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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 4  |  Page : 341-343
 

Treatment of skeletal class III malocclusion using face mask therapy with alternate rapid maxillary expansion and constriction (Alt-RAMEC) protocol


Department of Pedodontics, Government Dental College and Hospital, Kozhikode, Kerala, India

Date of Web Publication18-Sep-2015

Correspondence Address:
Dr. Anand Ramchandra Rathi
Department of Pedodontics, Government Dental College and Hospital, Kozhikode - 673 008, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.165713

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   Abstract 

Class III malocclusion is very common malocclusion and can be due to maxillary retrusion, mandibular prognathism, or combination. Ellis and McNamara found a combination of maxillary retrusion and mandibular protrusion to be the most common skeletal relationship (30%). The treatment should be carried out as early as possible for permitting normal growth of the skeletal bases. Reverse pull head gear combined with maxillary expansion can effectively correct skeletal Class III malocclusion due to maxillary deficiency in growing patient. An eight-year-old female patient with chief complaint of prognathic mandible and anterior crossbite was successfully treated in duration of 5 months with facemask and expansion therapy based on Alternate Rapid Maxillary Expansion and Constriction (Alt-RAMEC) protocol.


Keywords: Alt-RAMEC, maxillary expansion, reverse pull head gear


How to cite this article:
Rathi AR, Kumari N R, Vadakkepuriyal K, Santhkumar M. Treatment of skeletal class III malocclusion using face mask therapy with alternate rapid maxillary expansion and constriction (Alt-RAMEC) protocol. J Indian Soc Pedod Prev Dent 2015;33:341-3

How to cite this URL:
Rathi AR, Kumari N R, Vadakkepuriyal K, Santhkumar M. Treatment of skeletal class III malocclusion using face mask therapy with alternate rapid maxillary expansion and constriction (Alt-RAMEC) protocol. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 Dec 9];33:341-3. Available from: http://www.jisppd.com/text.asp?2015/33/4/341/165713



   Introduction Top


The prevalence of Class III malocclusion has been described between 1 and 10%. [1],[2] The combined use of rapid maxillary expansion and facemask has been a contemporary technique for the maxillary protraction in growing patients with Class III, based on the assumption that the rapid maxillary expansion opens the circumaxillary sutures and facilitates the maxillary protraction. [3],[4],[5],[6] Profit and Fields reported that maxillary expansion must be used before maxillary protraction to mobilize the maxillary sutures. [7] The goal of rapid maxillary expansion should be to displace maxilla anteriorly and to disarticulate the circumaxillary sutures, rather than to expand the maxilla transversely. To disarticulate the circumaxillary sutures without overexpansion of the maxilla, an alternative technique is Alternate Rapid Maxillary Expansion and Constriction (Alt-RAMEC) protocol for 1 month. [8],[9],[10]

Present case report reveals the treatment outcome of a patient with skeletal Class III who was treated using reverse pull headgear and rapid maxillary expansion using Alt-RAMEC protocol.


   Case Report Top


An 8-year-old female patient reported with chief complaint of forwardly placed lower jaw. Extraoral examination showed a prognathic mandible, deficient mid face, and a concave lateral profile [Figure 1]; and intraoral examination shows maxillary and mandibular anteriors in cross bite relation with 2 mm of reverse over jet and 4 mm of overbite and well-aligned dentition [Figure 2].
Figure 1: Pre-treatment extraoral photographs


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Figure 2: Pre- treatment intraoral photographs


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Cephalometric examination reveals true skeletal Class III malocclusion with retrognathic maxilla as compared to mandible.

Treatment objective was to correct reverse over jet and to improve the facial profile with a bonded protraction plate with Hyrax expansion screw using Alt-RAMEC protocol for 1 month duration followed by use of Petitmal type of reverse pull headgear therapy.

Bonded protraction plate using clear acrylic was made incorporating 0.9 mm Hyrax expansion screw and hooks in premolar region for engaging elastics from reverse pull headgear, then protraction plate was cemented using luting glass ionomer cement (GIC).

Based on Alt-RAMEC protocol, activation of screw (one turn per day) was done for 1 st week, followed by deactivation for next week, and to continue alternate week activation and deactivation for 1 month to loosen the circummaxillary suture and promote forward and downward growth of maxilla. Following Alt-RAMEC protocol, patient was asked to wear petitmal type of reverse pull head gear daily for 14 h engaging 5/16" elastics from horizontal crossbar of reverse pull head gear exerting heavy forces on craniofacial segment of about 14oz for about 14 h daily.

Patient was monitored every 2 weeks for initial 2 months followed by every 1 month. At 2 nd recall visit after 1 month, edge-to-edge bite was observed before application of extraoral force. Correction of reverse over jet and improved facial profile was achieved in 5 months, after that patient was asked to continue the use of reverse pull head gear and protraction plate for desired overcorrection of maxillary protraction for another 4 months [Figure 3] and [Figure 4].
Figure 3: Post-treatment extraoral photographs


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Figure 4: Post-treatment intraoral photographs


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   Discussion Top


Skeletal Class III malocclusions in growing children remain one of the most challenging problems and early treatment has been advocated to reduce the need of camouflage orthodontic treatment or surgery in the permanent dentition. The combined use of rapid maxillary expansion and facemask has been a contemporary technique for the maxillary protraction. [4],[5],[6],[7],[8],[9] Clinical results demonstrated in the present case that skeletal Class III malocclusion can be treated efficiently during adolescent growth spurt period with facemask therapy along with Alt-RAMEC protocol. Clinical appearance of edge-to-edge bite after 1 month following Alt-RAMEC protocol before application of extraoral forces suggests the greater efficiency of Alt-RAMEC protocol to displace maxillary forward and downward and rapid correction of reverse over jet within 5 months after application of extraoral force.


   Conclusion Top


Present case revealed that reverse pull head gear therapy with bonded RME appliance following Alt-RAMEC protocol protruded the maxilla and inhibited forward growth of the mandible along with anterior cross bite correction and improved facial profile. This approach can be effective treatment option for management of skeletal Class III malocclusion during active growth period. However, further follow-up of the patient is required as mandible still continues to grow till adolescence period [Table 1].
Table 1: Pre and post treatment cephalometric values of patient with skeletal Class III malocclusion


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   References Top

1.
Ellis E 3 rd , McNamara JA Jr. Components of adult Class III malocclusion. J Oral Maxillofac Surg 1984;42:295-305.  Back to cited text no. 1
    
2.
Jacob PP, Mathew CT. Occlusal pattern study of school children (12-15 years) of Tiruvananthapuram city. J Indian Dent Assoc 1969;41:271-4.  Back to cited text no. 2
[PUBMED]    
3.
Campbell PM. The dilemma of Class III treatment. Early or late? Angle Orthod 1983;53:175-91.  Back to cited text no. 3
[PUBMED]    
4.
Turley PK. Orthopedic correction of Class III malocclusion with palatal expansion and custom protraction headgear. J Clin Orthod 1988;22:314-25.  Back to cited text no. 4
[PUBMED]    
5.
Baccetti T, McGill JS, Franchi L, McNamara JA Jr. Tollaro Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy. Am J Orthod Dentofacial Orthop 1998;113:333-43.  Back to cited text no. 5
    
6.
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. 6
    
7.
Liou EJ, Tsai WC. A new protocol for maxillary protraction in cleft patients: Repetitive weekly protocol of alternate rapid maxillary expansions and constrictions. Cleft Palate Craniofac J 2005;42:121-7.  Back to cited text no. 7
    
8.
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. 8
    
9.
Liou EJ. Tooth borne orthopedic maxillary protraction in Class III patients. J Clin Orthod 2005;39:68-75.  Back to cited text no. 9
    
10.
Wang YC, Chang PM, Liou EJ. Opening of circumaxillary sutures by alternate rapid maxillary expansions and constrictions. Angle Orthod 2009;79:230-4.  Back to cited text no. 10
    


    Figures

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

  [Table 1]



 

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures
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