ALT-RAMEC
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PROBLEM TREATMENT
orthopedic
Orthodontic camouflage
Orthognathic surgery
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Many studies have found that in most patients, the hypoplastic maxilla is often
the primary etiology of a Class III malocclusion.(40%)
Haas reported that maxillary expansion alone often causes the maxilla to
advance and drop vertically, rotating the mandible down and back.
In 1987, McNamara presented a case report and used a bonded expansion
appliance in conjunction with a facemask to treat Class III patients with
maxillary deficiency
These studies also found that the amount of forward movement of the maxilla
was limited to 2 to 4 mm
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Histological changes n the circum-maxillary
sutures
increase in the
widening of the
number of
sutures
osteoblasts
deposition of
osteoid on both changes in the fiber
sutural bone bundle orientation
surfaces
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ALTERNATIVE RAPID
PALATAL EXPANSION AND
CONSTRICTION
DISADVANTAGE
Potential risk to periodontal
status of anchor teeth
Double-hinged expansion appliance
two rotational hinges posteriorly
a jackscrew in the center
0.051-inch wires attached to the appliance
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Different protocols for Alt-Ramec
5 weeks 7 weeks 9 weeks
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Comparison of Alt-RAMEC Protocol and RME
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check weekly the patient to evaluate the opening of the suture (confirmed by the
immediate opening of interincisal diastema after few days of expansion)
CORRECTION OF LATE ADOLESCENT SKELETAL
CLASS III USING THE ALT-RAMEC PROTOCOL
AND SKELETAL ANCHORAGE
Buyukcavuş MH, Sari OF, 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.
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Figure 1. Facial and
intraoral
photographs taken at the
initial visit (age: 16 years, 7
months).
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Treatment Objectives
(1) to improve the profile and facial appearance, ( primary complaint )
(2) to provide Class I functional ideal occlusal relationship, and
(3) To correct anterior crossbite and Class III malocclusion
TREATMENT OPTIONS
Orthognathic surgery including maxillary advancement and mandibular set
back planning of fixed orthodontic treatment were discussed with the
patient.
Other treatment options included:
(1) distalization of the mandibular teeth with skeletal anchorage units
(2), mandibular interproximal reduction & Class III elastics (4), and/
or maxillary protraction with a face mask
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TREATMENT STAGES
9 WEEKS
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During the protocol, miniplates were placed surgically.
Under local anesthesia, two I-shaped miniplates were
placed in the apertura piriformis region of the maxilla
with six screws. The tip of the I-shaped plate was bent
to form a hook.
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POST PROTRACTION
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POST PROTRACTION POST PROTRACTION
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MBT 0.22 slot metal brackets (Mini Ovation,
Dentsply GAC International, Bohemia, NY, USA),
leveling was performed with
0.016 in Nickel-Titanium
0.016 × 0.016-inch, Nickel-Titanium
0.016 × 0.022-in, Nickel-Titanium
0.017 × 0.025-in, Nickel-Titanium
and 0.019 ×0.025-in Nickel-Titanium archwires arch wires and
0.019× 0.025-in steel arch wires, respectively.
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POST TREATMENT
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PRE TREATMENT POST TREATMENT
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DISCUSSION
Direct support 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
Maxillary protraction with a face mask fromthe plates placed in
the aperture piriformis region can provide pure skeletal
protraction while reducing the dental effect by preventing the
dental mesialization of the upper arch.
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This method also eliminates thepotential for posterior
rotation of the mandible and the related negative effects,
since it allows application of force through the resistance
center of the maxilla
With face mask in the maxilla, 2.8 mm of forward movement
was detected, while only a 0.3° increase was observed in the
vertical direction of the patient.
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Determination of the optimal time to start treatment is one of
the critical points for the successful treatment of a Class III
malocclusion
Although most studies report that face mask treatment is
more effective in patients with primary and early mixed
dentition, few studies have indicated that this treatment
should be performed at 13–14 years of age
The advantages of early treatment include minimization of
excessive closure of the dentition and mandible during this
period, which can yield better facial esthetics and increase the
patient's self-confidence
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CONCLUSION
Protraction was achieved in the late period, consistent with the
findings obtained with early applications in the literature.
These findings should be supported by prospective studies with large
sample sizes in the future.
This approach may be an alternative to orthognathic surgery in
compromised cases in the late stages of growth and development.
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A systematic review and meta-analysis was conducted for
comparative assessment of the dentoalveolar, skeletal and soft
tissue effectiveness of Alt-RAMEC/PFM therapy and RME/PFM
therapy.
It was concluded that the skeletal effects contributing towards
enhancement of profile was better in Alt-Ramec than RME.
Dentoalveolar changes measured in this review did not show much
difference between two protocols and data was insufficient for
assessing the soft tissue changes.
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Influence of the Alt-RAMEC protocol on the airway
Yılmaz et al-
Yilmaz BS, Kucukkeles N. Skeletal, soft tissue and airway changes following the alternate
maxillary expansions and constrictions protocol. Angle Orthod 2014; 84: 868-7
Effects in unilateral cleft lip and palate
Forward movement of the maxilla
clockwise rotation of mandible
lower molar height
upper incisor proclination
buccal alveolar bone thickness
increase in molar inclination
Shalvi singh. Evaluation of Alt-RAMEC With Facemask in Patients With Unilateral Cleft lip and Palate
(UCLP) Using Cone Beam Computed Tomography (CBCT) and Finite Element Modeling—A Clinical
Prospective Study. ACPC 2021
References
Buyukcavuş MH, Sari OF, 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.
Contemporary orthodontics,profit 5th edition
Do-de Latour TB, Ngan P, Martin CA, Razmus T, Gunel E. Effect of
alternate maxillary expansion and contraction on protraction of the
maxilla: A pilot study. Hong Kong Dent J 2009; 6: 72-82. 18.
Kaya D, Kocadereli I, Kan B, Tasar F. Effects of facemask treatment
anchored with miniplates after alternate rapid maxillary expansions
and constrictions; a pilot study. Angle Orthod 2011; 81: 639- 46.
Yilmaz BS, Kucukkeles N. Skeletal, soft tissue and airway changes
following the alternate maxillary expansions and constrictions
protocol. Angle Orthod 2014; 84: 868-7.
Celikoglu M, Buyukcavus MH. Evaluation of the effects of two
different Alt-RAMEC procedures: Five weeks versus nine weeks. Aust
Orthod J 2017; 33: 249-57
Thank you
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