# Sandibular Molar Distalization in Class III Malocclusion: A Systematic Review
## 4 Discussion
### MMD with Skeletal Anchorage
#### 4.2.3 Ramal Plates  
The lower arch distalization technique with Ramal Plates (Figure 8) has been proposed in several clinical studies that extoll its advantages.  
[PERSON] et al. published case reports in which they used the ramal plates to perform camouflage in adult patients with TCM who had refused orthodontic treatment combined with surgery [57]. In the case reports proposed by the authors, the insertion technique is described, as follows. The ramal plates were installed in the retromolar fossa, which is located between the anterior border of the mandibular ramus and the temporal crest. A flap was created in the retromolar area, and the L-shaped plate was fixed with two screws, 5 mm long, and 2 mm wide. Then, the flap was sutured so that the anterior hole of the plate was 3 mm lateral to the buccal surface of the second molar so that the force vector was as parallel as possible to the functional occlusal plane [58]. On leveled arches with steel posted arches, an elastic chain was applied betw  
Figure 8: Ramal plate in the retromolar area.  
Figure 7: Mini-plates with TADs.  
plate and the arch hook. During distalization, it is important to control mandibular anterior tooth movements. As the force vector is above the center of resistance of the anterior teeth, counterclockwise rotation, and thus, uncontrolled tipping of the anterior teeth, must be prevented. To control the position of the root apices, third-order bending in the anterior section of the arch might be useful [57].  
The technique proved to be effective and efficient; it allowed the distalization of the entire lower arch in the clinical cases mentioned, which were skeletal TCMs of medium severity, treated without surgery [57; 59].  
Encouraging results also came from a study by [PERSON] et al., who evaluated the effects of distalization with ramal plates by analyzing the pre- and post-treatment latero-lateral telera-idiographs of 22 patients [34]. After the completion of alignment and leveling, 0.019 \(\times\) 0.025 steel arch elastic tractions were applied and stretched between the last ring of the plate and the bracket of the first molar, exerting 300 g of force per side. The tractions were replaced every 3 weeks, and distalization ended when an acceptable overjet was reached. The valid distalization of the mandibular arch was achieved with ramal plates, without significant changes in the vertical position of the mandibular molars or the angle of the mandibular plane; however, the amount of root distalization was not statistically significant. Therefore, a branch plate can be considered a viable treatment option for the total distalization of the lower arch in TCM patients who refuse surgical treatment or extractive treatments [34].  
A clinical study by [PERSON] et al. made a comparison between distalization performed with ramal plates and distalization performed with mini-screws [30]. The latero-lateral radiographs of 40 patients with TCM, 20 of whom were treated with distalization via mini-screws, and 20 were treated via distalization with ramal plates, were analyzed. It was found that distalization on ramal plates is more effective, and it produces a clockwise rotation of the mandible, unlike distalization with mini-screws which is less effective, but produces greater molar intrusion and counterclockwise rotation of the occlusal plane [34]. Knowing these differences, one can be guided in the clinical choice of treatment, starting with the patient's verticality characteristics [30].