Correction of Severe Class III Malocclusion by Mandibular Molar Distalization with Ramal Plates

Abstract

This retrospective investigation aims to evaluate the dentoskeletal and soft tissue changes after the distalization of the mandibular dentition using the ramal plates in nonextraction camouflage treatment of severe Class III malocclusion with a full-cusp discrepancy or more at the first molars. The sample consisted of pre- (T1) and post-treatment (T2) lateral cephalograms from 25 adult patients who were treated with the ramal plates for mandibular total distalization. The skeletal, dental, and soft tissue variables were analyzed from T1 to T2 in order to determine the effects of mandibular dentitional distalization. The mandibular first molars distalized 3.65 mm at the crown and 1.81 mm at the root. Similarly, the mandibular incisors retracted 3.32 mm at the crown and 0.81 mm at the root. Skeletally, the Wits appraisal displayed a significant increase of 1.56 mm. Also, soft tissue changes showed a significant lower lip retraction of 1.26 mm. These findings suggest that the ramal plates exhibited effective mandibular distalization in treating severe Class III malocclusion, which may be considered a viable alternative to the orthognathic surgical approach in some patients.

1. Introduction

Class III malocclusion is characterized by the relative forward position of the mandible usually in connection with the mandibular dentition 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 profile in 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 openbite 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, He 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 dentition for the correction of Class III malocclusion without premolar extractions (Figure 1 and Figure 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, Yeon 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]. Furthermore, the force application vector with the ramal plate tended to result in the extrusion of the mandibular posterior dentition, which may be a potential advantage in treating Class III [12].

Several reports are available in the literature on the nonextraction treatment of severe Class III patients with TSADs [11,16,17,18]. However, they have been mostly limited to case report studies. Also, previous research publications on the use of the ramal plates in mandibular distalization movement have mainly focused on mild to moderate Class III malocclusions [10,11,12,13], and information on severe Class III patients is largely lacking. Therefore, this retrospective investigation aims to evaluate the dentoskeletal and soft tissue changes after the distalization of the mandibular dentition using the ramal plates in nonextraction camouflage treatment of severe Class III malocclusion with a full-cusp discrepancy or more at the first molars among adults.

2. Materials and Methods

The sample consisted of pre- and post-treatment lateral cephalograms from 25 adult patients (19 males and 6 females; mean age: 25.0 ± 7.9 years old). All patients were treated with the ramal plates as only skeletal anchors in the mandibular arch for total distalization at Seoul St. Mary’s Hospital. The sample size for this study was determined based on the previous research on the treatment effects of the ramal plate [10]. At least 16 patients were deemed necessary to detect an effect size of 0.75 units with a type I error of 0.05 and a power of 0.8 using G*Power 3.1.9.7 (Universität Düsseldorf, Düsseldorf, Germany). Approval was obtained from the Institutional Review Board of the Catholic University of Korea (KC23RISI0728). Informed consent was obtained from all participants in accordance with the Declaration of Helsinki.

The inclusion criteria included minimum skeletal maturity of a cervical vertebral stage of V at the time of treatment initiation [19], Class III malocclusion with one entire cusp discrepancy or greater at the first molars, the absence of or extraction of mandibular third molars prior to distalization, and no craniofacial anomalies nor systemic diseases that affect orthodontic movement. The criteria were chosen to ensure that only skeletally mature non-growers with severe dental Class III relationships were included in the study.

2.1. Treatment Progress

Initially, all patients were bonded on fixed orthodontic brackets with 0.022-inch (in) slots and Roth prescriptions (Clarity and Victory series; 3M Oral Care, St. Paul, MN, USA). Leveling and alignment progressed gradually from 0.014 in a nickel-titanium alloy to heavier stainless steel (ss) archwires (Ormoco, Brea, CA, USA). Before leveling was completed, the mandibular third molars were extracted, and the ramal plates were inserted in the retromolar fossa using an L-plate (Le Forte system; Jeil Medical Corp., Seoul, Republic of Korea), which was anchored by two miniscrews of 2 mm in diameter and 5 mm in length. A hook from the plate was extended through the mucosa and adjusted so that its vertical level was close to the mandibular molars’ facial axis points while its transverse position was slightly lateral to the buccal groove of the second molars. Once 0.019 × 0.025 ss were engaged, elastomeric power chains were used between the ramal plate hook and hooks crimped on the lower archwire between the canines and lateral incisors to exert between 300 and 350 g of retraction force until a desired positive overjet was gained.

2.2. Cephalometric Analysis

Pre- and post-treatment lateral cephalograms were digitized before the insertion of orthodontic appliances (T1) and after debonding (T2) using V-Ceph 6.0 software (Osstem, Seoul, Republic of Korea). To evaluate the anterior–posterior change in the mandibular dentition, the vertical reference line was represented by drawing the Frankfort horizontal (FH) plane and then adding a perpendicular line to the FH plane at the pterygoid point. Also, the horizontal reference line was represented by the mandibular plane (MP) to evaluate the vertical position of the mandibular dentition. Twenty-two linear and angular measurements were recorded by one examiner (AA) as shown in Figure 3 and Figure 4 and

Table 1. Definitions of dental cephalometric variables.

Variables	Definitions
Frankfort Horizontal (FH) Plane	Plane extending from the most inferior point of the orbital margin to the external auditory meatus.
Vertical Frankfort Horizontal (VFH)	Plane that is perpendicular to the Frankfort plane and passes through the most posterior point of the pterygomaxillary fissure.
Mandibular Plane (MP)	Plane extending from the gonion to menton.
Molar Crown (6C) to B	Distance from the first molar crown to the vertical Frankfort horizontal (VFH).
Molar Root (6R) to B	Distance from the first molar root to the vertical Frankfort horizontal (VFH).
Incisal Tip (1T) to B	Distance from the incisal tip to the vertical Frankfort horizontal (VFH).
Incisal Root (1R) to B	Distance from the incisal root to the vertical Frankfort horizontal (VFH).
Molar Crown (6C) to C	Distance from the first molar crown to the mandibular plane (MP).
Molar Root (6R) to C	Distance from the first molar root to the mandibular plane (MP).
Incisal Tip (1T) to C	Distance from the incisal tip to the mandibular plane (MP).
Incisal Root (1R) to C	Distance from the incisal root to the mandibular plane (MP).
Molar Long Axis/C (6/MP) Angle	Angle formed between the first molar long axis and mandibular plane (MP).
Incisor Long Axis/C (1/MP) Angle	Angle formed between the incisor long axis and the mandibular plane (MP).

.

2.3. Dental Cast Analysis

Pre- and post-treatment dental casts were obtained at T1 and T2, and arch dimensional changes were evaluated by the examination of arch depth and arch width. First, arch depth was defined by the distance from the contact point between the right and left central incisors to the line connecting the first molars’ right and left distal contact points (Figure 5 and

Table 2. Definitions of the dental cast variables.

Variables	Definitions
Arch Depth	Distance from the line between the most distal points of the first molars to the contact point formed by the central incisors.
Intercanine Width	The distance between the canine cusp tips.
1st Interpremolar Width	The distance between the first premolar buccal cusp tips.
2nd Interpremolar Width	The distance between the second premolar buccal cusp tips.
1st Intermolar Width	The distance between the mesiobuccal cusp tips of the first molars.

). Then, arch width at the canines, premolars, and molars was measured from the buccal cusp tips and their respective contralateral counterparts. To ensure the reliability and consistency of the measurements, eight randomly selected cephalograms and study models were measured twice at intervals of 2 or more weeks by the same examiner (AA).

2.4. Statistical Analysis

The statistical analysis was performed using SPSS 26.0 (SPSS Inc., Chicago, IL, USA). The Shapiro–Wilk test was conducted to evaluate the distribution normality. The paired t-test was utilized except for the variables with non-normal distribution, in which the Wilcoxon Signed Rank test was applied to assess the statistical differences between pre- and post-treatment with significance set at p < 0.05.

3. Results

The intraclass correlation test confirmed the intraexaminer reliability, ranging from 0.910 to 0.999 for the tested variables. At the end of the orthodontic treatment, a positive overjet was gained in all patients. The mean treatment duration was 27.8 ± 7.8 months from initial bonding to bracket removal, while active distalization force was applied on the ramal plates for 16.2 ± 5.7 months.

In the evaluation of dental treatment effects, the mandibular first molars and incisors displayed a significant distalization at the level of crowns and roots, as shown in Figure 6. The lower first molars distalized significantly by 3.65 mm at the crown and 1.81 mm at the root apex with distal tipping of 6.36° (p < 0.01, respectively;

Table 3. Changes in the dental cephalometric variables.

Variables	Pretreatment	Post-Treatment	Treatment Effects	p
6C to VFH (mm)	21.74 ± 3.88	18.09 ± 4.19	−3.65	0.000 *
6R to VFH (mm)	19.45 ± 4.05	17.64 ± 3.94	−1.81	0.000 *
1C to VFH (mm)	54.68 ± 2.81	51.36 ± 2.91	−3.32	0.000 *
1R to VFH (mm)	47.62 ± 3.50	46.81 ± 3.68	−0.81	0.002 *
6C to MP (mm)	25.57 ± 3.57	25.75 ± 3.46	0.18	0.367
6R to MP (mm)	12.29 ± 2.91	12.97 ± 2.87	0.68	0.086
1C to MP (mm)	41.25 ± 3.27	42.01 ± 4.27	0.76	0.123
1R to MP (mm)	24.54 ± 2.74	25.78 ± 2.88	1.24	0.003 *
L1-MP angle (°)	83.88 ± 4.93	75.86 ± 4.65	−8.02	0.000 *
L6-MP angle (°)	72.37 ± 8.03	66.01 ± 7.74	−6.36	0.000 *
Overjet (mm)	0.19 ± 1.87	3.67 ± 0.96	3.48	0.000 *†
Overbite (mm)	0.68 ± 1.33	2.25 ± 0.91	1.57	0.000 *†

Notes. All data are presented as the mean ± standard deviation, * p < 0.01. †, analyzed by the Wilcoxon Signed Rank test; otherwise, the paired t-test was used to compare pretreatment and post-treatment measurements. Treatment effects are described as post-treatment subtracted by pretreatment values.

). Similarly, the lower incisors showed a significant retraction of 3.32 mm at the crown and 0.81 mm at the root, with a lingual tipping of 8.02° (p < 0.01, respectively). In contrast, both crowns of the lower first molars and incisors exhibited insignificant extrusions by 0.18 mm and 0.76 mm. Also, the overjet and overbite increased by 3.48 mm and 1.57 mm (p < 0.01 for both).

Regarding skeletal treatment effects, Wit’s appraisal showed a significant increase of 1.56 mm from −7.06 mm to −5.50 mm (p < 0.01;

Table 4. Changes in the skeletal and soft tissue cephalometric variables.

Skeletal Variables	Pretreatment	Post-Treatment	Treatment Effects	p
SNA (°)	82.14 ± 3.70	81.99 ± 3.73	−0.15	0.419
SNB (°)	83.21 ± 3.73	82.84 ± 3.54	−0.37	0.114 †
ANB (°)	−1.07 ± 2.30	−0.66 ± 2.26	0.41	0.123
Wits appraisal (mm)	−7.06 ± 1.89	−5.50 ± 2.29	1.56	0.000 *
Pog to N perpendicular (mm)	4.43 ± 5.71	4.40 ± 5.59	−0.03	0.946
FMA (°)	26.86 ± 6.79	27.03 ± 6.78	0.17	0.550
Facial height ratio (%)	65.46 ± 5.12	65.68 ± 4.88	0.22	0.496
Soft tissue variables
Mentolabial angle (°)	137.08 ± 9.51	139.21 ± 9.62	2.13	0.182
Upper lip E-plane (mm)	−2.21 ± 1.72	−2.18 ± 1.51	0.03	0.989 †
Lower lip E-plane (mm)	1.73 ± 2.61	0.47 ± 2.15	−1.26	0.003 *†
Soft tissue Pog to VFH (mm)	61.40 ± 6.01	60.55 ± 6.02	−0.85	0.000 *

Notes. All data are presented as the mean ± standard deviation, * p < 0.01. †, analyzed by the Wilcoxon Signed Rank test; otherwise, the paired t-test was used to compare pretreatment and post-treatment measurements. Treatment effects are described as post-treatment subtracted by pretreatment values.

). However, both the ANB angle and pogonion to the nasion-perpendicular line showed insignificant sagittal skeletal alterations. In addition, the stability of the vertical mandibular position was marked by little changes in FMA and facial height ratio values throughout the treatment (p = 0.550 and 0.496, respectively).

Changes in soft tissue variables demonstrated that the lower lip displayed a significant retraction of 1.26 mm (p = 0.003), as shown in Table 4. A similar change in the soft tissue pogonion was also observed as it was significantly retruded by 0.85 mm after treatment (p < 0.01). To illustrate the typical treatment changes associated with the ramal plates, the pre- and post-treatment lateral cephalograms are presented in Figure 7.

Pre- and post-treatment dental cast analyses revealed that the arch depth did not significantly change in the maxilla and mandible. However, the mandible showed an increase in the interdental width in the first premolars, second premolars, and first molars by 2.93 mm, 2.48 mm, and 0.94 mm, respectively (p < 0.01, except the first molar with p = 0.041;

Table 5. Change in the arch dimensions of the maxillary and mandible dentition.

Maxillary Arch Dimensions (mm)	Pretreatment	Post-Treatment	Treatment Effects	p
Arch depth	37.51 ± 2.90	37.84 ± 2.49	0.33	0.387
Intercanine width	35.52 ± 1.90	37.17 ± 1.49	1.65	0.000 **
1st Interpremolar width	44.01 ± 2.74	46.86 ± 1.45	2.85	0.000 **
2nd Interpremolar width	50.64 ± 3.52	52.22 ± 1.64	1.58	0.044 *
1st Intermolar width	56.22 ± 3.41	56.05 ± 3.20	−0.17	0.966
Mandibular Arch Dimensions (mm)
Arch depth	34.17 ± 2.54	33.89 ± 1.83	−0.28	0.227
Intercanine width	27.75 ± 1.88	27.17 ± 1.73	−0.58	0.110
1st Interpremolar width	34.28 ± 2.93	37.21 ± 1.63	2.93	0.000 **†
2nd Interpremolar width	41.44 ± 3.49	43.92 ± 1.68	2.48	0.000 **
1st Intermolar width	47.81 ± 3.05	48.75 ± 2.03	0.94	0.041 *

Notes. All data are presented as the mean ± standard deviation, * p < 0.05, ** p < 0.01. †, analyzed by the Wilcoxon Signed Rank test; otherwise, the paired t-test was used to compare pretreatment and post-treatment measurements. Treatment effects are described as post-treatment subtracted by pretreatment values.

). A similar trend of arch width expansion was evident in the maxillary canines and first and second premolars, where they increased by 1.65 mm, 2.85 mm, and 1.58 mm, respectively (p < 0.01, except the second premolar with p = 0.044).

4. Discussion

The present investigation aimed to evaluate the skeletal, dental, and soft tissue changes after mandibular dentitional distalization aided by using the ramal plates in nonextraction camouflage treatment among skeletally mature patients. The pretreatment cephalometric values of our sample included a mean ANB angle of −1.07°, Wits appraisal of −7.06 mm, and a minimum of full-cusp Class III at the first molars. Such severe dentoskeletal discrepancies would often require considerations for the camouflage treatment involving premolar extractions or even orthognathic surgical approaches. Instead, our attempt to treat through mandibular total arch distalization facilitated with the ramal plates resulted in a significant amount of molar retraction with the correction of anterior crossbites. Despite insignificant post-treatment skeletal changes, the soft tissue relationship improved with the retraction of the lower lip and soft tissue pogonion. The overall ramal plate treatment effects demonstrated successful camouflage treatment outcomes for severe Class III adult patients without premolar extractions.

Among TSADs, the miniscrews became popular due to their relatively low cost, easy maneuverability, and biomechanical versatility. However, their need for frequent repositioning during active retraction has remained a weakness. Also, the retromolar region could not be regarded as attractive alternative miniscrew insertion sites because of its frequent association with soft tissue irritation and lower survival rates of TSADs compared to other areas of the mouth [20]. The failure rate of orthodontic miniscrews was reported as 16.4% after a meta-analysis [21], but when limited to the premolar and molar areas, it increased to 29.0% with 27 failures out of 93 in a more recent study [22]. Similarly, the miniscrews placed in the retromolar region showed a failure rate of 23.2% [20]. On the contrary, the miniplate displayed significantly higher stability, with a success rate of 92.7% to 98.6% [21,23]. Lam et al. reported that the miniplates reached a success rate of 98.7% with their heads exposed in the mandibular molar areas, while none of the plates failed during the lower total retraction for Class III correction [22]. Similarly, our ramal plates showed a 100% success rate during this investigation.

Recently, the ramal plates have been advocated to overcome the weaknesses of the miniscrews [6]. According to Kook et al., in contrast to the traditional miniplates where the elastic hooks were positioned below the archwire 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 Sugawara 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°, representing insignificant changes for both. Previously, Yu 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, Yeon et al. later reported that their lower molar did not significantly extrude, similar to our results, but the FMA significantly increased by 0.77° (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°. 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 skeletal 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°, while the lower incisor crowns retracted by 3.32 mm and 8.02°. In addition, the lower lip was significantly retracted due to the lower incisor retrusion. Simultaneously, the relaxation of the genial 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 widths had significantly increased while the intercanine width stayed unchanged. In the orthognathic correction of severe Class III malocclusion, the mandibular posteriors become often buccally 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 archwire coordination between the two arches. After analyzing the TSADs’ effects on the mandibular transverse dimension, Kim et al. concluded that the ramal plates produced the least amount of buccal crown tipping, whereas the SAS miniplates showed the largest [12]. Therefore, the type of TSADs should be recognized as an important factor that could attenuate the degree to which the lower archwire would be expanded during interarch coordination.

The presence of bone support at the distal area of the second molars may be considered a prerequisite for successful mandibular molar retraction. Kim et al. reported the lingual cortex of the mandibular body as the molar distalization limit in the mandible after an anatomical survey of three-dimensional (3D) data from cone-beam computed tomography (CBCT) [25]. According to a more recent meta-analysis [26], the patients with Class III malocclusion displayed an average of 4.43 mm for the mandibular retromolar space length (MRSL). Since our patients exhibited 3.65 mm and 1.81 mm for the retraction of the molar crowns and root tips, respectively, it may be suggested that most Class III patients have a sufficient amount of retromolar bone support to correct the full-cusp discrepancy through molar distalization. However, it should also be noted that the Class III group in the meta-study showed considerable variation with a 3.14 mm MRSL at the lower end of a 95% confidence interval. Therefore, clinicians may consider implementing safeguards by confirming the availability of MRSL based on CBCT images prior to the active molar distalization phase.

This investigation presents several important strengths. First, this is one of the rare attempts to analyze the effects of nonextraction camouflage treatment through mandibular distalization among severe Class III non-growers. The minimum requirement of a full-cusp discrepancy in our inclusion criteria was more stringent than those of similar previous studies [10,13,24]. In fact, the rigor of the sample selection used in this study could be met only with a limited number of case reports currently available in the literature [11,16,17,18,27]. Another noteworthy advantage of the present study is that, despite the employment of lateral cephalograms limited to the sagittal and vertical planes, the changes in the transverse dimension have also been assessed through a dental cast analysis. Thus, the treatment effects were evaluated in all three planes of space, at least at the crown level, where the focus of most orthodontic treatments lies. However, the limitations of this study are also apparent. We could not assess the evolving relationship between the inner cortical bone and dental root surfaces since it would require 3D treatment records such as CBCT. The reason why the CBCT has not been part of clinical records among the selected patients may have been influenced by various factors such as a low cost–benefit ratio and unnecessary radiation exposure risk. Also, it should be considered that routine orthodontic cases may not be recommended for supplementary CBCT scans [28]. Another limitation may be that we could not evaluate the long-term retention stability of our camouflage treatment, which should be an important aspect, especially given the severe nature of the pretreatment malocclusion. Finally, it is important to recognize the implications of the present retrospective study design. It inherently limits the grounds to establish a control group, which is important in reducing biases and confirming causal relationships. Thus, in the future, prospective randomized controlled studies may be beneficial to include well-designed control groups, 3D diagnostic records, and a more extended follow-up period to analyze the post-retention changes.

5. Conclusions

The following conclusions were drawn based on the results of this investigation.

• The ramal plates are effective in mandibular total retraction among adults.
• Severe Class III malocclusion can be successfully corrected without premolar extractions through the distalization of mandibular dentition. Thus, dental camouflage treatment with the ramal plates may offer a viable alternative to the orthognathic surgical approach in some patients.
• The ramal plate therapies provide effective vertical control in dentoskeletal dimensions.
• The skeletal anatomical boundaries of the retromolar region may limit the amount of mandibular molar retractions; however, the Class III correction of a full-cusp discrepancy through molar distalization was not hindered by such limitations.