Oh, that, that's, that's that's pretty standard. That's that's like, you know, a a good max expansion. That is real world, not like, you know, people talk about one to one expansion all the way superiorly up to, you know, like the orbits. Do you really want? Okay, this is just for everybody, right? That thinks that, you know, one to one expansion all the way up to here is good. Some expansion up there is obviously necessary to solve some superior nasal constriction issues, but if you were one to one, then you're taking the bottom half of the orbit and expanding it independent of the top half of the orbit, right? If it's just like, just so purely like that's not what happens in nature, right? That's not what happens in FME or EASE or anything, right? It's just, you know, so, um, you know, I think there's an obsession for like, oh, look what percentage of the expansion goes up to the, you know, top of the nose. Well, probably some percent, but you, you certainly don't want one to one past a certain amount, right? Right. So, yeah, I'm catching what you're pitching. Yeah. Yeah. No, no, half eyeball drifting for me. But I don't get when you say that. I don't understand, cuz is the orbital, is that two pieces of bone that converge at some suture? It's a few pieces of bone that converge, yeah. And so if the, if the expansion goes to far up the Y axis, only the bottom bone of the orbital is going to move, is that what you're suggesting? Well, I'm saying the, the whole eye socket move. Well, because the inter, interpupillary distance, because the frontal bone won't move with expansion. What part of the frontal bone is moving? So the frontal bone is this, the blue, yes. This is frontal on your shirt. So, right. And so, ah, we have the green and we have the blue. B, go get that little skull diagram. That's actually what we made that design from. Was that skull? That this is that skull. That's the original skull. Okay, there you go. That's the one. That's the one. But, um, so what he's saying is that one to one is not logical or possible. Dr. Jafari, you take the skull because actually Z, you don't have a zoomed in shot. Frontal button. Yeah, hold it up and hold it closer to your body because otherwise it's going to be out of focus. Yes. So, so now using that, explain your point about why perfectly parallel expansion up the Y axis or the the good ratio of expansion going up the Y axis rather than it being conical along the Y axis is actually not as good as it's cracked up to be. Oh, yeah. You, I'm asking either of you guys. Oh, okay. Well, you know, and it's not, you know, again, it's not a matter of, I think good or bad. I think it's really more of just realistic, like, you know, in nature, right? You are going to get with a petal application of force, a little bit more at the level of the mid pallet than you are at the superior part of the nose. And that's okay. You can get a very high quality, clinic, uh, measurable improvement in nasal breathing, right? With, you know, expansion that doesn't go up one to one. And I just use the orbital thing to illustrate that that's not feasible or possible. There's sutures, and you're increasing the lower half of your eye socket without moving the upper half of. So you're like, now, do you think that's what explains why some people get ocular issues with with palatal expansion, with skeletal palatal expansion? You know, I've heard reports. It's very rare. It's definitely not something. It's a very exotic, but possible thing, right? And, um, I don't think it's necessarily that phenomenon, but I do think obviously you can see the maxilla and the zygoma, right? And the, you know, basically that whole lateral part of the nose, medial part of the orbit, right? Those are all structures affected by expansion. So you can imagine how moving those structures might in some cases maybe impinge a nerve or displace a this or, you know, and that's why you're also going slower is probably wiser, right? So that if you do start impinging on a nerve, you have time to react. Correct. Now, um, what was I going to say? Yeah, but to your point, though, in nature, if the tongue is the pallet expander, and if I start going off on a broscience tangent, just stop me. But if the tongue is the natural bot expander, it's going to kind of expand in this conical way. It's not going to, it's not going to split your face in half, you know what I mean? This is not going to do that, right? Yeah. So interesting. But the point that Dr. Casey Lee makes a lot, though, is that you do want some expansion up the Y axis in the back. I think he's right about that. Yeah. I think he's right about that. I think that, um, again, I am as much of a fan of posterior expansion as anybody else. I just don't think it's talked about the right way. That's what I guess. But I think if somebody does an analysis on everything I've said today on this podcast, I think they will see that I'm basically supporting the fact that, okay, there's an importance for posterior expansion. I think some of the hype or, uh, desire for posterior expansion is warranted. But if you talk about it in a vacuum or in a very dichotomous way, that's simply just wrong and shortsighted in my opinion. Look at the big picture, basically. All right. Um, are there any other comments you want to make about the FME? So tell me about cases where the FME might not be the most appropriate type of expander that you would use. When would a partner's custom expander or similar be more appropriate? That's also a very good question. I think that, you know, the way that I'm navigating this myself, um, is that I think that both custom Marpes and FMEs are fantastic expanders. I don't, you know, and so when you say like latest and greatest, it's definitely latest, and it's definitely greatest in some regards with some aspects of its engineering and, you know, physical features. But it doesn't necessarily make it the greatest expander, making Marpes extinct, right? Marpes definitely have a place, and they're still my go-to expander for most people who need a modest amount of skeletal expansion, right? It is, you know, very predictable. It does have less factors in the workflow. It is more customizable. So the advantages, I would say, of Marpe are probably just the following few bullet points. You can customize the underbody of the expander framework to conform to an individual's anatomy. If they have a torus or something? Sure. Yep. A torus is a very good example of that, right? Or maybe a hyper high, vaulted, narrow pallet? Correct. Correct. Right. Or asymmetry? Or asymmetry. So some of the things that we design is we can actually angle the way the body sits to possibly even decrease a can and things like that. And we have had success with terms of our patients with that as well. Wow. We're fixing the asymmetry with the custom RP? Wow. That's instead of it making, instead of making it worse, we're actually placing it to and designing it where we're actually helping their asymmetry. So if the pallet is like this, you might place the appliance like that and try to like, yeah, stuff like that. Yeah. As long as that's happening in a context of it being appropriate in the rest of the skeleton. We talked about the eyeballs, right? Um, so yes, but yeah, those are the types of, right? Some people have depth asymmetries, right? Malar or zygomatic prominence is greater or lesser on one side than the other. Well, you might be able to adjust for that in a custom appliance. Mhm. I have some patients that have very pinched in nasal bases. What does that mean? It means the nasal cavity may have a bulbous or a width, but that little part of bone that's actually available for bone anchorage at the top of the roof of the mouth and at the base of the nose may be very narrow or thin. You need to thread the needle any which way you can, you know, and have that, you know, like if I'm predetermined to where my tads are going to go because that's what comes in the framework, I may not choose that device, right? I may choose something that allows me to place anything wherever the heck I want. Do you ever still use MSE type twos? Yeah, I, I use them for, um, teenagers, maybe even some like young adults. It's very, you know what I mean? Um, but yeah, mostly kids. Kids are great, you know, candidates for MSE type two. What about surgical assisting? These FMEs, do they require less surgical assisting, or do you still do the piezo assist just for good measure, just to really pave the way? I think everything you said is correct. I think we are doing it for good measure now because we're early in FME. We obviously have yet to see, you know, what I mean, um, what we can get away with with or without surgical assistance with a lot of these FMEs. But of course, um, also given some of the practical context in which we're doing FME, of course, because because we don't have some of that collateral bracing of tooth anchorage, because we don't have some of the other what we've now grown to see as luxuries with other kinds of expanders, we want to now just eliminate any variables that we know might contribute to failure, right? So, so that's why we're doing, um, you know, bone cuts on almost everybody. But I do contend, and in general, I'm somebody who's actually tried to push the limits of what is possible without the cordotomy. Mariana Evans is big on that, pushing that limit. Absolutely. And I think it's good because it forces you to keep doing better. Marpes. Absolutely. For better expanders. It's the ultimate litmus test. It sure is. And I mean, you know, these days, I've actually gotten away from doing, you know, um, cordotomies on almost all females in any circumstance, right? We're going to do a few just really partial kind of, you know, baby cordotomies for some of our female FME patients coming up. But, but I thought you believed in equity. Well, the bone is created equal. We, we know this. We, we know that the bone is not created equal, right? Everybody has equal rights to expansion, though. So holler at us if you're male or female. But, but it's just another shitty thing that men have to deal with. They have to get the piezo knife, man. That's what I'm saying. You know, you know, yeah, I mean, more, more often than not, yeah, you know, build skyscrapers, take the piezo knife to the dome, you know, exactly. Y. Hey, can I ask you a question about the piezo knife? That maybe because you have an engineering background, you're, you can help me answer. Why is, how does the piezo knife? I don't have an engineering background. I thought you were had an undergrad in engineering. No, no, I do not. Oh, yeah, I'm your father. My father. Your father is an engineer. So that's, that's an engineering background. That's an engineering background. But I'm not like, even on tenth as smart as that man. I mean, he's, he's on another level. He's a good, he's a professor at. He is a professor at Wayne State University in Detroit, Michigan. Yep. Yep. I met him once. Good guy. Um, shout out to your old man. Yeah, buddy. I'll let him know you said what's up. So, but how does the piezo knife not cut?

Soft tissue, but it cuts bone. It's like magic. It's a, it's a frequent. I asked because when do, when Dr. Alfie was going in to like do, to finish off the maxilla at the terago-maxillary area, he would just take that thing and just go with it. And I would be like, "Whoa, that's..." But he'd be like, "No, man, it won't cut soft tissue, it'll just cut bone. You can do that." It's, it's basically the Noodle Theory, right? Like you have, um, you know, let's say you have nerves or blood vessels or whatever, right? And you, you put this thing in there. Well, um, you know, of course, you're, you're putting something in there that, um, you know, of course, like when you're doing like a spinal tap or something like that, right? Like you're probably not going to hit a nerve because things kind of move out of the way, right? So for looser soft tissue vascular structures, that's kind of part of the phenomenon. But the real inherent thing in the P-Paso is the frequency, right? This is basically a frequency-modulated. You won't actually see the P-Paso tip like shaking around. You turn it on and the thing looks still. So how does it even cut? It's like a super ultra-high frequency kind of thing. Is it actually moving and the eye just can't see it? Or does it not actually move? If you touch it, it's got to be moving. It's not just emitting sound. You can put it on your finger, it's not going to cut your finger. Come on, man, for real.

But how does it cut through the P, the the palatal mucosa? Well, okay, if you apply enough force, you can pierce it just through brute force. But that's why we use a 15 blade to go through the, make initial soft tissue incision and then do the P-Paso because you get a finer cut. You're pushing a blade through it. Exactly. Because if you just push the blade through it, then you got to push harder. Pushing harder creates heat. Heat creates, you know. Yeah.

So, is that your own innovation on P-Paso surgical assist? I don't think it is. I mean, it just made sense to me though. That like, if this thing is not meant to cut soft tissue, let me cut the soft tissue and then hit the, get the hard tissue with the hard tissue cutter and then close up the soft tissue. So you're telling me I could take a P-Paso saw, turn it on, and I could go and it, and if I don't push hard enough, it's not going to cut? Yeah, that's correct. That's nuts. No, it's going to get hot. It's going to get very hot. It's going to get, it might burn me. Yeah, that's why you need, you need a lot of saline. It's not going to pierce the tissue without like brute force, right? Did you know that, Bailey? I had no idea. That's insane. It is insane. I mean, if you're feeling frisky, just go ahead and get a P-Paso, put it on your, what's it called? Take that to the test. That's crazy though. Mr. P-Paso must have made a lot of money on that thing. Yeah, right. Y. Is he a Mr. P-Paso? Or is it, is that, is it not a Mr. P-Paso? Is it, we use P-Paso in different, different types in dentistry too. So for example, um, if you get your teeth cleaned, you can use a, what we call a cavitron or a P-Paso, different version of ultrasonic cleaning to clean your teeth. All right. I, I guess I, it's the noodling thing kind of makes sense. Mhm. It essentially just wiggles its way around the soft stuff. Kind of. Yeah, pretty much. And it's, well, and, and it's just, it doesn't, it doesn't cut it. Like the frequency does not allow it to damage soft tissue. Okay. You know, but somehow bone responds differently to that because of its rigidity. Correct. Okay. Yep. All right, we'll go with that.

Um, the big question: Do I need expansion prior to MMA surgery? Uh, that's right on that for me. That's a great question. I think we should both answer that. Um, I'll just give a quick blurb. Um, you know, which is basically, um, you know, what is, what is like literally everything else we've talked about in this interview? I mean, you have to really look at the individual situation and know what your objectives are. So, if, what is necessary to put an individual's anatomy, teeth, bones, you know, tongue, airway, nose in a position that supports your primary objective, which is curing a sleep or breathing problem, right? Then what needs to happen? Sometimes expand and then do the surgery. What pros and cons are there in doing that? Well, of course, expansion necessitates that, you know, you're doing something presurgically. Maybe you're doing, um, you know, I think, uh, you're, you're doing something a little more conservative to assess the potential therapeutic yield of that intervention before committing yourself to a larger intervention. You're staging it out. To me, you're not going all in. Not going all in. I, I get that part. So to me, that's a big benefit of going that way. So you're saying it might help you avoid surgery completely? It, in some cases, where it's otherwise appropriate, otherwise feasible, to avoid surgery. Yes. There's some cases. You know, it's going to be a slam dunk surgery. Those are the ones I'm talking about. The ones that they're already dead set on doing the surgery, but they're just wondering if they should do the expansion first.

Well, what about the wisdom teeth? If you have your wisdom teeth and you expand, and that could potentially help the wisdom teeth come in, and then would you have to remove them for jaw surgery? I asked Dr. Alfie if he's ever done a jaw surgery on someone who had their wisdom teeth. He said it's not, no, because they're right in the way of the B-B-S-O cuts, right? Especially on the mandible, right? I mean, because one thing I learned during watching Dr. Alfie was that the hardest part of of releasing both jaws essentially is down here, here, and here. It's like tough access, and you're kind of blind in a way. So you can imagine the catastrophe that would be if there was a wisdom tooth back there that was in the way. So I think, I don't think you're keeping your wisdom teeth if you're doing jaw surgery under any circumstance. That shouldn't be the expectation. Correct. There are, have you ever seen it? I've never seen it. You have seen it? I have seen it. Show us the cases. Pro. Yeah, yeah. No, I have. No, I believe it. I, hey, although one of the cases I'm thinking about was somebody who had four premolar extractions, so maybe the wisdom teeth were in a second molar position, right? But like, anyways, did you, have you ever seen a double jaw on someone with 32 teeth? I mean, come to think of it, maybe not, right? That's what I'm saying. Dr. Alfie hasn't, and he's done a lot of jaw. I have. But then they became a 28-tooth-er because of the surgery that's there. There you go. I guess that's the sacrifice. You know, sacrifice. Long term, you don't, I mean, you're getting bones like way forward in your face, you know, I mean, at that point, you know, it's, it's okay to, you know, sacrifice the pawn to get the queen, something like that. Yeah, yeah.

Well, what if you're, uh, I know we talked about this briefly, but what if you're like an MMA fighter or a football player? You know, jaw surgery can't really be an option because if you get hit wrong and one of those plates shifts or moves, like that's pretty scary. Also a very common question that I'm seeing more and more often. But Dr. Alfie said his brother, Dr. Alfie's brother, uh, is into Jiu-Jitsu and is considering jaw surgery, and that's his hangup. He's like, "I don't know." But D-D-Ra's like, "Dude, six months and you're good to go. Twelve if you want to be safe." Because essentially, you get to a point where you can remove the plates, and the bone is there, it's healed, really, it's fused.

What do you guys think? Is so, going back to the pros and cons of pre-, uh, pre-surgery expansion? I think it's a little bit more predictable orthodontically. Um, if, and also the cuts. Um, if you're like, some, some of the cuts may damage the teeth or put the teeth at a greater risk too. The Le- for cuts, or the specifically the segmental cuts? Yeah, yeah. Dr. Alfie would, whenever someone was considering segmental, he would say, "There's a little bit of an increased risk to the teeth." So, and then orthodontically, it's probably more predictable. So then it's okay, well, why ju-, why not just do jaw surgery? What are the benefits of expansion? So that's, you could just touch on it. It's the opposite. So I mean, you could get relief much sooner, possibly, right? So the question that I'm wondering is, the total, the maximum net nasal breathing benefit? Yes. Obviously, you get nasal breathing benefit from expansion. Yes. You get nasal breathing benefit from jaw surgery. Maybe we can talk about the anatomy of that in a second. But is the maximum possible nasal breathing benefit, jaw surgery plus expansion? Theoretically? Theoretically, sure. Yeah. Because I think there are parts of the nasal cavity. This now ties into the anatomy of the question. And now the actual anatomy that, you know, expansion, uh, affects are broad, you know, more broadly applied in bone-anchored expansion than they are in jaw surgery. Can you dive a little bit more deeper into that?

Uh, expansion goes higher up, correct? And, um, and of course, you know, you're getting, you know, uh, changes in structures that are above the osteotomy line. So that's really the crux of it. Is it, what's happening above the osteotomy line? Correct. Oh, Trump got shot. Shut the up. Trump got shot in Pennsylvania. Come on, man. What? My phone's blowing up. Really? Are you serious? Yeah, let me just, I mean, I'm getting like a bunch of text messages. I'm going, I'm going to go on Google News real quick. Trump rushed off stage after gunfire, gunshots reportedly fired at Donald Trump. Well, it doesn't sound like he's dead. Well, I can't wait for Kamala Harris to be our president. Maybe we shouldn't put that in. It's a neutral comment. Well, I don't see anything conclusive here. So in the absence of anything conclusive, let's, uh, jump back to this.

So doctors Jafari and Noaz. So this is an E-E-S, all right? And it's a before and after. So what we're really talking about is, so the osteotomy is, is basically right here. If it's a, even if it's a little higher, it's never going to be any higher than that in a double jaw, right? And so if you, this is the high, this bottom green line is essentially the highest you're going to get expansion with a double jaw. But the expander, you can see change higher up, correct? Up to basically from this line up is what you get with the expander. You can even see, um, lateral migration, um, of the fronto-nasal suture area. Look at that, right? See how it kind of swings out? I don't see that. Can you point that out? Yes. Um, check this bone out right here, right? So you have, you have just a little bit of change up there. Yeah, which is scary because sometimes when that thing budges, you get leveling problems with expanders, right? You get one side of the face drop because of that. Exactly. But this is clean. This is clean. And this is a modest amount of expansion, right? You know, you don't see that happen in anybody who's. Look at this change, right? You, you're going from what, like 19 millimeters to 20? There you go. 19.3 to 20.6. I, I don't think this treatment is complete. Correct. This is early stages, but I think it's a good visual for seeing changes upstream of the osteotomy of your typical jaw. Exactly.

So, but then we get to the question of how much does a patient really experience that change? And like, 'cause what patients are doing is they're doing a cost-benefit analysis as to whether or not they can skip, especially patients that are orthodontically already ready for surgery. Like, "Hey, can I go in and get an 80% fix for 20% of the effort by just doing this double jaw?" It's predictable, it's precise, it's going to, it's going to address the AP in addition to the transverse. But the, the, the only thing that I think people are unsure of is, am I going to miss out on the nasal breathing benefits of the expansion? And is that going to cause me to continue mouth breathing? And is my jaw surgery going to therefore be unstable? Or am I otherwise going to be dissatisfied with my nasal breathing even after the jaw surgery if I don't do the MARPE first? And I guess you would have to say it varies. There's no way of knowing, really. Is there any way of predicting that? Not until we have more data, more AI modeling of what kind of, you know, like, let's say you input a skull into a futuristic AI program and it kind of, you know, predicts perhaps where this person's expansion is likely to succeed or fail, or how prone they are to symmetry problems, this, that, whatever. Then maybe. But until then, maybe not. But if you were a betting man and you had to bet on the best possible approach, maximalist approach, bone-anchored for getting, yeah, bone-anchored first. That's always the safe play. Yeah. So for someone who, especially 'cause you can correct for the deficiencies that occur within that in the ensuing surgery, right? Yeah. You can go to town with it. And if you get an asymmetry, you just fix it there, right? And then, I mean, I'd say for a lot of our patients, it's staged. So even if they're not fully committed, once again, it's kind of, you're not going all in. You can see what kind of benefit you get with the expander first, right? One, that's cheaper, it's less hassle, um, you know, recovery time, etcetera. You know, all those benefits too. Less risk, right?

Now, one other thing that I want to get your opinion on that I saw Dr. Alfie do. It's kind of his signature thing. I don't know if other surgeons do this, maybe you know. But one thing he does is after he plates the maxilla, he takes his saw and he just cuts out a big sliver of bone from right here. Mhm. Cuz, cuz what I was seeing, and he would point this out to me on every patient that he did this to, he's like, "Look at all these bone spurs, look at all this extra bone mass that's protruding here. All of this is unnecessary, and it's, it's, you know, inhibiting the nasal aperture." What do you guys think about that? I mean, it sounds like to me a sound thing to do if that's indeed, yeah, if you have too much bone mass there. Um, you know, uh, as to whether how standard or signature it is, I don't necessarily know. Um, but is it a sound thing to do? Yeah, absolutely. You could see that anatomically potentially improving nasal breathing. Correct. Yeah. Mhm. Because the, the width of this bone right here, yep, is your aperture. That's your aperture. That's your aperture. And then that's the tunnel entrance, correct? And then you just have to think about again, how your soft tissue is going to respond to that. A person's, you know, alar base going to be too wide? What kind of suture are you doing to manage said width? The issue and the alar base, like all that kind of stuff, right? So there's a lot of factors to consider. But, um, alone, sure, you know, like if you have redundant bone there that you don't need, little bony projections, yeah, correct. It sounds sound to me that one would remove that to improve the aperture. Yeah. How would it's, it's basically essentially a lateralization of the nasal wall, you mean? It's equivalent to an expansion in a way. Yeah, at least of that particular area, right? That's, that's, that's what I'm saying. I think that option is attractive to a lot of people who just want to get in, get out, get an 80% fix. I think there's again, merit to that as well. Yeah. You know, um, you know, and that's why I mean, when we plan these things, you have to really talk to the patient, you know, and there's no one-size-fits-all. It's finding out what benefits they want, what's their timing, what their lifestyles is like, you know, there, it's, it's not, you have, and not nothing's in a vacuum. It's really get to know the patient. And I'd say one of our combined skill sets is really listening to our patients and understanding where they're coming from. Um, you know, we, we really pay attention to that, right? And trying to figure out what works for their lifestyle, for their personality, for who they are, you know, and all those other factors that come with each individual. Totally. You know, and I think that's one of our skill sets. Totally.

I guess what I'm saying is, how do you manage what a patient says they want and what they're willing to do with what's actually going to get them the exp- result? Do you know what I mean? Because I feel like sometimes skeletal expansion and jaw surgery is just, especially jaw surgery, is so far out of the paradigm of patients as they enter this space that it's like, you see these patients and you just know that they're retronic. You can just see it, you know? But like, you can't just say to someone, "Yeah, man, you to get what you're looking for, you're going to need to do the double jaw." How do you, how do you, do you do more listening than talking? Do you never propose something that they don't mention first? How do you walk that fine line with some of these procedures that can become very invasive, so to speak?

Oh, no, we mention those things without them asking all the time. You, you kind of have to. I mean, that's, that's your responsibility because you know, when, when we're taught in school, I mean, an option is to do nothing. That's an option too, right? And so we have to discuss, like, you can choose not to do anything, or you can do the most extreme, right? And so we, we, we try to present as many options as possible and then kind of see what their lifestyle requires and what they need, right? And then kind of figuring out what's the good balance for that patient, right?

How do you guys coach people on choosing jaw surgeons? Do you have a one person that you can rely on? Do you have a, like, what's your decision tree? I have a trusted few. Um, you know, like, I mean, and, you know, again, the disclaimer for this comment is that there are very good jaw surgeons everywhere whose names don't float around from either our recommendations or in the echo chambers. There are good jaw surgeons everywhere with very good surgical skills, experience, this, that. And some of them have, you know, been fortunate enough to, you know, what I mean, like, uh, do some good work for patients and we know, you know, you see what I'm saying. So, um, so I, you know, we all will have our preferred surgeons because we know who can do what, who has what capabilities. Um, and, um, I think really, when it comes to the patient, um, choosing a surgeon, because it's not uncommon that perhaps, you know, because of a logistical or travel or cost issue, we have to give names of two or three. Right? If we give the two or three, and all other things being equal, I will tell them, "Go with who you feel understands your problem the best, and who you think, you know, the, you know, I mean, like, let's say if one of them is willing to share a plan with you and the other one is not, and that's important to you, then you might know who's a better fit for you, right?" And so forth. So I think that those are some of the things. But I think, um, you know, of course, orthodontic surgeons, this is the kind of thing where, you know, you want somebody who does a lot of them.

Time out. Do you pronounce the G or do you not pronounce the G? Do you say orthog- or do you say ortho-? 'Cause I just added the G recently, but I'm having doubts. I think, um, I think I tend to skip it. I do too. Orthog- I say, I say the G. You say the G, Bailey? I don't even say it 'cause I don't know. Is there two G's in there? I think it's ortho-gnathic. There's two G's. There's one G. One G. I thought it was a silent G. 'Cause you, I thought so too. Like gnome. Yeah. Nath. Like neological principles, right? Yeah. We need to standardize that. Well, we're not going to standardize that.

One thing we can standardize is naming nasomaxillary expanders because the way you guys use the term MARPE is specific to Partners Custom MARPEs. But I use MARPE as an umbrella term to refer to all naso-max. You are more correct. I, we just had to just refer to it as that for this discussion because it's part is too much of a mouthful. Exactly. And there's also other custom MARPEs, correct? Okay. All right. So I don't have to change my whole ebook. You know, the T-P-D is technically a MARPE if you think about it. It's not in the classical sense, of course. MSSE, FME, and Partners MARPEs and other custom MARPEs are all MARPEs, right? The T-P-D is not really a MARPE. It kind of technically is if you consider the tiny little anchor screws to put the little plates into the, you know, side walls of the bone. Those are micro-implants. Those are like kind of micro-imp-, just kind of like little fixation screws. So maybe it's not quite like MARPE, but it's, you know, it's some kind of bone-anchored. You're putting a fastener into a bone. Yeah, yeah. All right. Anyway, that was a tangent. But, um, getting back to. So let me just pose this to you. So Anil Rama said that when you're choosing a jaw surgeon, just focus on aesthetics and let the functional cards fall as they will. Basically, like, because you could do, so for example, when I do my, you know, coaching sessions with clients on weekends, they will have seen four different jaw surgeons, all the usual suspects from the echo chamber. And you'll have one of them recommending 14 millimeters advancement on the mandible, and one of them is recommending seven. So it's like, that's radically different. How do you bring, how do you, you know, two top world-class experts suggesting such radically different things? Obviously, one of them, the way I read that, one of them is airing on the side of a more conservative, natural-looking aesthetic that's not going to stretch things or cause the chimp lip that you can just tell that someone, they almost look like a mannequin after because it's such an aggressive movement. The skin doesn't react well to it. And one of them is airing on the side of maximizing the airway. Mhm. So do you agree with Anil Rama that you should always air on the side of aesthetics? And because there's no guarantee that 14 millimeters advancement is even going to solve your sleep issue, but at least you can know that you're going to look good after? Or do you?

I'd say, once again, I mean, when, when we do anything, it's patient-specific. So if patient more aesthetically inclined, then that's something to, for patients like, "Hey, I don't care what I look like, I just want max." Then that's true. You know what I mean? So, you know, I, we see this all the time with our patients, right? And so we kind of have to figure out what's the best solution for them individually. So even to answer that question, I would say it's debatable. It all goes back to what the patient wants and what, what needs their psychology, their life circumstance. Totally. And both of those surgical plans could be sort of anatomically well within the range of responsible treatment. Because it's one thing to be irresponsibly, you know, one way or another way, right? But then it's, um, you know, I think if, if it's not breaching some sort of standard of care issue to make a certain change, um, it's possible that both the 7 millimeter and the 14 millimeter people are right.

Do you think there's a better chance that the 14 millimeter expansion is going to experience a more significant airway benefit? If you were in Vegas? Absolutely. Because believe it or not, some of these top surgeons in the echo chamber will say, "No, there's no, there's, you cannot say that the bigger expansion is going to be more of an airway benefit." Well, what's the relative benefit? I mean, you know, are you tapping out and you're just doing more expansion? You think the curve flattens at the top? Yeah, I, I do think it flattens. It's not like, you know. So are you compromising aesthetics so much that you're getting minimal benefit by going seven more? I mean, those are questions that individually have to be answered for that patient. And maybe we need more data also to know about this. Or is it really patient-specific? It has to do with the shape of their airway. It, all of that, all the above. It can't be generalized like that. And then that's why, like, on the talk spaces, you know, a patient will say, "Oh, this applies to that." Doesn't, doesn't mean anything. You, or you, or you. It could be for the one individual. Totally. And that's why you have to have a surgeon that's going to communicate well with you, hear you out, listen to you, show you the plan, right? And if they're just kind of shoving it, you got to go, "This, I probably wouldn't suggest that for most patients." Yeah, especially if they're, they want that hand-holding and that, you know, interaction, right? And that's kind of what, where we come in. Is we know that as providers, we listen to our patient. I mean, to to the level where our staff gets annoyed because we're our consults very long. I hear, we literally will answer every single question in seven different ways, and you know, they ask the same thing seven different ways, and he'll spend hours talking to them. Yeah. And then, you know, there's no other way to ask the same question at that point, right? Yeah. They do tend to ask the same questions over and over in different ways. Dr. Ting made that observation as well. And he's still patient of where he'll still answer it, right? He is. Dr. Dr. Noaz is an extremely patient man. I can vouch. I can vouch for that. Same handsome, not so much. Come on. Wrong. Maybe after my FME, after the FME, exactly. After his FME, and I'm a with all that new oxygen, my cortisol levels are going to drop, I'm going to lose like 60 pounds, and then then I'm going to hit the scene. The ultimate biohack. But I still love my why. But ladies, ladies. No idea. The man does have a ring on his finger. Um, all right. Um, well, I don't, I don't think I'm going to make it to that party. Hey, the party was here. No, no, we got to, we got to get you into that party. 7:00 PM, the grill is shut down. The party's over. It's all right. I'm going to have to mail him a nice gift. Oh, no, it's all right. Oh, we're sorry about there. I'm the one who K-, I'm, it's on me. You know, we said we were going to do an hour. I don't even know. We're at hour three. Two, two and change. Almost three. Yeah. Oh, wow. The camera's still running, so that means we haven't run out of hard drive space, which is good.

So, um, all right, well, thank, I mean, thank you for having us. Yeah, it was, uh, it was an amazing, uh, change up to our schedules, right? I mean, we don't normally take off. So, no. Yeah, you guys being really hospitable hosts, you and your wife and your baby. Oh, yeah. I'm glad you guys got to meet the baby. Yeah. I think we're going to go have dinner now, right? Yes, we are. With the baby. Yeah. You know, some Ronnie's Wholesome Foods, cattle, yeah, cattle with some beef tallow and some bones. Some bones. Some draw-develop kind of food for dessert. We, instead of putting ice cream in a cone, we just put beef tallow. All right, well, um, Dr. Noaz, Dr. Jafari, Bailey, AKA Brun and Jolly, and Jolly, #Jolly. So, well, definitely follow us on Jaw Complex. Yeah. How can people reach out to you? How can they contact your practice? How can they follow your work? What are all the contacts, guys? Uh, they are these. And I guess when I say these, you can maybe overlay links to our office numbers and Instagram. And if not, link in the description. Link in the description. Okay. Yeah. Okay. But if someone wants to become your patient, is it pretty simple to call and make an appointment? Just go to team.com. And, yeah. And where do you practice out of, roughly? What's your? The whole Eastern Seaboard. So we've got, um, you know, so I'm Williston, Vermont, New York City, and Ponte Vedra Beach, Jacksonville area, Florida. And, uh, we overlap in New York and Jersey and Pennsylvania. And you guys will be at MU-CON on August 17th? I think I'll have to be there because I made a commitment to speak. So. Wow. Yeah. Dr. Jafari, we'll be there. I will be as well. You'll be in the audience? Yeah. I'll be cheering them all. Hey, hey, hey. I'll be cheering both y'all with signs and everything. I'm, let y'all's biggest fan. This is like crazy. This is so wild. That's that's awesome, man. Um, you were thinking about doing something special for MU-CON, right? Maybe some some shirts and stuff, custom-designed shirts? And then possibly, if patients want to get some consults afterwards, maybe the next day? We're thinking about that too. Oh, really? Just like, well, we'll, we're still figuring that out. But if they're already in New York City, and our office is literally Midtown, as well as the conference, we're trying to figure out how to kind of maybe do some flat. Yeah, definitely, definitely. Kind of, they're already out there, maybe just do a consult. Could be a good opportunity, at least take some scans and you know, you guys with some data, data collection. Yep. Yeah. I'm speaking at MU-CON as well. I'm speaking at noon time, I think. Yes, you are. On Saturday. Well, what are you going to be talking about? I don't know. What do you guys think I should talk about? I, so I think you should actually talk about, um, patient advocacy in the airway and facial development realm, right? That's my domain. Yeah. I think you should talk about that. I should keep my lane, correct? Yeah. I mean, I think you've, you've done a great job of introducing something to basically the world, right? Made it more mainstream. And I think that, you're, you're very good at synthesizing information and, um, presenting it back really, really, really well, right? Yeah. Thank you. Yeah, thank you. I mean, I think I, you know, I, you know, you're definitely a huge pioneer in all this, you know, and I think that, uh, yeah, I appreciate that. Yeah, thank you. It's just, in 20 minutes, you can only make so many points. I'm just trying to think. So something you could be like, "What to look for in an orthodontist, what to look for in an OS surgeon, what to look for in a functional therapist." I don't know, something like that. And, right. And what, um, and how to navigate talk spaces, right? Like, "Hey, maybe some of the information on there is good, some of it is not good. There, there are places where you can actually have access to high-level discussion amongst the people for these things." And I'm very impressed with a lot of that dialogue, but understand that it's happening in the context of people without formal training. And just to say that, just to say that, I think is valuable. We'll be launching a Patreon where we discuss a lot of, um, educational stuff too. Content. You guys should launch a school instead of Patreon. Patreon's dead. Oh, okay. Like S-S-K-L school? Yeah, it's going to be a paid membership. Y- Yeah. School all day. Really? That's Hermos. Hermos right here. Yeah, yeah. All right, then we'll reach out to him. Yeah, yeah. You guys, I'm, I'm thinking about doing something like that too. At some, not this year, maybe in the future. Yeah. But just a place where I could do like group calls. Yeah, you can schedule calls, you can put up video courses, you can put up PDFs. M- I think I'm not chilling for school. I don't know. But I think it's, I mean, I've kind of, you know, heard about school from, I follow Alex Orosi anyways. Yeah. I've seen ads about it. Yeah. I think another good point is, what kind of touching on what Noaz was saying, was people, patients hyper-obsessing over their in in the talk spaces, Reddit, and Discord. And just maybe advise them to kind of touch some grass. Oh, you think some, some breathing? Take that route, huh? The mental health path, maybe just a little bit. 'Cause that's some advice that you had given me, and I was like, "What?" He's right. But yeah, just being so obsessed in, breathe. Yeah. And then doing like a five-minute segment on game and how it's important to have game, not just a good jaw. Exactly. Yeah. I mean, I think, um, you know, I think this whole idea, I mean, clearly, you know, I mean, you go to, you go to parts of, I mean, you go to really any part of the world to see this phenomenon. Tajikistan. Tajikistan. Let's go. Um, you know, D is over there. I mean, you'll see very, very, uh, extremely attractive women with less attractive men. I mean, everywhere. I mean, it happens in my household, you know? So, I mean, you know, that's just a small example. But I'm just gaining you that for me, bro. You're too humble. You're too humble. N-, but I mean, you know, that's the thing though, is like, you know, I think for a lot of these people out there who think that they don't necessarily have chances to mate and procreate with women, um, you know, maybe you'll be more attractive to them if you're not constantly obsessing over your facial structure, right? And now come to someone who understands your gripe about your own facial structure, right? Like, like us to talk about that, but don't make your life about it. Yeah. You know, life is too short and you have too many opportunities to excel at something, whatever it is you want to excel at, to be worrying about that kind of stuff, right? I mean, look at me, I have 24 teeth in my mouth. I'm like, you know what? What do they call it in the, they would call me a jawl, right? I got these tiny ass jaw with them 25% of my teeth missing. I'm a jawl, right? Yeah. You know, and I'm not that tall, I'm overweight, I'm like, you know, I'm not, you know what I mean? And, yeah, yeah. You know, but I've managed to do a thing or two in my life because I had a purpose and a vision and, and, you know what I mean? And in point. Yeah, no, totally, totally. No, I, you know, you say it a little bit tongue in cheek, but it's actually, yeah, it's an important point. Yeah. You know, and you, there's countless examples, correct? That it's not just about jaw structure. Absolutely. But it's hard to drive that point home. Y-, I mean, not only do I have really like deficient jaw structure, let me tell you this, I don't have jaw, good jaw structure. And I have probably some of the worst sleep habits of anybody. And probably some of the, you know, worst lifestyle sort of circumstances that permit really good, restful, regular sleep and sleep hygiene patterns. Um, I'm functioning like, I think pretty good. Why? What's the magic sauce there? Oh, uh, the power nap. So we've actually, so we've, we've talked about this before. A lot of this eight hours straight, a lot of it, they say that it, it could have stemmed from the whole Industrial Revolution and working shift work, right? So when we were farmers and gatherers, you know, you took a nap, you, you know, woke up at sunrise, you took a nap during midday when it's the hottest, and then you went back out, and then you went to sleep when it, when the sun went down, right? And then you could nap if you needed to. But with the Industrial Revolution, I mean, you kind of had to do your shift work, right? You have to pack it all in. And I mean, in C-, in certain cultures, whether it's, you know, Greece or Spain, you take the, you know, siesta, right? And then some people are very good at doing, um, polyphasic sleeping too, where they do blocks. Where there are some, some genius people like Dr. Noaz. I mean, I think Tesla used to do polyphasic sleeping. I think Da Vinci, right? And so, you know, there's not a one-size-fits-all to that either, right? What does polyphasic sleep mean to you? Does that mean splitting the night into two segments? Or does that mean sleeping throughout the day and night and not even discriminating between day and night? That could be it. Who knows? It's multi-, multi-, more than one. Yeah. Versatile. Sometimes you wonder how much, like, and also the thing is, like, you know, when, you know, with sleep hygiene and things, people will start, they'll get, they'll start obsessing about being tired the next day. So they'll get insomnia because of that. Like, "Oh man, I should be sleeping right now." Yeah. And so it's a lot more, it could be mental. It's totally mental, right? 'Cause if they got out of bed and then left the room and then, you know, I don't know, did something else, then they could probably fall asleep earlier and sooner than them obsessing about, "I'm going to be tired tomorrow." And do you think that there's a degree of mental fortitude necessary to function in modern-day society? I mean, and in other words, I think people need to chill the out, like, you know, and just kind of step by step. I think mindfulness meditation is massive, right? Yeah. You know, if you just chill, take a double, was it Dr. Human says, take a double breath? Yeah, double breath is good when you're working out too. Yeah, just relaxes you. I mean, everybody's so hyper and high-tense and strung up. Life's going to go on. Yeah. People allow their thoughts to control them. You have to be able to control your thoughts. And none of us are going to make it out alive anyways, so. Totally. No, not even a little bit. Yeah, yeah.

All right, guys, well, um, yeah, lots of wisdom there. And, uh, we'll end on that. And thank you for coming all the way up from New York, Philly, Philadelphia, New York, Maryland, to Nor-, to Boston, to my studio to record this podcast. I enjoyed it. And, uh, yeah, let's go have some dinner and play with the baby. Yeah, buddy. Ha. All right, take care, guys. Thank you. Thank you. Peace.

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FME Matrix Download | #65 - Dr. Newaz & Dr. Jaffari

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