JID: EJWF

ARTICLE IN PRESS [mNS;January 11, 2024;14:28]

Journal of the World Federation of Orthodontists xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of the World Federation of Orthodontists

journal homepage: www.jwfo.org

Special Article

Orthodontic considerations in hypodivergent craniofacial patterns

Johnny J.L. Liaw a,b, Jae Hyun Park c,d,∗
a
Adjunct clinical instructor, Department of Orthodontics, National Taiwan University Hospital, Taipei, Taiwan
b
Director, Beauty Forever Dental Clinic, Taipei, Taiwan
c
Professor and chair, Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona
d
International Scholar, Graduate School of Dentistry, Kyung Hee University, Seoul, Korea

a r t i c l e i n f o a b s t r a c t

Article history: This article examines the characteristics of hypodivergent craniofacial patterns and explores treatment
Received 24 November 2023 modalities in response to these features. It discusses the impact of robust masticatory muscles, which pro-
Revised 10 December 2023
duce heavy occlusal forces. In addition, it examines the use of Botox or splints to reduce gonial angles in
Accepted 10 December 2023
individuals with a square face. A nonextraction treatment approach supported by temporary skeletal an-
Available online xxx
chorage devices is recommended; however, if anatomical limitations persist, extraction may be necessary
Keywords: when arch expansion, molar distalization, incisor proclination, or interproximal reduction cannot create
Hypodivergent craniofacial pattern the necessary space. In hypodivergent cases where a nonextraction approach is impractical, a single-arch
Low mandibular plane angle extraction strategy may be considered to prevent a reduction in the vertical dimension. Emphasizing es-
Skeletal anchorage thetics, particularly maxillary incisor display, a protocol of total arch extrusion of the maxillary dentition
Total arch distalization assisted with temporary skeletal anchorage device, bite raisers, and interarch elastics is suggested.
Total arch extrusion
© 2023 World Federation of Orthodontists. Published by Elsevier Inc. All rights reserved.

1. Introduction maxillary and mandibular molars [4,5]. Employing methods such as

Malocclusion is characterized by the misalignment or improper
positioning of teeth when the jaws are closed. Contributing factors
include genetics, premature loss of primary teeth, inadequate
dental care, and habits such as thumb-sucking or tongue-thrusting.
The position of the jaw bones, specifically the maxilla and
mandible, as well as the surrounding tissues like masticatory
muscles and the tongue, closely influence malocclusion [1,2].
Additionally, the craniofacial pattern plays a significant role in this
condition. Therefore, it is essential to consider the impact of the
craniofacial pattern on orthodontic treatment to effectively address
malocclusion [3].
Traditionally, malocclusions have been classified into Angle’s
Class I, II, and III, focusing on the sagittal relationships between
Funding: The authors have not declared a specific grant for this research from
any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: Authors have completed and submitted the ICMJE Form for
Disclosure of potential conflicts of interest. None declared.
Provenance and peer review: Commissioned and internally peer reviewed.
∗
Corresponding author: Postgraduate Orthodontic Program, Arizona School of
Dentistry & Oral Health, A.T. Still University, 5835 East Still Circle, Mesa, 85206, Ari-
zona.
E-mail address: jpark@atsu.edu (J.H. Park).
headgear and high-pull J-hook for anchorage control during sagittal
correction has been a significant concern [6,7]. In the early 20 0 0s,
the advent of temporary skeletal anchorage devices (TSADs) such
as miniscrews and miniplates gained popularity as sources of ab-
solute anchorage for maximal anchorage control [7,8].
In the 1960s, orthodontists redirected their attention to vertical
relationships between the maxilla and mandible. Schudy’s work
regarding the influences of vertical and anteroposterior growth
on facial type introduced a novel dimension to orthodontic case
assessments. Investigations into the facial frame, applying the
pogonion formula, and recognizing both clockwise and counter-
clockwise mandibular rotations have elucidated the developmental
patterns of hyperdivergent and hypodivergent facial structures
[9,10]. Presently, it is widely acknowledged that variations in
growth at the condylar level and within the molar alveolar bone
contribute to mandibular rotation, ultimately determining the
positioning of the chin.
Vertical control aimed at preventing the extrusion of post-
erior teeth, especially in high-angle cases, as extrusion could
compromise the facial profile and chin projection. With the in-
troduction of skeletal anchorage, open bite malocclusions were
successfully treated through molar intrusion using TSADs [11,12].
Hyperdivergent Class II malocclusions were reported to benefit
from maximal retraction of the maxillary arch and active vertical

2212-4438/$ – see front matter © 2023 World Federation of Orthodontists. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ejwf.2023.12.007

Please cite this article as: J.J.L. Liaw and J.H. Park, Orthodontic considerations in hypodivergent craniofacial patterns, Journal of the World
Federation of Orthodontists, https://doi.org/10.1016/j.ejwf.2023.12.007
JID: EJWF
ARTICLE IN PRESS
2 J.J.L. Liaw and J.H. Park / Journal of the World Federation of Orthodontists xxx (xxxx) xxx
control, leading to improved facial profiles and enhanced chin
projection [13,14].
Pioneered by Angell and Haas, rapid palatal expansion (RPE)
emerged in the early 1900s as a solution for transverse discrepan-
cies [15]. However, its primary limitation lies in its suitability with
adolescent patients. In adults requiring transverse correction, sur-
gically assisted RPE may be recommended. A recent breakthrough,
miniscrew-assisted RPE (MARPE), presents a novel approach for ad-
dressing transverse discrepancies in adult patients [16,17].
Three-dimensional control of tooth movement with skeletal an-
chorage has revolutionized orthodontic treatment by providing a
more efficient and predictable means of moving teeth. The use of
TSADs has made it possible to increase treatment efficiency, reduce
treatment time, and improve treatment outcomes. The ability to
control tooth movement in all three planes of space has also led to
more precise and accurate tooth positioning, as well as improved
esthetics and functional outcomes.
The use of TSADs has evolved through phases, commencing
with the management of sagittal anchorage, progressing to vertical
control, and subsequently incorporating transverse control through
MARPE. While active vertical control has shown promising ad-
vancements in addressing hyperdivergent cases, there has been
comparatively limited exploration in applying TSADs to hypodiver-
gent cases. This article endeavors to concentrate on the orthodontic
considerations regarding hypodivergent malocclusions.
2. Characteristics
Hypodivergent craniofacial patterns or skeletal deep overbite in
Sassouni’s classification of skeletal facial patterns are character-
ized by the convergence of four planes (Frankfurt horizontal plane,
palatal plane, occlusal plane, mandibular plane), small cranial base
and gonial angles, upright incisors, short posterior dental height, a
decrease in lower anterior facial height (LAFH) than in upper an-
terior facial height, stronger masseter muscles, a square face, and
a short but thick symphysis [18–20]. In addition, the cortical bone
and alveolar ridge tend to be thicker in hypodivergent cases than
in hyperdivergent cases.
3. Treatment planning
A short, lower face may be associated with various types
of malocclusions depending on the underlying structural causes.
While traditional orthodontic treatments can correct the malocclu-
sion, they often fail to address the esthetic concerns linked to a
hypodivergent craniofacial pattern, including a square face, inad-
equate incisor display, or vertical proportion disharmony. Unfor-
tunately, Creekmore said, “high angle faces tend to become even
higher, whereas low-angle faces tend to get lower” [18]. However,
“the control of posterior tooth eruption is the most manageable
factor available to the orthodontist in the overall control of ante-
rior vertical dimension of the lower face.” Orthopedic treatment
might be possible in growing patients by using extraoral traction,
interarch elastics, arch wires, activator, etc. In adults with short
faces, a comprehensive approach involving orthodontics and or-
thognathic surgery is often necessary [19,20]. Surgically advancing
the mandible while preserving the curve of Spee is commonly em-
ployed to manage Class II malocclusions. For cases involving verti-
cal maxillary deficiency, Le Fort I osteotomy with inferior reposi-
tioning offers the required spatial correction.
The integration of TSADs has introduced an alternative avenue.
Total arch extrusion of the maxillary dentition, facilitated by TSADs,
may present an opportunity to address hypodivergent conditions
without resorting to orthognathic surgery. This approach has the
Please cite this article as: J.J.L. Liaw and J.H. Park, Orthodontic considerations in hypodivergent craniofacial patterns, Journal of the World
Federation of Orthodontists, https://doi.org/10.1016/j.ejwf.2023.12.007
[mNS;January 11, 2024;14:28]
potential to enhance esthetics, particularly in terms of maxillary
incisor display, providing a viable option for improving the overall
facial harmony of patients with hypodivergent pattern.
The occlusal force and the strength of masticatory muscles were
evidenced to be higher in patients with hypodivergent pattern
[3,21]. Orthodontists experienced much slower tooth movement
in patients with hypodivergent pattern, especially when extraction
space needed to be closed. Therefore, a nonextraction approach is
preferred over extraction treatment.
In hypodivergent malocclusions where a nonextraction ap-
proach is preferred, TSADs play a significant role in increasing the
likelihood of a successful nonextraction treatment. Extrusive me-
chanics are utilized in the treatment to promote the eruption of
posterior teeth and induce backward rotation, aiming to counteract
the inherent tendency of forward rotation of the mandible. There-
fore, the use of bite raisers or interarch elastics is encouraged dur-
ing treatment to enhance the overall facial height. However, it is
worth noting that heavy occlusal force may hinder the eruption of
posterior teeth. If maxillary incisor extrusion is indicated for an ap-
propriate maxillary incisor display, a comprehensive approach in-
volving total arch extrusion anchored with TSADs along with the
use of bite raisers and interarch elastics might be considered. The
treatment objectives include an increase in the LAFH, more harmo-
nious vertical proportions, and improved maxillary incisor display
with long-term stability.
However, when extraction becomes necessary either because of
severe crowding or unfavorable proclination of the incisors after
alignment, and anatomical constraints limit the effectiveness of ex-
pansion or distalization in creating adequate space for all teeth, the
bottom line is a single-arch extraction in the maxillary dentition. In
cases with extremely hypodivergent craniofacial patterns, orthog-
nathic surgery is a viable consideration.
4. Biomechanics considerations
4.1. Deep bite correction
Hypodivergent cases often exhibit a deep overbite, which can
be effectively addressed through anterior intrusion, posterior ex-
trusion, or a combination of both. While posterior extrusion might
not be suitable for hyperdivergent cases, it is generally welcomed
in hypodivergent cases. However, it is noteworthy that even with
encouragement for posterior extrusion using appropriate mechan-
ics, there is a tendency for relapse because of the substantial oc-
clusal forces in hypodivergent cases.
To enhance stability in deep bite correction, the preferred strat-
egy is anterior intrusion in hypodivergent cases. The biomechanics
of anterior intrusion encompass a range of techniques, including
the use of high-pull J-hooks, intrusion arches, utility arches, bite
plates or bite turbos, functional appliances, and miniscrew anchor-
age [22–25]. Nevertheless, controversies may arise regarding the
rate and extent of incisor intrusion achieved through these meth-
ods.
Consensus suggests that intrusion with utility arches may lead
to more pronounced side effects in the posterior teeth, particularly
in vertical dimension. Therefore, the authors advocate for the use
of anterior miniscrews to facilitate bite opening in challenging deep
bite cases, especially those with hypodivergence, and suggest a fo-
cus on optimizing treatment efficiency. For Class II Division 2 mal-
occlusion, the use of anterior miniscrews is also very helpful in re-
gaining torque with the retroclined maxillary incisors (Figs. 1–4).
The moment generated by the anteriorly positioned intrusive force
is much larger than the moment produced by the archwire in the
bracket slot.
JID: EJWF
ARTICLE IN PRESS [mNS;January 11, 2024;14:28]

J.J.L. Liaw and J.H. Park / Journal of the World Federation of Orthodontists xxx (xxxx) xxx 3

Fig. 1. (A) A Class II Division 2 case featuring moderate protrusion and a gummy smile revealed an evident deep overbite characterized by retroclined maxillary incisors.
(B) A nonextraction approach of total arch distalization with infrazygomatic (IZC) miniscrews was used for Class II correction. The deep overbite was corrected by placing
anterior subapical miniscrews between the maxillary central incisors. (C) Class II dental relationships and deep overbite were successfully corrected, and the facial profile was
significantly improved.

Fig. 2. The torque of the retroclined maxillary incisors was regained successfully,
the gummy smile was also solved. (A) Pretreatment maxillary incisor display. (B)
Pretreatment maxillary incisor retroclination. (C) Posttreatment maxillary incisor
display. (D) Posttreatment maxillary incisor proclination.

4.2. The number of anterior miniscrews
When it comes to using anterior miniscrews to intrude the an-
Fig. 3. The cephalometric superimposition reveals a total arch intrusion and retrac-
tion of the maxillary dentition to correct the gummy smile and Class II dental re-
lationships. Additionally, the extrusion of the mandibular molars can be observed
subsequent to the use of bite turbos for bite disocclusion. Pretreatment (black);
posttreatment (red).

terior teeth, the optimal number of anterior miniscrews is a ques-

tion of frequent discussion [26]. While a single midline miniscrew
may suffice for effective bite opening, two anterior miniscrews are
often used because of the need for a balanced force system. The
decision to not place a miniscrew in the midline is often influ-
enced by concerns about the labial frenum, which could be sus-
ceptible to ulceration. A possible solution is a frenectomy. Alterna-
tively, the use of a subapically-positioned anterior miniscrew with
a wire extension presents another viable option [27]. The wire ex-
tension from the subapical miniscrew tends to be less irritating
than the head of an anterior interdental miniscrew.

Please cite this article as: J.J.L. Liaw and J.H. Park, Orthodontic considerations in hypodivergent craniofacial patterns, Journal of the World
Federation of Orthodontists, https://doi.org/10.1016/j.ejwf.2023.12.007
JID: EJWF
ARTICLE IN PRESS
4 J.J.L. Liaw and J.H. Park / Journal of the World Federation of Orthodontists xxx (xxxx) xxx
Fig. 4. The anchorage setup in a Class II Division 2 malocclusion is shown in A to
C. The progressive lateral cephalogram (A) showing infrazygomatic (IZC) miniscrews
for total arch distalization of the maxillary dentition and anterior subapical minis-
crews for gummy smile correction and bite opening that are illustrated in B and C.
A single anterior miniscrew in the midline might tend to pro-
cline and intrude the maxillary incisors instead of providing pure
intrusion, but this is good for the torque control of the maxillary
incisors during maximal anterior retraction with TSADs, which re-
quire intrusive retraction.
When addressing the control of occlusal plane cant, an off-
center miniscrew is essential for unilateral intrusion. This require-
ment might be independent of the position of any other anterior
miniscrew.
4.3. Sagittal correction
Total arch distalization with TSADs for sagittal correction should
be considered with most hypodivergent malocclusions, depending
on the facial profile and interarch dental relationships. A nonex-
Fig. 5. (A) A mild skeletal Class III and dental Class I malocclusion showed inadequate maxillary incisor display. (B) After 1 month of miniscrew-assisted total arch extrusion,
the maxillary incisors and maxillary molars were extruded by the deactivation of the extrusion spring. (C) The posttreatment facial profile improved slightly through the total
arch extrusion of the maxillary dentition to rotate the mandible backward.
Please cite this article as: J.J.L. Liaw and J.H. Park, Orthodontic considerations in hypodivergent craniofacial patterns, Journal of the World
Federation of Orthodontists, https://doi.org/10.1016/j.ejwf.2023.12.007
[mNS;January 11, 2024;14:28]
traction treatment approach without TSADs is also possible if the
facial profile and available space allow for acceptable tooth posi-
tioning. RPE or MARPE might be indicated for transverse discrep-
ancies. Infrazygomatic miniscrews are important for total arch dis-
talization of the maxillary dentition for Class II correction and fa-
cial profile reduction [27]. Cone-beam computed tomography can
be used to check for possible interference between the miniscrews
and the moving roots to ensure a successful total arch distalization.
4.4. Botox effect
The square face, attributed to a decreased LAFH and hypertro-
phied masticatory muscles, may appear less prominent after or-
thodontic treatment. This is often true when orthodontic tooth
movements emphasize extrusion rather than intrusion, resulting in
reduced activity of the masticatory muscles during treatment and
less efficient chewing. Patients typically express satisfaction with
the positive changes in their facial appearance, and some practi-
tioners appreciate the Botox-like effects of the orthodontic treat-
ment [27].
However, a potential relapse of the square face may manifest
in follow-up examinations as chewing efficiency is regained and
muscle strength rebuilds, despite recommendations for patients to
avoid vigorous chewing of hard foods and clenching. One possible
cause for this relapse is nocturnal bruxism. In response, the use of
a splint during sleep is proposed as a potential solution to miti-
gate the recurrence of the square face. In addition to the nocturnal
splint, the injection of Botulinum type A is deemed even more ef-
fective in paralyzing hyperactive masticatory muscles. The use of
Botox might be recommended at the onset of orthodontic treat-
ment to enhance treatment effects by reducing occlusal force [28].
Nevertheless, it is worth noting that repeated injections might be
necessary, given that its effectiveness lasts only six months, leading
to some patients’ hesitation in opting for Botox.
JID: EJWF
ARTICLE IN PRESS [mNS;January 11, 2024;14:28]

J.J.L. Liaw and J.H. Park / Journal of the World Federation of Orthodontists xxx (xxxx) xxx 5

4.5. Insufficient maxillary incisor display

In cases where there is inadequate maxillary incisor display

before treatment, emphasis on anterior intrusion for bite open-
ing may be directed towards the mandibular anterior teeth, while
extrusion of the maxillary anterior teeth is deemed appropriate
[27]. Nevertheless, if the vertical dimension remains constant, the
clearance for maxillary incisor extrusion might be inadequate to
improve maxillary incisor display, even with successful mandibu-
lar anterior intrusion facilitated by lower anterior miniscrews. This
is particularly notable in cases involving single-arch extractions,
where there is a more favorable space allowance for maxillary in-
cisors to intrude compared with the mandibular incisors.
In attempts to address this challenge, the authors experimented
with maxillary incisor extrusion assisted by anterior miniscrews.
There was an initial improvement in maxillary incisor display;
however, a subsequent relapse was observed.
A total arch extrusion of the maxillary dentition, which involved
simultaneous extrusion of both maxillary anterior and posterior
teeth, proved to be a more successful approach in enhancing the Fig. 6. The maxillary incisor display was enhanced significantly after the total arch
display of maxillary incisors [29]. The treatment effects appeared extrusion of the maxillary dentition. (A) Pretreatment maxillary incisor display. (B)
to be stable during the follow-up period. Pretreatment maxillary incisor proclination. (C) Posttreatment maxillary incisor dis-
play. (D) Posttreatment maxillary incisor proclination.

4.6. Vertical dimension

Theoretically, the vertical dimension has been considered ge-

netically determined and unchangeable because of the influence
of muscular forces [30,31]. Any increase in the vertical dimension
can result in relapse over time. In cases where esthetic improve-
ment is desired without resorting to orthognathic surgeries involv-
ing downward grafting of the maxilla, clinicians are now explor-
ing the possibility of increasing the vertical dimension through or-
thodontic extrusion with the assistance of skeletal anchorage.
Possible rationales for increasing vertical dimension include fa-
cilitating prosthetic reconstruction, altering occlusal relationships,
and improving esthetics by balancing vertical proportions or en-
hancing the maxillary incisor display.

4.7. Interocclusal clearance

To achieve effective extrusion of the maxillary dentition, it was

crucial to ensure the appropriate interarch clearance in terms of
overjet and overbite. To provide the necessary interocclusal clear-
ance for the maxillary incisors to extrude, posterior bite raisers
can be employed to hinge the mandible backward (Figs. 5–9) [32].
However, it is crucial to acknowledge that patients with a low Fig. 7. The cephalometric superimposition shows the total arch extrusion of the
mandibular plane angle often exhibit greater muscular forces. The maxillary dentition and clockwise rotation of the mandible. Pretreatment (black);
posterior teeth, where the bite raisers are bonded, may have the posttreatment (red).
tendency to intrude under substantial occlusal forces when func-
tioning as the primary occlusal support during bite closure. There-
fore, the simultaneous use of interarch elastics is recommended
to augment the extrusion of the remaining dentition that was ini-
tially out of occlusion because of the presence of bite raisers. How-
ever, using interarch vertical elastics is highly dependent on patient
compliance with the treatment protocol.
To avoid the intrusion of posterior teeth bonded with bite rais-
ers, one potential approach would be to adjust the location of the
bite raisers on the extruded molars to alleviate the intrusion of
Fig. 8. The mechanics for total arch extrusion employ the interdental miniscrews
those teeth alternatingly. The injection of Botulinum toxin type A placed between maxillary canines and first premolars, a 0.017 × 0.025-in titanium-
into the masseter muscle is another consideration [13]. This can be mollybdenum alloys (TMA) extrusion spring, interarch box elastics, and bite raisers,
a potential solution to address the challenges posed by strong oc- (A) before activation (B) after activation. The height of the bite raisers can be ad-
clusal forces as much as possible. justed to reactivate and sustain the force system.

Please cite this article as: J.J.L. Liaw and J.H. Park, Orthodontic considerations in hypodivergent craniofacial patterns, Journal of the World
Federation of Orthodontists, https://doi.org/10.1016/j.ejwf.2023.12.007
JID: EJWF
ARTICLE IN PRESS
6 J.J.L. Liaw and J.H. Park / Journal of the World Federation of Orthodontists xxx (xxxx) xxx
Fig. 9. The progressive records of the maxillary incisor display, (A) pretreatment, (B) midtreatment before total arch extrusion. (C) Posttreatment illustrates effective total
arch extrusion to improve the maxillary incisor display with the skeletal anchorage.
4.8. Maxillary incisor extrusion versus total arch extrusion
As the treatment goal was to enhance the patient’s maxillary in-
cisor display, maxillary incisor extrusion anchored with miniscrews
was tried in the first place [33]. Some improvement in the max-
illary incisor display was noted after the TSAD-assisted maxillary
incisor extrusion, but unfortunately, there was a relapse tendency
during the treatment process because of the heavy occlusal force.
A simultaneous extrusion approach for both the maxillary incisors
and molars was a potential solution to mitigate the risk of relapse.
This strategy aims to achieve a more stable improvement in the
display of the maxillary incisors, with the extruded molars acting
as a keystone to prevent excessive forces on the extruded incisors.
While molars remain susceptible to occlusal forces that could lead
to a relapse tendency, the probability of molar intrusion is dimin-
ished because of the distinct nature of tooth movement types. Ex-
trusion is generally more feasible than intrusion, and the morpho-
logical differences, such as the single conical root in anterior teeth
compared with the trifurcation of molar roots, contribute to this
reduced likelihood.
4.9. Occlusal plane control
Extrusive forces exerted in the maxillary posterior teeth tend to
rotate them palatally. It is advantageous to introduce some expan-
sion in the maxillary archwire with palatal root torque or to use a
transpalatal arch to control the arch width and the torque of pos-
terior teeth. By controlling the extent of maxillary incisor extrusion
more than that of the maxillary molars, it is possible to achieve a
clockwise rotation of the occlusal plane, which in our patient not
only improved the maxillary incisor display and smile arc but also
contributed to good occlusion and stability.
5. Conclusions
Special consideration is essential for craniofacial patterns that
exhibit vertical features. While intrusive mechanics are preferred
in hyperdivergent cases, extrusive mechanics are desirable in hy-
podivergent cases, although the characteristic heavy muscle may
not allow the extrusion to happen or may tend to reintrude
the extruded teeth. To accomplish efficient treatment with es-
thetic outcomes, a nonextraction approach was preferable with
the help of TSADs. If extraction is unavoidable, it is advisable to
limit extraction to a single arch within the maxillary dentition
to prevent loss of vertical dimension. For deep bite correction in
hypodivergent cases, posterior extrusion may be more favorable,
although anterior intrusion proves to be more attainable and sta-
ble. In cases with inadequate maxillary incisor display, a total arch
extrusion of the maxillary dentition might be a possible treat-
ment strategy to enhance maxillary incisor display with reasonable
stability.
Please cite this article as: J.J.L. Liaw and J.H. Park, Orthodontic considerations in hypodivergent craniofacial patterns, Journal of the World
Federation of Orthodontists, https://doi.org/10.1016/j.ejwf.2023.12.007
[mNS;January 11, 2024;14:28]
Acknowledgments
Dr. Johnny J.L Liaw contributed to treating patients and writ-
ing. Dr. Jae Hyun Park contributed to the reviewing and writing the
case. Both authors have read and agreed to the published version
of the manuscript.
References
[1] Harvold EP. The role of function in the etiology and treatment of malocclusion.
Am J Orthod 1968;54:883–98.
[2] Nielsen IL. Vertical malocclusions: etiology, development, diagnosis and some
aspects of treatment. Angle Orthod 1991;61:247–60.
[3] Weijs WA, Hillen B. Correlations between the cross-sectional area of
the jaw muscles and craniofacial size and shape. Am J Phys Anthropol
1986;70:423–31.
[4] Katz MI. Angle classification revisited. 1: is current use reliable? Am J Orthod
Dentofacial Orthop 1992;102:173–9.
[5] Katz MI. Angle classification revisited 2: a modified Angle classification. Am J
Orthod Dentofacial Orthop 1992;102:277–84.
[6] Feldmann I, Bondemark L. Orthodontic anchorage: a systematic review. Angle
Orthod 2006;76:493–501.
[7] Mariani L, Maino G, Caprioglio A. Skeletal versus conventional intraoral anchor-
age for the treatment of Class II malocclusion: dentoalveolar and skeletal ef-
fects. Prog Orthod 2014;15:43.
[8] Munoz A, Maino G, Lemler J, Kornbluth D. Skeletal anchorage for Class II cor-
rection in a growing patient. J Clin Orthod 2009;43:325–31.
[9] Lee J, Miyazawa K, Tabuchi M, Kawaguchi M, Shibata M, Goto S. Midpalatal
miniscrews and high-pull headgear for anteroposterior and vertical anchorage
control: cephalometric comparisons of treatment changes. Am J Orthod Dento-
facial Orthop 2013;144:238–50.
[10] Krishnaswamy NR. Vertical control with TADs: procedures and protocols.
Semin Orthod 2018;24:108–22.
[11] Erverdi N, Keles A, Nanda R. The use of skeletal anchorage in open bite treat-
ment: a cephalometric evaluation. Angle Orthod 2004;74:381–90.
[12] Kuroda S, Sakai Y, Tamamura N, Deguchi T, Takano-Yamamoto T. Treatment
of severe anterior open bite with skeletal anchorage in adults: compari-
son with orthognathic surgery outcomes. Am J Orthod Dentofacial Orthop
2007;132:599–605.
[13] Wang XD, Zhang JN, Liu DW, et al. Nonsurgical correction using miniscrew-as-
sisted vertical control of a severe high angle with mandibular retrusion and
gummy smile in an adult. Am J Orthod Dentofacial Orthop 2017;151:978–88.
[14] Liaw JJ, Park JH, Shih IY, Yang SY, Tsai FF. Treatment of a high angle protru-
sion case optimized with interdisciplinary approaches and TSADs. Am J Orthod
Dentofacial Orthop Clin Companion 2021;1:245–58.
[15] Haas AJ. Long-term posttreatment evaluation of rapid palatal expansion. Angle
Orthod 1980;50:189–217.
[16] MacGinnis M, Chu H, Youssef G, Wu KW, Machado AW, Moon W. The effects of
micro-implant assisted rapid palatal expansion (MARPE) on the nasomaxillary
complex—a finite element method (FEM) analysis. Prog Orthod 2014;15:52.
[17] Suzuki H, Moon W, Previdente LH, Suzuki SS, Garcez AS, Consolaro A. Minis-
crew assisted rapid palatal expander (MARPE): the quest for pure orthopedic
movement. Dent Press J Orthod 2016;21:17–23.
[18] Creekmore TD. Inhibition or stimulation of the vertical growth of the facial
complex, its significance to treatment. Angle Orthod 1967;37:285–97.
[19] Opdebeeck H, Bell WH. The short face syndrome. Am J Orthod
1978;73:499–511.
[20] Turley PK. Orthodontic management of the short face patient. Semin Orthod
1996:138–52.
[21] Ueda HM, Miyamoto K, Saifuddin M, Ishizuka Y, Tanne K. Masticatory muscle
activity in children and adults with different facial types. Am J Orthod Dento-
facial Orthop 20 0 0;118:63–8.
[22] Ng J, Major PW, Heo G, Flores-Mir C. True incisor intrusion attained during
orthodontic treatment: a systematic review and meta-analysis. Am J Orthod
Dentofacial Orthop 2005;128:212–19.
JID: EJWF
ARTICLE IN PRESS
J.J.L. Liaw and J.H. Park / Journal of the World Federation of Orthodontists xxx (xxxx) xxx
[23] Kumar P, Datana S, Londhe SM, Kadu A. Rate of intrusion of maxillary incisors
in Class II Div 1 malocclusion using skeletal anchorage device and Connecticut
intrusion arch. Med J Armed Forces India 2017;73:65–73.
[24] González Del Castillo McGrath MG, Araujo-Monsalvo VM, Murayama N,
et al. Mandibular anterior intrusion using miniscrews for skeletal anchor-
age: a 3-dimensional finite element analysis. Am J Orthod Dentofacial Orthop
2018;154:469–76.
[25] Liu L, Zhan Q, Zhou J, et al. Effectiveness of an anterior mini-screw in achiev-
ing incisor intrusion and palatal root torque for anterior retraction with clear
aligners: a finite element study. Angle Orthod 2021;91:794–803.
[26] Vela-Hernández A, Gutiérrez-Zubeldia L, López-García R, et al. One versus two
anterior miniscrews for correcting upper incisor overbite and angulation: a ret-
rospective comparative study. Prog Orthod 2020;21:34.
[27] Liaw JJ, Park JH. Total arch distalization with extra-alveolar miniscrews for
nonextraction treatment of a low angle Class II Division 1 case: a 10-year fol-
low-up. Am J Orthod Dentofacial Orthop Clin Companion 2023;3:43–54.
Please cite this article as: J.J.L. Liaw and J.H. Park, Orthodontic considerations in hypodivergent craniofacial patterns, Journal of the World
Federation of Orthodontists, https://doi.org/10.1016/j.ejwf.2023.12.007
[mNS;January 11, 2024;14:28]
7
[28] Mücke T, Löffel A, Kanatas A, et al. Botulinum toxin as a therapeutic agent
to prevent relapse in deep bite patients. J Craniomaxillofac Surg 2016;44:
584–589.
[29] Hammad T, Moussa H, Marzouk W, Ismail HA. Effect of maxillary and
mandibular extrusion arches on dentoskeletal changes in adults with anterior
open bite: a quantitative analysis. Angle Orthod 2023;93:26–32.
[30] Bloom D, Padayachy J. Increasing occlusal vertical dimension—why, when and
how. Br Dental J 20 06;20 0:251–6.
[31] Abduo J, Lyons K. Clinical considerations for increasing occlusal vertical dimen-
sion: a review. Aust Dent J 2012;57:2–10.
[32] Liou EJW, Wang YC. Orthodontic clockwise rotation of maxillomandibular com-
plex for improving facial profile in late teenagers with Class III malocclusion: a
preliminary report. APOS Trends Orthod 2018;8:3.
[33] Liaw JJL, Park JH, Tsai FF, Tsai BMY, Liao WWT. Total arch extrusion with skele-
tal anchorage to improve inadequate maxillary incisor display in a case of ver-
tical maxillary deficiency. Angle Orthod 2023. doi:10.2319/070323-462.1.