# Correction of Severe Class III Malocclusion by mandibular
## 1 Introduction  
Class III malocclusion is characterized by the relative forward position of the mandible usually in connection with the mandibular denti being more mesial than the relationship found in normal occlusion. Severe Class III malocclusion poses a significant challenge to orthodontists. In many cases, its treatment is marked by the unpredictability of mandibular growth, which could contribute to difficulties in rehabilitating desirable masticatory functions and facial esthetics. The prevalence of Class III malocclusion has been reported to vary from 1.2% to 26.7% depending on ethnic background [1, 2]. According to a more recent study [3], the Class III prevalence showed an average frequency of 7.2%. Additionally, skeletal Class III malocclusion is known to constitute a disproportionately large portion of orthodontic patients in certain far-east countries. Various environmental and epigenetic factors can influence the severity of Class III malocclusion [4]. While its correction depends on age and severity, an orthognathic surgical approach is often a preferred treatment option in severe anteroposterior skeletal discrepancy. According to a recent survey of dental hospital patients, over two-thirds of orthognathic surgery was associated with severe Class III malocclusion [5]. Subsequently, various treatment modalities have been advocated to camouflage the dentoskeletal profilein an attempt to avoid invasive surgical procedures and associated potential adverse effects. However, the correction of Class III malocclusion in adults through lower molar distalization can be more complicated compared to the retraction of the upper arch in the Class II treatment. This complexity arises from several factors such as intricate root morphology of the lower molars, greater bone density in the lower posterior region, and further limited placement sites available for effective anchorage devices [6]. Mandibular cervical headgear, for example, has been reported for its efficacy in lower molar retraction but its effectiveness in severe Class III adult treatment has not been demonstrated [7]. In contrast, the multiloop edgewise arch wire technique has been shown to successfully distalize the lower molars by more than 3 mm in adults when used in conjunction with Class III elastics [8]. It should be noted, however, that most of this distal movement resulted from the tipping movement of the molars, and without patient compliance in wearing elastics, an anterior opbenite could develop. Advancements in the use of temporary skeletal anchorage devices (TSADs) have expanded the possibilities of dental movement [9]. The advantages of TSADs include the elimination of the need for patient compliance, as well as the absence of anchor loss associated with target movement. This, for example, contrasts with Class III elastics, which rely on patient cooperation and can lead to anchor loss that is manifested as the proclination of the upper incisors. Previously, [PERSON] et al. compared the Class III treatment effects of direct anchorage with mandibular miniscrews versus indirect anchorage with maxillary miniscrews combined with Class III elastics, and concluded that although the lower molars distalized similarly close to 3.3 mm in both methods, the direct anchorage led to shorter treatment duration and more effective bodily movement [8]. Among TSADs, ramal plates have gained recognition for their effectiveness as anchors in the retraction of the entire mandibular denti for the correction of Class III malocclusion without premolar extractions (Figures 1 and 2) [6; 10; 11; 12; 13]. Unlike orthodontic miniscrews that may show inefficient distalization for a distance greater than 2 to 3 mm due to limited interradicular distances [14; 15], the ramal plates were less affected by such limitations and could withstand a greater traction force. Recently, [PERSON] et al. compared the treatment effects of ramal plates to those of miniscrews and concluded that the lower molars in the ramal plate group retracted further with less tipping [13].