A 12-year-old girl presented, complaining of prominent lower front teeth, protruded chin, and compromised mastication and phonation. She had very low self-esteem as she was constantly ridiculed for her unpleasant smile and facial appearance. The family history was not suggestive of any genetic predisposition. Extraoral examination revealed a bilaterally symmetrical face, a mesoprosopic facial form, a concave facial profile with midface deficiency, a retrusive upper lip, a prominent lower lip, an acute nasolabial angle, and a shallow mentolabial sulcus (Figure 1). A low lip line was evident upon smiling with almost negligible maxillary incisor display and excessive mandibular incisor display. CO-CR discrepancy was discernible with the inability to move the mandible backward with the incisors edge to edge in the retruded contact position. However, mild deviation of the mandible towards the left was noted on jaw closure from initial contact position to habitual occlusion position. The tongue was normal in size and function. In addition, the patient exhibited habitual oral breathing despite a patent nasal airway. TMJ exhibited normal functional activity.
 Intraorally, she displayed bilateral Cl III molar and canine relationships with retained upper right deciduous canine and lower deciduous second molars. A long span of crossbite extending from the maxillary right deciduous canine to the left permanent first molar was observed. Incisor overbite was 5 mm, and overjet was -4 mm. The upper dental midline was shifted to the right of the facial midline by 2 mm. The lower dental midline was shifted to the left by 3mm compared to the upper dental midline (Figure 1). Both dental arches were relatively well-aligned. Model analysis revealed a transpalatal arch width of 33 mm in the first molars.
 A panoramic radiograph, taken at the early permanent dentition stage of development, did not reveal any bony or periodontal abnormalities (Figure 2a). Cephalometric analysis revealed a skeletal Cl III anteroposterior relationship (ANB, -6 ; Wits appraisal, -8 mm), a retrognathic maxilla (SNA, 76 ), a prognathic mandible (SNB, 82 ), and a hypodivergent growth pattern. A large maxillomandibular discrepancy with Co-A to Co-Gn of 26 mm was noted (the normal range is 20-23 mm). The maxillary incisors were slightly proclined (U1 to SN, 105 ), whereas mandibular incisors had normal inclinations (IMPA, 89 ) (Figure 2b; Table 1). The soft tissue analysis confirmed upper lip retrusion and lower lip protrusion. The patient was in the CS3 stage of skeletal maturation, according to the CVMI method.
 Based on the clinical and cephalometric examinations, the cause of this patient's malocclusion was an underdeveloped maxilla and mandibular prognathism.
 The treatment goals were to (1) improve the skeletal jaw relationship by protracting the maxilla anteriorly relative to the cranium and redirecting mandibular growth, (2) correct anterior and posterior crossbites, (3) eliminate CO/CR discrepancy, (4) achieve esthetically favorable and functionally effective overjet and overbite, (5) establish canine-guided functional occlusion with anterior guidance, (6) improve frontal and profile esthetics, and (7) ensure that the patient breathed mostly through the nose.
 Considering the patient's age and severity of the skeletal and occlusal disharmony, a bone-anchored maxillary protraction treatment protocol was suggested since it offers the advantages of ensuring 24-hour bone-borne force, at the same time avoiding the problems associated with dental anchorage. However, the patient and her parents declined this approach because of the underlying concerns about the associated surgical risks. Thus, a conservative two-stage treatment approach commensurate with the patient's young age and the parents' wishes was adopted. An orthopedic approach involving concurrent Alt-RAMEC and PFM therapy for effective maxillary advancement was contemplated as a stage 1 procedure, followed by fixed orthodontic mechanotherapy during phase 2 to achieve well-interdigitated buccal occlusion. However, the parents were informed of the possible need for orthognathic surgery in the future, considering the likelihood of intermaxillary sagittal relationship worsening if the craniofacial growth proved unfavorable or if the patient did not comply with the recommended duration of orthopedic treatment.
 The first phase of treatment involved the Alt-RAMEC protocol performed with an 11-mm bonded Hyrax-type expander (Leone A2620, Leone Orthodontic Products, Italy), with the simultaneous use of a Petit-type facemask for protraction of the maxilla. A 7-week Alt-RAMEC protocol of alternating expansions and constrictions commenced with expansion in the first week, alternating to constriction in the second week, and completed with expansion in the seventh week (Figures 3a, 3b, and 3c). Daily activation of the expansion or constriction was 0.4 mm (0.20 mm per turn, one turn in the morning, and one turn at night). 5/16", 14 oz. Protraction elastics (600 g per side) were attached from the hooks on the maxillary expander near the maxillary canines, with a downward and forward pull of 30  from the occlusal plane (Figures 3d and 3e). The facemask was worn for 16 hours per day for nine months.
 Following the removal of bonded Hyrax assembly after six months, the skeletofacial esthetics improved considerably. However, a posterior open bite of large magnitude (approximately 5 mm) was observed (Figure 4). At the beginning of phase 2 treatment, 0.022*0.028-inch slot pre-adjusted fixed appliances (MBT prescription) were placed in the maxillary and mandibular dental arches. Initial alignment and leveling were achieved with sectional archwires in the upper arch and continuous wires in the lower arch, starting with improved superelastic 0.016-inch NiTi wire, followed by 0.020*0.020-inch SS wire. A modified occlusal settling appliance,consisting of retentive pin-head clasps and lateral acrylic flanges, was used as an interim adjunct to prevent lateral tongue thrust to facilitate rapid settling of buccal segment occlusion (Figure 5).
 Third molar germectomy was performed, followed by distalization of the mandibular right second molar, using compressed nickel-titanium open-coil spring on a 0.017*0.025-inch stainless steel (SS) wire to create space for mandibular right second premolar. Simultaneous use of short Cl III elastics helped counteract the mesial reactionary forces. Once adequate space had been created, the second premolar erupted spontaneously in its position in the arch (Figure 5). A normal sequence of continuous stainless-steel archwires was subsequently used to level and coordinate the arches.
 While maintaining the original intercanine width in mandibular arch form, individualized first- and third-order bends were carefully incorporated in the maxillary and mandibular continuous 0.019*0.025-inch SS archwires to detail the tooth positions. Judicious use of short and light (3.5 oz.) Cl III and vertical spaghetti elastics helped improve occlusal interdigitation.
 After debonding, retention consisted of maxillary and mandibular wraparound Hawley retainers worn during the daytime and a reverse twin block (RTB) appliance at night for 24 months. The patient was regularly monitored every six months to evaluate mandibular growth.
 The total treatment duration was 27 months. Post-treatment final records showed the achievement of the desired treatment objectives, i.e., significant improvement in facial esthetics with the correction of the maxillary deficiency, better lip support and an improved nasolabial angle, along with the establishment of normal overjet and overbite, and well-intercuspated buccal occlusion with canine guidance (Figure 6). Dramatic improvement of the lip line and smile arc was discernible with adequate maxillary incisor display on smiling. Anterior movement of the upper lip, posterior movement of the lower lip, and soft tissue pogonion contributed to improvements in the patient profile. Nasal breathing also showed spontaneous improvements. Reverse twin block with upper and lower acrylic guided components was used as passive retention at night to prevent relapse (Figure 6).
 A panoramic radiograph revealed good root parallelism with no significant apical resorption (Figure 7a). Cephalometric superimposition demonstrated improvements in the maxillomandibular relationship (Wits, -8 mm  -1 mm; ANB, -6    1 ), the sagittal position of the maxilla (SNA, 76   79 ), and establishment of a harmonious soft-tissue profile along with the clockwise rotation of mandibular base (FMA, 24 ; SN-GoGn, 32 ) (Figures 7b, 7c, and 7d).
 At 2.5-year and 4-year follow-up appointments, the harmonious facial balance and intermaxillary dental relationships were well-maintained (Figures 8 and 9).