396
that the tongue could be a major factor in some
malocclusions.
John Mew
London, United Kingdom
Am J Orthod Dentofacial Orthop 2012;141:395-6
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2012.02.008
Questioning treatment strategies in
hyperdivergent patients
I t was fascinating to read the retrospective research ar-
ticle in the September issue comparing 2 contrasting
conventional strategies to treat growing hyperdivergent
patients (Gkantidis N, Halazonetis DJ, Alexandropoulos
E, Haralabakis NB. Treatment strategies for patients
with hyperdivergent Class II Division 1 malocclusion:
is vertical dimension affected? Am J Orthod Dentofa-
cial Orthop 2011;140:346-55). One method was
a nonextraction approach with extrusive mechanics,
and the other was an extraction approach with intru-
sive mechanics. One aim was to study the wedge-
effect phenomenon, which has implications in the
control of vertical dimensions. Although clinically im-
portant conclusions were made from the study, some
additional points could have been described or con-
sidered that might have led to additional important
conclusions.
First, which type of intrusive mechanics was used for
the extraction patients? As stated in the methods sec-
tion, Goshgarian arches were used. But it has been
shown that these are effective for holding molars verti-
cally and not for intruding them. Second, the inclusion
of the second molars should have been avoided, since
it can lead to opening the bite.
How was 5 mm of mesialization of the mandibular
molars achieved in the extraction patients, since no
additional mechanics were used, such as Class II
elastics?
The wedge-effect concept can also be applied when
distalization of molars is attempted; this should have
been considered for the nonextraction patients. In
such patients, the use of low-pull headgear for distaliza-
tion can increase the vertical dimension.
One important variable in hyperdivergent patients
is vertical movement of the molars. This is a major
problem; in this study, this factor needed more dis-
cussion.
April 2012  Vol 141  Issue 4
Readers' forum
I do agree with the conclusions drawn from the study,
but indirectly it also highlights the importance of newer
vertical holding mechanics such as temporary anchorage
devices as well as functional treatments. It would be fas-
cinating to view the comparison between conventional
mechanics with additional vertical holding mechanics
and modified functional strategies.
This is one of the few articles on vertical dimensions
that highlights the role of skeletal as well as neuromus-
cular functions in hyperdivergent patients by using
contrasting treatment strategies. I commend the au-
thors for their interesting and thought-provoking
article.
Umal H. Doshi
Aurangabad, Maharashtra, India
Am J Orthod Dentofacial Orthop 2012;141:396
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2012.02.016
Author’s response
W e would like to thank Dr Doshi for his useful com-
ments and the opportunity to discuss our article.
We contrasted 2 treatment strategies and named them
“intrusive” and “extrusive” based on their intent and
how they are customarily perceived by clinicians. The
aims were to test the combined effect of all appliances
and interventions of each strategy and to evaluate their
effectiveness on vertical control. Thus, we did not ask
whether intrusion is, in principle, feasible, but, rather,
whether vertical control is different between these spe-
cific, commonly applied treatments.
Concerning molar position, the origin of our refer-
ence system was sella, so part of the molar displacement
was attributed to facial growth. In the mandibular arch,
both groups showed anterior molar displacement,
which was larger in the extraction group by 3 mm,
due to anchorage loss during retraction. Almost 1 mm
of distalization of the maxillary molars was achieved
in the nonextraction group through regular use of
low-pull headgear and Class II elastics, but this did
not affect the vertical dimension differently from the
other group, where mesial molar movement was evi-
dent. In the extraction group, spaces were closed
through intra-arch mechanics (power chains). The influ-
ence of low-pull headgear on the vertical dimension has
been examined in previous studies, and similar results
were obtained (see the “Discussion” section in our
article).
American Journal of Orthodontics and Dentofacial Orthopedics