## 2 Materials and Methods  
Four adolescent patients (aged 13.75-14.92 years), two females and two males, with skeletal Class III malocclusions, were treated by one of the authors (M.K.-M.). Pretreatment cephalograms, occlusion and facial appearance of all the patients described has been presented in Figure 1.  
Both male patients started treatment at the beginning of the pubertal growth period (CS3 in cervical vertebral maturation), female patient 2 began after the pubertal growth spurt (CS4), and female patient 1 began after the completion of growth, according to CS (CS6), but while still growing in concordance with the body growth chart (Figure 2) and superimpositions [11]. The diagnosis of Class III malocclusion was made based on occlusion, including reverse overjet, angle and canine Class III and cephalometric analysis--there was a negative ANB and negative WITS value below \(-2\). All patients were of European ancestry, had severe skeletal Class III malocclusion with anterior cross-bite and Wits appraisal less than \(-7.5\) (\(-7.8\) mm to \(-12.93\) mm), no permanent teeth congenitally missing or extracted before or during treatment except for the lower third molars, cephalograms of adequate quality available at T1 and at the final observation (T2) after the three-stage nonsurgical treatment. Pre and posttreatment cephalometric measurements are presented in Table 1.  
The option of future orthodontic/orthognathic surgery had been offered to the patients with regard to the severity of the skeletal deformities and skeletal maturation [29; 30]. All patients and their parents declined the surgical option and decided to try the alternative orthodontic-orthopedic treatment. An informed consent form was signed by all the patients' relatives before the proposed treatment. The height of the body had been measured for approximately 3-5 months in all patients to carefully detect the body growth changes strictly correlated to the growth of the mandible. The increase in body height has been presented in Figures 2-5. Figure 1: Pretreatment cephalograms, occlusion and facial appearance of the patients described. The second phase of the treatment consisted of the bonded Haas-type expander combined with the face-mask, a lower fixed appliance and long Class III elastics worn full time to enhance maxillary protraction, as described in the literature [22; 23; 25]. The treatment strategy and course have been presented in Figures 8 and 9. Figure 4: Changes in body height in patient 3. Figure 5: Changes in body height in patient 4. Figure 3: Changes in body height in patient 2. The acrylic splints of the appliance were formed higher in its posterior part in order to induce intrusion of the lower molars to counteract the clockwise mandibular rotation produced by the face-mask [22; 23; 25]. At the beginning of the treatment, the contact with the splints was only on the lower second molars, but over time, the strength of the masticatory muscles produced progressive contact with the acrylic splints of the posterior teeth, as visible in Figure 9.  
Figure 8: Intraarol view during the beginning of the second phase of treatment (in patient 2). Figure 6: Individual chin-cup. Figure 7: Facial and occlusal improvement after four months of chin-cup treatment (patient 3). Maxillary protraction with the face-mask was started after the first 10 turns of RME activation, with a forward and downward direction of the protraction force and an inclination of approximately 30\({}^{\circ}\) to the occlusal plane [31]. Patients were asked to wear the face-mask for 14 h a day (from 7 pm to 7 am at night and 2 h during daytime), 5 days a week and the whole day, except for meals, on the weekends. The elastics, with a force of 450-550 g per side controlled by a force gauge, were applied from the posterior hooks on the Haas-type appliance (placed between the second premolars and the first molars) to the face-mask.