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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 376-381  

Treatment of class III malocclusion with activation-deactivation rapid palatal expansion and reverse headgear in a growing patient (alternate-rapid maxillary expansion and contraction)


Department of Orthodontics and Dentofacial Orthopedics, Maharishi Markandeshwar College Dental Sciences and Research, Maharishi Markandeshwar (Deemed to be University), Ambala, Haryana, India

Date of Submission05-Jan-2020
Date of Decision16-Apr-2020
Date of Acceptance25-May-2020
Date of Web Publication20-Dec-2020

Correspondence Address:
Dr. Hemant Garg
#1744, Sec 17, Huda, Jagadhari, Yamuna Nagar - 135 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ccd.ccd_10_20

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   Abstract 


Treatment of Class III malocclusion is a challenge for orthodontists. The best time to intercept this malocclusion is as early as in the deciduous dentition. Orthopedic management of Class III individuals with retruded maxilla is by protraction facemask along with rapid maxillary expansion (RME). It results in forward and downward maxillary growth and backward mandibular rotation. Alternate RME and contraction (Alt-RAMEC) produces faster and more efficient results than maxillary protraction alone. The present case report describes the clinical application of Alt-RAMEC protocol for the treatment of a Class III malocclusion.

Keywords: Alternate-rapid maxillary expansion and contraction, Class III malocclusion, facemask, rapid palatal expansion, reverse headgear


How to cite this article:
Garg H, Kaur J, Arya S, Shah S. Treatment of class III malocclusion with activation-deactivation rapid palatal expansion and reverse headgear in a growing patient (alternate-rapid maxillary expansion and contraction). Contemp Clin Dent 2020;11:376-81

How to cite this URL:
Garg H, Kaur J, Arya S, Shah S. Treatment of class III malocclusion with activation-deactivation rapid palatal expansion and reverse headgear in a growing patient (alternate-rapid maxillary expansion and contraction). Contemp Clin Dent [serial online] 2020 [cited 2021 Jun 20];11:376-81. Available from: https://www.contempclindent.org/text.asp?2020/11/4/376/304131




   Introduction Top


Treatment of Class III malocclusion is a challenge for orthodontists. A Class III growth pattern is a disproportion with excessive mandibular growth, deficient maxillary growth, or combination of the two.[1] According to Tweed,[2] it can be pseudo Class III or skeletal Class III malocclusion. According to Moyers,[3] it can be osseous, muscular, or dental in origin.

The prevalence of Angle Class III malocclusion varies from 0% to 26%.[1] Class III individuals with reduced maxilla and normal mandible were reported as 19.5% (Ellis and McNamara, 1984), 25% (Guyer et al., 1986), 26% (Jacobson et al., 1974), 33% (Sanborn, 1955), and 37% (Williams and Anderson, 1986).[4] The best timing to intercept this malocclusion is as early as in the deciduous dentition. Orthopedic management of Class III individuals with retruded maxilla is by protraction facemask along with (rapid maxillary expansion [RME]). It results in forward and downward maxillary growth and backward mandibular rotation.[1] It is concluded by various studies that alternate RME and contraction (Alt-RAMEC) produces faster and more efficient results than maxillary protraction alone.[1],[4],[5],[6]

Alt-RAMEC was introduced by Liou and Tsai in 2005. It disarticulates circum-maxillary sutures without overexpansion. In the protocol, alternate expansion and contraction are to be followed for 1 week alternatively. Its rationale is equivalent to simple tooth extraction, as the tooth is loosened from the socket with buccal and lingual rocking movements.[4],[7],[8]

The present case report describes the clinical application of Alt-RAMEC protocol for the treatment of a Class III malocclusion.


   Case Report Top


A 9-year-old female patient reported to the department of orthodontics and dentofacial orthopedics with a chief complaint of backwardly placed upper front teeth. Extraoral examination revealed a concave facial profile with characteristic maxillary retrusion. Intraoral examination revealed an anterior crossbite with a reverse overjet of 4 mm and an overbite of 6 mm. There was no functional shift. The upper dental midline was shifted toward the right side by 2 mm. Molar relationship was super Class I bilaterally. The patient was in a mixed dentition phase. The patient had SNA and SNB of 77° and 80°, respectively, with ANB of -3°. U1 to NA was 22° and L1 to NB was 16° with an average toward horizontal growth pattern (SN-GoGn = 30°, FMA = 23°), therefore, the patient was diagnosed as skeletal Class III [Figure 1] and [Table 1]. Alt-RAMEC approach was chosen so as to loosen the circum-maxillary suture more extensively than RME alone.
Figure 1: Pretreatment photographs and radiographs

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Table 1: Cephalometric comparison at various stages of treatment

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Treatment progress

Initially, expansion was done with a hyrax expander for 1 week, i.e., the sagittal split screw was activated twice a day with 90° turns. After 1 week of expansion, the split screw was deactivated for a week of contraction. The Alt-RAMEC protocol was followed for a time of 8 weeks [Figure 2].
Figure 2: After alternate.rapid maxillary expansion and contraction protocol

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After 8 weeks of phase 1 treatment, the maxillary sutures were sufficiently loosened with normal transverse relation, thereafter followed by facemask (Petit) therapy [Figure 3] for 7 months. Alt-RAMEC was done to loosen the sutures so that protraction can be done with ease. A protraction force of 400 g was applied on each side from elastics which were connected to the facemask with downward and forward force vectors having an inclination of 20°–30° to the occlusal plane. The patient was instructed to wear the facemask for 10–12 h per day. Facemask therapy produced promising results in this patient [Figure 4]. After the protraction phase, the retention phase was followed with a retention plate for 10 months.
Figure 3: Petit facemask

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Figure 4: After facemask therapy

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A fixed orthodontic treatment was initiated with a preadjusted edgewise appliance (slot 0.022” × 0.028” ) and the wire sequence used to level and align the arch was 0.014” , 0.016” , 0.018” and 0.016” ×0.022” NiTi, 0.016” ×0.022” SS, 0.017” ×0.025” SS and 0.019” ×0.025” SS. In this case, surgical exposure was done with relation to 23, and Beggs bracket was bonded on 23. Traction was done to bring 23 into alignment. After leveling and aligning, 0.018 SS was used for final finishing. Marked cephalometric and photographic changes were obtained in this case [Figure 5],[Figure 6] and [Table 1].
Figure 5: Posttreatment photographs and radiographs

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Figure 6: Post debonding photographs

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   Discussion Top


Class III malocclusion alters patient's psychological status because of unfavorable facial appearance, thereby necessitating an immediate action to improve facial esthetics.[8] RME was proposed by Angell and clinically consolidated by Haas in 1961.[9] RME increases maxillary transverse dimensions skeletally and along with facemask, it is used in Class III individuals with maxillary retrusion.[10] An alternate approach to disarticulate circum-maxillary suture was proposed by Liou and Tsai in 2005 (Alt-RAMEC protocol). Comparative studies showed that Alt-RAMEC showed two times higher anterior maxillary displacement than the conventional method and the protraction was 8 weeks faster than that in the RME group.[6]

The present case was treated with Alt-RAMEC protocol followed by facemask therapy to get more benefits. In this case, SNA had increased by 7°, N perpendicular to point A increased by 6mm and ANB had increased by 4°, suggesting a significant increase to the cranial base. Baik concluded in a study that more maxillary advancement can be achieved with Alt-RAMEC, when used in conjunction with a facemask.[11] Westwood et al. also found significant improvement in maxillary advancement (SNA 1.6°).[12] Isci et al. reported significant increase in SNA (1.2°), ANB (1.6°), and overjet (2.2 mm) as compared to the Rapid Maxillary Expansion/ Facemask (RME/FM) group.[4]

In the present case, lower anterior facial height increased by 4.5 mm. It is due to the downward movement of the maxilla and downward and backward rotation of the mandible, which also reduced the facial concavity. The soft-tissue effects included marked forward movement of the upper lip, whereas the lower lip did not show much improvement.

With Alt-RAMEC and facemask therapy, anterior and vertical movements of maxilla lead to skeletal changes. Significant downward and backward movement of the mandible contributes to Class III correction and improved facial profile.


   Conclusion Top


Class III malocclusion requires early intervention to benefit and satisfy patients. Alt-RAMEC protocol is effective in the early treatment of Class III malocclusion. It provides quicker and good treatment outcomes with long-term stability. The Alt-RAMEC protocol produces forward movement of the maxilla and backward rotation of the mandible, which leads to skeletal correction of overjet and improves patient profile. Long-term follow-up is advised till the cessation of mandibular growth.

Acknowledgment

The authors would like to thank Dr. Vinay Dua, Dr. Aman Walia, and Dr. Manoj Kumar for their valuable contributions in the case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Patel U, Baswaraj, Agarwal C, Ramani A, Lalakiya H. Early orthopaedic correction of class III malocclusion with alternate rapid maxillary expansion and constriction (ALT-RAMEC) and face mask: Case report. Int J Adv Res 2015;3:1288-91.  Back to cited text no. 1
    
2.
Tweed CH. Clinical Orthodontics. St Louis: Mosby; 1966. p. 715-26.  Back to cited text no. 2
    
3.
Moyers RE. Handbook of Orthodontics. 4th ed Chicago: Year Book Medical Publishers; 1988. p. 410-5.  Back to cited text no. 3
    
4.
Isci D, Turk T, Elekdag-Turk S. Activation-deactivation rapid palatal expansion and reverse headgear in Class III cases. Eur J Orthod 2010;32:706-15.  Back to cited text no. 4
    
5.
Franchi L, Baccetti T, Masucci C, Defraia E. Early Alt-RAMEC and facial mask protocol in class III malocclusion. J Clin Orthod 2011;45:601-9.  Back to cited text no. 5
    
6.
Pithon MM, Santos NL, Santos CR, Baião FC, Pinheiro MC, Matos MN, et al. Is alternate rapid maxillary expansion and constriction an effective protocol in the treatment of Class III malocclusion? A systematic review. Dental Press J Orthod 2016;21:34-42.  Back to cited text no. 6
    
7.
Liou EJ. Effective maxillary orthopedic protraction for growing Class III patients: A clinical application simulates distraction osteogenesis. Prog Orthod 2005;6:154-71.  Back to cited text no. 7
    
8.
Krishna KR, Jeevan M, Pradeep K, Anoosha M, Padma PC. Face mask with ALT-RAMEC – A case report. J Med Sci Clin Res 2019;7:172-8.  Back to cited text no. 8
    
9.
Haas AJ. Rapid expansion of the maxillary dental arch and nasal cavity by opening the midpalatal suture. Angle Orthod 1961;31:73-90.  Back to cited text no. 9
    
10.
Caprioglio A, Meneghel M, Fastuca R, Zecca PA, Nucera R, Nosetti L. Rapid maxillary expansion in growing patients: Correspondence between 3-dimensional airway changes and polysomnography. Int J Pediatr Otorhinolaryngol 2014;78:23-7.  Back to cited text no. 10
    
11.
Baik HS. Clinical results of the maxillary protraction in Korean children. Am J Orthod Dentofacial Orthop 1995;108:583-92.  Back to cited text no. 11
    
12.
Westwood PV, McNamara JA Jr., Baccetti T, Franchi L, Sarver DM. Long-term effects of Class III treatment with rapid maxillary expansion and facemask therapy followed by fixed appliances. Am J Orthod Dentofacial Orthop 2003;123:306-20.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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