Advanced biomechanics for total arch

movement and non-surgical treatment

for hyperdivergent faces
Kee-Joon Lee, and Sung-Jin Kim

In contrast to conventional biomechanical concepts in orthodontics where a

segment of teeth has been the target of orthodontic movement, current
technology enables predictable displacement of the whole arch, mainly
based on the relationship between the center of resistance of entire dental
arch and the location of the force vector. Alveolar interradicular miniscrews
produce a highly constant linear force vector that would eventually displace a
large segment, i.e., the entire dental arch.
The clinical implication of the so-called ‘total arch movement’ includes
efficient tooth movement without round-tripping during treatment, com-
pliance-free treatment and higher possibility of non-surgical and/or non-
extraction treatment in non-growing subjects. Substantial biomechanics
including the location of the center of resistance of the entire arch and
simulated dental arch displacement according to the position of the force
vector, provide the theoretical basis for possible movement of the entire
dentition in three dimensions, represented as total arch rotation, distalization
and intrusion. In particular, total arch intrusion can be useful for the
improvement of profile in hyperdivergent face.
This article provides with biomechanical backgrounds and clinical appli-
cations of total arch movement for effective camouflage of dental and
skeletal discrepancies. (Semin Orthod 2018; 24:83–94.) & 2018 Elsevier Inc. All
rights reserved.

Transition from segmental movement to
total arch movement
onventional orthodontic biomechanics
C used to describe the static and/or dynamic
relationship between the anchor tooth/segment
and the moving tooth/segment within the arch
or between the arches, since majority of the tooth
movement was resulted from a reciprocal trac-
tion. In fact, precision control of the anchor
segment and moving segment was not easy due to
the inherent difficulty in the estimation of actual
anchorage value.1 Calibration of the appliance to
Department of Orthodontics, Institute of Craniofacial Deformity,
College of Dentistry, Yonsei University, 50-1, Yonsei-ro, Seodaemun-
gu, Seoul 03722, Republic of Korea.
Corresponding author. Tel.: þ82 2 2228 3105; fax: þ82 2 363
3404. E-mail: orthojn@yuhs.ac
& 2018 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2018.01.008
deliver precise force system to the target segment
is theoretically possible. However, periodic
adjustment and reactivation are essential to
ensure desired tooth movement.2
In this context, it is no exaggeration that the
introduction of simple miniscrew type temporary
anchorage devices have changed the paradigm of
orthodontic biomechanics via elimination of side
effects.3 Following the insertion of the miniscrew,
the force system is created mostly as a single line of
force represented by the direction of elastomeric
chains or springs engaged between the miniscrew
head and another point in the dentition (bracket
or archwire hook).4 Since the force vector is
produced from a point that does not belong to
alpha (anterior) or beta (posterior) segment,
reactive movement of the anchorage unit is not
much concern. The resultant tooth movement is
largely determined by the relationship between
the line of force and the center of resistance of
target segment. Furthermore, the force system

Seminars in Orthodontics, Vol 24, No 1, 2018: pp 83–94 83

84 Lee and Kim

construction and interpretation of the outcome
can be less complicated than those of conventional
mechanics.
For instance, a single force vector applied to a
rigid incisor sectional wire would induce imme-
diate lingual rotation of the anterior segment. The
rotational tendency is proportional to the moment
of force, which is calculated by multiplying the
magnitude of the force by the distance from the
center of resistance to the line of force (Fig. 1A).
When a continuous archwire was used, now the
target segment is the whole arch and the center of
resistance can be localized around the premolar
(Fig. 1B). The effect of identical force vector would
be different mainly because of the change in the
size of the target segment, and also the change in
the distance between the line of force and the
center of resistance. The rotational tendency of the
incisors is now reduced compared to the previous
case. Therefore, the effect of force is dependent
upon the configuration of the target segment. This
schematization again implies that the rotation of
the whole occlusal plane may be expressed during
retraction of anterior teeth. Hence displacement
of the whole dental arch may be an unavoidable
effect when using orthodontic miniscrews.
If the identical miniscrew was used for molar
distalization, the elastomeric chain may result in
a counterclockwise rotation of the segment
rather than distal displacement worsening Class
II molar relation. The resultant displacement
pattern largely depends on the relative position
of the center of resistance (Fig. 1C).
Current evidences of total arch movement
In terms of molar distalization, for example,
conventional distalization recruited various extra-
or intra-oral appliances which inevitably causes
undesired movement of anchorage segment.5,6

Figure 1. Defining the target segment. (A) Single force application to incisor segment; (B) single force application
to the whole arch; and (C) single force causing clockwise rotation of posterior segment (Cresα: center of resistance of
anterior segment, Cresβ: center of resistance of posterior segment, CresT: center of resistance of total arch).
 Advanced biomechanics for total arch movement and non-surgical treatment for hyperdivergent faces 85

Figure 2. Pendulum appliance and resultant force system. (A) Before installation of appliance; (B) after
activation; and (C) resultant distal tipping of the molar.

Byloff and Darendeliler7 described that clinical
effect of the pendulum appliance was a combined
distal tipping of the molar and forward movement
of the premolars and incisors. Distal tipping of
molar was evident mainly due to the position of
the force vector applied to the crown level (Fig. 2).
Modification of the appliance by incorporation of
uprighting bends lead to less tipping of the molars
but even more anchorage loss, indicating inherent
limitation of the intraoral molar distalizing
appliances8 (Fig. 2).
In contrast to these findings, the concept of
simultaneous movement of the whole dental arch
has already been in clinical use for more than a
decade. Sugawara et al.9,10 introduced the use of
miniplates for respective maxillary or mandibular
molar without causing undesired movement of
incisors. Related to this, simultaneous incisal and
molar movement using interradicular miniscrews
placed between the 2nd premolar and the 1st
molar was proposed by others, eliminating the
need for incisor retraction subsequent to the
molar distalization.11,12 Those clinical evidenced
support the idea that monocortical-type mini-
crews are able to displace the whole dentition.
A linear force applied to the anterior segment
on a continuous archwire and interradicular
miniscrews was found to induce relatively stable
distalization of molars regardless of the tipping
of the anterior segment (Fig. 3), which was
considered another biomechanical advantage.13
When a anteroposteriorly long segment is given a
horizontal force vector at parallel direction, the
rotation tendency tends to be reduced.14
Total arch movement in three dimensions
Interradicular miniscrews provides a point of
force application localized above the archwire
level, which can be disintegrated into horizontal
and vertical force vectors, implicating the pres-
ence of intrusive component of force. Unlike
the conventional force produced by reciprocal
elastomeric tie between alpha and beta segment,
which is purely horizontal, the linear force may
exert intrusion effect on the entire arch in theory.
Upadhay et al. reported the clinical outcome
of en-masse retraction of anterior teeth following
premolar extraction using bimaxillary inter-
radicular mini-implants in their randomized
86 Lee and Kim

Figure 3. Simulation of arch displacement using finite element.13 (A) Force application to the continuous
archwire and (B) force application to the long lever arm.

controlled clinical trial. One of the interesting
findings was the significant reduction of the
mandibular plane angle in the mini-implant
group which was not evident in the conventional
retraction group, implying intrusive effect.15,16
Furthermore, Bechtold et al.17 found an
intrusion of the whole dental arch during
distalization of the dental arch using dual
interradicular miniscrews in the maxilla.
Additional force vector created by interadicular
miniscrew positioned between the 1st and the 2nd
premolars changed the relationship between the
imaginary center of resistance of the whole arch
and the lines of force, leading to simultaneous
upward and backward displacement of the entire
dental arch.
Location of the center of resistance
Various experimental methods such as laser
holography, photoelasticity and electrical resist-
ance strain gauge methods, have been utilized to
locate the center(s) of resistance of various teeth
segments.13,18–20 Finite element is a mathemat-
ical tool which can be used to find relatively
precise location of the center of resistance under
given material properties.
In a series of finite element analyses, center of
resistance of entire dental arch was localized at
the mesial side of the 2nd premolar in the
maxillary arch, and at the interradicular area
between the 2nd premolar and the 1st molar in
the mandibular arch, respectively (Fig. 4).21,22

Figure 4. Estimated center of resistance in the non-extraction model.

 Advanced biomechanics for total arch movement and non-surgical treatment for hyperdivergent faces
Figure 5. Arbitrary movement of total arch and relevant force vector. (A) Total arch distalization; (B) total arch
intrusion; and (C) total arch rotation.
Hence construction of a force system using the
information is possible. For instance, a rota-
tional movement would be resulted by a line of
force passes far from the center of resistance,
which a force vector that runs through the
center of resistance would lead to translation
of the dental arch in the horizontal and/or
vertical direction. In particular, the vertical
control may be crucial in terms of finding
creative solutions for many clinical challenges
(Fig. 5).
Taken together, it is conceivable that the
resultant displacement is a function of the line
of force relative to the center of resistance of
the entire dental arch. Therefore, localization
of the centers of resistance of the target seg-
ments is crucial to anticipate and interpret the
displacement pattern of the dental arch in
response to the lines of force from the
miniscrews.
87
Predictable total arch movement for
creative troubleshooting
Case 1: Total arch rotation for full cusp Class II/
III molar relation without extraction
Severity of the malocclusion is often described as
the severity of anteroposterior discrepancy in the
molar relation. Therefore, a full-cusp Class II
molar relationship, for instance, would require
major molar ‘distalization’ well above 4–5 mm for
conversion to Class I molar relation, for which
extraction of maxillary premolars are readily
chosen. On the other hand, it is well known
that the anteroposterior dental relation is
associated with the steepness of the occlusal
plane, according to the description of ‘Wits
appraisal’.23,24 This notion implicates the effec-
tiveness of arbitrary rotation of the occlusal plane
for the correction of molar relation. A clinical
example is shown like the following.
88 Lee and Kim

Figure 6. Initial intraoral view: initial diagnostic model and final intraoral view.

A 16-year-old male patient visited the Ortho- debonding of the braces were conducted to
dontic Department with excessive overjet. Full finish the treatment. The overall treatment time
cusp Class II molar relationship was found at was 26 months but complicated molar distalizers
the initial intraoral examination and also at the were not necessary at any point for major cor-
initial model (Fig. 6). Cephalometric analysis rection of the molar (Figs. 6 and 7).
revealed Class I skeletal relationship, low It was noteworthy that the occlusal plane rotation
mandibular plane angle together with flat contributed to the molar correction. The actual
occlusal plane.
In order to correct the molar relation and
incisal overjet, either extraction of maxillary pre-
molars or major molar distalization of more than
5 mm was an option. In view of the flat occlusal
plane, however, it was presumed that an effective
rotation of the occlusal plane would favor con-
version of molar relation from Class II to Class I.
According to these presumptions, a force
system with linear forces located far from the
estimated center of resistance of the whole
maxillary arch using interradicular miniscrews
between the 1st and the 2nd molar in the
maxilla and between the canine and the 1st
premolar in the mandible, were constructed
to induce rotation of the respective dental
arches, by maximizing the ‘moment of force’
(Fig. 7).
Subsequent retraction of upper incisors was
performed. Desirable molar and incisor relation Figure 7. Force system involving linear vectors for
was obtained after 1.5 year. Occlusal settling and effective rotation of occlusal plane.
 Advanced biomechanics for total arch movement and non-surgical treatment for hyperdivergent faces
amount of the maxillary molar distalization was
measured as 3.5 mm in each side. The combined
clockwise rotation of occlusal plane, the distalization
of the upper molar and mild mesial tipping of lower
molar have led to effective conversion of molar
relation from complete Class II to Class I without
extraction and without patient’s compliance at all
(Fig. 8). A controlled lingual rotation (tipping) of
upper incisor along with pure intrusion of lower
incisor contributed to the rotation of the occlusal
plane, reduction of the overjet and correction of
deep bite. This case visualizes how a theory can be
effectively translated into practice.
Predictable total arch distalization and
intrusion
Total arch distalization can be readily utilized for
the correction of the either Class II or Class III
problem. In addition, vertical correction via total
arch intrusion can also be realistic and can be a
useful solution for clinical challenges.
Total arch distalization can be performed using
interradicular miniscrews inserted at an oblique
angle, for effective two to three millimeters of dis-
talization without damaging the adjacent roots.11
Figure 8. Cephalometric superimposition showing conversion from full Class II to Class I and the pattern of
occlusal plane rotation.
89
Considering the small distance between the center
of resistance and the possible horizontal line(s) of
force, the resultant pattern of displacement of the
dental arch may not be a sensitive function of the
position of the interradicular miniscrews whether
they are located between the molars, or between the
premolars. In contrast, the pattern of displacement
is affected by the location of force vector when it
comes to total arch intrusion, because the distance
between the center of resistance and the line of
force changes greatly. Even if the center of
resistance of the entire arch was localized by
experimental methods, it is still challenging to
pinpoint the center of resistance in each case.
Therefore, it is recommended to use dual
miniscrews for predictable total arch intrusion
to stabilize the dental arch during intrusion
without tilting and also to have the intrusion
force efficiently distributed throughout the dental
arch (Fig. 9).
Case 2: Total arch intrusion for retraction of lips
without extraction
A 25-year-old female patient presented with a
chief complaint of severe lip protrusion.
90
Figure 9. Difference between total arch distalization and intrusion. Position of interradicular miniscrew is more
important in case of total arch intrusion.
Her initial extraoral view showed severe lip
protrusion at reposed lip position along
with significant lip incompetency. In particular,
she had received orthodontic treatment pre-
viously involving four premolars extraction,
which meant extraction of premolars was not
supposedly an option for her lip protrusion
(Fig. 10).
Her initial cephalometric analysis revealed
hyperdivergent face, upright upper incisor and
increased ANB angle (data not shown). She
was diagnosed as hyperdivergent Class II with
Class I dental relationship. In order to improve
the facial profile, elimination of the lip
incompetency was considered essential. More-
over, lip incompetency in this particular case
was found to be associated with relatively short
upper and lower lips compared to the
underling dentoalveolar structure. Therefore,
ample vertical intrusion as well as posterior
retraction was necessitated. Hence maximum
posterosuperior displacement of the whole
maxillary arch and posteroinferior displace-
ment of the mandibular arch were defined as
the required movement. According to this,
interradicular buccal miniscrews were used in
the respective maxillary and mandibular arch.
Oblique upward lines of force were applied,
along with stiff working wire of .016 × .022-in
stainless steel (Fig. 10).
Following the detailing of the occlusion,
brackets were removed. Extraoral photographs
Lee and Kim
showed well balanced lip profile between the
nose and the soft tissue chin point, demon-
strating remarkable improvement in the facial
profile (Fig. 11).
From the cephalometric superimposition,
simultaneous intrusion of both maxillary and
mandibular arch was noted as planned. Anterior
facial height was reduced by 3.0 mm. This
Intrusive displacement and distal movement
of incisors contributed to the profile change by
eliminating the severe lip incompetency
(Fig. 12).
Case 3: Total arch intrusion for gummy smile and
lip incompetency
A 33-year-old woman presented with gummy
smile and protrusion of the lips. Initial exami-
nation revealed crowding with missing lower
right lateral incisor, which may limit the amount
of anterior retraction for the improvement of the
lip profile (Figs. 13 and 14).
In order to minimize or eliminate the
existing lip incompetency and gummy smile,
simultaneous intrusion of both maxillary and
mandibular dentition was indicated. Multiple
interradicular miniscrews were placed and
intrusive force vector was given. Following 30
months of treatment, sufficient change in
the lip profile was obtained (Figs. 13 and
14). Gummy smile was significantly reduced
and the smile esthetics was improved.
Advanced biomechanics for total arch movement and non-surgical treatment for hyperdivergent faces 91

Figure 10. Intraoral photographs: initial, during treatment and final.

Figure 11. Extraoral photographs: initial and final.

92 Lee and Kim

From the cephalometric superimposition, it

can be found that the combined retraction of
incisors and reduction of vertical dimension
commonly contributed to the profile change by
alleviating the mentalis hyperactivity (Fig. 15).

Figure 12. Cephalometric superimposition.
Conclusion
Force vectors produced by miniscrews inserted in
the alveolar bone are unique in that they are highly
constant and intrusive. Due to this nature, careful
analysis and interpretation is utmost important for
prediction of the results. It is important to under-
stand that displacement of the whole arch can
always take place when using miniscrews. Arbitrary
total arch rotation can be an alternative to major
distalization in severe Class II/III cases, and total
arch intrusion can replace surgical intervention in
hyperdivergent cases displaying severe lip pro-
trusion and/or gummy smile.

Figure 13. Intraoral photographs: initial, during treatment and final.

 Advanced biomechanics for total arch movement and non-surgical treatment for hyperdivergent faces
Figure 14. Extraoral photographs: initial and final.
References
Figure 15. Cephalometric superimposition.
Acknowledgements
This study was supported by the Yonsei University
College of Dentistry (6-2017-0012).
93
1. Burstone CJ. Rationale of the segmented arch. Am J
Orthod. 1962;48:805–822.
2. Viecilli RF, Chen J, Katona TR, Roberts WE. Force system
generated by an adjustable molar root movement
mechanism. Am J Orthod Dentofacial Orthop. 2009;135:
165–173.
3. Papadopoulos MA, Papageorgiou SN, Zogakis IP. Clinical
effectiveness of orthodontic miniscrew implants: a meta-
analysis. J Dent Res. 2011;90:969–976.
4. Lee KJ, Park YC, Hwang CJ, et al. Displacement pattern of
the maxillary arch depending on miniscrew position in
sliding mechanics. Am J Orthod Dentofacial Orthop.
2011;140:224–232.
5. Kinzinger G, Syree C, Fritz U, Diedrich P. Molar
distalization with different pendulum appliances:
in vitro registration of orthodontic forces and moments
in the initial phase. J Orofac Orthop. 2004;65:389–409.
6. Kinzinger GS, Gross U, Fritz UB, Diedrich PR. Anchorage
quality of deciduous molars versus premolars for molar
distalization with a pendulum appliance. Am J Orthod
Dentofacial Orthop. 2005;127:314–323.
7. Byloff FK, Darendeliler MA. Distal molar movement using
the pendulum appliance. Part 1: clinical and radiological
evaluation. Angle Orthod. 1997;67:249–260.
8. Byloff FK, Darendeliler MA, Clar E, Darendeliler A. Distal
molar movement using the pendulum appliance. Part 2:
the effects of maxillary molar root uprighting bends.
Angle Orthod. 1997;67:261–270.
9. Sugawara J, Daimaruya T, Umemori M, et al. Distal
movement of mandibular molars in adult patients with
the skeletal anchorage system. Am J Orthod Dentofacial
Orthop. 2004;125:130–138.
94 Lee and Kim
10. Sugawara J, Kanzaki R, Takahashi I, Nagasaka H, Nanda
R. Distal movement of maxillary molars in nongrowing
patients with the skeletal anchorage system. Am J Orthod
Dentofacial Orthop. 2006;129:723–733.
11. Yamada K, Kuroda S, Deguchi T, Takano-Yamamoto T,
Yamashiro T. Distal movement of maxillary molars using
miniscrew anchorage in the buccal interradicular region.
Angle Orthod. 2009;79:78–84.
12. Jeon JM, Yu HS, Baik HS, Lee JS. En-masse distalization
with miniscrew anchorage in Class II nonextraction
treatment. J Clin Orthod. 2006;40:472–476.
13. Sung EH, Kim SJ, Chun YS, Park YC, Yu HS, Lee KJ.
Distalization pattern of whole maxillary dentition according
to force application points. Korean J Orthod. 2015;45:20–28.
14. Choy K, Pae EK, Park Y, Kim KH, Burstone CJ. Effect of
root and bone morphology on the stress distribution in
the periodontal ligament. Am J Orthod Dentofacial Orthop.
2000;117:98–105.
15. Upadhyay M, Yadav S, Nagaraj K, Patil S. Treatment
effects of mini-implants for en-masse retraction of
anterior teeth in bialveolar dental protrusion patients:
a randomized controlled trial. Am J Orthod Dentofacial
Orthop. 2008;134:18–29e11.
16. Upadhyay M, Yadav S, Nanda R. Vertical-dimension
control during en-masse retraction with mini-implant
anchorage. Am J Orthod Dentofacial Orthop. 2010;138:96–108.
17. Bechtold TE, Kim JW, Choi TH, Park YC, Lee KJ.
Distalization pattern of the maxillary arch depending
on the number of orthodontic miniscrews. Angle Orthod.
2013;83:266–273.
18. Tanne K, Koenig HA, Burstone CJ. Moment to force
ratios and the center of rotation. Am J Orthod Dentofacial
Orthop. 1988;94:426–431.
19. Tanne K, Nagataki T, Inoue Y, Sakuda M, Burstone CJ.
Patterns of initial tooth displacements associated with
various root lengths and alveolar bone heights. Am J
Orthod Dentofacial Orthop. 1991;100:66–71.
20. Tominaga JY, Tanaka M, Koga Y, Gonzales C, Kobayashi
M, Yoshida N. Optimal loading conditions for controlled
movement of anterior teeth in sliding mechanics. Angle
Orthod. 2009;79:1102–1107.
21. Jeong GM, Sung SJ, Lee KJ, Chun YS, Mo SS. Finite-
element investigation of the center of resistance of the
maxillary dentition. Kor J Orthod. 2009;39:83–94.
22. Jo AR, Mo SS, Lee KJ, Sung SJ, Chun YS. Finite-element
analysis of the center of resistance of the mandibular
dentition. Korean J Orthod. 2017;47:21–30.
23. Jacobson A. The “Wits” appraisal of jaw disharmony. 1975.
Am J Orthod Dentofacial Orthop. 2003;124:470–479.
24. Tanaka JL, Ono E, Filho Medici E, Cesar de Moraes L,
Cezar de Melo Castilho J, Leonelli de Moraes ME.
Influence of the facial pattern on ANB, AF-BF, and Wits
appraisal. World J Orthod. 2006;7:369–375.