Correction of Late Adolescent Skeletal Class III Using The Alt-RAMEC Protocol and Skeletal Anchorage
Correction of Late Adolescent Skeletal Class III Using The Alt-RAMEC Protocol and Skeletal Anchorage
Correction of Late Adolescent Skeletal Class III Using The Alt-RAMEC Protocol and Skeletal Anchorage
Muhammed Hilmi This case report describes skeletal anchorage-supported maxillary protraction
Büyükçavuşa performed with the Alternate Rapid Maxillary Expansion and Constriction (Alt-
Ömer Faruk Saria RAMEC) protocol over a treatment duration of 14 months in a 16-year-old
Yavuz Findikb female patient who was in the late growth-development period. Miniplates
were applied to the patient's aperture piriformis area to apply force from the
protraction appliance. After 9 weeks of following the Alt-RAMEC protocol,
miniplates were used to transfer a unilateral 500-g protraction force to a
Petit-type face mask. A significant improvement was observed in the soft
a
Department of Orthodontics, Faculty tissue profile in measurements made both cephalometrically and in three
of Dentistry, Süleyman Demirel
dimensional photographs. Subsequently, the second phase of fixed orthodontic
University, Isparta, Turkey
b treatment was started and the treatment was completed with the retention
Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, Süleyman phase. Following treatment completion, occlusion, smile esthetics, and soft
Demirel University, Isparta, Turkey tissue profile improved significantly in response to orthopedic and orthodontic
treatment.
Received January 6, 2022; Revised August 11, 2022; Accepted August 29, 2022.
How to cite this article: Büyükçavuş MH, Sari ÖF, Findik Y. Correction of late adolescent
skeletal Class III using the Alt-RAMEC protocol and skeletal anchorage. Korean J Orthod
2023;53(1):54-64. https://doi.org/10.4041/kjod21.337
54
Büyükçavuş et al • Late adolescent skeletal Class III correction
www.e-kjo.org https://doi.org/10.4041/kjod21.337 55
Büyükçavuş et al • Late adolescent skeletal Class III correction
(1) to improve the profile and facial appearance, which correct anterior crossbite and Class III malocclusion.
was the primary complaint of the patient, (2) to provide
Class I functional ideal occlusal relationship, and (3) to TREATMENT ALTERNATIVES
Radiographs of the hand-wrist and cervical vertebrae
showed that the patient was in the post-pubertal period
(Figure 3). Since the chief complaint of our patient was
the profile appearance, which would not change much
with camouflage treatment, orthognathic surgery was
suggested as a definitive solution. Orthognathic surgery
including maxillary advancement and mandibular set
back planning of fixed orthodontic treatment were dis-
cussed with the patient. This approach would allow cor-
rection of the skeletal concern and create an ideal oc-
clusion with good facial and dental esthetics. However,
the patient refused the surgical approach. Other treat-
ment options included: (1) distalization of the mandibu-
lar teeth with skeletal anchorage units (2), mandibular
interproximal reduction (3), Class III elastics (4), and/
or maxillary protraction with a face mask. The patient
evaluated the advantages and disadvantages of each of
these treatment options.
Since the primary complaint of the patient was re-
lated to the profile and facial appearance, a treatment
plan that could affect the skeletal soft tissue as well as
Figure 2. Lateral and posteroanterior cephalographs, and achieve dental correction was emphasized. We planned
panoramic radiograph taken at the initial visit (age: 16 to start with the Alt-RAMEC protocol to increase both
years, 7 months). the skeletal changes and to ensure the effectiveness of
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Büyükçavuş et al • Late adolescent skeletal Class III correction
Figure 4. Post-protraction
facial and intraoral photo-
graphs.
Figure 5. Post-protraction
lateral cephalograph and
panoramic radiograph.
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Büyükçavuş et al • Late adolescent skeletal Class III correction
approximately 500 g applied bilaterally with an antero- 20 hours per day until at least a 2-mm positive overjet
inferior force vector of approximately 30° to the oc- was achieved. Protraction treatment was completed in 6
clusal plane from the hooks of the I-shaped miniplates. months (Figures 4 and 5).
The patient was evaluated at monthly intervals, and Subsequently, the acrylic coverage RME appliance
she was instructed to wear the appliances for at least was removed and the fixed treatment phase was started
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Büyükçavuş et al • Late adolescent skeletal Class III correction
(Figure 6). Miniplates were used for retention and dur- were observed with forward movement of the base
ing fixed treatment at night. After the protraction phase, of the maxilla (sella-nasion-A point [SNA]: 79.87° to
the fixed orthodontic phase was started. After the ap- 84.58°) and slight forward movement of the mandible
plication of MBT 0.22 slot metal brackets (Mini Ova- (sella-nasion-B point [SNB]: 80.77° to 81.43°). A mini-
tion, Dentsply GAC International, Bohemia, NY, USA), mal increase in vertical dimensions (sella-nasion to
leveling was performed with 0.016, 0.016 × 0.016-inch gonion-gnathion [SN/GoGn]: 30.85° to 31.03°) was also
(in), 0.016 × 0.022-in, 0.017 × 0.025-in, and 0.019 × observed. This can be explained by the posterior rota-
0.025-in Nickel-Titanium archwires arch wires and 0.019 tion of the mandible due to the effect of the face mask.
× 0.025-in steel arch wires, respectively. After ensuring Dentoalveolar changes included minimal protrusion with
that the molar and canine teeth were in Class I occlusion the face mask in the upper incisors and retrusion after
at the finishing stage, digitation elastics were applied fixed treatment and after retention. Although slight
to the mandibular canines and first premolars from the retrusion was observed with the face mask in the lower
maxillary canines. Lastly, an essix plate was placed for incisors, the crowding was corrected with protrusion at
stabilization of both arches. The total treatment period the end of the treatment. An increase in overjet (from
was approximately 14 months (Figures 7 and 8). –0.83 mm to 4.29 mm) and overbite (0.26 mm to 1.71
mm) was observed (Table 1).
RESULTS In the three dimensional photographs captured before
and after protraction of our patient, both measurements
Post-treatment data revealed that the treatment goals and volumetric registration were obtained with the
were achieved. Since the patient did not want to under- 3dMD Vultus program (3dMD VultusR software version
go orthognathic surgery or tooth extraction, the initial 2.3.0.2; 3dMD, Atlanta, GA, USA). In 3dMD measure-
complaint was largely addressed to and the malocclusion ments, both volumetric (midface volume: pre, 28,113
was resolved, although the results were not ideal. Smile mm3; post, 28,665 mm3) and linear increments were
esthetics and anterior crossbite improved and tooth observed in the middle part of the face. These changes
midlines were aligned with the facial midline. Acceptable were followed by changes in the measurements in the
overbite and overjet were obtained with Class I canine upper lip and nasal region (Table 2). Although the mea-
and molar relationships. No significant root or bone re- surements of the lower part of the face and the man-
sorption was observed in the post-treatment panoramic dible showed a reduction, there was no clinically signifi-
image, and good root parallelism was visible. cant change (Figure 9).
In the lateral cephalometric analysis, skeletal changes The patient's post-treatment short-term results (after
6 months) (Figure 10) and long-term results (2 years
later) also showed a low relapse rate (Figure 11). Both
the profile view and the relationship between the teeth
and jaws remained stable (Figures 12 and 13). The pa-
tient did not report any temporomandibular joint pain
or discomfort during or after orthodontic treatment. She
was satisfied with her occlusion and facial esthetics and
showed a perfect fit while putting on the face mask and
elastics, which ensured that the treatment plan proceed-
ed as expected.
DISCUSSION
The widespread use of skeletal anchorage units in
orthodontic treatments has helped to solve many previ-
ously reported treatment-related problems. Direct sup-
port from the jaws can prevent unwanted anchorage
losses in fixed orthodontic treatments and is aimed to
minimize the possible dental effects and increase the
skeletal effect in functional and orthopedic treatments.
For this purpose, skeletal anchorage units have been fre-
Figure 8. Lateral and posteroanterior cephalographs, and quently used in the treatment of skeletal Class III maloc-
panoramic radiograph taken at the debond visit (age: 17 clusions.6
years, 9 months). The literature contains multiple studies reporting
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Büyükçavuş et al • Late adolescent skeletal Class III correction
treatments such as the use of face masks from plates the zygoma. Maxillary protraction with a face mask from
placed in the zygoma region or Class III elastics between the plates placed in the aperture piriformis region can
the anchorage units placed in the symphysis region and provide pure skeletal protraction while reducing the den-
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Büyükçavuş et al • Late adolescent skeletal Class III correction
tal effect by preventing the dental mesialization of the before protraction. Many studies using the Alt-RAMEC
upper arch. In addition, this method also eliminatesthe protocol in the literature have reported that an aver-
potential for posterior rotation of the mandible and the age of two-fold more protraction can be achieved in
related negative effects, since it allows application of comparison with conventional face mask applications.8,9
force through the resistance center of the maxilla.5-7 However, studies using both Alt-RAMEC and skeletal an-
In this case report, three treatment options were pre- chorage units are very limited in the literature.10 To our
sented to our patient in late adolescence who had com- knowledge, the current literature does not include any
pleted active growth development. The patient refused study in which this method was applied in the late pe-
dental camouflage treatment because her main com- riod, making the present case report the first of its kind.
plaint was her profile appearance. The patient was also The patient was successfully treated because of her
informed about the possibility of an orthognathic surgi- cooperation and because the malocclusion were not
cal procedure and was explained that maxillary protrac- very severe. An ideal overjet–overbite relationship was
tion with skeletal anchorage could be tried before the achieved without any protrusion in the upper incisors.
operation. To examine the movement of the jaws skeletally, exami-
To increase the chance of treatment success, we aimed nations were conducted according to the fixed reference
to mobilize the sutures with the Alt-RAMEC protocol planes. With the application of a skeletal anchorage-
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Büyükçavuş et al • Late adolescent skeletal Class III correction
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Büyükçavuş et al • Late adolescent skeletal Class III correction
Initial
Post-protraction Figure 13. Cephalometric su-
Post-retention
perimpositions.
Park et al. 16 applied camouflage treatment to a portunity for maxillary protraction and enlargement in
19-year-old patient using an RME and a face mask. patients who are in the late stages of growth.
They concluded that if the mandibular plane angle of
an adult patient with a Class III malocclusion is low, an CONCLUSIONS
expander and face mask can be used to allow the man-
dible to rotate down and back to improve its profile. Using both Alt-RAMEC and skeletal anchorage, pro-
However, when the patient was examined both cephalo- traction was achieved in the late period, consistent with
metrically and in terms of soft tissue profile, the overjet the findings obtained with early applications in the lit-
improved with mesialization in the upper arch and pro- erature. These findings should be supported by prospec-
trusion in the upper incisors (U1-SN: pre, 111.9°; post, tive studies with large sample sizes in the future. This
116°). In our case report, the skeletal change was deter- approach may be an alternative to orthognathic surgery
mined to be effective in correction. in compromised cases in the late stages of growth and
Determination of the optimal time to start treatment development.
is one of the critical points for the successful treatment
of a Class III malocclusion. Although most studies report AUTHOR CONTRIBUTIONS
that face mask treatment is more effective in patients
with primary and early mixed dentition, few studies Conceptualization: MHB, ÖFS. Data curation: MHB.
have indicated that this treatment should be performed Formal analysis: MHB, ÖFS. YF. Funding acquisition:
at 13–14 years of age.17,18 This case report demonstrates None. Methodology: MHB, ÖFS. Project administration:
that miniplates with protraction and an expander ap- MHB, ÖFS, YF. Visualization: MHB. Writing–original
pliance can be used to treat early adult patients with a draft: MHB. Writing–review & editing: MHB, ÖFS. YF.
Class III malocclusion. The decision to perform ortho-
pedic treatment in the early period or to wait for the CONFLICTS OF INTEREST
completion of growth development is not an easy one.
The advantages of early treatment include minimiza- No potential conflict of interest relevant to this article
tion of excessive closure of the dentition and mandible was reported.
during this period, which can yield better facial esthet-
ics and increase the patient's self-confidence. However, REFERENCES
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