Journal of Orthodontics

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The effectiveness of alternating rapid maxillary

expansion and constriction combined with
maxillary protraction in the treatment of patients
with a class III malocclusion: a systematic review
and meta-analysis

Mohammed Almuzian, Elise McConnell, M. Ali Darendeliler, Fahad Alharbi &

Hisham Mohammed

To cite this article: Mohammed Almuzian, Elise McConnell, M. Ali Darendeliler, Fahad Alharbi
& Hisham Mohammed (2018) The effectiveness of alternating rapid maxillary expansion and
constriction combined with maxillary protraction in the treatment of patients with a class III
malocclusion: a systematic review and meta-analysis, Journal of Orthodontics, 45:4, 250-259, DOI:
10.1080/14653125.2018.1518187

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View supplementary material Published online: 25 Sep 2018.

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JOURNAL OF ORTHODONTICS
2018, VOL. 45, NO. 4, 250–259
https://doi.org/10.1080/14653125.2018.1518187

SCIENTIFIC SECTION

The effectiveness of alternating rapid maxillary expansion and constriction

combined with maxillary protraction in the treatment of patients with
a class III malocclusion: a systematic review and meta-analysis
a,b
Mohammed Almuzian , Elise McConnella, M. Ali Darendelilera, Fahad Alharbic and Hisham Mohammedb
a
Discipline of Orthodontics, School of Dentistry, Faculty of Medicine and Health, Sydney Dental Hospital, University of Sydney, Sydney, Australia;
b
Department of Orthodontics, Edinburgh dental Institute, University of Edinburgh, Edinburgh, UK; cDepartment of Preventive Dental Sciences,
Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia

ABSTRACT ARTICLE HISTORY

Objectives: To establish the effectiveness of Alternate Rapid Maxillary Expansion and Constriction Received 15 May 2018
combined with Protraction Facial Mask (Alt-RAMEC/PFM) approach in treating Class III Accepted 25 August 2018
growing patients compared with PFM combined with conventional Rapid Maxillary Expansion
KEYWORDS
(RME/PFM). Systematic review; meta-
Search sources: Unrestricted search in five electronic databases and manual searching were analysis; Alt-RAMEC;
undertaken up to February 2018. protraction facemask; palatal
Data selection: Randomised clinical trials (RCTs) evaluating the effectiveness of Alt-RAMEC/PFM expansion; class III; RCTs
were selected.
Data extraction: Screening of references, data extraction and assessment of bias risk were
evaluated independently by two reviewers.
Results: Five RCTs comparing the Alt-RAMEC/PFM with RME/PFM met the inclusion criteria.
Small but statistically significant mean differences favouring Alt-RAMEC/PFM protocol as
measured by SNA angle (1.16°; 95% CI 0.65 to 1.66), SNB angle (0.67°; 95% CI 0.32 to 1.02) and
ANB angle (0.66°; 95% CI 0.08 to 1.25) were noted. Alt-RAMEC/PFM exhibited a more favourable
overjet correction when compared to RME/PFM, however, differences in other dental changes
were insignificant.
Conclusion: There is limited evidence with high risk of bias that Alt-RAMEC/PFM can result in a
statistically significant increase in maxillary protraction compared with RME/PFM in Chinese
subjects over the short-term. High-quality long-term RCTs with inclusion of patient-reported
outcomes are required.

Introduction
The claimed benefits of rapid maxillary expansion (RME)
include disarticulation of the circum-maxillary sutures
and forward movement of the maxilla as a result of
the palatal shelves pivoting around the pterygomaxil-
lary junction (Haas 1970; Ngan et al. 1997; Turley
2007; Almuzian et al. 2018). However, several studies
have disclosed uncertainty with regard to the clinical
benefits of RME in relation to maxillary protraction
(Foersch et al. 2015).
A new approach entitled ‘Alternating Rapid Maxillary
Expansion and Constriction (Alt-RAMEC) protocol’ was
introduced more than a decade ago by Erik Liou in an
effort to achieve greater forward movement of
the maxilla following maxillary protraction (Liou and
Tsai 2005). The original Alt-RAMEC protocol involved
expansion of the maxilla (1mm/day) in the first week
followed by constriction (1 mm/day) in the following
week. This procedure was repeated for 7–9 weeks, so
as to achieve maximum disarticulation of the maxillary
sutures without consequent over-expansion (Liou and
Tsai 2005).
A recent systematic review (Pithon et al. 2016) found
that using Alt-RAMEC/PFM protocol is effective; however,
the authors did not include studies published in
languages other than English which implied language-
restriction in their inclusion criteria. Pithon and col-
leagues also included non-randomised clinical trials
(Kaya et al. 2011; Al-Mozany et al. 2017) and a retrospec-
tive study (Masucci et al. 2014); while also including
studies that recruited participants with cleft lip and
palate (Liou and Tsai 2005). Furthermore, the authors of

CONTACT Mohammed Almuzian dr_muzian@hotmail.com Discipline of Orthodontics, School of Dentistry, Faculty of Medicine and Health, Sydney Dental
Hospital, The University of Sydney, Rm2.22, Building C12, Sydney, NSW 2006, Australia
Supplemental data for this article can be accessed at https://doi.org/10.1080/14653125.2018.1518187
© 2018 British Orthodontic Society

the previous systematic review could not perform a
meta-analysis to aggregate the findings of the included
studies. Therefore, we suggest that a new comprehen-
sive and unrestricted systematic review is required. The
aims of the current review were to assess the dentoal-
veolar, skeletal and soft tissue effectiveness of Alt-
RAMEC/PFM therapy in Class III growing patients.
Additionally, the total duration of treatment, patient-
reported outcomes and other commonly reported
adverse effects secondary to the Alt-RAMEC/PFM
approach were investigated.
Methods
The study was planned and reported according to pre-
ferred reporting items for systematic reviews (PRISMA)
(Moher et al. 2009) and Cochrane guidelines for Systema-
tic Reviews (Higgins et al. 2011). The study protocol was
registered with PROSPERO (CRD42016036887).
Eligibility criteria
Table 1 describes the main research question which was
defined in PICOS format.
Information sources and search strategy
Five electronic databases and additional manual search
in seven leading orthodontic journals were undertaken
up to 8 February 2018 (Supplementary table 1). The
reference lists of all eligible articles were manually
examined for any additional relevant literature. The rel-
evant manufacturers and corresponding authors of all
selected trials were contacted via email to identify
ongoing and unpublished studies and to clarify trial
details if required.
Study selection
Two independent reviewers (MA and HM) screened in
duplicate, titles and abstracts using the eligibility criteria.
Manual search was undertaken by one reviewer (MA).
Full texts were examined for eligibility and disagree-
ments, if presented, were resolved by discussion with a
third reviewer (FA).
Data extraction
The data were extracted independently by two reviewers
(MA and HM) using a pre-piloted standardised data
extraction form. In the case of disagreement between
the reviewers, a consensus was made through open dis-
cussion with a third reviewer (FA).
JOURNAL OF ORTHODONTICS 251
Table 1. PICO format.
Population Studies were considered only if participants of any gender
were growing and healthy with a Class III skeletal pattern
exhibiting maxillary retrusion within the age range of 7–
14 years.
Intervention Participants undergoing orthodontic treatment for maxillary
retrusion using PFM combined with Alt-RAMEC protocol
in primary, secondary or tertiary orthodontic settings
were included.
Comparators The control group consisted of (1) untreated participants;
(2) participants who received PFM therapy in conjunction
with conventional RPE; or (3) participants who received
PFM alone without expansion, all exhibiting Class III
skeletal pattern due to maxillary retrusion.
Outcome 1. The primary outcomes were:
. The amount of overjet correction measured clinically or
cephalometrically;
. Skeletal changes including position of the maxilla and
mandible and their interrelationship (ANB).
2. Secondary outcomes were:
. Dental changes including upper and lower incisors’
angulation changes according to the most common
endpoint;
. Soft tissue changes measured clinically or
cephalometrically;
. Vertical skeletal changes as measured by maxillary to
mandibular plane angle (MMPA) ;
. Treatment duration of orthodontic treatment and
number of orthodontic appointments;
. Quality of treatment outcomes;
. Patient-reported outcomes, including pain/discomfort
reported during orthodontic treatment; and
. Complications or adverse effects of the intervention.
Types of . Only human randomised clinical trials (RCTs) were
studies included. Animal studies, case reports, case series,
review articles, abstracts and discussions were excluded.
. There was no limitation in terms of language,
publication’s year, publication status, or publication
type.
Assessment of risk of bias in the included studies
Two authors (HM and MA) independently assessed the
risk of bias for each article using the Cochrane Risk of
Bias Assessment Tool (Higgins et al. 2011). Disagree-
ments were resolved by consulting the third reviewer
(FA). The overall risk of bias of individual studies was
categorised as low (if all domains were at low risk of
bias), high (if one or more domains were at high risk of
bias), or unclear (if one or more domains were at
unclear risk of bias).
Approach to data synthesis
Quantitative analysis of the assigned studies was con-
ducted using Review Manager (RevMan) Version 5.3
(Copenhagen: The Nordic Cochrane Centre, The
Cochrane Collaboration, 2014). For continuous data, the
mean difference (MD) with its 95% confidence intervals
(CI) was chosen as a summary effect. Statistical aggrega-
tion of the results was carried out using a random-effects
252 M. ALMUZIAN ET AL.
inverse variance model accounting for between-study
variance. Chi2 and I2 statistics were computed to quantify
statistical heterogeneity.
Additional analyses
Egger’s linear regression test (Egger et al. 1997) was pre-
planned to examine publication bias across studies
altogether with the visual inspection of a generated
contour-enhanced funnel plot if sufficient trials (>10
trials) were located.
Results
The initial search yielded a total of 1206 records. After
duplicate removal, using EndNote reference manager
software, the remaining 793 studies were reviewed
leading to the exclusion of 783 ineligible articles. Full-
text articles for the remaining 10 trials were obtained
and assessed according to the inclusion criteria
described earlier (Figure 1). This resulted in the exclusion
of two references; a retrospective study (Do-deLatour
et al. 2009) and a study that measured airway changes
only (Chang et al. 2017) which is beyond the scope of
this review. Four out of the remaining 8 trials were under-
taken in China by Dr Liu’s team (Liu and Zhou 2009; Liu
and Zhou 2013, 2014; Liu et al. 2015). Two enquiries
were sent to the corresponding authors, two weeks
apart, to confirm if all of these trials were conducted sep-
arately; however, no response was received. The authors
therefore made a judgement to include the largest and
most recent trial (Liu et al. 2015), excluding the others
due to duplicity with these considered as preliminary
reports of the large trial. The final number of trials
included in the systematic review was 5 (Isci et al.
2010; Chen and Xie 2012; Liu et al. 2015; Yao et al.
2015; Xiong et al. 2017).
Characteristics of the studies
None of the included studies compared Alt-RAMEC/PFM
to untreated group or participants who received PFM
alone without expansion. All included trials were two
intervention arms trials, Alt-RAMEC/PFM and RME/PFM
(Table 2). 74 patients received Alt-RAMEC/PFM and 73
patients received RME/PFM. An a priori sample size calcu-
lation was performed in only one included study (Liu
et al. 2015).
All included RCTs were performed in China (Chen and
Xie 2012; Liu et al. 2015; Yao et al. 2015; Xiong et al. 2017),
with the exception of one quasi-RCT which was per-
formed in Turkey (Isci et al. 2010). Two articles were pub-
lished in English (Isci et al. 2010; Liu et al. 2015) while the
remaining three RCTs were published in Mandarin (Chen
and Xie 2012; Yao et al. 2015; Xiong et al. 2017).
Participants
The mean age of the subjects in the Alt-RAMEC/PFM
groups and RME/PFM ranged from 10.11–12.1 years
and 9.81–11.94 years, respectively (Table 3).
Characteristics of the interventions
All included studies compared Alt-RAMEC/PFM to RME/
PFM. All included studies used a banded hyrax as an
RME appliance in conjunction with the PFM. The protrac-
tion protocol did not vary significantly between the
studies with regard to force magnitude, direction and
duration, similarly there was a mild inter- and intra-
studies variation in terms of RME activation protocol
(Table 3).
Risk of bias
The results of the risk of bias assessments are presented
in Figure 2. In summary, one study was assessed as
having an overall low risk of bias (Liu et al. 2015), three
studies had an overall unclear risk of bias (Chen and
Xie 2012; Yao et al. 2015; Xiong et al. 2017) and one
study had a high risk of bias (Isci et al. 2010).
Synthesis of results
Overjet
Only one study with a high risk of bias (Isci et al. 2010)
assessed changes in overjet secondary to Alt-RAMEC/
PFM and RME/PFM treatment. In a narrative synthesis,
over a 12-month period, the MD changes in overjet
were 7.13 ± 2.09 mm (P < 0.0003) and 4.97 ± 2.07 mm
(P < 0.0003), in the Alt-RAMEC/PFM and RME/PFM
groups respectively, which was significant in favour of
the former group (P < 0.001). Maxillary skeletal contri-
bution was 22.8% higher than mandibular skeletal contri-
bution to overjet correction in the Alt-RAMEC/PFM
group; whereas, in the RME/PFM group, the percentages
of maxillary and mandibular contributions were almost
equal. Maxillary dental contribution was marginally
higher (approximately 7%) than mandibular dental con-
tribution to overjet correction in both groups.
SNA, SNB and ANB
SNA, SNB and ANB angles were examined as indications
of the anterior-posterior changes of the maxilla and
 JOURNAL OF ORTHODONTICS 253

Figure 1. Study selection flow chart.

Table 2. A summary of the key study design parameters of included articles.

Study Alt-RAMEC RPE/PFM Method error Statistics used
Study design Country group group analysis for data Methods of assessment
Chen and Xie RCT China N = 10 N = 10 No Yes Lateral cephalograms before and after treatment
(2012)
Isci et al. RCT* Turkey N = 15 N = 15 No Yes Lateral cephalograms taken treatment, after first 6
(2010) months, after second 6 months
Liu et al. RCT China N = 22 N = 21 Yes Yes Lateral cephalograms taken before and after
(2015) treatment
Xiong et al. RCT China N = 10 N = 10 Yes Yes Lateral cephalograms before and after treatment
(2017)
Yao et al. RCT China N = 17 N = 17 No Yes Lateral cephalograms before and after treatment
(2015)
Abbreviations: Alt-RAMEC, alternating rapid maxillary expansion and constriction; RCT, randomised clinical trial, RPE, rapid palatal expansion, PFM, protraction
facemask, N, number.
*Although the study was noted as a prospective trial, inadequate randomisation was performed.
254 M. ALMUZIAN ET AL.

Table 3. Description of participants and interventions of the included studies.

Chen and Xie (2012) Isci et al. (2010) Liu et al. (2015) Xiong et al. (2017) Yao et al. (2015)
Participants 10 (12.1 ± 1.4 years) 15 (11.34 ± 1.81 years) 22 (10.11 ± 1.44 years) 10 (average 10.6 years) 17 (average 10.89 years)
number (Age)
Alt-RAMEC/
PFM group
Participants 10 (11.8 ± 1.6 years) 15 (11.94 ± 1.62 years) 21 (9.81 ± 1.72 years); 1 10 (average 11.2 years) 17 (average 10.89 years)
number (Age) lost to follow-up
RPE/PFM group
Appliance (Extra- PFM PFM PFM PFM PFM
oral) (Rail-type) (Delaire-type) (Delaire-type/ Rail-
type)
Expander Banded hyrax Banded hyrax Banded hyrax Banded hyrax Banded hyrax
(4 bands) (4 bands) (4 bands) (4 bands) (4 bands)
Alt-RAMEC Expansion and Expansion and constriction Expansion and Expansion and Expansion and constriction
protocol constriction rates 2 rates 2 times per day constriction rates 4 constriction rates 2 rates 4 times per day
times per day (0.2 mm every 12 hours) times per day (1 mm/ times per day (1 mm/day) for 7 weeks
(0.2 mm every 12 for 4 weeks day) for 7 weeks (0.2 mm every 12 Sequence: Alternating 7
hours) for 5 weeks Sequence: Alternating 7 Sequence: Alternating hours) for 5 weeks days of expansion
Sequence: days of expansion 7 days of expansion Sequence: followed by 7 days of
Alternating 7 days of followed by 7 days of followed by 7 days of Alternating 7 days of constriction
expansion followed constriction constriction expansion followed
by 7 days of by 7 days of
constriction constriction
RPE protocol Expansion for 2 times Expansion for 2 times per Expansion for 4 times Expansion for 2 times Expansion for 4 times per
per day (0.2 mm day (0.2 mm every 12 per day (1 mm/day) per day (0.2 mm day (1 mm/day) for 1
every 12 hours) for 1 hours) for 1 week for 1 week every 12 hours) for 1 week
week week
PFM protocol 500 g/side; 15–30 350 g/side; 16–18 hours/ 400–500 g/side; 15–30 600 g; 15–30 degrees Force levels of 3.92 to 4.90 N
degrees downward day for first 3 months; 12 degrees downward downward from on each side with at least
from occlusal plane; hours/day second 3 from occlusal plane; occlusal plane; wear 12 hours of daily wear; 15–
wear for at least 14 months; 6 hours/day for wear for at least 14 for at least 12 hours/ 30 degrees downward
hours/day the following 6 months hours/day day from occlusal plane
Experimental N/A 1-month Alt-RAMEC + 12 10.95 ± 2.73 months N/A N/A
period Alt- months PFM
RAMEC/PFM
group
Experimental N/A 1 week RPE + 12 months 11.19 ± 2.75 months N/A N/A
period RPE/ PFM
PFM group
Treatment N/A N/A Positive OJ; Class II or Positive OJ; Class II or Positive OJ, Class I molars
completion Class I molars Class I molars
criterion
Abbreviations: Alt-RAMEC: alternating rapid maxillary expansion and constriction; RPE, rapid palatal expansion; PFM, protraction facemask; OJ, overjet; N/A, not
available.

mandible, and their inter-relationship respectively. included in a random-effects meta-analysis to assess

Four studies were included in the meta-analyses
(Chen and Xie 2012; Liu et al. 2015; Yao et al. 2015;
Xiong et al. 2017). Data from 117 participants were
changes in these cephalometric angles. The MD
changes for SNA, SNB and ANB between the Alt-
RAMEC/PFM and RME/PFM protocols were 1.16° (95%
CI 0.65 to 1.66; I2: 16%; P < 0.00001; 4 trials), 0.67°
(95% CI 0.32 to 1.02; I2: 0%; P = 0.0002; 4 trials)
and 0.66° (95% CI 0.08 to 1.25; I2: 36%; P = 0.03; 4
trials), respectively in favour of Alt-RAMEC/PFM
group (Figure 3(A–C)).

Mandibular plane angle (MP-SN angle)

MP-SN angle was examined as an indication of the
vertical and rotational change of the mandible in
three trials (Chen and Xie 2012; Liu et al. 2015; Xiong
et al. 2017). Statistically insignificant differences (MD
−0.21°; 95% CI −1.73 to 1.3; I2: 71%; P = 0.78; 3 trials)
Figure 2. Risk of bias summary. were found between both protocols (Figure 3(D)).
 JOURNAL OF ORTHODONTICS 255

Figure 3. Forest plot denoting the (A) SNA, (B) SNB, (C) ANB, and (D) MnP-SN angles.

Lower incisor angulation (L1-MnP) Upper incisor angulation (U1-MxP)

LI-MP was examined as an indication of mandibular
dento-alveolar change. The pooled effect of the data
from 83 participants (Chen and Xie 2012; Liu et al.
2015; Xiong et al. 2017) was not statistically significant
(MD 0.38°; 95% CI −0.76 to 1.52; I2: 0%; P = 0.51; 3
trials) (Figure 4(A)).
Data from 63 participants (Liu et al. 2015; Xiong et al.
2017) were included in a random-effects meta-analysis
to assess the changes in upper incisor angulation
between the two protocols (Figure 4(B)). Again, statisti-
cally insignificant results were noted (MD 0.02°; 95% CI
−1.56 to 1.6; I2: 0%; P = 0.98; 2 trials).
256 M. ALMUZIAN ET AL.
Figure 4. Forest plot denoting the (A) L1-MnP and (B) U1-MxP angles.
Soft tissue changes
Although soft tissue changes were assessed in two
RCTs eligible for quantitative synthesis (Chen and Xie
2012; Liu et al. 2015), statistical pooling of the
results could not be carried out due to heterogeneity
in the soft tissue variables. In one trial (Liu et al. 2015),
a vertical axis was created (VRL), which was con-
structed by passing a line perpendicular to the hori-
zontal axis through Sella point, and then the
following cephalometric landmarks to measure soft
tissue changes:
• H angle of convexity (°): angle formed by a line
tangent to the chin and upper lip with the line connect-
ing N point to B point (NB)
• ULC-VRL (mm): perpendicular distance from soft
tissue point A to VRL
• LLC-VRL (mm): perpendicular distance from soft
tissue point B to VRL
An increase in H angle and ULC-VRL and a decrease in
LLC-VRL were noted in both protraction groups in one
study (Liu et al. 2015). More pronounced changes for H
angle and LLC-VRL measurements were evident in the
Alt-RAMEC/PFM group (H angle increase of 8.08 ± 3.69°
and LLC-VRL decrease of 1.27 ± 1.53 mm) compared
with the RME/PFM group (H angle increase of 6.95 ±
3.86° and LLC-VRL decrease of 2.82 ± 1.57 mm). An
improvement in soft tissue position of both lips was
noted in both protraction protocols in another study
(Chen and Xie 2012). Anterior movement of the upper
lip was more pronounced in the Alt-RAMEC/PFM group
compared with the RME/PFM group. However, statisti-
cally insignificant differences were noted concerning
the posterior displacement of the lower lips in relation
to the Esthetic line (E-line).
Duration of protraction phase
One high-quality study (Liu et al. 2015) eligible for quan-
titative synthesis, reported on the total treatment dur-
ation (TTD); from the beginning of expansion to the end
of protraction, and protraction phase time (PPT); from
the beginning to the end of protraction. TTD was 11.19
± 2.75 months with RME/PFM group and 10.95 ± 2.73
months with Alt-RAMEC/ PFM group; however, the
effect of protraction protocols on TTD was statistically
insignificant (MD 0.24; 95% CI, −1.45 to 1.92; P = 0.779).
On the other hand, PPT was significantly longer (MD
1.78; 95% CI 0.15 to 3.42; P = 0.033) in RME/PFM groups
(10.84 ± 2.76 months) compared to Alt-RAMEC group
(9.06 ± 2.55 months).
Adverse effects
One high-quality study (Liu et al. 2015) reported on these
outcomes. In this trial, none of the participants in either
RME/PFM or Alt-RAMEC/PFM groups had serious harms
and that there was no difference in terms of participants’
cooperation or average wearing time among the two
groups (11.5 hours).
Patient-reported outcomes
None of the included trials assessed patient-reported
outcomes or the number of orthodontic appointments.
 JOURNAL OF ORTHODONTICS 257

Additional analyses and quality of evidence

MODERATE

MODERATE

MODERATE

MODERATE
Certainty
Inspection of publication bias could not be established

LOW
⊕⊕⊕

⊕⊕⊕

⊕⊕⊕

⊕⊕⊕
Low
⊕⊕

⊕⊕
due to the limited number of included RCTs. The
quality of resultant evidence ranged from low to moder-

(0.76 lower to 1.52 higher)

(1.56 lower to 1.6 higher)

(1.73 lower to 1.3 higher)

MD 1.16 degrees higher

MD 0.67 degrees higher

MD 0.66 degrees higher

MD 0.02 degrees higher

MD 0.38 degrees higher

ate (Table 4).

MD 0.21 degrees lower

(0.65 higher to 1.66

(0.32 higher to 1.02

(0.08 higher to 1.25

Absolute
(95% CI)
Discussion

Effect

higher)

higher)

higher)
Summary of evidence
Most of the cephalometric skeletal and dental measure-
ments were comparable statistically. However, outcomes

(95% CI)
Relative
regarding overjet changes, soft tissues changes, treat-

–
ment duration, adverse effects of intervention and
patient compliance had to be reported narratively as

RPE/
FM
they were assessed either differently or only in one trial.

58

58

58

31

41

41
№ of patients
None of the studies reported about patient-reported out-

ALT-RAMEC/
comes or number of orthodontic appointments.

FM
Change in overjet was only measured in one study
(Isci et al. 2010), and hence definitive conclusions could

59

59

59

32

42

42
not be drawn, and the primary outcome of this review
could not be addressed adequately. This study found

considerations
that the overjet increased following PFM in both Alt-
RAMEC/PFM and RME/PFM groups, as a result of a com- Other

bination of skeletal and dento-alveolar changes.

none

none

none

none

none

none
However, the Alt-RAMEC/PFM group exhibited a higher
level of maxillary skeletal contribution to overjet
Imprecision
not serious

not serious

not serious

not serious

not serious
seriousc
changes, whereas the RME/PFM group exhibited nearly
equal levels of maxillary and mandibular skeletal contri-

Abbreviations: CI, confidence interval; MD, mean difference; Mn-SN, mandibular plane to SN plane.
butions (Isci et al. 2010).
Indirectness
not serious

not serious

not serious

not serious

not serious

not serious

Downgraded one level for risk of bias: Most of the studies presented with unclear risk of bias
At a skeletal level, the general consensus of the body
of evidence in this review indicated that Alt-RAMEC/PFM
results in a small but significantly greater protraction of
the maxilla, similar to the findings of the previous
Inconsistency
not serious

not serious

not serious

not serious

not serious

review (Pithon et al. 2016). The enhanced sagittal maxil-

Certainty assessment

Downgraded one level for inconsistency: Increased statistical heterogeneity

serious

lary protraction in the Alt-RAMEC/PFM group may be due

to the effect of Alt-RAMEC protocol in loosening the
Risk of bias

circum-maxillary sutures (Liou and Tsai 2005; Wang

seriousa

seriousa

seriousa

seriousa

seriousa
a
Table 4. Overall summary of the evidence (GRADE).

serious

et al. 2009; Almuzian et al. 2016). In terms of mandibular

Downgraded one level for imprecision: Only two small trials

changes, the findings of this review was that Alt-RAMEC/

PFM results in a lesser sagittal effect on the mandible
Study design

compared with RME/PFM, contradicting with the

randomised

randomised

randomised

randomised

randomised

randomised

findings by Pithon and colleagues (Pithon et al. 2016),

trials

trials

trials

trials

trials

trials

however it is important to consider that the latter

review was limited to studies published in English,
included non-RCTs and participants with cleft lip and
Upper incisors’ inclination/ 2

Lower incisors’ inclination/ 3

palate.
Outcome/ № of studies

The current meta-analysis reveals a lower but statisti-

Mn-SN plane/ 3 trials

cally insignificant clockwise rotation of the mandibular

plane in Alt-RAMEC/PFM group compared to RME/ PFM
ANB/ 4 trials
SNA/ 4 trials

SNB/ 4 trials

group, similar to the findings of the previous review

trials

trials

(Pithon et al. 2016) which theoretically could be due to

the fact that the reactionary force of the PFM on the
b
a

c
258 M. ALMUZIAN ET AL.
mandible during protraction is more disseminated in the
Alt-RAMEC/PFM group compared to the counterpart (Liu
et al. 2015).
This review also showed that both Alt-RAMEC/PFM
and RME/PFM resulted in a similar degree of upper inci-
sors’ proclination and lower incisors’ retroclination.
However, the standard deviations for changes in the inci-
sors angulation were large, indicating significant individ-
ual variability among participants of both groups.
The extent of soft tissue changes was assessed in two
studies (Chen and Xie 2012; Liu et al. 2015), however, it
was not possible to analyse quantitatively due to differ-
ences in the utilised cephalometric landmarks. In
general, an improvement in the total facial convexity
was stated in both studies (Chen and Xie 2012; Liu
et al. 2015) in favour of Alt-RAMEC/PFM group.
One of the included trials (Liu et al. 2015) revealed
that participants from Alt-RAMEC/PFM and RME/PFM
groups had similar total treatment duration, cooperated
equally and developed no side effects secondary to
either interventions. However, protraction time for Alt-
RAMEC/PFM protocol was almost two months shorter
than the RME/PFM. None of the studies reported about
other patient-reported outcomes or number of ortho-
dontic appointments.
Strengths and limitations
The authors attempted to minimise bias by undertaking
a comprehensive and unrestricted search of multiple
databases and literature sources aiming to identify
every single research paper that matched the inclusion
criterion.
However, the body of evidence was generally of low
to moderate quality, mainly due to the unclear
domains presented in many included trials and the
small sample sizes. Furthermore, all studies eligible for
quantitative synthesis were conducted in China; hence,
generalisability of the obtained results is limited. The
authors acknowledge that there were minor between-
study variances in terms of activation protocol and age
of the participants. For this reason, clinical heterogeneity
was taken in consideration and random-effects model
was adopted in the meta-analysis of the results.
Implications for future research
There is a need for further long-term and high-quality
RCTs to assess the dento-skeletal and soft tissue
changes of these techniques. Academics are encouraged
to register their trials a priori and calculate the required
sample sizes for their studies. Important outcomes such
as patient-reported outcomes and number of required
orthodontic appointments following Alt-RAMEC/PFM
therapy should be also investigated.
Conclusions
There is limited evidence at high risk of bias suggesting
that overjet and facial profile are improved secondary to
Alt-RAMEC/PFM in comparison to RME/PFM in Chinese
growing children.
There is also low to moderate quality of evidence
suggesting that on a short-term basis, Alt-RAMEC/PFM
results in a greater skeletal sagittal improvement with
more maxillary protraction and less mandibular clock-
wise rotation when compared to the conventional
approach (RME/PFM) in Chinese growing children,
although changes in incisor inclinations were similar,
regardless of the utilised expansion method.
Limited evidence suggests that total treatment dur-
ation and participants’ cooperation do not seem to be
affected by expansion method.
These favourable effects might not be considered
clinically significant and high-quality RCTs comparing
the Alt-RAMEC/PFM protocol to PFM alone or to
untreated controls, reporting on patient-reported out-
comes, are required.
Acknowledgements
The authors would like to thank Lajos Bordas from the Dentistry
Library, University of Sydney for his valuable assistance in devis-
ing and implementing the search. We would also like to thank
Dr Khaled Ahmed and Dr Ting Wang from the University of
Hong Kong for supplying the Chinese articles.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Mohammed Almuzian http://orcid.org/0000-0002-1696-6649
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