CLINICIAN'S CORNER

Distalization of the mandibular dentition

with a ramal plate for skeletal Class III
malocclusion correction
Yoon-Ah Kook,a Jae Hyun Park,b Mohamed Bayome,c Sungkon Kim,d Eugene Han,e and Chang Hyen Kimf
Seoul, Korea, Mesa, Ariz, Asuncion, Paraguay, and Los Angeles, Calif

The retromolar fossa is an anatomically suitable skeletal anchorage site. The aim of this report was to introduce a
novel appliance for the correction of skeletal Class III malocclusions with mandibular dentition distalization. The
placement site and the procedure of the ramal plate are described. The resulting force vectors are parallel to the
functional occlusal plane leading to efficient molar distalization. This approach is demonstrated with 2
adult patients who refused a surgical treatment option. This ramal plate may be indicated for total arch distaliza-
tion for nonextraction and nonsurgical cases. (Am J Orthod Dentofacial Orthop 2016;150:364-77)

A
severe anteroposterior skeletal discrepancy in a pa-
tientwithaClassIIImalocclusionisgenerallytreated
withorthognathic surgery.However,amildtomod-
erate skeletal Class III malocclusion can be treated by either
surgery or camouflage.1,2 Traditionally, patients who were
reluctant to undergo surgical procedures to improve their
Class III dental relationships turned to camouflage
orthodontic treatment with different extraction patterns
according to the proclination of the mandibular incisors
and the amount of negative overjet.3-5
Recently, temporary skeletal anchorage devices (TSADs)
have decreased the need for extractions and surgical proce-
dures.6-11 Previous studies have reported the achievement
a
Professor, Department of Orthodontics, Seoul St. Mary's Hospital, Catholic
University of Korea, Seoul, Korea.
b
Professor and chair, Postgraduate Orthodontic Program, Arizona School of
Dentistry & Oral Health, A. T. Still University, Mesa, Ariz; adjunct professor,
Graduate School of Dentistry, Kyung Hee University, Seoul, Korea.
c
Research assistant professor, College of Medicine, Catholic University of Korea,
Seoul, Korea; visiting professor, Department of Postgraduate Studies, Universidad
Auton oma del Paraguay, Asunci on, Paraguay.
d
Resident, Department of Orthodontics, Seoul St. Mary's Hospital, Catholic
University of Korea, Seoul, Korea.
e
Resident, Department of Orthodontics, University of Southern California, Los An-
geles, Calif.
f
Associate professor, Department of Oral and Maxillofacial Surgery, Seoul St. Mary's
Hospital, Catholic University of Korea, Seoul, Korea.
All authors have completed and submitted the ICMJE Form for Disclosure
of Potential Conflicts of Interest, and none were reported.
This study was partly supported by the fund of the Department of Orthodontics,
Graduate School of Clinical Dental Science, Catholic University of Korea.
Address correspondence to: Yoon-Ah Kook, Department of Orthodontics, Seoul
St. Mary's Hospital, Catholic University of Korea, 222 Banpo-daero, Seocho-Gu,
Seoul 137-701, Korea; e-mail, kook190036@yahoo.com.
Submitted, September 2015; revised and accepted, March 2016.
0889-5406/$36.00
Ó 2016 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.03.019
364
of 4 to 5 mm of mandibular molar distalization using
miniscrews in the retromolar area.6,7 Distalization of the
mandibular molars enables retraction of the incisors to
achieve a positive overjet. Other studies have reported
successful mandibular total arch distalization using
stainless steel miniscrews placed in the buccal shelf.12,13
Miniplates can withstand the higher forces required
to distalize the whole dentition, unlike miniscrews.14 Su-
gawara et al15 reported the use of miniplates for
mandibular distalization, and they placed the miniplates
on the mandibular body. In contrast, our ramal plates are
installed medial to the anterior border of the ramus
because the force vector might be more favorable from
the retromolar area for some patients because it is
more parallel to the functional occlusal plane.
Therefore, the purpose of this article is to introduce
placement of a ramal plate in the retromolar fossa as a novel
approach to efficient mandibular total arch distalization.
A ramal plate is placed in the retromolar fossa, located
between the anterior border of the mandibular ramus and
the temporal crest (Fig 1).16 After doing the flap in the ret-
romolar area, the L-plate (LeForte System; Jeil Medical,
Seoul, Korea; length of the short arm, 10 mm; length of
the long arm, 15.5 or 22 mm; diameter, 2.5 mm) is adapted
to fit the bone surface. The third molars are extracted dur-
ing the procedure. The anterior hole of the plate that ex-
tends into the oral cavity is positioned horizontally to be
3 mm lateral to the buccal surface of the second molar,
and between the buccal groove of the second molar and
its distal surface, anteroposteriorly (Fig 2).
The plates are fixated with 2 screws (with pilot dril-
ling), 2 mm in diameter, 5 mm in length. The flap
is sutured (usually 2 sutures) over the plate, and the
Kook et al
Fig 1. Placement site of the ramal plate showing the retromolar fossa: A, frontal view; B, oblique view;
C, ramal plate before bending; D and E, ramal plate bent and placed on site.
hook is extended out of the mucosa, vertically at the
level of the second molar tube and horizontally within
3 to 6 mm lateral to the buccal surface of the
second molar. Elastic chain can be tied around the ante-
rior screw hole of the plate, or it might be cut occlusally
to convert it into a hook for easier placement of elastics
or nickel-titanium closed-coil springs that are connected
to hooks crimped to the archwire between the lateral in-
cisors and the canines immediately after the plate is
placed (Fig 3). Analgesics might be prescribed after
placement to alleviate any postoperative pain.
PATIENT 1
A 21-year-old man came with a chief complaint of “I
cannot chew properly.” He had a brachyfacial, symmetrical
face and a prognathic mandible with a Class III appearance.
American Journal of Orthodontics and Dentofacial Orthopedics
365
Intraorally, his maxillary central incisors showed an over-
jet of 1 mm and an overbite of 0.5 mm. He also had an ante-
rior crossbite on his maxillary right lateral incisor and
posterior open bites with a frontal and lateral tongue-
thrust habit when swallowing. He had full-step Class III
molar relationships on the right side and end-on Class III
relationships on the left side with moderate crowding in
both arches. He also had a 3-mm curve of Spee on the
mandibular arch. The intermolar widths were narrow, and
the mandibular posterior teeth were tilted lingually (Fig 4).
The mandibular right third molar was missing (Fig 5).
The patient had a skeletal Class III (ANB,
4.0 ; Wits
appraisal,
7.0 mm; Harvold analysis, 35.5 mm) with a
hypodivergent growth pattern (FMA, 20.0 ). The
mandibular incisors were retroclined (IMPA, 79.0 ),
and the maxillary incisors were proclined (U1-FH,
August 2016  Vol 150  Issue 2
366
Fig 2. Placement procedure: A, incision; B, flap reflection showing retromolar fossa; C, adjusting the
plate during placement; D, after placement of the ramal plate.
Fig 3. The ramal plate connected with an elastomeric
chain to a hook on the archwire.
127.0 ). The interincisal angle was 134.5 , showing
dental compensation of the skeletal Class III discrepancy
(Table I).
The following treatment objectives were established:
(1) correct the jaw discrepancies of the maxilla and the
mandible, (2) correct the anterior crossbite and the pos-
terior open bites, (3) improve the narrow maxillary inter-
molar widths and the torque of the mandibular posterior
teeth, (4) improve overbite and overjet, (5) establish a
stable Class I dental relationship, and (6) and improve
facial and dental esthetics.
The first treatment option was to perform 2-jaw sur-
gery to correct the patient's skeletal discrepancies. The
second option was to distalize the mandibular arch
with ramal plates as TSADs after extraction of the
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Kook et al
mandibular left third molar. The patient selected the sec-
ond treatment option with the ramal plates to avoid sur-
gical treatment.
The patient was bonded with 0.022-in straight-wire
fixed orthodontic appliances on the maxillary and
mandibular dentitions with an initial wire of 0.016
copper-nickel-titanium. The wires were gradually
changed to 0.019 3 0.025 stainless steel.
Distalization was continued for 6 months. Superim-
position of the cone-beam computed tomography
(CBCT) images taken before and after distalization
shows the amount of molar distalization. A panoramic
image was also reconstructed from the CBCT images af-
ter distalization (Fig 6). The appliances were removed
27 months after the initial bracket placement. The pro-
longed treatment time was mainly because the patient
missed several appointments. Maxillary and mandibular
fixed retainers were bonded, and myofunctional therapy
was recommended to control his tongue-thrust habit.
A Class I dental relationship was established. Normal
overbite and overjet were obtained. Adequate interdigi-
tation was achieved except on his second premolars
because of the severity of his tongue-thrust habit
(Fig 7). The maxillary intermolar width increased from
38.5 to 41.0 mm.
The posttreatment lateral cephalometric analysis and
the superimposition showed that ANB increased from

4.0 to
2.5 , but his Class III profile was not
improved significantly because of his prominent chin.
Kook et al 367

Fig 4. Pretreatment facial and intraoral photographs.

Fig 5. Pretreatment radiographs: A, panoramic radiograph; B, lateral cephalogram.

The maxillary incisor inclinations were improved (U1-
FH, from 127.0 to 116.5 ). The mandibular incisor tip
and pogonion were distalized by 2.5 and 1.5 mm,
respectively. Lower anterior vertical height increased by
2 mm (Figs 8 and 9; Table I). The maxillary molars
were extruded about 1.7 mm by up-and-down elastics.
The mandibular first molar crown was distalized by
4.2 mm and the apex by 3.2 mm.
At the 33-month follow-up, the treatment effects
were maintained, and the radiographs showed
fairly stable results (ANB,
2.0 ; U1-FH, 115.5 ;
IMPA, 82.5 ; FMA, 21.5 ). However, the patient still

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368 Kook et al

Table I. Cephalometric analysis of patient 1

Measurement Norm Pretreatment Posttreatment
Horizontal skeletal pattern
SNA ( ) 82.0 87.0 87.0
SNB ( ) 80.0 91.0 89.5
ANB ( ) 2.0
4.0
2.5
A-point to N perpendicular (mm) 1.1 0.5 1.0
Pog to N perpendicular (mm)
0.3 11.0 9.5
Wits appraisal (mm)
2.2
7.0
2.0
Harvold analysis (mm) 35.8 35.5 36.0
Vertical skeletal pattern
Facial height ratio (posteroanterior) (%) 66.4 72.5 71.0
FMA ( ) 24.0 20.0 21.5
ODI ( ) 73.3 61.0 65.0
Dental analysis
U1 to FH ( ) 116.5 127.0 116.5
IMPA ( ) 90.0 79.0 83.0
Interincisal angle ( ) 124.0 134.5 139.5
FH to occlusal plane ( ) 10.5 0.5 3.5
Soft tissue analysis
TVL to UL (mm) 5.0 6.5 5.0
TVL to LL (mm) 2.5 6.5 3.0
TVL to Pog0 (mm)
3.0 6.0 4.5
Nasolabial angle ( ) 85.0 106.5 110.0
ODI, Overbite depth indicator; TVL, true vertical line; UL, upper lip; LL, lower lip; Pog0 , soft tissue pogonion.

Fig 6. A, Superimposition of CBCT images taken before and after distalization. Vertical line drawn at
the distal contact point of the mandibular first molar is to measure distalization. B, Panoramic image
from the CBCT images after distalization.

had a tongue-thrust habit, which opened his bite on the
left second premolar and first molar. Myofunctional
therapy to control his tongue thrust was stressed again.
He was referred to his oral surgeon for an evaluation of
his maxillary third molars (Figs 10 and 11).
PATIENT 2
A 22-year-old man came with a chief complaint of
“my lower teeth are sticking out.” He had
had previous treatment with 4 first premolar extrac-
tions during adolescence (Figs 12 and 13). He was
slightly dolichofacial, with a symmetrical face and a
straight profile. Intraorally, his maxillary central
incisors showed edge-to-edge bites. He also had an
anterior crossbite on his maxillary right lateral incisor
and an open bite on his left lateral incisor. In addi-
tion, he had a tongue-thrust habit when swallowing.
He had Class III canine and molar relationships on
both sides with mild crowding on the maxillary
arch and moderate crowding on the mandibular
arch. Generalized gingival recession was seen on
several teeth (Fig 12).

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Kook et al 369

Fig 7. Posttreatment facial and intraoral photographs.

Fig 8. Posttreatment radiographs: A, panoramic radiograph; B, lateral cephalogram.

He had all 4 third molars (Fig 13) and a skeletal Class
III (ANB, 0.5 ; Wits appraisal,
6.5 mm) with a hyperdi-
vergent growth pattern (FMA, 32.5 ). The mandibular
incisors were retroclined (IMPA, 86.0 ), and the maxillary
incisors were proclined (U1-FH, 122.5 ) (Table II).
The first treatment option was to perform 2-jaw sur-
gery to correct the patient's skeletal discrepancy, but
because he had already had his premolars extracted,
additional premolar extractions were not considered.
The other option was to distalize the mandibular arch

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370
Fig 9. Cephalometric superimpositions. Black, pretreatment; red, posttreatment.
using ramal plates as TSADs after extraction of both
mandibular third molars.
The patient refused the surgical treatment option and
selected the one with the ramal plates. He was referred to
a periodontist to evaluate his periodontal conditions.
Ramal plates were placed on both sides of the
mandible. Mandibular distalization was achieved with
ramal plates and Class III elastics. Miniscrews (Dual
Top, 1.6 3 6 mm; Jeil Medical) were also installed in
the maxilla between the first and second molars on
the buccal and palatal surfaces to intrude the maxillary
molars to prevent occlusal interferences during
mandibular distalization. To prevent clockwise rotation
of the mandible because of the extrusion of the poste-
rior maxillary molars, Class III elastics were engaged
from the TSADs to the mandibular canine hooks. The
anterior crossbite was corrected, and overjet increased
by 6 mm after 9 months (Fig 14, A and B). The patient
was first bonded with lingual appliances on the maxil-
lary arch for esthetic reasons but later changed to labial
appliances for better detailing during the finishing
period. Gingival recession on maxillary left first molar
increased during orthodontic treatment; therefore,
periodontal surgery was scheduled by the periodontist
(Fig 14, C).
At debonding, maxillary and mandibular
fixed retainers were bonded, and wraparound removable
retainers were delivered to secure the stability of both
arches. The total treatment took 38 months. Treatment
time was longer than usual because of the switch from
lingual to labial appliances, the root canal treatment of
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Kook et al
the mandibular left second molar, and the periodontal
treatment.
Because he did not wear the up-and-down elastics
regularly during the finishing stage and had a tongue-
thrust habit, the maxillary left second premolar and first
molar, and the maxillary right second molar do not show
ideal interdigitation, but the patient was satisfied (Fig 15).
The maxillary incisors were slightly retroclined (FH-
U1, from 122.5 to 121.5 ). The mandibular incisors
were retroclined (IMPA, from 86.0 to 68.5 ) to correct
the overjet and perform interproximal reduction to
reduce the black triangles in the mandibular anterior
teeth (Table II). The superimposition showed distaliza-
tion of the mandibular dentition without a significant
mandibular plane change (Figs 16-18).
DISCUSSION
Treatment of Class III patients is challenging. Recent
applications of TSADs to distalize the mandibular molars
have increased the range of the nonsurgical treatment
options. With the application of miniscrews in interra-
dicular spaces, it is difficult to distalize more than 2 to
3 mm because of space limitations.17-19 However, with
ramal plates, there is no relocation of the miniscrews
during distalization.
Generally, plates can withstand heavy forces, and
their stability is increased because they are installed
with 2 screws.20,21 Several studies have reported lower
failure rates for miniplates than for miniscrews.20,22 A
systematic review showed that the failure rate of
Kook et al 371

Fig 10. Posttreatment facial and intraoral photographs at 33 months.

Fig 11. Posttreatment radiographs at 33 months: A, panoramic radiograph; B, lateral cephalogram.

miniplates was 7.3%, whereas that of miniscrews was
16.4%.21 In addition, miniscrews placed in the mandible
have a greater failure risk than in the maxilla.20
The hook of the plate was exposed through the retro-
molar region; this might cause less irritation than when
it is through the movable vestibular mucosa. In addition,
the point of force application in our report was between
the buccal groove of the second molar and its distal sur-
face, anteroposteriorly. This allows a longer range of ac-
tion as seen in Figure 19, where the dot on the ramal
plate shows the longest distance to the hook.
With miniscrews placed in the buccal shelf, the lateral
component of the force may act to increase the interca-
nine width and consequently affect the stability of the

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372 Kook et al

Fig 12. Patient 2: Pretreatment intraoral photographs.

Fig 13. Patient 2: Pretreatment radiographs: A, panoramic radiograph; B, lateral cephalogram.

treatment results. They may also cause rotation of the
occlusal plane, increasing the vertical dimension, based
on the relationship between the force vector and the cen-
ter of resistance of the entire arch.23,24 However, the force
of the ramal plate is more parallel to the functional
occlusal plane, and the lateral component is minimal,
causing less rotation than with miniscrews. This
parallelism to the occlusal plane might be more
favorable in some cases, depending on the desired tooth
movement, especially in patients with a Class III open
bite. Therefore, because the ramal plate can withstand
heavy forces and produces a more favorable force vector
with a longer range of action, it might be more efficient
in mandibular total arch distalization (Fig 19).
Figure 20 describes the force system and the resultant
displacement. Distalization was achieved by application
of a force parallel to the functional occlusal plane. This
force caused a combination of translation and counter-
clockwise rotation of the mandibular occlusal plane
around a point slightly apical to the center of resistance
of the mandibular dentition. Consequently, this resulted
in distalization of the whole dentition in addition to
intrusion of the posterior teeth and extrusion of the
anterior teeth, as shown in the patients.
Several studies reported less than 3.5 mm of mandib-
ular arch distalization using miniscrews.25-27 A previous
study reported a first molar distal tipping ratio of 46%.15
Our report showed less tipping of the molars during dis-
talization; patient 1 had 4.2 mm of distalization with a
distal tipping ratio of 24%, and patient 2 had 4.9 mm
of distalization and a distal tipping ratio of 37%. These
were measured using the reference lines Frankfort

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Kook et al 373

Table II. Cephalometric analysis of patient 2

Measurement Norm Pretreatment Posttreatment
Horizontal skeletal pattern
SNA ( ) 82.0 83.0 83.0
SNB ( ) 80.0 82.5 81.5
ANB ( ) 2.0 0.5 1.5
A-point to N perpendicular (mm) 1.1 4.0 3.5
Pog to N perpendicular (mm)
0.3 8.5 6.5
Wits appraisal (mm)
2.2
6.5
3.0
Harvold analysis (mm) 35.8 41.5 41.5
Vertical skeletal pattern
Facial height ratio (posteroanterior) (%) 66.4 60.0 60.0
FMA ( ) 24.0 32.5 34.5
ODI ( ) 73.3 55.5 55.0
Dental analysis
U1 to FH ( ) 116.5 122.5 121.5
IMPA ( ) 90.0 86.0 68.5
Interincisal angle ( ) 124.0 118.0 134.5
FH to occlusal plane ( ) 10.5 5.5 4.5
Soft tissue analysis
TVL to UL (mm) 5.0 7.0 6.0
TVL to LL (mm) 2.5 9.0 4.5
TVL to Pog0 (mm)
3.0 0.5
1.5
Nasolabial angle ( ) 85.0 93.5 98.0
ODI, Overbite depth indicator; TVL, true vertical line; UL, upper lip; LL, lower lip; Pog0 , soft tissue pogonion.

Fig 14. Patient 2: A and B, Lateral cephalograms after leveling and after total arch distalization; C, in-
traoral photographs after distalization.

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374
Fig 15. Patient 2: Posttreatment intraoral photographs.
Fig 16. Patient 2: Posttreatment lateral cephalogram.
horizontal and a vertical to Frankfort horizontal, and the
distal tipping ratio represented the root-to-crown move-
ment.
In patient 1, up-and-down elastics were used for
posterior open-bite correction, which resulted in a clock-
wise rotation of the mandible (FMA increased by 1.5 ).
Previous studies demonstrated the relationship between
the anteroposterior position of pogonion to the vertical
movement of the posterior teeth.26,27 Our patient's
brachyfacial profile was improved by increasing the
vertical dimension and slightly retruding pogonion
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Kook et al
(Fig 9). Even though the 33-month follow-up records
showed a stable treatment outcome, an increase in the
mandibular plane angle should be controlled with
caution to prevent increasing the risk of relapse.
During distalization, management of the mandibular
anterior teeth within the alveolar bone is essential. Since
the force vector is above the center of resistance of the
anterior teeth, counterclockwise rotation and conse-
quently uncontrolled tipping of the anterior teeth might
be expected. Therefore, to control the position of their
apices, a third-order bend at the anterior section of the
archwire might be necessary. In patient 1, IMPA was
increased during leveling and alignment, and the ten-
dency of linguoversion of the anterior teeth was mini-
mized. This gain was maintained during distalization.
However, in patient 2, IMPA was decreased because
the premolars had already been extracted in the previous
treatment, and the amount of anterior retraction needed
was too large to be done as bodily movement. Addition-
ally, interproximal reduction was done on the mandib-
ular anterior teeth to reduce the black triangles. No
signs or symptoms were found of adverse effects on
gingival recession, mobility, and bone loss.
When the ramal plate is placed, there is a possibility
that the retromolar foramen might be near the placement
area. However, the incidence of this happening is between
9% and 25%.16,28,29 Because the neurovascular bundle is
connected to the pulp tissue and periodontium of the third
molar through the foramen, it is necessary to examine the
placement site after flap reflection relative to the position
of this foramen (Fig 2, B). Moreover, the surgical proce-
dures for placement and removal of the plates on each
side might be considered a drawback for this appliance
compared with the miniscrew.
Kook et al 375

Fig 17. Patient 2: Cephalometric superimpositions. Black, pretreatment; red, posttreatment.

Fig 18. Patient 2: Comparison of A, pretreatment and B, posttreatment facial profiles.

In our results for patient 1, the ramal plate signifi-
cantly distalized the whole mandibular dentition (Fig 9).
In patient 2, 5 mm of molar distalization and 6 mm of
overjet correction were achieved in only 9 months.
Therefore, the ramal plate can be considered a viable
treatment option for Class III malocclusion patients
with moderate to severe crossbite who want to avoid
orthognathic surgery. Further study is recommended to
evaluate the skeletal, dental, and soft tissue changes
with a larger sample after application of the ramal plate.

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376 Kook et al

Fig 19. Comparison of the force vector in each device: A, lateral view; B, occlusal view. Dots indicate
the positions of the miniscrew head and the ramal plate hook: a, interradicular miniscrew; b, buccal
shelf miniscrew; c, ramal plate hook.

CONCLUSIONS
The retromolar fossa is an anatomically suitable
placement site for ramal plates. The resulting force vec-
tors are parallel to the occlusal plane, leading to efficient
molar distalization. Ramal plates may be a viable treat-
ment option for mandibular total arch distalization in
Class III patients who are reluctant to have orthognathic
surgery.

ACKNOWLEDGMENTS

The authors would like to thank Dr Noha H. Abbas for

her assistance in preparing Figure 20.

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level of the archwire; B, distalization and counterclock-
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the center of rotation (blue dot), which is slightly apical
to the center of resistance of the mandibular dentition
(green dot, pretreatment; red dot, posttreatment); blue
dentition, pretreatment; red dentition; posttreatment.
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August 2016  Vol 150  Issue 2