Original Article

The Cleft Palate-Craniofacial Journal

2019, Vol. 56(2) 159-167
Short- and Long-Term Effects of Late Maxillary ª 2018, American Cleft Palate-
Craniofacial Association

Advancement With the Liou-Alt-RAMEC Article reuse guidelines:

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DOI: 10.1177/1055665618772395
Protocol in Unilateral Cleft Lip and Palate journals.sagepub.com/home/cpc

Maria Costanza Meazzini, DMD, MMSc1, Laura B. Zappia, DDS1,

Chiara Tortora, DDS1, Luca Autelitano, MD1, and Roberto Tintinelli, MD2

Abstract
Objective: The objective of this retrospective longitudinal study was to evaluate short- and long-term results of the application of
the Liou Alt-RAMEC (alternate rapid maxillary expansion and constriction) technique, a late orthopedic maxillary protraction
technique, with intraoral anchorage, in patients with cleft.
Materials and Methods: Twenty-six patients with unilateral cleft lip and palate (UCLP) were consecutively treated with the
Alt-RAMEC technique. The average age of the patients was 11.7 years (10.3-13.2 years) before protraction and 18.3 years
(17.4-21.1 years) at long-term follow-up. A sample of nontreated patients with UCLP was used as a control group. It was matched
for sex, skeletal class III, and age (11.3 years). The control sample had records at the end of growth (18.7 years).
Results: The sagittal advancement of A-point, after the application of the technique, was 5.7 (2.17) mm. Some mandibular den-
toalveolar and positional adaptation was noted. The position of the maxilla was stable in the long term. On the other hand, the
UCLP control group showed hardly any growth at the maxillary level during the long-term follow-up period.
Conclusion: Our results showed that the Alt-RAMEC technique, performed at the correct time, with a double-hinged expander,
followed by class III spring or elastic traction, 24 hours per day, allows for satisfactory maxillary protraction, with, at this stage,
apparently stable long-term results. Nevertheless, as only 50% of the patients had long-term follow-up data, we are still unable to
predict the percentage of patients which will not eventually need orthognathic surgery.

Keywords
midfacial growth, maxilla, orthodontics, osteogenesis, nonsyndromic clefting, cephalometry, facial growth, orthopedic treatment,
skeletal morphology

Introduction
The incidence of maxillary hypoplasia in patients with unilat-
eral cleft lip and palate (UCLP) needing osteotomies at the
completion of growth varies in the literature: 25% (Ross,
1987), 48% (Daskalogiannakis and Mehta, 2009), and 26%
(Meazzini et al., 2008). Developing midfacial retrusion in CLP
children has been conventionally treated with protraction face
mask at an early age (Tindlund, 1989). Maxillary skeletal base
protraction with face mask in UCLP is reported to range
between 0.95 and 1.68 mm (Chen and So, 1996). Some authors
reported up to 2.5 mm (Segal et al., 2017). In patients with
cleft, though, given the precocity of face mask application, 2
to 3 years after the completion of treatment, there is a recur-
rence of the skeletal defect, caused by a reversal of the growth
to the original growth pattern (Tindlund, 1994). Rapid maxil-
lary expansion (RME) loosens the articulations of the maxillary
complex from the rest of the skull, whereby rendering more
effective maxillary protraction (Ngan et al., 1996). The Alt-
RAMEC (alternate rapid maxillary expansion and constriction)
technique (Liou and Tsai, 2005) is a protocol which allows to
disarticulate the circummaxillary sutures in patients who are
close to the end of craniofacial growth; the technique uses a
2-hinged rapid palatal expander (RPE), which is unique in its
1
Department of Maxillo-Facial Surgery, Smile House, Regional Center for CLP,
San Paolo Hospital, University of Milan, Milan, Italy
2
San Paolo Hospital, University of Milan, Milan, Italy
Corresponding Author:
Maria Costanza Meazzini, Department of Maxillo-Facial Surgery, Smile House,
Regional Center for CLP, San Paolo Hospital, University of Milan, Via Appiani 7,
Milano 20121, Italy.
Email: cmeazzini@yahoo.it
160
biomechanics, expanding and rotating each half of the maxilla
outward, while buttressing against the pterygoids posteriorly.
Timing of treatment seems fundamental for the success of the
technique in the long term. The treatment is started when the
vertebral stage of maturation is between V2 and V3 (Baccetti
et al., 2002). Liou has shown a significant advancement of A-
point (5.8 [2.3] mm) in 6 months and those results remained
stable without significant maxillary relapse after 5 years (Liou
and Tsai, 2005).
The objective of this study was to assess the long-term
validity of this technique in patients with cleft. This study
followed the principles of the Declaration of Helsinki.
Materials and Methods
Patients
A modification of the original Liou Alt-RAMEC technique has
been applied since 2005 by the authors in 96 patients; of these
patients, 48 were noncleft, nonsyndromic, class III patients. Of
the remaining 48 cleft and craniofacial patients, 29 had complete
UCLP, 6 complete bilateral cleft lip and palate, 5 cleft palate, 2
patients were affected by orofacial digital syndrome, 3 patients
by Beckwith-Wiedemann syndrome, 1 achondroplasia, 1 Myhre
syndrome, and 1 was affected by cleidocranial dysplasia.
Given that the growth pattern of these different craniofacial
anomalies is very dissimilar, as they have different underlying
genetic defects, in order not to include any ethiological selec-
tion bias, only the 29 patients affected by UCLP were included
in this study.
Therefore, inclusion criteria were as follows:
 Caucasian patients
 Patients with complete UCLP consecutively treated with
Alt-RAMEC
 Vertebral stage of maturation V2-V3 at the beginning of
treatment (usually corresponding to late deciduous or
permanent dentition)
 Skeletal class III malocclusion with no shift from centric
relation to centric occlusion. The skeletal class III
malocclusion was clinically identified by the presence
of class III molar relation and class III incisal relation,
with an edge-to-edge or reverse overjet.
 Full cooperation of the patients
Three of the consecutively treated patients with UCLP had
to be excluded due to complete lack of cooperation. There-
fore, the actual total study sample included 26 patients. The
average age of the patients in the sample was 11.7 (10.3-13.2)
years before treatment (T0) and 12.4 years after maxillary
protraction (T1). The average age at long term (Tlt) was
18.3 (17.4-21.1) years.
Control Sample
Twelve of the 26 patients with UCLP had long-term results
(over 5 years posttreatment, range: 5.3-10.7 years).
The Cleft Palate-Craniofacial Journal 56(2)
Therefore, as a control sample, a group of 12 patients with
UCLP, who presented a class III malocclusion, not treated
orthopedically, extrapolated from a larger sample of patients
with UCLP (Meazzini et al., 2015b), was matched for sex,
severity of class III, and age (average age: 11.3, range: 10.1-
12.8 years) at T0. The control sample had records at the com-
pletion of growth (Tlt) at an average age of 18.7 years (range:
18.3-21.8 years). The characteristics of the control sample
need to be further clarified. By “untreated,” we mean patients
who were followed orthodontically by different operators but
had yearly checkups in our center. At the age at which the
study sample was treated with the Alt-RAMEC technique, this
group of patients had no type of maxillary protraction treat-
ment, not even class III elastics. All patients though had had at
least one earlier expansion treatment, and in 70% of the cases,
an early (5-7 years) face mask protraction treatment had been
carried out.
The Alt-RAMEC Protocol
The double-hinged maxillary expander (DHME) consisted of
a jackscrew in the center and 2 hinges of rotation posteriorly
(Liou and Tsai, 2005) (Figure 1A). In the lower arch, a double
lingual arch with anterior hooks was soldered on molar and
premolar bands (Figure 1B). The treatment protocol, as sug-
gested by Liou, consisted in 7 cycles with 7 days of expansion
and 7 days of constriction, 1 mm per day, alternatively. After
7 weeks of alternate expansion–constriction, a mild mobility
of the whole maxilla was felt clinically and a mild discomfort
was reported by the patient, especially at the paranasal area.
In 30% of the patients, there was a need to go up to 9 or
11 cycles, in order to achieve mildly perceivable maxillary
mobility.
When no dental movement was desired, the original pro-
tocol was modified adding temporary skeletal anchorage
devices (TADs) provided by 2 maxillary and 2 mandibular
titanium miniscrews (cortical anchorage miniscrews,
OrthoEasy, Forestadent; Figure 1C). Two TADs were posi-
tioned in the maxilla between the roots of the first molars and
the second premolars and in the mandible between the roots of
the canines and the lateral incisors. Temporary skeletal
anchorage devices were used indirectly, with ligature wires
to the dental appliances. In 10 of the patients, who had sig-
nificant lower anterior crowding and missing lateral incisors
in the maxillary arch, some dental movement was needed in
order to close the lateral space and relieve mandibular crowd-
ing, and therefore, no TADs were used.
Additionally, in all patients, lower incisors were initially
aligned and proclined prior to the maxillary protraction
phase, as is usually done prior to a surgical correction of
the class III. Even in those patients in whom TADs were
used, mandibular anterior teeth were bonded to ensure extra
stability. After the completion of the expansion/constriction
cycles, the technique included 5 to 8 months of active max-
illary protraction.
Meazzini et al 161

Figure 1. A, Double-hinged maxillary expander. B, Lower double lingual arch. C, Temporary anchorage devices positioned in the maxillary and
mandibular arch for indirect anchorage. Note the heavy intraoral elastics, substituting protraction springs. D, Protraction springs.

Figure 2. A, Cephalometric superimposition T0-T1. Reference lines and cephalometric points. B, Cephalometric superimposition from T0 to
Tlt of a nontreated patients with UCLP matched at T0 for sex and severity of maxillary hypoplasia with a UCLP patient treated with Alt-RAMEC.
C, Cephalometric superimposition from T0 to Tlt of a patient with UCLP who has been treated with Alt-RAMEC. The dotted line shows the T0
tracing, the continuous line shows the cephalometric tracing at Tlt. Cephalometric landmarks: S, sellion, midpoint of the fossa hypophysealis; A,
subspinal, deepest anterior point in the maxilla; nasion, anterior point at the frontonasal suture; B, supramental, deepest anterior point of the
mandible; Oclp, posterior occlusal point, distal cusp of the upper first molar; UI, upper incisor point, incisal edge of the upper central incisor; LI,
lower incisor point, incisal edge of the lower central incisor; Go, gonion, midpoint of the angle of the mandible; Gn, gnathion, most anterior
inferior point of the contour of the symphysis. Alt-RAMEC indicates alternate rapid maxillary expansion and constriction; UCLP, unilateral cleft
lip and palate.

The maxillary protraction was delivered by a pair of non-
compliant tooth-borne, intraoral maxillary protraction springs
(Figure 1D). The springs produced a force of 300 g per side.
Given the relatively frequent breakage of the b-titanium
springs, all patients continued protraction with intraoral elastics
(300 g), to be used 24 hours a day, also during meal times
(Figure 1C).
Cephalometric Analysis
For each patient, a lateral cephalometric radiograph was taken
before (T0) and after maxillary protraction (T1) and at long
term (Tlt). Cone beam computed tomography scans were not
offered by our national health system until recently and were
therefore not available for most patients.
Lateral cephalometric tracings were superimposed on the
anterior cranial base, orienting on Sella-Nasion (SN) line. For
linear measurements, a constructed true vertical line at 7 to SN
was used (Figure 2A). The method was previously described
(Meazzini et al., 2012; Meazzini et al., 2015a). In Figure 3,
the lateral X-rays and clinical photographs pretreatment, post-
treatment, and at the long term follow-up of a female UCLP
patient are shown.
Statistical Analysis
After Shapiro-Wilk normality test, descriptive statistics of the
data at T0, T1, and Tlt were calculated for the treated sample.
A paired t test was carried out to evaluate the changes of
measurements from T0 to T1 and from T1 to Tlt of the study
sample.
To compare the differences in the linear and angular mea-
surements at T0 and at Tlt between treated and nontreated
patients and also to compare the changes from T0 to Tlt in the
162 The Cleft Palate-Craniofacial Journal 56(2)

Figure 3. Example of UCLP female patient followed long term. A, Profile of a female UCLP patient at 12.5 years of age pretreatment. B, Lateral
X-ray pretreatment: lower incisors were decompensated pretreatment in this patient and no TADs were used. C, Lateral occlusal photograph
pretreatment. D, Profile at the end of maxillary protraction. E, Lateral X-ray posttreatment. F, Lateral occlusal photograph posttreatment. G,
Profile 10.7 years posttreatment. H, Lateral X-ray 10.7 years posttreatment. I, Lateral occlusal photograph 10.7 years posttreatment. TADs
indicates temporary anchorage devices; UCLP, unilateral cleft lip and palate.

treated sample with the changes during the same period of
growth in the nontreated UCLP control sample, considering
the small sample size (n ¼ 12 in each group), a nonparametric
test, the Wilcoxon signed rank test was carried out.
Given the large number of multiple comparisons, a
Benjamini-Hochberg procedure was applied. The raw P values,
significant using the Benjamini-Hochberg procedure with the
false discovery rate, were utilized.
A Cronbach a intraclass correlation coefficient was used to
assess cephalometric intraexaminer reliability. Point detection
and measurements were performed twice by the same trained
operator (M.C.M.) at 4-month interval, which is suitable to
assess test–retest reliability.
A power analysis was run for each test, given the sample
size reached in the retrospective collection of the data, setting a
(type I error) at 0.05 and a large population size effect. The
power (1  b) of each test was over 0.85 (GPower3, 2012,
Düsseldorf, Germany). Statistical analysis was carried out with
Stata 10 software (StataCorp. 2007; Stata Statistical Software:
Release 10, College Station, Texas: StataCorp LP).
Results
The intraclass correlation coefficient used to assess consistency
of the single rater was 0.942, thus providing an indication of
good intrarater reliability. After the Benjamini-Hochberg cor-
rection, the P value was set at .031. Nevertheless, we have
reported all P values in the tables.
Short-Term Results
At T1, the maxilla was advanced at A-point on average 5.7 mm
(P < .001). Wits occlusal indicator was increased 9.2 mm. The
mandibular posterior rotation was not significant. A counter-
clockwise rotation of the occlusal plane was evident in all
patients (OP-GoGn increased 9  ). Nasion was advanced
2.9 mm on average. All measurements and the results of the
paired t test are listed in Table 1.
In 20% of the patients, we observed temporary mild velo-
pharyngeal incompetence. All the patients returned to prepro-
traction speech within 6 months. Two patients developed
reciprocal temporo-mandibular joint (TMJ) click, which was
addressed with physical therapy.
Long-Term Results
The maxilla remained stable, with no significant relapse, in all
patients following long-term posttreatment (average age: 18.3;
range: 17.8-21.1). The mandible grew, after the completion of
treatment, at B-point on average 2.9 mm and at Pogonion (Pog)
2.6 mm. Statistical significance of each linear and angular
change between the end of treatment and the long-term
follow-up is depicted in Table 2.
Clinically, none of the patients presented periodontal prob-
lems or loss of vitality of teeth. None of the patients had a
permanent TMJ dysfunction in the long term.
Meazzini et al 163

Table 1. Treatment Results and Long-Term Follow-Up of Alt-RAMEC.a

Difference P Value Difference P Value

T0 T1 Tlt T1  T0 T1 vs T0 Tlt  T1 Tlt vs T1
SNA ( ) 74.02 (4.02) 77.45 (4.09) 77.08 (4.65) 3.43 (1.44) .03b 0.37 (1.48) .7
SNB ( ) 76.21 (3.53) 75.8 (4.33) 75.31 (4.23) 0.42 (1.97) .511 0.48 (2.57) .69
ANB ( ) 2.19 (2.93) 1.58 (1.18) 1.6 (1.84) 3.77 (1.33) .01c 0.18 (1.47) .83
PnsAns^GoGn ( ) 25.87 (6.44) 28.27 (6.32) 26.4 (9.05) 4.4 (3.08) .12 1.87 (4.86) .43
Wits (mm) 7.08 (6.3) 2.08 (3.78) 2.16 (1.41) 9.27 (4.87) .001d 0.02 (1.96) .47
UI^LI ( ) 137.43 (8.09) 134.98 (9.71) 137.83 (9.31) 2.45 (8.22) .51 2.84 (6.37) .91
UI^PnsAns ( ) 109.1 (6.87) 114.22 (10.74) 110.1 (8.56) 5.12 (8.03) .17 4.12 (10.47) .67
LI^GoGn ( ) 90.13 (5.2) 97.8 (8.26) 92.65 (7.58) 7.68 (7.91) .01c 5.16 (8.76) .21
SN^GoGn ( ) 36.42 (5.82) 37.39 (6.08) 37.21 (6.46) 0.97 (2.62) .69 0.18 (2.95) .51
OP^GoGn ( ) 16.8 (5.29) 26.02 (6.15) 22.5 (7.07) 9.22 (5.31) .003d 3.53 (3.34) .29
A Vert (mm) 49.09 (9.91) 50.77 (8.93) 53.56 (8.03) 1.68 (3.37) .11 2.79 (1.48) .26
A Horiz (mm) 43.83 (14.5) 49.60 (14.8) 49.13 (11.26) 5.77 (2.17) .09 0.47 (1.52) .20
B Vert (mm) 85.38 (16.26) 88.76 (16.34) 90.49 (11.89) 3.38 (3.89) .006d 1.73 (2.09) .33
B Horiz (mm) 50.39 (14.23) 47.09 (16.03) 51.05 (12.05) 2.70 (2.9) .008d 2.96 (2.26) .001d
N Vert (mm) 6.09 (4.3) 6.29 (5.14) 9.44 (1.95) 0.19 (1.9) .62 3.16 (1.64) .018c
N Horiz (mm) 63.74 (12.33) 66.72 (13) 67.86 (8.77) 2.98 (1.74) .008d 1.14 (3.58) .57
Pog Vert (mm) 98.93 (18.83) 103.81 (18.85) 108.66 (13.05) 4.88 (5.19) .06 4.85 (2.59) .07
Pog Horiz (mm) 50.03 (14.94) 49.34 (17.21) 52.01 (12.47) 0.71 (3.46) .06 2.67 (3.91) .052
Ans Vert (mm) 43.4 (9.36) 44.03 (9.5) 45.7 (6.22) 0.37 (2.84) .53 1.67 (1.83) .06
Ans Horiz (mm) 58.14 (5.79) 62.1 (6.61) 63.01 (5.74) 3.97 (1.89) .0000d 0.91 (0.77) .052
H symph (mm) 39.32 (4.44) 43.1 (3.44) 42.76 (2.81) 4.79 (3.59) .008d 0.35 (2.36) .56
Abbreviations: Alt-RAMEC, alternate rapid maxillary expansion and constriction; T0, cephalometric X-ray before treatment; T1, cephalometric X-ray immediately
after maxillary protraction; Tlt, cephalometric X-ray at long term after the end of treatment; SNA, SNB, ANB, SN^GoGn, SN^PnsAns, angular changes relative to
cranial base (SN) of A-point, B-point, mandibular plane (GoGn); PnsAns^GoGn, angular changes relative to PnsAns of mandibular plane; UI^PnsAns, LI^GoGn,
angular changes of upper incisors and lower incisors position; Wits, changes in Wits index of A-B-points positions relative to occlusal plane; (A, B, N, Pog, Ans)
Vert, Horiz, vertical and horizontal movement of A, B, N, pogonion, anterior nasal spine points relative to reference line; H Symphysis, changes in height of the
symphysis measured from lower incisal edge to Gn point.
a
Average linear and angular changes (standard deviation) at different time points: changes between pretreatment and immediately post-traction (T1  T0),
changes between pretreatment and long-term evaluation (Tlt  T0), and P values of the paired t tests.
b
Paired t test: P < .05.
c
Paired t test: P < .025.
d
Paired t test: P < .01.

Comparison With Nontreated Class III UCLP Patients Discussion

At T0, there were no significant cephalometric differences
between the treated and nontreated groups (Wilcoxon sign
test), confirming the adequacy of the matching in terms of
cephalometric severity of the class III skeletal discrepancy
(Table 2). The comparison of the changes from T0 to Tlt
between the treated and the control groups showed that,
while in the control group there was an average negative
sagittal movement of A-point of 0.5 mm during the long-
term follow-up period, the position of A-point in the treated
patients with UCLP was still close to the advancement
measured at T1 (T0-Tlt: 5.3 mm). Mandibular horizontal
growth was also different (4 mm in nontreated UCLP vs
1.9 mm in treated UCLP patients at Pog point). On the
other hand, while in nontreated patients the mandibular
plane angle diminishes with growth, in treated patients it
is slightly increased (SN^GoGn ¼ 3.5  in nontreated
UCLP vs 0.7 in treated UCLP sample). Comparison of all
other variables from T0 to Tlt between treated UCLP and
nontreated UCLP patients is listed in Table 2 and depicted
in Figure 2B and C.
The results of this clinical retrospective study support the
hypothesis that a repetitive weekly protocol of Alt-RAMEC,
using a 2-hinged expander with skeletal anchorage and
intraoral traction, allows to obtain significant advancement of
the maxilla in patients with cleft. The patients selected for this
study were all UCLP. The total amount of maxillary advance-
ment was almost 6 mm in 6 months; the long-term evaluation
revealed that the maxillary advancement was stable.
Other authors have reported treatment with a modification
of the Alt-RAMEC technique, but contrary to the original pro-
tocol, they all use a traditional RME (Kaya et al., 2011; Canturk
and Celikoglu, 2015). Kaya reports an average maxillary
advancement of 2 mm adding mini plates and a face mask,
while Canturk reports over 3 mm maxillary advancement
applying nighttime face mask and daytime class III elastics.
None of these studies show any long-term follow-up data. Ishi
et al. (2010) showed a larger advancement (4.1 mm) using an
RPE and face mask 16 h/d. Al-Mozany (2011), also using a
traditional RPE, added palatal TADs and class III elastics
obtaining 3.2 mm advancement.
164
Table 2. Comparison of Treated and Control Sample.a

Difference Difference P Value Difference

Nontreated Treated vs P Value Nontreated Treated vs P Value Difference Tlt Difference Tlt  Change T0  Tlt
Treated Cleft Cleft Control Nontreated Difference Treated Cleft Cleft Control Nontreated Difference  T0 Treated T0 Nontreated Treated vs
Values Sample At T0 At T0 at T0 at T0 Sample at Tlt At Tlt at Tlt at Tlt Sample Sample Nontreated
SNA ( ) 74.02 (4.11) 72.56 (2.59) 1.46 .62 77.08 (2.98) 71.37 (2.08) 5.71 .001b 3.06 (2.53) 1.19 (3.02) .003b
SNB ( ) 76.21 (3.61) 74.5 (3.77) 1.71 .47 75.35 (3.7) 76.12 (3.56) 0.75 .72 0.87 (4.58) 1.62 (2.18) .09
ANB ( ) 2.19 (0.5) 1.93 (4.37) 0.26 .99 1.5 (1.74) 4.81 (1.47) 6.31 .001b 3.19 (2.69) 2.88 (1.33) .00003b
PnsAns^GoGn 25.04 (5.44) 26.72 (3.98) 1.67 .88 26.71 (7.6) 24.68 (2.29) 2.03 .63 1.8 (5.21) 2.04 (3.92) .026c
( )
Wits (mm) 7.18 (6.5) 5.46 (10.13) 1.72 .83 2.1 (1.48) 8.09 (5.62) 10.19 .0005b 9.28 (6.21) 2.63 (3.34) .00005b
UI^PnsAns ( ) 109.1 (7.03) 107.43 (10.3) 2.67 .76 110.48 (6.5) 112.81 (7.46) 2.32 .87 21.85 (7.69) 1.87 (10.8) .28
LI^GoGn ( ) 90.13 (5.32) 90.75 (6.32) 0.61 .83 92.15 (7.76) 86.93 (7.98) 5.22 .15 1.47 (7.89) 5.38 (8.1) .064
SN^GoGn ( ) 36.42 (5.95) 37.06 (6.32) 0.36 .28 37.2 (3.52) 35.21 (4.62) 1.99 .92 2.02 (10.83) 6.45 (11.42) .026c
OP-GoGn ( ) 17.11 (0.03) 18.88 (6.42) 1.77 .06 22.16 (1.05) 19.8 (7.94) 2.36 .55 0.78 (4.73) 3.56 (3.08) .007b
SN^OP ( ) 19.31 (5.92) 19.82 (0.1) 0.13 .69 15.03 (2.47) 15.41 (3.35) 0.37 .29 5.15 (1.34) 1.87 (7.03) .003b
A Vert (mm) 49.09 (9.91) 49.07 (17.68) 0.02 .36 53.56 (8.03) 56.41 (20.6) 3.15 .07 5.47 (4.06) 6.34 (3.58) .15
A Horiz (mm) 43.83 (14.5) 44.68 (23.41) 0.85 .75 49.53 (11.26) 42.52 (12.86) 7.01 .023d 5.30 (2.95) 0.82 (4.19) .0000b
B Vert (mm) 85.38 (16.26) 84.63 (30.88) 1.75 .81 90.49 (11.89) 87.21 (33.28) 3.28 .76 5.11 (3.15) 2.59 (3.74) .25
B Horiz (mm) 50.39 (14.23) 50.24 (21.05) 0.15 .36 51.05 (12.05) 53.31 (20.89) 1.75 .81 0.66 (3.89) 4.97 (3.15) .07
N Vert (mm) 6.09 (4.3) 6.3 (3.5) 0.2 .09 9.44 (1.95) 8.28 (3.54) 1.17 .35 3.35 (2.74) 2.02 (2.37) .72
N Horiz (mm) 63.74 (12.33) 63.31 (27.35) 0.43 .80 67.86 (8.77) 66.81 (27.47) 1.05 .82 4.12 (2.22) 3.5 (1.47) .09
Pog Vert (mm) 98.93 (18.83) 95.73 (35.64) 3.2 .71 108.66 (13.05) 100.54 (38.12) 8.13 .52 9.73 (4.84) 5.81 (4.01) .045c
Pog Horiz 50.03 (14.94) 49.70 (21.37) 0.34 .95 52.01 (12.47) 53.71 (21.26) 1.7 .56 1.99 (5.92) 4.01 (7.31) .03c
(mm)
Ans Vert (mm) 43.40 (9.36) 42.04 (15.7) 1.36 .18 44.7 (6.22) 44.48 (15.66) 0.23 .32 2.30 (2.55) 1.44 (2.13) .385
Ans Horiz 58.14 (15.79) 60.63 (26.89) 2.5 .60 63.01 (15.74) 60.15 (25.05) 2.86 .08 4.87 (1.73) 1.49 (2.29) .04c
(mm)
H Symph (mm) 39.26 (4.55) 37.76 (6.5) 1.50 .23 42.76 (4.26) 38.87 (5.05) 3.11 .15 8.49 (5.49) 3.65 (4.99) .0018b
Abbreviations: Treated sample: T0, tracings pretreatment; Tlt, long-term evaluation. Nontreated control sample: T0, tracings made at an average age of 11.3 (matched to the treated sample); Tlt, tracing at the end of
growth of the control sample. Tlt  T0, Change (growth) between pretreatment measurements (T0) and measurements at long-term follow-up (Tlt); UCLP, unilateral cleft lip and palate.
a
Descriptive statistics (average linear and angular measurements [standard deviation]) and statistical comparison (Wilcoxon signed test) of dentoskeletal variables at T0 and Tlt of the treated sample and the nontreated
UCLP control sample during the same period of growth. Average linear and angular changes (standard deviation) in treated and nontreated sample between pretreatment tracings (T0) and long-term follow-up (Tlt) and
their statistical comparison (Wilcoxon signed test).
b
Wilcoxon signed test: P < .01.
c
Wilcoxon signed test: P < .05.
d
Wilcoxon signed test: P< .025.
Meazzini et al 165

Table 3. Studies on the Applications of the Alt-RAMEC Technique.a

Age, A-Point
Author PTS years Alt-RAMEC Technique Advancement Long Term
Liou and Tsai (2005) 10 class III UCLP (6 F/4 M) 9-12 -DHE (7 weeks) 7-mm per 5.8 mm >5 years follow-up stable
week maxillary position
-3 months springs 300 g 24 h/d
Isci et al. (2010) 15 class III (8 F/7 M) 11.3 -RPE (4 weeks) 2.8-mm per 4.1 mm None
week
-6 months FM 700 g 16 h/d
Al-Mozany et al. 14 class III (7 F/7 M) 11.02 -RPE þ TADs (9 weeks) 2.8 per 3.2 mm None
(2011) week
-Class III elastics 400 g
Kaya et al. (2011) 15 class III (9 F/6 M) 11.6 -RPE þ miniplates 2 mm None
-8 weeks FM 400 g
Canturk and Celikoglu 15 class III (7 F/8 M) 11.2 -RPE (8 weeks) 2.8-mm per 3.8 mm None
(2015) week
-7 months FM 500 g 20 h/d
Present Study 26 class III UCLP 12.3 -DHE (7-9 weeks) 7-mm per 5.7 mm 5-10 years
(16 F/10 M) week
-6 months class III elastic or
springs 300 g
Abbreviations: Alt-RAMEC, alternate rapid maxillary expansion and constriction; DHE, double hinge expander; F, female; FM, face mask; M, male; PT, patients;
RPE, traditional unidirectional rapid palatal expander; TADs, temporary anchorage devices; UCLP, unilateral cleft lip and palate.
a
We have listed the number of patients, the average age of the patients at the time of treatment, the modifications of the technique applied, the average
advancement of A-point, and the long-term follow-up.

There are reports in the literature on different applications of
Alt-RAMEC, but applied at a much younger age, and, there-
fore, not comparable with this study. We have listed all the
literature published on the use of an Alt-RAMEC technique
applied at similar ages (circumpubertal), which may be com-
pared to this study in Table 3.
The reasons which may have allowed a greater advancement
in the present study (A-point 5.7 mm) and in Liou’s study (A-
point 5.8 mm) (Liou and Tsai, 2005) may be more than one.
 First, the 2-hinged expander has a specific geometry
which rotates each half of the maxilla outward and for-
ward around the tuberosities and not around the poster-
ior nasal spine, as with a hyrax (Liou and Tsai, 2005).
This allows a better loosening of all circummaxillary
sutures (Wang et al., 2009). Therefore, studies which
apply a normal RME (Isci, 2010; Al-Mozany, 2011;
Kaya et al., 2011; Canturk and Celikoglu, 2015) instead
of a DHME might obtain less advancement, as the lat-
eral circummaxillary sutures only bend but do not open
sufficiently. This seems to be an important clinical dif-
ference, and although it has already been shown in ani-
mals (Wang et al., 2009), it certainly needs further
investigation in patients. In addition to the maxilla, in
most patients, the nasal bones were also displaced and
protracted anteriorly (Table 1). This explains the dis-
comfort, reported by many patients, over the nasal area
during the Alt-RAMEC, again suggesting that the naso-
maxillary complex is being disarticulated. Histologi-
cally, Wang et al. (2009) demonstrated that what
occurs at the circummaxillary sutures is not a simple
deposition of osteoid, as found in RME, but a process
of sutural stretching and protraction osteogenesis.
 Second, springs or intraoral elastics are used 24 hours
per day, even during eating time, and this is a funda-
mental advantage over face mask, which is usually only
worn during nighttime.
 Third, the skeletal anchorage allows distributing the
forces of traction directly to the bones, with greater
maxillary advancement and significant reduction of den-
toalveolar compensation. Maxillary incisors were only
mildly proclined, confirming the sagittal efficacy of
TADs in controlling dental compensations. Further-
more, mandibular incisors were proclined before pro-
traction (Figure 3C) during the opening–closing phase
and during protraction. Therefore, mandibular incisors
are not only compensated (retroclined) after treatment
but often found to be slightly proclined at T1 (Table 1),
both thanks to the use of TADs, but mostly, due to the
orthodontic decompensatory preparation.
 Another clinical aspect which justifies the success in the
long term of this technique is certainly the timing of
treatment (Baccetti et al., 2002). The expansion/con-
striction cycle is started when sutures are still open,
though growth peak is almost reached. The protraction
mechanics is held till the process of craniofacial growth
is significantly decelerated. The timing seems to be the
key to stability, given the fact that it has been shown that
in patients with cleft treated in early mixed dentition
there is a recurrence of the malocclusion during the
subsequent 2 years of growth (Tindlund, 1994). The
decision of using vertebral stage of maturation as an
166
indicator was correlated with the decision to follow the
original protocol by Liou (Liou and Tsai, 2005). It is
important to remember, though, that vertebral stage of
maturation is not universally accepted and, as an index
of maturation, hand–wrist skeletal ages appear to offer
the best indication that peak growth velocity has been
reached (Mellion et al., 2013).
The availability of a control group consisting of patients
with nontreated UCLP, which presented a similar degree of
class III discrepancy at the same age at which the study sample
was treated, was of considerable value (Table 2). In
“nonprotracted” patients with UCLP, the maxilla, as shown
by other authors (Semb, 1991), does not move forward signif-
icantly in the second decade of life, while the mandible grows
and autorotates (Figure 2C), as it does in noncleft patients
(Björk, 1991). In the treated sample, mandibular growth
occurs, but its projection is reduced compared to the controls
and mandibular plane angle is increased. On the other hand, in
the maxilla, the average forward movement of 5.7 mm obtained
with the Alt-RAMEC does not grow further, but neither
relapses significantly after more than 5 years of follow-up. This
differential allows for the stability of the long-term result (Fig-
ure 2B).
The maxillary advancement obtained is lower than that
reported in patients treated later with orthognathic surgery at
the completion of growth (6.8 [1.7] mm; Chua et al., 2010).
This seems to point out that some of the patients treated with
Alt-RAMEC will not avoid surgery. The age range at the long-
term follow-up in this sample is from 17.4 to 21.1. Therefore, in
male patients with cleft, we are still unable to predict the pro-
portion of patients who will not require orthognathic surgery.
Furthermore, only 50% of the initial sample had sufficient
long-term follow-up records; therefore, results in the long term
cannot deliver, at this stage, any degree of certainty.
A significant advantage of this technique, though, is the
psychological aspect: The appearance of the patient improves
significantly during adolescence, which is a particularly diffi-
cult period for CLP children in terms of awareness and psy-
chosocial adjustment (Richman et al., 2012). Clearly, this
technique has some drawbacks: first, a high collaboration is
needed; second, vertical control does not seem to be efficient.
Even when TADs were used, some vertical dentoalveolar mod-
ifications were observed in the mandibular arch, with a vertical
increment of the symphyseal height (Tables 1 and 2), together
with a counterclockwise rotation of the whole occlusal plane.
We feel this is a major drawback of this technique. The over-
eruption of the incisal mandibular region and counterclockwise
rotation of the occlusal plane do not allow a proper correction
of the maxillary anterior vertical defect and, therefore, of the
incisal show. Furthermore, while the occlusal plane is rotated
counterclockwise, the mandible is rotated clockwise, whereby
reducing SNB and SNPg. The fact that mandibular projection
at B-point and Pog is reduced in these patients is another major
drawback of the technique. Given the fact that the mandible is
already more retrusive in patients with cleft (Semb, 1991), the
The Cleft Palate-Craniofacial Journal 56(2)
final profile is biretrusive. The final profile, therefore, is less
pleasing than what can be obtained with orthognathic surgery,
through a maxillomandibular advancement, often advocated in
patients with CLP to obtain maximal aesthetic result.
Conclusions
Our results seem to point out that the Liou Alt-RAMEC tech-
nique allows for a satisfactory maxillary protraction, if
performed:
 With the right timing, close to growth peak and not in
early deciduous dentition;
 With the correct double-hinged expander, which allows
true mobilization of the maxilla, and not a traditional
RPE;
 Followed by class III springs or elastic traction, applied
24 h/d, and not only nightly traction.
Although the study is retrospective and may not give the
evidence of a prospective randomized trial, the comparison
with a sample of nontreated patients with class III UCLP
allowed to suggest the positive effect of the treatment on the
maxillary position versus the evolution of the class III in cleft
children, of comparable age, who were not treated. Finally, as
only 50% of the initial sample had a sufficient long-term
follow-up and as long-term average age of the patients in this
study was 18.4 years, further follow-up is needed to assess the
proportion of patients who will avoid final orthognathic
surgery.
Authors’ Note
Roberto Tintinelli now has a private practice in Milan.
Acknowledgments
The authors thank Dr Andrea Montanari and Chico Onlus for the
generous donations to the Smile House through Operation Smile Italy.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article
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