Download Nonsurgical Treatment of a Class III Patient with

JIOS
10.5005/jp-journals-10021-1149
CASE REPORT
Nonsurgical Treatment of a Class III Patient with Alt-RAMEC Protocol and Facemask Therapy
Nonsurgical Treatment of a Class III Patient with
Alt-RAMEC Protocol and Facemask Therapy
1
Saurabh Chaturvedi, 2Lavesh Deshwal, 3Prachi Phadnis, 4Prashant Kamath, 5Anirudh Agarwal
ABSTRACT
Class III malocclusion has been the subject of interest in many investigations because of the challenges in its treatment. The skeletal manifestation
can be due to mandibular anterior positioning (prognathism) or growth excess (macrognathia), maxillary posterior positioning (retrognathism) or
growth deficiency (micrognathia), or a combination of mandibular and maxillary discrepancies. A 15-year-old Asian with a skeletal Class III
malocclusion and a severe anterior crossbite was treated with Alt-RAMEC protocol designed to loosen the sutures that connect the maxilla to
the surrounding bones via rapid expansion and contraction on an alternating weekly basis and facemask therapy. An Angle Class I molar
relationship was achieved with canine protected occlusion and incisal guidance. A wrap-around retainer was placed on the maxillary arch and a
lingual bonded retainer on the mandibular arch. Treatment time was 30 months.
Keywords: Dentofacial orthopedics, Growth modification, Malocclusion cephalometrics, Class III, Circum maxillary-sutures, Alt-RAMEC,
Retrognathism.
How to cite this article: Chaturvedi S, Deshwal L, Phadnis P, Kamath P, Agarwal A. Nonsurgical Treatment of a Class III Patient with AltRAMEC Protocol and Facemask Therapy. J Ind Orthod Soc 2013;47(3):159-162.
INTRODUCTION
Class III malocclusion has been the subject of interest in many
investigations, because of the challenges in its treatment. Angle
classified the malocclusions based on occlusal relationships,
considering the first permanent molar as the ‘key’ to
occlusion.1 Class III malocclusion is defined in cases that
mandibular first molar is positioned mesially relative to the
first molar of maxilla. The prevalence of Class III malocclusion
has been described between 1 and 10%,2-4 depending on ethnic
background,2,5 sex,4,6 and age7 of the sample as well as the
diagnostic criteria used.8 A complicating factor for diagnosis
and treatment of Class III malocclusion is its etiologic
diversity. Its origin can be skeletal or dentoalveolar. The
skeletal manifestation can be due to mandibular anterior
positioning (prognathism) or growth excess (macrognathia),
maxillary posterior positioning (retrognathism) or growth
1-3
Assistant Professor, 4,5Professor and Head
Department of Orthodontics and Dentofacial Orthopedics, NIMS
Dental College, Jaipur, Rajasthan, India
2,5
Department of Orthodontics and Dentofacial Orthopedics,
Rajasthan Dental College and Hospital, Jaipur, Rajasthan, India
3
Private Practice, Mumbai, Maharashtra, India
4
Department of Orthodontics and Dentofacial Orthopedics
Dr Syamala Reddy Dental College-Hospital and Research Centre
Bengaluru, Karnataka, India
1
Corresponding Author: Saurabh Chaturvedi, Assistant Professor
Department of Orthodontics and Dentofacial Orthopedics, NIMS Dental
College, Jaipur, Rajasthan, India, e-mail: [email protected]
Received on: 18/6/12
Accepted after Revision: 25/9/12
deficiency (micrognathia), or a combination of mandibular
and maxillary discrepancies.
A wide range of environmental factors have been
suggested as contributing to the development of Class III
malocclusion. Among those are enlarged tonsil,9 difficulty in
nasal breathing,9 congenital anatomic defects,10 disease of the
pituitary gland, 11 hormonal disturbances, 12 a habit of
protruding the mandible,11 posture,11 trauma and disease,10
premature loss of the sixth-year molar11 and irregular eruption
of permanent incisors or loss of deciduous incisors.12 Other
contributing factors, such as the size and relative positions of
the cranial base, maxilla and mandible, the position of the
temporomandibular articulation and any displacement of the
lower jaw also affect both the sagittal and vertical relationships
of the jaw and teeth.13-16 The position of the foramen magnum
and spinal column17 and habitual head position18 may also
influence the eventual facial pattern. The etiology of Class III
malocclusion is thus wide ranging and complex.
Class III malocclusions are difficult for treatment
planning. The clinician must choose either a camouflage
treatment to mask the Class III malocclusion or a surgical
alternative to correct the skeletal imbalance. In young patients,
the circumaxillary sutures are patent, and opening of these
sutures with orthopedic force can facilitate forward movement
of the maxilla.
DIAGNOSIS AND ETIOLOGY
The patient was an Asian boy, aged 15 years, with an
unremarkable medical history. He had a Class III dental
malocclusion and a slightly concave facial profile. His maxilla
appeared to be recessive. The maxillary and mandibular
dentition showed near normal alignment. His chief concerns
The Journal of Indian Orthodontic Society, July-September 2013;47(3):159-162
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Saurabh Chaturvedi et al
Fig. 1: Pretreatment extraoral photographs
Fig. 4: Pretreatment radiographs
Fig. 2: Pretreatment intraoral photographs
by 2 mm. The pretreatment cephalogram and its tracing (Fig. 4)
showed an ANB angle of –3.5°. The Wits appraisal of –11.5 mm
confirmed a skeletal Class III alveolar imbalance. The FMA of
28° suggested a vertical skeletal discrepancy. The Jaraback
ratio (anterior facial height/posterior facial height) of 66.39%
suggested a horizontal growth tendency. The panoramic
radiograph (Fig. 4) showed no pathology, supernumeraries or
congenitally absent teeth. The maxillary second permanent
molars were erupted. After the casts, the radiographs, the photos,
and the patient were studied, it was decided to approach his
problem as a Class III malocclusion with retrognathic maxilla
and prognathic mandible.
TREATMENT OBJECTIVES
The treatment objectives were to: (1) obtain a normal profile
line to nose relationship, (2) obtain normal canine and incisal
guidance, (3) correct the anterior crossbite, (4) correct the
Class III dental relationship and (5) place the dental midlines
in the middle of the patient’s face.
Fig. 3: Pretreatment dental casts
were ‘my lower teeth are bulging out and I have a very prominent
chin.’ The facial (Fig. 1) and intraoral photographs (Fig. 2)
demonstrate a slightly concave facial profile. The patient was
able to close his lips without mentalis strain. The mandibular
midline was deviated 2 mm toward his right. The dental casts
(Fig. 3) show an Angle Class III occlusion on both left and right
side. There was a crossbite of the maxillary teeth on the right
and a negative overjet of –3 mm. The maxillary and mandibular
second molars were erupted. The mandibular midline deviated
160
TREATMENT ALTERNATIVES
1. Using an extraction protocol, doing a camouflage
treatment.
2. Using the conventional RME and facemask therapy for
protraction of the maxilla.
TREATMENT PLAN
Merrifield’s total space analysis19,20 was used to determine
space requirements. A decision was made not to extract any
tooth and treat the case with a nonextraction protocol. As no
expansion of the maxillary arch was required, the Alt-RAMEC
JIOS
Nonsurgical Treatment of a Class III Patient with Alt-RAMEC Protocol and Facemask Therapy
protocol using Hyrax screw was chosen to disarticulate the
maxilla followed by protraction with facemask therapy. This
was followed by treatment with fixed orthodontic appliance
MBT 0.022 slot for final occlusal settling.
TREATMENT PROGRESS
The Alt-RAMEC protocol was designed to loosen the sutures
that connect the maxilla to the surrounding bones via rapid
expansion and contraction on an alternating weekly basis.21
For this case, a 7-week protocol was used. The maxilla was
expanded or contracted 1 mm per day (two turns in the morning
and two turns in the evening). The mobility of the maxilla was
checked before proceeding to maxillary protraction. The maxilla
could be clinically examined for mobility by holding patients’
head with one hand and rocking the anterior segment of the
maxilla up and down with the other hand.
The Petit protraction facemask was used for maxillary
protraction. To avoid an opening of the bite as the maxilla was
protracted, the elastics were attached near the maxillary canines
with a downward and forward pull of 30° to the occlusal plane.
A Correx gauge was used to measure the elastic force on the
Alt-RAMEC
to
ensure
that
approximately
380 gm of force was generated on each side. Patient was
instructed to wear the protraction facemask for 10 to 12 hours
per day, which included night-time wear.
All teeth were simultaneously banded or bonded with a
0.022" standard MBT appliance.
After the Alt-RAMEC protocol for 7 weeks, the hyrax
appliance was left in place for another 4 months for stabilization.
The molars and canines were now in Class I and the anterior
crossbite was corrected. Following this vertical, triangular, and
Class III elastics were used as needed for final occlusal settling.
Fig. 7: Post-treatment radiographs
Fig. 8: Pre- and post-treatment superimpositions
TREATMENT RESULTS
Fig. 5: Post-treatment extraoral photographs
The post-treatment facial (Fig. 5) and intraoral photographs
(Fig. 6) illustrate the improvement in the patient’s profile. His
midlines are coincident and in the center of his face. The posttreatment cephalometric radiograph and its tracing (Fig. 7)
illustrate the changes achieved with treatment. The mandibular
incisors were uprighted over the basal bone to an IMPA angle
of 88°. The FMA angle increased to 30°. The Wits appraisal
improved to 1 mm. The changes can be seen on pre- and posttreatment superimpositions (Fig. 8).The post-treatment
panoramic radiograph (Fig. 7) exhibits no pathology.
DISCUSSION
Fig. 6: Post-treatment intraoral photographs
Patients having Class III malocclusion may present with an
anterior crossbite and/or a Class III molar relationship.
Individuals with a true skeletal Class III malocclusion present
with either a midface deficiency and/or mandibular
prognathism.22 It has been reported that a significant percentage
of the skeletal Class III malocclusion cases are due to maxillary
retrusion. In young patients, the circumaxillary sutures are patent,
The Journal of Indian Orthodontic Society, July-September 2013;47(3):159-162
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Saurabh Chaturvedi et al
and opening of these sutures with orthopedic force can facilitate
forward movement of the maxilla. Rapid maxillary expansion has
been postulated as a means of disarticulating the maxilla from the
surrounding bones connected by circumaxillary sutures.
However, the circumaxillary sutures start to interlock or
interdigitate during pubertal growth, making them difficult to
protract in older patients.23 It was suggested that alternate rapid
maxillary expansions and contractions (Alt-RAMEC) can increase
the amount of maxillary protraction and result in a shorter period
of protraction.24-26 An animal study suggested that 5 weeks of
Alt-RAMEC opened both the sagittal and coronal circumaxillary
sutures more extensively than 1 week of RME.27
The Alt-RAMEC protocol has been shown to produce
significant anterior movement of point A in cleft-palate
patients when used in combination with intraoral protraction
springs.21,28 Isci et al reported a significantly greater increase
in SNA (+1.2°) and improvement in ANB (+1.6°) and overjet
(+2.2 mm) in a group treated with Alt-RAMEC (0.4 mm of
activation/deactivation per day over 4 weeks) and facial masks
compared with an RME/FM group, both with a mean age of
about 11.5 at the start of treatment.29
In the present case, a bonded expansion appliance was used
as these have been shown to reduce molar eruption during
maxillary expansion, possibly due to the splinting effect as
well as the occlusal bite-plate effect of the bonded expander.30
The success and failure of orthopedic treatment of children
with skeletal Class III malocclusion is substantially dependent
on patient compliance and growth potential. It should be noted
that the Alt-RAMEC patient did show marked improvement in
Class III malocclusion within the first few months of
protraction, possibly due to the loosening of the maxillary
sutures.
CONCLUSION
This treatment improved the patient’s profile, corrected the
crossbite and gave him an excellent functional occlusion. This
treatment result could not have been accomplished without
excellent patient cooperation. Maxillary protraction in
Class III patients using the hyrax expander for a repetitive
weekly protocol of Alt-RAMEC, and protraction facemask
appears to be an effective treatment course, and the results
obtained remain stable.
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