ORIGINAL ARTICLE

Relative effectiveness of facemask

therapy with alternate maxillary
expansion and constriction in the early
treatment of Class III malocclusion
Yuyao Liu,a Renya Hou,b Hairu Jin,a Xin Zhang,a Zuping Wu,a Zixuan Li,a and Jie Guoa
Jinan, Shandong Province, and Shijiazhuang, Hebei Province, China

Introduction: This study aimed to investigate the relative efficacy of maxillary protraction combined with a
modified alternate rapid maxillary expansion and constriction (Alt-RAMEC) protocol compared with conventional
protocols in the early orthopedic treatment of skeletal Class III malocclusion. Methods: A sample of 39 patients
was divided into 3 groups on the basis of different interventions. Conventional facemask (FM) with splint-type
intraoral devices was performed in the FM group (7 males and 5 females; mean age, 9.53 6 1.37 years).
Maxillary expansion with an activation rate of 0.5 mm/d (twice a day) followed by FM therapy was applied in
the rapid maxillary expansion group (RME/FM) (6 males and 6 females; mean age, 9.31 6 1.60 years). In the
Alt-RAMEC/FM group (7 males and 8 females; mean age, 10.01 6 1.31 years), Alt-RAMEC was started
simultaneously and throughout the entire course of maxillary protraction, with repetitive alternations between
activation and deactivation of expanders (0.5 mm/d for 7 days). The patients in all groups were instructed to
wear FMs for a minimum of 12 h/d. Pretreatment and posttreatment lateral cephalograms were all traced and
measured. Results: The Alt-RAMEC group showed statistically more significant maxillary advancement than
other groups (A-VRP, 3.87 mm vs 3.04 mm [RME/FM], vs 2.04 mm [FM]; P \0.05). Analysis of variance did
not reveal significant intergroup differences in palatal plane angulation changes (P .0.05). No pronounced
mandibular clockwise rotations were noted in the Alt-RAMEC/FM group with distinct intergroup differences
(P \0.05). There were more skeletal effects (88.7%) during overjet correction in the Alt-RAMEC/FM protocol.
Conclusions: A combination of the modified Alt-RAMEC protocol with FM revealed more favorable skeletal
effects compared with FM and RME/FM protocols in treating prepubertal patients with maxillary deficiency.
(Am J Orthod Dentofacial Orthop 2021;159:321-32)

M
axillary deficiencies with either normal or with other types.1,2 Considering the exceeding
abnormal mandibles possessed the largest pro- uncontrollability of mandibular growth, Oppenheim3
portion in Class III malocclusion compared firstly proposed maxillary advancement instead of
mandibular inhibition in 1944. Further development
based on this standpoint was made by Delaire.4
a
Department of Orthodontics, School and Hospital of Stomatology, Shandong
University, and Shandong Provincial Key Laboratory of Oral Tissue Regeneration,
and Shandong Engineering Laboratory for Dental Materials and Oral Tissue However, molar mesial movement, incisor tipping,
Regeneration, Jinan, Shandong Province, China. maxillary counterclockwise rotation, and anterior
b
Resident, MDS, Hospital of Stomatology, Hebei Medical University, Number constriction were confirmed to be the primary side
383, East Zhong Shan Road, Shijiazhuang, Hebei Province 050017, China.
All authors have completed and submitted the ICMJE Form for Disclosure of effects of conventional facemask (FM) therapy.5,6 In
Potential Conflicts of Interest, and none were reported. addition, maxillary forward displacement is based on
This study was supported by the National Natural Science Foundation of China skeletal reconstruction in the sutural area, more active
(grant no. 81771108) and the Key Research and Development Project of Shan-
dong Province (no. 2017GSF218017). bone remodeling is observed when circummaxillary
Address correspondence to: Jie Guo, Department of Orthodontics, School and sutures are repetitively weakened and opened. Rapid
Hospital of Stomatology, Shandong University, and Shandong Provincial Key maxillary expansion (RME) was then combined
Laboratory of Oral Tissue Regeneration, and Shandong Engineering Laboratory
for Dental Materials and Oral Tissue Regeneration, Number 44-1, Wenhua Road with FM therapy for its validity in disarticulating
West, Jinan, Shandong Province 250012, China; e-mail, kqgjsdu@163.com. circummaxillary sutures, effectively enhancing the
Submitted, July 2019; revised and accepted, December 2019. therapeutic outcome of protraction.6-10
0889-5406/$36.00
Ó 2020 by the American Association of Orthodontists. All rights reserved. Nevertheless, Liou et al11-13 emphasized the goal of
https://doi.org/10.1016/j.ajodo.2019.12.028 maxillary expansion used in FM therapy, which should
321
322 Liu et al

be the adequate disarticulation of the sutures and the from 7-12 years old; (2) anterior crossbite or edge-to-
displacement of the anterior maxilla, rather than edge incisor relationship; (3) ANB \0
; (4) a Wits
expanding the width of the maxilla. A new protocol appraisal of #2 mm24; (5) no functional shift (absence
called alternate maxillary expansion and constriction of pseudo–Class III malocclusion)25; (6) no permanent
(Alt-RAMEC) was then proposed in treating patients teeth congenitally missing before treatment or lost
with cleft palates. More remarkable maxillary anterior during treatment; and (7) midface deficiency diagnosed
movement was observed in the Alt-RAMEC/FM by the following specifications: concave profile (straight
group, whereas palatal overexpansion was avoided. or concave contour in soft-tissue analysis)26; convexity
Subsequently, Yen et al14 modified the protocol and (A-Np) \0
; decreased maxillary depth (FH-NA);
presented 8-week Alt-RAMEC followed by protraction; negative NA-PA angle.
the patients were instructed for Class III intermaxillary The exclusion criteria were as follows: (1) orthodontic
elastics in the daytime and FM at night. treatment history; (2) systemic disease; (3) congenital
However, the enhancement of Alt-RAMEC in craniofacial malformation, such as cleft lip or
maxillary protraction for patients with noncleft palate palate; (4) temporomandibular joint diseases; and
remains controversial. Several relevant studies with (5) cooperation disability.
inconsistent results have been reported, which varied The treated sample was divided into 3 groups
in study designs, sample size, and research according to different treatment protocols. The FM
approaches.15-18 Masucci et al18 indicated that group included 12 patients (7 males, 5 females), with
Alt-RAMEC/FM resulted in more skeletal effects an average age of 9.53 6 1.37 years. Another 12 patients
compared with RME/FM. Inconsistently, Do-delatour (6 males, 6 females) were included in the RME/FM group,
et al15 found greater maxillary advancement in the latter with a mean age of 9.31 6 1.60 years. The Alt-RAMEC/
protocol. In addition, unlike the simultaneous protocol FM group was composed of 15 patients (7 males,
we used in this study, most of the previous studies 8 females), with a mean age of 10.01 6 1.31 years. The
implemented Alt-RAMEC and maxillary protraction pretreatment (T1) growth periods for all patients were
separately.13,19,20 A limited number of studies focused assessed on the basis of Baccetti's23 modified cervical
on the effectiveness of simultaneous Alt-RAMEC/FM vertebral maturation. All patients showed Class I to Class
therapy.21,22 Baik19 claimed that protraction during III malocclusion, and the consistency among the 3 groups
palatal expansion would cause more counterclockwise was then tested by statistical analysis.
rotation of the palatal plane. Although the latest study Pretreatment (T1) and posttreatment (T2) lateral
by Canturk and Celikoglu21 suggested no significant cephalograms and panoramic radiographs for all
differences between FM treatment started subjects were taken under natural head postures with
simultaneously and after Alt-RAMEC, the former the same magnification factors. Root resorption of
protocol was recommended to raise efficiency. The posterior teeth in T2 was evaluated by panoramic
efficacy of protraction when simultaneously combined radiographs and periapical films.
with Alt-RAMEC in tooth-borne FM therapy still needs
to be confirmed. Hence, this retrospective study aimed Treatment protocol
to evaluate the skeletal and dental effect in a Intraoral devices with acrylic splint were used in the
simultaneous Alt-RAMEC/FM protocol relative to FM group (Fig 1, A). All appliances were uniformly
conventional FM and RME/FM therapies. bonded to the anchorage teeth by glass ionomer (first
molars and 2 deciduous molars, or the first premolars
MATERIAL AND METHODS and second deciduous molar). Adam clasps and
embrasure clasps were used for supplementary
Subjects retention. The thickness of the splint was properly
This study was ratified by Shandong University designed to separate the maxillary and mandibular
Medical Science Research Ethics Committee incisors with a 1 to 0 mm overbite obtained.
(no. 20190403). The sample consisted of 39 subjects, Protraction hooks were designed around canines and
20 males and 19 females, who started treatments in lateral incisors. Follow-up of patients were completed
the Department of Orthodontics at Stomatological every 4-6 weeks.
Hospital of Shandong University between February In the RME/FM group, tooth-borne soldered
2015 and September 2018. The inclusion criteria were maxillary expanders with acrylic splint were bonded to
as follows: (1) prepubertal or pubertal stage according posterior teeth (Fig 1, B). The protraction hooks were
to the cervical vertebral maturation method,23 ranging placed in the area around canines for the attachments

March 2021  Vol 159  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Liu et al 323

Fig 1. Intraoral devices: A, FM group; B, RME/FM group and Alt-RAMEC group.

of elastics. The patients in the RME/FM group completion criterion was a neutral or Class II occlusal
underwent expansion with an activation rate of relationship, along with the overjet reaching 3 mm. An
0.5 mm/d (twice a day) until the appropriate overcorrection was pursued as compensation for growth
overcorrection was achieved. The expansion procedure and the reduction in relapse.
was subsequently followed by FM therapy.
The intraoral devices in the Alt-RAMEC/FM Cephalometric analysis
group were identical to those in the RME/FM group All lateral cephalograms were traced by the same
(Fig 1, B). A simultaneous Alt-RAMEC protocol investigator (Y.L.). Cephalometric analysis was based
accompanied by FM therapy was applied. The expander on previously described methods, in which a coordinate
screw was activated at a rate of twice a day (0.5 mm/d) system containing a horizontal reference plane (HRP)
for 7 days and then converted into a 7-day deactivation and a vertical reference plane (VRP) was used.27,28 A
period (0.5 mm/d). Alt-RAMEC was performed line rotated clockwise 7
from the Sella-Nasion plane
throughout the whole treatment course. The at the sella was defined as HRP, whereas VRP was
guardians of the patients in both the RME/FM and perpendicular to HRP through point sella. Cephalometric
Alt-RAMEC/FM groups were informed to complete landmarks were based on a combination of Ricketts,
customized forms to record daily treatments. The Jacobson, and Downs analyses. A total of 36 variables
patients were followed up with at the second week to were selected, including 20 skeletal, 9 dental, and 7
ensure the stability of devices and correct operation. soft-tissue landmarks (Fig 2). Ten angular and 23 linear
The patients were notified to follow-up after the measurements were used to evaluate changes before and
completion of every 7-week circulation. after treatments. All tracing and measuring procedures
The FM therapies in the 3 groups followed the same were carefully performed and checked. For evaluating
protocol, which required the patients to wear the FM for the measurement errors, 10 cephalograms were
a minimum of 12 h/d. The FM was examined and firmly randomly selected, traced, and superimposed, and
adjusted by investigators. Protraction forces were subsequently repeated 2 weeks later by the same
imposed via elastics, delivering magnitudes of investigator. The paired t test was performed to detect
300-500 g of force per side. In addition, with the the difference between the 2 measurements (P .0.05).
objective of approaching the force vector to the center Measurement error was tested by Dahlberg formula.20,29
of resistance of the maxilla, the elastic direction was The Dahlberg standard variations showed that the error
30
-45
downward from the occlusal plane. All patients in angular measurements was \0.68
, and the linear
in the 3 groups used fully adjustable FMs for maxillary measurements error was \0.81 mm, indicating the
protraction (Delaire-type, Hangzhou Westlake reliability of measurements.
Biomaterial, Hangzhou, Zhejiang, China).
During the routine assessment conducted by
investigators, overjet, intercanine anteroposterior Sample size calculation
relationship, maxillary width, and soft-tissue changes Power Analysis and Sample Size software (version
were observed and recorded by chair-side examinations 15.0; NCSS, LLC, Kaysville, Utah) was applied to
and photographs. The splints were gradually ground calculate the sample size. Previous data from a study
once the anterior crossbite was corrected. Any by Liou and Tsai11 were used as a reference, in which
soft-tissue injury or damage on oral devices and the A-VRL increased by 1.6 mm in the RME/FM group and
FM received treatment and repair in time. The 3 mm in the Alt-RAMEC/FM group, with standard

American Journal of Orthodontics and Dentofacial Orthopedics March 2021  Vol 159  Issue 3
324 Liu et al

Fig 2. Cephalometric measurements: (1) SNA; (2) PP/FH; (3) PP/SN; (4) NP/FH; (5) SNB; (6) FMA;
(7) MP/SN; (8) ANB; (9) U1-SN; (10) IMPA; (11) FH-NA; (12) NA-PA; (13) A-HRP; (14) A-VRP;
(15) ANS-HRP; (16) ANS-VRP; (17) Convexity (A-Np); (18) B-HRP; (19) B-VRP; (20) Po-VRP;
(21) Co-Gn; (22) the Wits appraisal; (23) U1-HRP; (24) U1-VRP; (25) U6-HRP; (26) U6-VRP;
(27) L1-VRP; (28) overbite; (29) overjet; (30) UL-VRP; (31) LL-VRP; (32) stPo-VRP; (33) stA-VRP;
(34) stB-VRP; (35) UL-E line; and (36) LL-E line.

differences of 1 mm and 0.9 mm, respectively. showed no significant differences, which exhibited
Considering the unequal number of patients, consistency in the maturation stage among groups in
investigators designed the sample size ratio as 1:1:1.5 T1. The nonsignificant intergroup difference of
(FM: RME: Alt-RAMEC). A minimum sample size of 9 maxillary arch width demonstrated that patients were
and 14 patients was severally required to detect not assigned according to width. Variables in T1
significant differences (significance level of 0.05; 90% presented no significant differences among groups, as
power). The present study increased the sample size. shown in Table II. T1-T2 changes are reported in
Table III by listing the descriptive statistics. Multiple
Statistical analysis comparison results with intergroup mean differences in
changes are displayed in Table IV.
SPSS (mac OS, version 25.0; IBM, Armon, NY) was
used to perform all statistical analyses. The boxplot dis- Skeletal changes
played no outliers. The Shapiro-Wilk test indicated a
Regarding SNA angle and A-VRP changes as
normal distribution of chronological ages and treatment
references, sagittal advancements of point A
duration (P .0.05). Levene test showed intergroup
were significant in both the RME/FM group (SNA,
equal variance in these 2 aspects, and analysis of
2.42 6 1.02
; A-VRP, 3.04 6 0.78 mm) and the
variance was subsequently performed to detect
Alt-RAMEC/FM group (SNA, 3.30 6 0.77
; A-VRP,
differences among the groups at T1. Because of the
3.87 6 0.19 mm). In contrast to the Alt-RAMEC/FM
abnormal distribution of skeletal ages, a Kruskal-Wallis
group (1.23 6 2.55 mm), both the FM group
test was performed to test whether significant
(3.21 6 2.12 mm) and the RME/FM group
intergroup differences existed. All variables showed a
(2.92 6 1.24 mm) showed a greater amount of point B
normal distribution. A paired t test was performed to
backward movement. Regarding the bimaxillary
evaluate the significance of intragroup T1-T2 changes.
displacements in the vertical dimension, A-HRP and
ANOVA was also used to assess discrepancies in the
B-HRP significantly increased in all groups (P .0.05).
initial values and T1-T2 changes among the 3 groups.
Nonetheless, the indicators changed more in the other
Least significant difference tests were conducted to
two groups compared with the Alt-RAMEC/FM protocol.
implemented multiple comparisons of T1-T2 changes
The palatal plane showed no significant movement
among groups. A significance level of 0.05 was used in
in the FM group (PP-FH, 1.13 6 1.87
; PP-SN,
the statistical analysis.
0.83 6 2.06
), but both RME/FM (PP-FH,1.13 6
1.87
; PP-SN, 0.83 6 2.06
) and Alt-RAMEC/FM
RESULTS groups (PP-FH, 1.58 6 1.36
; PP-SN, 1.73 6
As shown in Table I, both the chronological age 2.75
) exhibited significant decreases. No significant
(P 5 0.425) and skeletal age (P 5 0.703) in the 3 groups difference was found between these 2 groups (P .0.05).

March 2021  Vol 159  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Liu et al 325

Table I. T1 characteristics and treatment duration

FM (n 5 12) RME/FM (n 5 12) Alt-RAMEC/RM (n 5 15) Differences between groups

Characteristics Mean SD Mean SD Mean SD P value

Chronological age (y) 9.53 1.37 9.31 1.60 10.01 1.31 NS
Skeletal age 1.67 0.78 1.92 0.79 1.73 0.70 NS
Treatment duration (m) 7.99 1.69 7.35 1.08 6.04 0.95 FM vs RME/FMy
FM vs Alt-RAMEC/FM**
RME/FM vs Alt-RAMEC/FM*

SD, Standard deviation; NS, no significant difference.

y
NS; *P \0.05; **P \0.01.

Mandibular backward and downward rotation differences exhibited between the remaining groups
showed significant increases in all groups except for (P \0.05).
the Alt-RAMEC/FM group, in which FMA and MP-SN
were increased by 1.03 6 2.64
and 0.87 6 2.58
, Soft tissue changes
respectively; this was only half the increase observed in The upper lips (UL-VRP, UL-E line) were moved
the other 2 groups (P \0.05). significantly forward in all groups. In addition to
Intermaxillary variables (ANB and Wits appraisal) Alt-RAMEC/FM group, a decrease in LL-VRP was
were increased significantly in all groups, and the significant in the control groups. However, no
intergroup comparison showed insignificant differences statistically significant differences were found in all
(P .0.05). soft-tissue landmarks among the three groups
(P .0.05).
Dental changes
The Alt-RAMEC/FM group presented the least Treatment duration
proclination of maxillary incisors (U1-SN, Compared with the control groups, the Alt-RAMEC
2.8 6 7.34
). Mandibular incisors in all groups showed group showed a significant reduction in treatment
statistically significant retroclination in T2. As for linear duration (6.04 6 0.95 months), which was shortened
measurements, since the measured dental displacements by approximately 18% and 25% compared with the
were actually a combination of skeletal and dental FM group (7.99 6 1.69 months) and the RME/FM group
changes, we set up variables called “actual dental (7.35 6 1.08 months) respectively (P \0.05).
changes,” in which the skeletal effects were subtracted
(Tables III and IV). According to the results, more
backward displacements of mandibular incisors were DISCUSSION
observed in the Alt-RAMEC group (actual L1-VRP, Most previous studies conducted maxillary
2.10 6 1.90 mm), only the FM group exhibited distinct protraction after RME or Alt-RAMEC. However, a few
forward movement of the maxillary incisors (actual studies indicated that different durations of RME or
U1-VRP, 2.29 6 1.54 mm). Alt-RAMEC might lead to efficacy variance. Celikoglu
In contrast to the nonsignificant changes in overbite, and Buyukcavus30 compared 5 weeks with 8 weeks of
overjet was all significantly improved by approximately Alt-RAMEC followed by FMs, in which a significant
6 mm. The intergroup comparison showed no significant enhancement of treatment effectiveness in the
differences (P .0.05). The contribution of skeletal and longer-duration group was reported. However, limited
actual dental displacements to overjet correction were studies have reported the simultaneous use of
respectively presented in Figure 3. Overjet correction Alt-RAMEC with FM.21,31 The treatment details were
was completed by 88.7% skeletal and 11.3% dental quite different between the study by Canturk and
effects in Alt-RAMEC/FM group, while fewer skeletal Celikoglu21 and the present study, including the daily
effects were observed in the other groups. Maxillary activation quantity (0.4 mm and 0.5 mm, respectively),
skeletal changes (62.4%) contributed a larger proportion daily FM wearing duration (20 hours and 12 hours,
than mandibular changes (26.3%) in the Alt-RAMEC/ respectively), and the Alt-RAMEC procedure duration
FM group. (8 weeks; throughout the entire treatment course,
The increase of intermolar width was more evident in respectively). In contrast, Nienkemper et al31 used
the RME/FM group (3.30 6 1.25 mm), with significant hybrid hyrax expanders with more frequent expansion

American Journal of Orthodontics and Dentofacial Orthopedics March 2021  Vol 159  Issue 3
326 Liu et al

Table II. Descriptive statistics of T1 in 3 groups

FM RME/FM Alt-RAMEC/FM ANOVA

Variables Mean SD Mean SD Mean SD P value

Maxillary skeletal measurements
SNA (
) 79.46 3.94 81.67 2.61 80.10 3.78 NS
PP-FH (
) 10.96 2.78 8.75 3.00 8.97 4.20 NS
PP-SN (
) 10.63 3.73 8.54 1.78 10.03 4.08 NS
A-HRP (mm) 49.50 2.74 48.83 3.90 49.87 3.52 NS
A-VRP (mm) 57.71 3.23 60.33 3.11 58.43 5.01 NS
ANS-HRP (mm) 42.58 2.41 42.04 2.65 43.83 3.60 NS
ANS-VRP (mm) 62.79 3.07 66.50 3.69 63.57 4.35 NS
FH-NP (
) 78.08 2.08 82.50 3.92 82.60 3.61 *
Convexity (A-Np) (mm) 1.63 1.15 1.83 1.76 0.70 1.80 NS
Maxillary depth (FH-NA) (
) 80.08 3.10 81.79 2.84 81.13 3.09 NS
NA-PA (
) 2.71 2.65 2.58 3.35 2.90 2.59 NS
Mandibular skeletal measurements
SNB (
) 81.08 3.47 83.54 2.68 81.47 4.43 NS
FMA (
) 35.63 2.23 32.75 3.16 33.87 5.21 NS
MP-SN (
) 36.00 3.61 33.88 4.00 35.63 4.31 NS
B-HRP (mm) 84.50 3.86 84.75 3.85 86.67 4.29 NS
B-VRP (mm) 56.96 3.55 61.63 4.58 58.63 7.71 NS
Po-VRP (mm) 56.13 3.87 58.50 3.99 57.77 7.12 NS
Co-Gn (mm) 104.96 4.50 104.79 5.16 106.83 6.23 NS
Intermaxillary skeletal measurements
ANB (
) 1.63 1.51 1.88 1.82 1.37 1.72 NS
Wits appraisal (mm) 10.42 2.60 9.38 2.32 8.73 3.20 NS
Dental measurements
U1-SN (
) 101.33 3.64 103.58 10.50 104.03 7.17 NS
IMPA (
) 86.63 6.06 84.21 7.22 85.57 6.95 NS
U1-HRP (mm) 70.38 2.36 69.33 4.65 72.07 5.72 NS
U1-VRP (mm) 59.83 3.27 63.67 4.64 61.43 6.42 NS
U6-HRP (mm) 61.42 2.59 60.21 4.02 62.73 62.83 NS
U6-VRP (mm) 35.46 2.72 35.00 3.44 33.87 5.59 NS
L1-VRP (mm) 63.38 2.50 66.83 3.40 64.53 7.00 NS
Overbite (mm) 2.54 1.78 2.96 2.58 3.13 1.75 NS
Overjet (mm) 3.54 1.60 3.25 1.67 2.77 2.27 NS
Maxillary arch width (mm) 46.47 3.07 47.17 3.73 46.83 3.21 NS
Soft-tissue measurements
UL-VRP (mm) 75.33 3.27 77.96 5.73 75.07 5.63 NS
LL-VRP (mm) 76.88 3.48 79.08 5.93 75.83 7.54 NS
stPo-VRP (mm) 68.71 4.40 73.46 5.47 69.70 8.92 NS
stA-VRP (mm) 71.21 3.52 73.21 4.89 71.27 4.98 NS
stB-VRP (mm) 68.88 4.39 72.83 5.21 69.33 8.24 NS
UL-E line (mm) 1.04 1.20 0.46 1.96 1.33 1.81 NS
LL-E line (mm) 2.21 1.80 3.04 1.47 2.30 1.31 NS
Note. ANOVA was used to assess the difference in variance among groups.
ANOVA, Analysis of variance; SD, standard deviation; NS, no significant difference.
*P \0.05.

(0.8 mm/d, 4 times/d) and a longer FM wearing time by expansion, Alt-RAMEC generated more effective
(16 h/d). Overall, the present study was the first to skeletal modification in the suture area.13,32,33 When
directly compare the simultaneous Alt-RAMEC/FM combing it with facemask, it was demonstrated to
protocol with the two conventional protocols. be more advantageous than RME alone with more
The anteroposterior advancement of the maxilla pronounced maxillary advancement and the
directly reflects the curative effect of maxillary prevention of overexpansion.11,17,20,34 Liou and
protraction, and adequate suture-opening is the Tsai11 observed a significant point A advancement
prerequisite for achieving ideal effectiveness. of 3.0 mm after Alt-RAMEC/FM, which was
Circummaxillary sutures are widened and stimulated approximately 2 times the amount of the RME group.

March 2021  Vol 159  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Liu et al 327

Table III. Changes between T1 and T2

FM RME/FM Alt-RAMEC/FM

Variables Mean SD P value Mean SD P value Mean SD P value

SNA (
) 1.54 0.86 *** 2.42 1.02 *** 3.30 0.77 ***
PP-FH (
) 1.13 1.87 NS 1.58 1.36 ** 1.73 2.75 *
PP-SN (
) 0.83 2.06 NS 1.17 1.75 * 1.40 1.71 **
A-HRP (mm) 1.08 0.85 ** 1.58 0.70 *** 1.27 1.08 **
A-VRP (mm) 2.04 1.30 *** 3.04 0.78 *** 3.87 0.19 ***
ANS-HRP (mm) 0.96 1.81 NS 1.50 1.26 ** 1.67 1.30 ***
ANS-VRP (mm) 1.54 1.16 ** 1.96 0.69 *** 2.77 0.94 ***
FH-NP (
) 1.42 1.92 * 1.38 1.67 * 1.20 2.27 NS
Convexity (A-Np) (mm) 2.33 0.58 *** 3.38 0.98 *** 3.40 1.72 ***
Maxillary depth (FH-NA) (
) 2.83 1.32 *** 2.92 1.95 *** 3.03 0.88 ***
NA-PA (
) 6.21 1.51 *** 6.13 1.82 *** 6.93 2.15 ***
SNB (
) 2.25 0.84 *** 1.17 0.75 *** 1.03 0.81 ***
FMA (
) 2.83 0.91 *** 2.50 0.98 *** 1.03 2.64 NS
MP-SN (
) 2.33 1.13 *** 2.38 0.83 *** 0.87 2.58 NS
B-HRP (mm) 4.88 2.60 *** 4.04 0.78 *** 2.77 1.96 ***
B-VRP (mm) 3.21 2.12 *** 2.92 1.24 *** 1.23 2.55 NS
Po-VRP (mm) 2.23 0.96 *** 1.83 1.47 ** 1.63 1.67 **
Co-Gn (mm) 1.50 2.24 * 1.21 1.94 NS 1.13 3.80 NS
ANB (
) 3.75 1.10 *** 3.92 1.08 *** 3.47 1.22 ***
Wits appraisal (mm) 3.46 1.29 *** 3.04 1.53 *** 3.97 2.26 ***
U1-SN (
) 5.96 4.91 ** 4.58 7.08 * 2.80 7.34 NS
IMPA (
) 5.13 3.41 *** 4.21 3.19 ** 3.87 3.43 **
U1-HRP (mm) 2.83 0.94 *** 2.92 0.95 *** 2.07 1.89 **
U1-VRP (mm) 4.33 1.84 *** 2.79 2.56 ** 2.47 3.26 *
U6-HRP (mm) 2.63 1.75 *** 2.25 0.99 *** 1.87 1.53 ***
U6-VRP (mm) 3.30 1.28 *** 3.08 0.92 *** 2.88 2.31 ***
L1-VRP (mm) 1.55 1.21 *** 3.13 1.64 *** 3.73 0.86 ***
Actual U1-HRP (mm) 1.75 1.56 ** 1.34 1.45 ** 0.80 2.16 NS
Actual U1-VRP (mm) 2.29 1.54 *** 0.25 2.68 NS 1.40 3.49 NS
Actual L1-VRP (mm) 0.68 1.68 NS 1.30 2.44 NS 2.10 1.90 **
Actual U6-HRP (mm) 1.55 1.85 * 0.67 1.51 NS 0.60 2.10 NS
Actual U6-VRP (mm) 1.26 1.50 * 0.04 0.86 NS 0.98 1.43 NS
Overbite (mm) 0.13 1.61 NS 0.83 1.81 NS 0.37 1.88 NS
Overjet (mm) 5.88 1.33 *** 5.92 1.55 *** 6.20 2.46 ***
Maxillary arch width (mm) 0.42 2.09 NS 3.30 1.25 *** 1.63 1.24 ***
UL-VRP (mm) 2.42 1.31 *** 2.63 1.13 *** 3.13 2.73 **
LL-VRP (mm) 1.67 2.50 * 1.63 1.71 ** 1.90 3.83 NS
stPo-VRP (mm) 1.63 3.11 NS 1.92 1.90 ** 2.10 3.44 *
stA-VRP (mm) 2.13 0.74 *** 2.38 1.15 *** 2.73 2.62 **
stB-VRP (mm) 1.13 2.53 NS 1.75 2.33 * 1.47 3.09 NS
UL-E line (mm) 2.17 1.29 *** 2.33 1.11 *** 2.50 2.46 **
LL-E line (mm) 1.08 1.43 * 0.83 1.27 NS 0.23 1.46 NS
Note. Intragroup differences were evaluated by paired t test.
SD, Standard deviation; NS, no significant difference; Actual, actual dental changes calculated by measured dental linear values minus skeletal
linear values.
*P \0.05; **P \0.01; ***P \0.001.

Compared with studies of Liu et al20 (3.04 mm), Alt-RAMEC group. In our simultaneous Alt-RAMEC
Canturk and Celikoglu21 (3.02 mm), and Yilmaz and protocol, we hypothesized that during the whole
Kucukkeles34 (0.89 mm), the present study showed a treatment course, continuous stimulation at
greater forward movement of point A in the low-intensity maintains the circummaxillary sutures
Alt-RAMEC/FM group (A-VRL, 3.87 mm). In addition, in hyperactive status, which results in more sagittal
the changes in other variables (SNA, A-Np, maxillary displacement under equivalent force conditions.
depth, etc.) were the most significant in the Nevertheless, differences in the quantity of maxillary

American Journal of Orthodontics and Dentofacial Orthopedics March 2021  Vol 159  Issue 3
March 2021  Vol 159  Issue 3

328
Table IV. Multiplicative comparison of the mean differences of T1-T2 changes among groups by LSD
FM vs RME FM vs Alt-RAMEC RME vs Alt-RAMEC

Mean difference of the Mean difference of the Mean difference of the

Variables changes (95% CI) P value changes (95% CI) P value changes (95% CI) P value
SNA (
) 0.88 (1.61 to 0.14) * 1.76 (2.45 to 1.07) *** 0.88 (1.58 to 0.19) *
PP-FH (
) 0.46 (1.31 to 2.23) NS 0.61 (1.07 to 2.29) NS 0.15 (1.53 to 1.83) NS
PP-SN (
) 0.33 (1.19 to 1.85) NS 0.33 (0.88 to 2.00) NS 0.23 (1.21 to 1.68) NS
A-HRP (mm) 0.50 (1.40 to 0.40) NS 0.83 (0.94 to 0.77) NS 0.42 (0.44 to 1.27) NS
A-VRP (mm) 1.00 (1.54 to 0.12) * 1.83 (2.41 to 0.84) *** 0.83 (1.71 to 0.13) *
ANS-HRP (mm) 0.54 (1.76 to 0.67) NS 0.71 (1.86 to 0.45) NS 0.17 (1.32 to 0.99) NS
ANS-VRP (mm) 0.41 (1.20 to 0.37) NS 1.23 (1.97 to 0.48) ** 0.81 (1.55 to 0.63) *
FH-NP (
) 0.04 (1.69 to 1.61) NS 0.22 (1.78 to 1.35) NS 0.18 (1.74 to 1.39) NS
convexity (A-Np) (mm) 1.04 (2.07 to 0.01) * 1.07 (2.04 to 0.01) * 0.02 (1.00 to 0.95) NS
Maxillary depth (FH-NA) (
) 0.08 (1.25 to 1.09) NS 0.20 (1.31 to 0.91) NS 1.12 (1.23 to 0.99) NS
NA-PA (
) 0.08 (1.47 to 1.63) NS 0.73 (2.20 to 0.75) NS 0.81 (1.63 to 1.47) NS
SNB (
) 1.08 (1.75 to 0.42) ** 1.22 (1.85 to 0.59) *** 0.13 (0.76 to 0.50) NS
FMA (
) 0.33 (1.16, 1.83) NS 1.80 (0.38, 3.22) * 1.47 (0.05,2.89) *
MP-SN (
) 0.04 (1.52 to 1.44) NS 1.47 (0.06, 2.87) * 1.51 (0.10, 2.91) *
B-HRP (mm) 0.83 (0.77 to 2.44) NS 2.11 (0.59, 3.63) ** 1.28 (0.25 to 2.80) NS
American Journal of Orthodontics and Dentofacial Orthopedics

B-VRP (mm) 0.29 (2.02 to 1.44) NS 1.98 (3.62 to 0.33) * 1.68 (0.04 to 3.32) *
Po-VRP (mm) 0.50 (1.68 to 0.68) NS 0.70 (1.82 to 0.42) NS 0.20 (1.32 to 0.92) NS
Co-Gn (mm) 0.29 (2.09 to 2.67) NS 0.37 (1.89 to 2.63) NS 0.08 (2.18 to 2.33) NS
ANB (
) 0.17 (1.11 to 0.78) NS 0.28 (0.61 to 1.18) NS 0.45 (0.45 to 1.35) NS
Wits appraisal (mm) 0.42 (1.06 to 1.90) NS 0.51 (1.91 to 0.90) NS 0.93 (2.33 to 0.48) NS
U1-SN (
) 1.38 (2.09 to 6.84) NS 3.16 (2.03 to 8.35) NS 1.78 (3.41 to 6.97) NS
IMPA (
) 0.92 (3.69 to 1.86) NS 1.26 (3.89 to 1.37) NS 0.34 (2.97 to 2.29) NS
Actual U1-HRP (mm) 0.83 (1.28 to 1.11) NS 0.77 (0.37 to 1.90) NS 0.85 (0.29 to 1.99) NS
Actual U1-VRP (mm) 1.54 (0.68 to 3.76) NS 1.86 (0.23 to 3.97) NS 0.33 (1.78 to 2.43) NS
Actual L1-VRP (mm) 1.58 (0.55, 2.62) ** 2.19 (1.21, 3.17) *** 0.61 (0.37 to 1.59) NS
Actual U6-HRP (mm) 0.38 (0.84 to 1.59) NS 0.76 (0.39 to 1.91) NS 0.38 (0.77 to 1.53) NS
Actual U6-VRP (mm) 0.21 (0.67 to 1.08) NS 0.39 (0.44 to 1.22) NS 0.18 (0.65 to 1.01) NS
Maxillary arch width (mm) 2.88 (4.16 to 1.59) *** 1.22 (2.44 to 0.00) NS 1.66 (0.44 to 2.88) ***
UL-VRP (mm) 0.21 (1.82 to 1.41) NS 0.72 (2.25 to 0.82) NS 0.51 (2.04, 1.03) NS
LL-VRP (mm) 0.04 (2.45 to 2.37) NS 0.23 (2.06 to 2.52) NS 0.28 (2.01 to 2.56) NS
stPo-VRP (mm) 0.29 (2.14 to 2.73) NS 0.48 (1.84 to 2.79) NS 0.18 (2.13 to 2.49) NS
stA-VRP (mm) 0.25 (1.74 to 1.24) NS 0.61 (2.02 to 0.81) NS 0.36 (1.77 to 1.06) NS
STB-VRP (mm) 0.63 (1.62 to 2.87) NS 0.34 (1.79 to 2.47) NS 0.28 (2.41 to 1.84) NS
UL-E line (mm) 0.17 (1.66 to 1.32) NS 0.33 (1.75 to 1.08) NS 0.17 (1.58 to 1.25) NS
LL-E line (mm) 0.25 (1.40 to 0.90) NS 0.85 (1.95 to 0.25) NS 0.60 (1.70 to 0.50) NS

LSD, least significant difference; CI, confidence interval; SD, standard deviation; NS, no significant difference; Actual, actual dental changes calculated by measured dental linear values minus skeletal
linear values.

Liu et al
*P \0.05; **P \0.01; ***P \0.001.
Liu et al 329

Fig 3. Skeletal and dental changes contributing to overjet correction in 3 groups.

advancement might be due to diverse races, effect and the downward movement of the anterior
chronological and skeletal ages, force magnitude, maxilla.5,10,19,32,36 In the present study, the
gender distribution, and patient compliance. Alt-RAMEC/FM group showed no significant increase
The counterclockwise rotation of the palatal plane in the mandibular plane (FMA, 1.03
; MP-SN, 0.87
).
while protracting was observed in previous This outcome was in accordance with the results of Liu
studies.8,20,35,36 Theoretically, the ideal force vector et al,20 but only half the increase was observed in the
should pass through the resistance center of the maxilla latter study (2.00
) and in the study by Yilmaz and
to obtain bodily movement of the maxilla.5,6,20,37 In the Kucukkeles34 (1.77
). Isci et al16 inconsistently reported
present study, the palatal plane angle decreased, despite a slightly greater increase in Alt-RAMEC/FM with no
designing a protraction force of 30
-45
downward significant intergroup difference. Generally,
from the occlusal plane, which was the optimal direction tooth-borne maxillary expansion led to molar extrusion
instructed by several studies.5,6,38 Slightly more palatal and buccal tipping, which might result in clockwise
plane rotations were observed in the Alt-RAMEC group rotation of the occlusal plane.22,39 However, a smaller
(1.73
) than those in the other 2 groups. However, a increase in the mandibular plane angle in the present
counterclockwise rotation is sometimes favorable, study can be partly ascribed to the favorable influence
especially when treating patients with a deep overbite of acrylic splints and the shorter treatment duration.
and excessive incisor display. However, this rotation is This postulation was demonstrated in another
detrimental for patients with a shallow overbite, as it splint-based study by Masucci et al.18
can aggravate the open bite tendency. Liu et al20 inferred For class III patients with severe vertical growth
that a significant counterclockwise rotation in Alt- patterns, mandibular clockwise rotation further
RAMEC resulted from more loosened circummaxillary increases the lower facial height and damages the
sutures, but no significant difference between the profile. Open bite tendency may accordingly be
Alt-RAMEC and RME groups was observed in our study. aggravated.20 Although no significant difference in
A substantial number of studies indicated clockwise airway volume changes was reported in the previous
mandibular rotation-a combination of the chincup study,35 excessive mandibular backward movements

American Journal of Orthodontics and Dentofacial Orthopedics March 2021  Vol 159  Issue 3
330 Liu et al

might decrease the pharyngeal airway dimension. From width was liable to relapse. Moreover, as Ngan et al44
our outcomes, the Alt-RAMEC/FM protocol might be indicated, buccally inclined molars were tended to retain
more suitable for such patients. Nevertheless, more less expansion compared with lingually inclined molars.
clockwise rotation may be beneficial in certain patients, Overall, RME/FM appeared to be more suitable for
especially for those with horizontal growth patterns and patients with distinct transverse deficiencies than the
excessive overbites. A redirection of future mandibular other 2 protocols. However, correction of the
growth may consequently occur. The sagittal intermaxillary transverse discrepancy is available after
discrepancy and profile would be improved in such improving the sagittal relationship; maxillary expansion
patients.40 Therefore, an appropriate protocol should should be used under a strict selection of indications.
be chosen carefully on the basis of different growth Intergroup significant differences in treatment
patterns. duration were exhibited in the present study, which was
Studies have shown that protraction resulted in shortened by approximately 20% in the Alt-RAMEC/FM
maxillary incisor proclination and mandibular incisor retro- group (6.04 months) compared with the FM group
clination.8,10,19,20,41 In the present study, as pronounced (7.99 months) and RME/FM group (7.35 months). This
sagittal displacement of the maxilla, the Alt-RAMEC/FM outcome might result from more efficient sutural
group presented the least forward movements of maxillary disarticulation by repetitive stimulation.33 Canturk and
incisors and molars. The increase in U1-SN angle was only Celikoglu21 also recommended the simultaneous
2.80
in the Alt-RAMEC/FM group, which was more Alt-RAMEC/FM protocol because it saved time from wait-
noticeable in the FM (5.96
) and RME/FM groups ing until the completion of Alt-RAMEC for FM therapy.
(4.58
). Moreover, partial patients with initially flared Although similar durations were observed between
maxillary incisors conversely moved lingually after protrac- RME/FM and Alt-RAMEC/FM in a study by Liu et al,20
tion according to actual U1-VRP changes. We hypothe- Liou13 suggested that the Alt-RAMEC/FM protocol could
sized that the Alt-RAMEC resulted in spontaneous shorten the treatment duration while causing equivalent
decompensation of incisors as the skeletal relationship skeletal changes. However, in the present study, because
improved. As the stimulation of the orthopedic force and of the limited sample size, the treatment duration among
space widened, crowded anterior teeth voluntarily aligned. the 3 groups showed statistically significant differences
The buccal inclination of incisors was decreased and coun- that may not be large enough to be noticeable in clinical
teracted part of the proclination effects caused by maxillary use. Besides, treatment duration varied between studies,
protraction. These findings indicated that the Alt-RAMEC/ and the disparity might be due to differences in the FM
FM protocol produced fewer dental effects. In addition, the wearing time, palatal activation rate, and patient
mandibular incisors were retroclined significantly in all compliance. Further studies are required to confirm the
groups with insignificant intergroup differences. clinical efficiency and achieve cost reduction for patients.
Overjet correction was significant in all groups, Improving facial esthetics is another aim of
especially in Alt-RAMEC/FM (6.27 mm). The orthopedic treatments for patients with Class III
combination of skeletal and dental effects contributed malocclusion. Maxillary anterior movement in
to such a distinct increase. In the Alt-RAMEC/FM group, conjunction with an appropriate mandibular clockwise
the overjet correction was completed by 88.7% skeletal rotation led to an improved concave profile. In
and 11.3% dental effects, which showed significantly accordance with previous studies, soft tissue also
more skeletal contributions than those in the other 2 showed great improvements in all groups.16,20,21,34 The
groups (Fig 3). Isci et al16 reported 93% skeletal changes pronounced soft-tissue changes attributed to skeletal
when used Alt-RAMEC/FM protocol, whereas Cha42 only modification, whereas the sensitivity of soft tissue to
observed 63.1% skeletal effects. skeletal changes varied among patients.
Although statistically significant, no distinct Considering that Alt-RAMEC was used throughout
transverse-dimensional changes were sighted in clinical the treatment, it was critical to pay close attention to
observation in the Alt-RAMEC group. The alternation periodontal structures. In the present study, we
routine was usually ended with constriction other than decreased the daily expansion rate to twice a day
expansion, and the amount of expansion rarely (0.5 mm/d), which was only half of the magnitude of
accumulated during the treatment. In contrast, the the study of Liou and Tsai.11 None of the patients
RME/FM group induced more maxillary expansion but reported abnormal pain, despite mild discomfort in
with a smaller magnitude than that in another study.43 very few patients. According to clinical examination,
This might be due to the following reasons. First, no T2 panoramic radiographs and periapical films, neither
retention devices for expansion were used afterward, distinct detrimental influences on periodontal and
as well as the influence of protraction, with the maxillary craniofacial structures nor root resorption were observed

March 2021  Vol 159  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Liu et al 331

after treatments. However, it was deficient and 1-sided 2. Compared with conventional FM and RME/FM
to evaluate the periodontal effects by 2-dimensional therapies, Alt-RAMEC/FM shows greater maxillary
x-ray plain films only. Because not all patients agreed advancement and insignificant mandibular
to cone-beam computed tomography at T2, there were clockwise rotation. Overjet correction was
difficulties in assessing the condition of buccal and completed by more favorable skeletal effects.
lingual alveolar bones without cone-beam computed 3. The modified Alt-RAMEC/FM protocol showed no
tomography, which was one of the limitations of this significant undesired tooth side effects compared
study. Studies on long-term stability and safety are with those in the FM and RME/FM protocol.
required to evaluate the effectiveness of this modified 4. Although the reduction in treatment duration in the
protocol synthetically. Alt-RAMEC/FM group was statistically significant, it
Several studies31,45 have reported more potential might not be clinically relevant because of the small
damage to periodontal tissue in tooth-borne orthopedic range of intergroup differences. Further observation
appliances than the bone-anchored protocol. Because or- is required to confirm the virtual efficacy and
thopedic force is transferred through the skeletal long-term stability.
anchorage in the latter protocol, the risk of tooth damage
could be minimized. Wilmes et al45 conducted Alt-
CREDIT AUTHOR STATEMENT
RAMEC with mini-implants in the anterior palate and
claimed minimal risk of periodontal damage and the elim- Jie Guo contributed to the conception and design of
ination of other drawbacks (tooth loosening, molar mesial this study. Yuyao Liu performed the main literature
migration, tipping) caused by tooth-anchored therapy. retrieval, data acquisition, and statistical analysis, and
Although bone-anchored FM therapy is invasive, it is still wrote and revised the manuscript. Renya Hou helped
controversial with respect to comfortability and therapeu- perform the literature retrieval and statistical analysis
tic safety; clinical use should be chosen with principle. and draft the manuscript. Hairu Jin performed the
statistical analysis and graphic processing and helped
Limitations with a major revision. Xin Zhang, Zuping Wu, and
Zixuan Li contributed to the literature retrieval and
It should be noted that the first limitation of our
manuscript structural revision.
study is the absence of a blank control group consisting
of untreated patients who matched the treated groups
REFERENCES
regarding race, growth period, sex distribution, and
malocclusion patterns. We failed to perform it because 1. Dietrich UC. Morphological variability of skeletal Class 3 relation-
of the insufficient number of untreated samples or ships as revealed by cephalometric analysis. Rep Congr Eur Orthod
Soc 1970;131-43.
incomplete information. In addition, considering that
2. Ellis E 3rd, McNamara JA Jr. Components of adult Class III maloc-
our sample was not large, we did not divide the patients clusion. J Oral Maxillofac Surg 1984;42:295-305.
into subgroups on the basis of sex and age, although 3. Oppenheim A. A possibility for physiologic orthodontic movement.
these factors may affect the heterogeneity of efficacy. Dent Rec (London) 1945;65:278-80.
Because this study was retrospective, although group 4. Delaire J. [Manufacture of the “orthopedic mask”]. Rev Stomatol
Chir Maxillofac 1971;72:579-82. French.
assignment proceeded without subjective factors, com-
5. Hata S, Itoh T, Nakagawa M, Kamogashira K, Ichikawa K,
plete randomization was not realized (eg, drawing Matsumoto M, et al. Biomechanical effects of maxillary protrac-
lots), and potential bias might be introduced into the tion on the craniofacial complex. Am J Orthod Dentofacial Orthop
study. Further studies are needed, especially randomized 1987;91:305-11.
controlled trials, to evaluate the long-term stability and 6. Gautam P, Valiathan A, Adhikari R. Skeletal response to maxillary
protraction with and without maxillary expansion: a finite element
other potential influence factors.
study. Am J Orthod Dentofacial Orthop 2009;135:723-8.
Notwithstanding these limitations, this study 7. Haas AJ. The treatment of maxillary deficiency by opening the
suggests the comparative effectiveness among 3 midpalatal suture. Angle Orthod 1965;35:200-17.
different interventions. 8. Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I. Skeletal
effects of early treatment of Class III malocclusion with maxillary
expansion and face-mask therapy. Am J Orthod Dentofacial Or-
CONCLUSIONS thop 1998;113:333-43.
9. Haas AJ. Long-term posttreatment evaluation of rapid palatal
expansion. Angle Orthod 1980;50:189-217.
1. The modified Alt-RAMEC/FM protocol can fortify 10. Vaughn GA, Mason B, Moon HB, Turley PK. The effects of maxil-
the clinical outcomes of FM therapy, effectively lary protraction therapy with or without rapid palatal expansion: a
improving skeletal and soft-tissue disharmonies in prospective, randomized clinical trial. Am J Orthod Dentofacial
the early treatment of Class III malocclusion. Orthop 2005;128:299-309.

American Journal of Orthodontics and Dentofacial Orthopedics March 2021  Vol 159  Issue 3
332 Liu et al

11. Liou EJ, Tsai WC. A new protocol for maxillary protraction in cleft 29. Dahlberg G. Statistical Methods for Medical and Biological Stu-
patients: repetitive weekly protocol of alternate rapid maxillary ex- dents. London, United Kingdom: George Alien and Unwin; 1940.
pansions and constrictions. Cleft Palate Craniofac J 2005;42: 30. Celikoglu M, Buyukcavus MH. Changes in pharyngeal airway
121-7. dimensions and hyoid bone position after maxillary protraction
12. Liou EJW, Chen PKTJ. New orthodontic and orthopaedic manage- with different alternate rapid maxillary expansion and construc-
ments on the premaxillary deformities in patients with bilateral tion protocols: a prospective clinical study. Angle Orthod 2017;
cleft before alveolar. bone grafting 2003;7:73-82. 87:519-25.
13. Liou EJ. Effective maxillary orthopedic protraction for growing 31. Nienkemper M, Wilmes B, Franchi L, Drescher D. Effectiveness of
Class III patients: a clinical application simulates distraction osteo- maxillary protraction using a hybrid hyrax-facemask combination:
genesis. Prog Orthod 2005;6:154-71. a controlled clinical study. Angle Orthod 2015;85:764-70.
14. Yen SL. Protocols for late maxillary protraction in cleft lip and pal- 32. Nartallo-Turley PE, Turley PK. Cephalometric effects of combined
ate patients at Childrens Hospital Los Angeles. Semin Orthod 2011; palatal expansion and facemask therapy on Class III malocclusion.
17:138-48. Angle Orthod 1998;68:217-24.
15. Do-deLatour TB, Ngan P, Martin CA, Razmus T, Gunel E. Effect of 33. Wang YC, Chang PM, Liou EJ. Opening of circumaxillary sutures by
alternate maxillary expansion and contraction on protraction of alternate rapid maxillary expansions and constrictions. Angle Or-
the maxilla: a pilot study. Hong Kong Dent J 2009;6:72-82. thod 2009;79:230-4.
16. Isci D, Turk T, Elekdag-Turk S. Activation-deactivation rapid 34. Yilmaz BS, Kucukkeles N. Skeletal, soft tissue, and airway changes
palatal expansion and reverse headgear in Class III cases. Eur J Or- following the alternate maxillary expansions and constrictions
thod 2010;32:706-15. protocol. Angle Orthod 2014;84:868-77.
17. Franchi L, Baccetti T, Masucci C, Defraia E. Early Alt-RAMEC and 35. Onem Ozbilen E, Yilmaz HN, Kucukkeles N. Comparison of the ef-
facial mask protocol in Class III malocclusion. J Clin Orthod 2011; fects of rapid maxillary expansion and alternate rapid maxillary
45:601-9. expansion and constriction protocols followed by facemask ther-
18. Masucci C, Franchi L, Giuntini V, Defraia E. Short-term effects of a apy. Korean J Orthod 2019;49:49-58.
modified Alt-RAMEC protocol for early treatment of Class III 36. Kim JH, Viana MA, Graber TM, Omerza FF, BeGole EA. The effec-
malocclusion: a controlled study. Orthod Craniofac Res 2014;17: tiveness of protraction face mask therapy: a meta-analysis. Am J
259-69. Orthod Dentofacial Orthop 1999;115:675-85.
19. Baik HS. Clinical results of the maxillary protraction in Korean chil- 37. Yan X, He W, Lin T, Liu J, Bai X, Yan G, et al. Three-dimensional
dren. Am J Orthod Dentofacial Orthop 1995;108:583-92. finite element analysis of the craniomaxillary complex during
20. Liu W, Zhou Y, Wang X, Liu D, Zhou S. Effect of maxillary protrac- maxillary protraction with bone anchorage vs conventional
tion with alternating rapid palatal expansion and constriction vs dental anchorage. Am J Orthod Dentofacial Orthop 2013;143:
expansion alone in maxillary retrusive patients: a single-center, 197-205.
randomized controlled trial. Am J Orthod Dentofacial Orthop 38. Tanne K, Hiraga J, Sakuda M. Effects of directions of maxillary
2015;148:641-51. protraction forces on biomechanical changes in craniofacial com-
21. Canturk BH, Celikoglu M. Comparison of the effects of face mask plex. Eur J Orthod 1989;11:382-91.
treatment started simultaneously and after the completion of the 39. Al-Mozany SA, Dalci O, Almuzian M, Gonzalez C, Tarraf NE, Ali
alternate rapid maxillary expansion and constriction procedure. Darendeliler M. A novel method for treatment of Class III maloc-
Angle Orthod 2015;85:284-91. clusion in growing patients. Prog Orthod 2017;18:40.
22. Wilmes B, Nienkemper M, Drescher D. Application and effectiveness 40. Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects of face
of a mini-implant- and tooth-borne rapid palatal expansion device: mask/expansion therapy in Class III children: a comparison of three
the hybrid hyrax. World J Orthod 2010;11:323-30. age groups. Am J Orthod Dentofacial Orthop 1998;113:204-12.
23. Baccetti T, Franchi L, McNamara JA Jr. An improved version of the 41. Turley PK. Orthopedic correction of Class III malocclusion with
cervical vertebral maturation (CVM) method for the assessment of palatal expansion and custom protraction headgear. J Clin Orthod
mandibular growth. Angle Orthod 2002;72:316-23. 1988;22:314-25.
24. Arman A, Ufuk Toygar T, Abuhijleh E. Evaluation of maxillary pro- 42. Cha KS. Skeletal changes of maxillary protraction in patients ex-
traction and fixed appliance therapy in Class III patients. Eur J Or- hibiting skeletal Class III malocclusion: a comparison of three skel-
thod 2006;28:383-92. etal maturation groups. Angle Orthod 2003;73:26-35.
25. Peter N. Early treatment of Class III malocclusion: is it worth the 43. Rinaldi MRL, Azeredo F, de Lima EM, Rizzatto SMD, Sameshima G,
burden? Am J Orthod Dentofacial Orthop 2006;129:S82-5. de Menezes LM. Cone-beam computed tomography evaluation of
26. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and bone plate and root length after maxillary expansion using tooth-
treatment planning–part II. Am J Orthod Dentofacial Orthop 1993; borne and tooth-tissue-borne banded expanders. Am J Orthod
103:395-411. Dentofacial Orthop 2018;154:504-16.
27. Kaya D, Kocadereli I, Kan B, Tasar F. Effects of facemask treatment 44. Ngan P, Yiu C, Hu A, H€agg U, Wei SH, Gunel E. Cephalometric and
anchored with miniplates after alternate rapid maxillary expansions occlusal changes following maxillary expansion and protraction.
and constrictions; a pilot study. Angle Orthod 2011;81:639-46. Eur J Orthod 1998;20:237-54.
28. Zhang Y, Fu Z, Jia H, Huang Y, Li X, Liu H, et al. Long-term stability of 45. Wilmes B, Ngan P, Liou EJW, Franchi L, Drescher D. Early Class III
maxillary protraction therapy in Class III patients with complete facemask treatment with the hybrid hyrax and Alt-RAMEC proto-
unilateral cleft lip and palate. Angle Orthod 2019;89:214-20. col. J Clin Orthod 2014;48:84-93.

March 2021  Vol 159  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics