The Journal of EVIDENCE-BASED DENTAL PRACTICE

REVIEW ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS

ALTERNATE RAPID MAXILLARY EXPANSION

AND CONSTRICTION (ALT-RAMEC) MAY BE
MORE EFFECTIVE THAN RAPID MAXILLARY
EXPANSION ALONE FOR PROTRACTION
FACIAL MASK TREATMENT
Which approach is more effective for class III growing patients, alternate rapid maxillary expansion and constriction
combined with protraction facial mask (Alt-RAMEC/PFM) or rapid maxillary expansion combined with protraction facial mask
(RME/PFM)?

REVIEWERS
TINGTING ZHAO, FANG HUA, HONG HE

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

The effectiveness of Alt-RAMEC combined with maxillary protraction in the SORT SCORE
treatment of patients with a class III malocclusion: a systematic review and meta-
A B C N/A
analysis, Mohammed Almuzian, Elise McConnell, M. Ali Darendeliler, Fahad SORT, Strength of Recommendation Taxonomy.
Alharbi & Hisham Mohammed. J Orthod 2018;45(4);250-9.
LEVEL OF EVIDENCE
1 2 3
See article 101451 for complete details regarding SORT and
LEVEL OF EVIDENCE grading system.
SUMMARY

Selection Criteria
The authors searched 4 databases (MEDLINE, Cochrane Library, Scopus, and SOURCE OF FUNDING
LILACS) and 2 trial registers (US National Institutes of Health Trials Register and No financial support was reported.
WHO International Clinical Trials Registry Platform) up to February 2018. Manual
searches were carried out by examining the reference lists of eligible articles.
TYPE OF STUDY/DESIGN
Randomized controlled trials (RCTs) evaluating the effectiveness of alternate rapid Systematic review.
maxillary expansion and constriction combined with protraction facial mask (Alt-
RAMEC/PFM) on class III malocclusion were selected. Growing patients exhibiting a
class III skeletal pattern and maxillary retrusion, within the age range of 7 to 14 years,
were considered for inclusion. Exclusion criteria were animal studies, case reports, case KEYWORDS
series, review articles, abstracts, and discussions. There were no restrictions regarding Alt-RAMEC, Protraction facial mask,
language, publication year, publication status, or publication type. Palatal expansion, Class III
malocclusion, Orthodontics
A total of 1206 items were identified through the electronic and manual searches.
Two authors screened these items independently and in duplicate. After the
application of eligibility criteria, 5 studies were deemed eligible and included in
the review.
J Evid Base Dent Pract 2020: [101408]
Key Study Factors
1532-3382/$36.00
Four of the 5 included studies were RCTs and the other 1 was a quasi-RCT. All of
ª 2020 Elsevier Inc.
them compared Alt-RAMEC/PFM with rapid maxillary expansion combined with
All rights reserved.
protraction facial mask (RME/PFM), using a banded hyrax as the rapid maxillary doi: https://doi.org/10.1016/
expansion (RME) appliance. j.jebdp.2020.101408

June 2020 1
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
A total of 147 participants were involved in these trials.
Seventy-four patients (age 10.11–12.1 years) received Alt-
RAMEC/PFM, and 73 patients (age 9.81–11.94 years)
received RME/PFM. All 4 RCTs were conducted in China,
and the quasi-RCT was carried out in Turkey. Two articles
were published in English, whereas the remaining 3 articles
were published in Chinese.
The authors used the Cochrane Risk of Bias (RoB) Tool to
assess the RoB of all included trials.
Main Outcome Measures
The primary outcomes of this review were the amount of
overjet correction measured clinically or cephalometrically,
and changes in the skeletal position of the maxilla and
mandible as well as their interrelationship.
Secondary outcomes included dental changes, soft tissue
changes, vertical skeletal changes, duration of orthodontic
treatment, number of orthodontic appointments, quality of
treatment outcomes, patient-reported outcomes, and
complications or adverse effects.
Main Results
Among the included studies, 1 had a low RoB, 3 had unclear
RoB, while for the other study, the RoB was high.
Changes in overjet, treatment duration, and adverse effects
were only reported in 1 of the studies. Two trials reported
upper incisor angulation and soft tissue changes, 3 of 4 trials
assessed mandibular plane angle (MP-SN) and the lower
incisor angulation, while 4 trials assessed the sella-nasion-
subspinale angle, sella-nasion-supramental angle, and
subspinale-nasion-supramental angle. None of the studies
looked at differences in patient-reported outcomes or
number of orthodontic appointments.
Results of meta-analyses suggested that, based on 4 trials and
moderate-certainty evidence, sella-nasion-subspinale angle,
sella-nasion-supramental angle, and subspinale-nasion-
supramental angle changes in the Alt-RAMEC/PFM group
were 1.16 (95% confidence interval [CI] 5 0.65 to 1.66;
P , .00001), 0.67 (95% CI 5 0.32 to 1.02; P 5 .0002), and
0.66 (95% CI 5 0.08 to 1.25; P 5.03) greater than those of the
REM/PFM group, respectively, indicating that Alt-RAMEC has
a small but significantly greater skeletal effect.
Based on 3 trials and low-certainty evidence, changes in the
mandibular plane angle were not significantly different be-
tween Alt-RAMEC/PFM and RME/PFM (P 5 .78).
According to 1 trial1 with a high risk of bias, improvement in
overjet was significantly greater in the Alt-RAMEC/PFM
group (7.13 6 2.09 mm) than the RME/PFM group
(4.97 6 2.07 mm; P , .001). However, based on low- to
moderate-certainty evidence, changes in the lower (P 5 .51;
2 Volume 20, Number 2
2 trials) and upper incisor angulation (P 5 .98; 3 trials) were
not significantly different between the 2 approaches.
Two trials with low to unclear risk of bias assessed soft tissue
changes and reported an improvement in total facial con-
vexity favoring the Alt-RAMEC/PFM group.
In addition, 1 trial with a low risk of bias found that time
spent in the protraction phase was significantly shorter in
the Alt-RAMEC group (MD 5 1.78; P 5 .033), but the total
treatment duration was not significantly different between
the 2 approaches (MD 5 0.24; P 5 .779).
Conclusions
The authors concluded that, compared to the RME/PFM
approach, Alt-RAMEC/PFM may result in significantly more
skeletal effects, as well as better improvement in overjet and
profile. However, the overall body of evidence was only of
low to moderate certainty.
COMMENTARY AND ANALYSIS
The global prevalence of angle class III malocclusion in the
mixed dentition varies from 0.7% to 12.6% for different pop-
ulations,2 and the etiology of class III malocclusion is
multifactorial. RME/PFM has been frequently used for the
treatment of growing patients with maxillary deficiency.3 In
these cases, RME is commonly carried out before protraction
to correct transverse discrepancy and to loosen the
circummaxillary sutures.4 Some clinicians report that a 5-mm
expansion is sufficient for sutural mobilization, whereas others
state that 12 to 15 mm are needed.5 However, excessive
expansions may result in discrepancies between the maxillary
and the mandibular arches.6
The Alt-RAMEC was first introduced by Erik Liou in 2005.7 The
protocol confers alternate movements of rapid maxillary
expansions and constrictions by opening and closing of the
RME screw for 7 to 9 weeks. The main goal of this protocol is
to achieve greater forward movement of the maxilla after
maxillary protraction because the effectiveness of protraction
depends on the degree of circummaxillary suture opening.7
The rationale for this technique is sutural expansion/
protraction osteogenesis. Many previous studies have shown
that, compared with RME, Alt-RAMEC can result in greater
suture mobilization and less skeletal resistance.8
The systematic review of Almuzian and colleagues9 aimed
to assess the dentoalveolar, skeletal, and soft tissue
effectiveness of Alt-RAMEC/PFM in class III growing pa-
tients. However, some limitations exist in this review.
First, according to the reported eligibility criteria, only RCTs were
considered for inclusion. However, among the 5 included
studies, 1 was a controlled clinical trial,1 which did not mention
randomization at all. Second, the search strategy used in this

review was not sensitive enough as it failed to identify some
eligible studies such as the study by Liu et al.10
Third, there was a noteworthy deviation between methods
in the registered review protocol11 and methods that were
actually used and reported. For instance, according to the
protocol, the authors intended to search the Cochrane
Library, MEDLINE, Embase, Web of Science, and Google
Scholar databases, but in the review article, only
MEDLINE, Cochrane Library, Scopus, LILACS, and 2 trial
registers were searched. Also, the predetermined
comparator was untreated participants, whereas the actual
comparator was patients treated with RME/PFM. In
addition, 2 predetermined outcomes (maxillary length and
mandibular length) were omitted from the review article.
However, the authors did not provide explanations or
justification for these discrepancies.
Nevertheless, the impact of these limitations on the general
conclusion of this systematic review may not be significant.
Further well-designed and well-conducted RCTs and SRs are
needed to provide more comprehensive and reliable evi-
dence regarding Alt-RAMEC.
In summary, compared to RME/PFM, Alt-RAMEC/PFM may
lead to more improvement in profile among class III growing
patients. In addition, patients treated with Alt-RAMEC/PFM
showed greater maxillary protraction and less clockwise
rotation in the mandible. Therefore, according to the
currently available evidence, the Alt-RAMEC/PFM protocol
may be an effective alternative to RME/PFM, especially for
class III growing patients without maxillary constriction.
REFERENCES
1. 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.
2. Alhammadi MS, Halboub E, Fayed MS, et al. Global distribution
of malocclusion traits: a systematic review. Dent Press J Orthod
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3. Ngan P, Hagg U, Yiu C, Merwin D, Wei SH. Soft tissue and
dentoskeletal profile changes associated with maxillary expan-
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tofacial Orthop 1996;109:38-49.
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The Journal of EVIDENCE-BASED DENTAL PRACTICE
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6. Haas AJ. Long-term posttreatment evaluation of rapid palatal
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7. Liou EJW, Tsai WC. A new protocol for maxillary protraction in cleft
patients: repetitive weekly protocol of alternate rapid maxillary ex-
pansions and constrictions. Cleft Palate-cran J 2005;42:121-7.
8. Liou EJ. Effective maxillary orthopedic protraction for growing
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osteogenesis. Prog Orthod 2005;6:154-71.
9. Almuzian M, Mcconnell E, Darendeliler MA, Alharbi F,
Mohammed H. The effectiveness of Alt-RAMEC combined with
maxillary protraction in the treatment of patients with a class III
malocclusion: a systematic review and meta-analysis. J Orthod
2018;45:250-9.
10. Liu W, Song Y, Wang X, He D, Zhou Y. A cone-beam computed
tomography evaluation of maxillary protraction with repetitive
rapid palatal expansions and constrictions. Chin J Stomato
2015;50:78-83.
11. Almuzian M, AI-Muzian L. The efficiency of Alt-RAMEC combined
conventional extra-oral traction in the treatment of Class III growing
patients: a systematic review. Available at: https://www.crd.york.ac.
uk/prospero/display_record.php?ID5CRD42016036887. Accessed
August 12, 2019.
REVIEWERS
TINGTING ZHAO, BDS, MSc
Department of Orthodontics, Hubei-MOST KLOS & KLOBM,
School & Hospital of Stomatology, Wuhan University, Wuhan,
China
FANG HUA, BDS, MSc, PhD
Department of Orthodontics and Center for Evidence-Based
Stomatology, Hubei-MOST KLOS & KLOBM, School & Hos-
pital of Stomatology, Wuhan University, Wuhan, China; Divi-
sion of Dentistry, School of Medical Sciences, The University of
Manchester, Manchester, UK, huafang@whu.edu.cn
HONG HE, BDS, MSc, PhD
Department of Orthodontics, Hubei-MOST KLOS & KLOBM,
School & Hospital of Stomatology, Wuhan University, Wuhan,
China, drhehong@whu.edu.cn
June 2020 3