Facemask with Alt Ramec protocol therapy

Young patients with Class III malocclusions and maxillary deficiencies are treated primarily with face masks. Because the force is applied to the teeth, however, the inevitable mesial migration of the dentition can result in anterior crowding and the need for subsequent extraction therapy. At the same time, the skeletal correction often turns out to be less effective than expected.

Facemask therapy is commonly combined with rapid palatal expansion (RPE) to take advantage of the expected stimulation of the mid-palatal sutures.

Liou’s Alt-RAMEC (alternating rapid maxillary expansion and constriction) protocol was designed to maintain this sutural stimulation over a longer period, thus achieving greater maxillary protraction. The expander is activated about 1mm (four turns) daily, alternating one week of expansion with one week of constriction.

It seems that the best type of treatment consists of two phases:

the first one with a maxillary expansion appliance that has to be activated until the desired transverse width is achieved, and the second one with a facial mask to obtain the advancement of the maxillary complex; the aim of the first step is not only to increase the transverse dimension of the palate but also to open the sutures of the midface complex to amplify the protraction effect of the face mask.

The alternate rapid maxillary expansions and constrictions (Alt-RAMEC protocol) followed by facial mask has also been successful in the late mixed or permanent dentition when the patient is close to the pubertal growth spurt because it seems to produce an adequate distraction of circummaxillary sutures condition that supports the second phase of protraction of the maxilla.