# Correction of Severe Class III Malocclusion by mandibular
## 4 Discussion
Recently, the ramal plates have been advocated to overcome the weaknesses of the miniscrews [6]. According to [PERSON] et al., in contrast to the traditional miniplates where the elastic hooks were positioned below the archive level, the direction of traction force with ramal plates was more parallel to the occlusal plane with an opportunity for improved force vector control [12]. With the ramal plates, the mandibular molars showed a 37.5% distal tipping ratio compared to 46.3% with the Skeletal Anchorage System (SAS) miniplates used by [PERSON] et al. [10, 24]. Our results could not confirm this difference between the two miniplate systems since the molar tipped distally with a ratio of 50.4% in the present study. However, it should be noted that the amount of molar tipping could have been affected by more severe Class III conditions in our sample. As such, our results demonstrated 3.65 mm of molar distalization, the largest among the similar miniplate studies [10, 13, 24]. At the same time, our results supported the merits of the ramal plates in the vertical control since no significant post-treatment vertical dentoskeletal changes were observed. The present study exhibited a lower molar extrusion of 0.18 mm and an FMA increase of 0.17\({}^{\circ}\), representing insignificant changes for both. Previously, [PERSON] et al. reported that their ramal plate treatment resulted in significant vertical dental changes with a molar extrusion of 0.77 mm (\(p<0.001\)) but with insignificant skeletal dimensional changes [10]. Conversely, [PERSON] et al. later reported that their lower molar did not significantly extrude, similar to our results, but the FMA significantly increased by 0.77\({}^{\circ}\) (\(p<0.004\)) [13]. These treatment changes suggest that the ramal plates may extrude the lower molars less than 1 mm with a potential increase in the FMA up to 1\({}^{\circ}\). Irrespective of their statistical significance, the clinical weight of such changes may be insubstantial, given the small magnitudes. Therefore, a conclusion may be drawn that the ramal plate therapies could effectively preserve the vertical dimensions through a minimum posterior dental extrusion and maxillomandibular bakeltal opening. Regarding the changes in the sagittal plane, most skeletal variables remained unchanged as our sample included only adults. However, the Wits significantly improved by 1.56 mm, which is congruent with other studies [10, 24]. This change may be explained by a mild counterclockwise rotation of the occlusal plane. In contrast, the dental variables included in this study demonstrated significant improvement in the anterior-posterior direction. The molars distalized by 3.65 mm with a distal tipping of 6.36\({}^{\circ}\), while the lower incisor crowns retracted by 3.32 mm and 8.02\({}^{\circ}\). In addition, the lower lip was significantly retracted due to the lower incisor retrusion. Simultaneously, the relaxation of the genital muscle tone promoted the significant posterior repositioning of the soft tissue pogonion. Comparable dental and soft tissue changes have been described by other investigators [10, 24], confirming the predictable treatment effect of the ramal plate. The evaluation of the study casts showed that the post-treatment mandibular arch depth was maintained as expected in a total arch distalization with corresponding amounts of the retraction of the incisors and molars. In contrast, the transverse analysis of the mandibular casts illustrated that the first and second premolar and the first molar widthshad significantly increased while the intercanine width stayed unchanged. In the orthophathic correction of severe Class III malocclusion, the mandibular posteriors become often bucucally uprighted during the presurgical decompensatory treatment phase. However, in camouflage orthodontic treatment, the desirable amount of mandibular buccal expansion is based on the need that arises during compensatory archive coordination between the two arches.