Surgical correction of the long face

syndrome
William H. Bell, D.D.S.,* Thomas D. Creekmore, D.D.S.,** and
R. G. Alexander, D.D.S.***
Dnllns. Texus

T reatment of adults with long faces has intrigued, challenged, and frus-
trated the surgeon and orthodontist for years. This dentofacial deformity, with
its wide spectrum of clinical manifestations, has been recognized and described
for years under different titles. Skeletal open-bite,l idiopathic long face,” hyper-
divergent face,” high angle type, total maxillary alveolar hyperplasia,” and verti-
cal maxillary excess;’have varying degrees of “excessive vertical maxillary height,”
as their common denominator. Such facial types, having a similar clinically rec-
ognizable dental, skeletal, ant1 facial morpholog,v, can be unified into one facial
type--the long face syndrome.”
The need for reduction of vertical facial height in persons with long faces has
been long recognized. In many adults or adolescents with long faces, however, it
is doubtful whether orthodontic treatment or orthopedic mechanics alone can
decrease maxillary height or inhibit its potential growth sufficiently to achieve
facial balance and an attractive smile. Orthodontic treatment in nongrowing pa-
tients seldom reduces anterior face height or improres the skeletal framework
(Fig. 1, Case 1). If the open-bite is corrected, this is usually accomplished at the
expense of facial esthetics by tipping the anterior teeth lingually and/or elongat-
ing the teeth. If maxillary incisors arc excessircly exposed relat,ive to the upper
lip, they will probably be exposed even more at the end of orthodontic treatment.
Moreover, lip incompetence remains after treatment.
Recurrence of the open-bite is nut uncommon and is observed after treatment
if the vertical growth of the jaws exceeds the eruptive potential of the incisors
(Fig. 2). This type of “relapse” occurs rather slowl,~ in contrast to the relatively
rapid relapse that ma;v occur if the teeth are elongated appreciably with vertical
elastics. This rapid vertical relapse may be due to strctchcd gingival fibers, much
the same as with rotation relapse.
‘Associate I’rofrssor, l’he University of Texas Health Science Center, Department of
Surgery, Division of Oral Surgery, Center for Correction of Dentofacial Deformities.
**In private practice of orthodontics, Houston, Texas.
‘**In private practice of ortlrodontics, Arlington, Texas.

40
Fig. 1. A to C, Class I crowded open-bite malocclusion of 23-year-old man before ortho-
dontic treatment. D to F, Occlusion 30 months after completion of orthodontic treatment
which required 18 months. All four first premolars were extracted. G, Composite cepha-
lometric tracings before treatment (solid line-23 years 7 months); after 18 months of
orthodontic treatment (broken line-25 years 1 month); and 30 months after completion
of orthodontic treatment (dotted line-27 years 7 months). The skeletal framework did
not change. The open-bite was closed by tipping the maxillary and mandibular incisors
lingually about their apices. The result was stable, but treatment elongated the maxillary
incisors relative to the upper lip. H to J, Postoperative appearance 30 months after treat-
ment. Lip incompetence is still evident; maxillary incisors are too long relative to the
upper lip; and excessive gingiva is displayed when the patient smiles.
 Am J. Orthod.
January 1977

Fig. 2, A to C. Two-year pretreatment growth study of a boy with Class II long face, non-
open-bite condition. A, Mandibular plane angle increased 3 degrees. B, Anterior dental
height increased 6 mm. C, Incisors erupted in compensation maintaining a non-open-bite
occlusion.

With the introduction of surgical techniques to shorten the face”, 7 by 1~

Fort I osteotomy* or combined anterior ant1 posterior maxillary osteotomies;. !’
the door was opened to new and exciting methods for t,reating the long fact
syndrome. When surgery to reposition the maxilla superiorly in combination with
orthodontic treatment is properly planned and cisccuted, the basic tlentofacial
deformity can bc corrcctctl to achieve occlusal ant1 facial harmony.

Evolution of surgical technique

The hallmarks of successful and stable maxillary surgery are complete mobil-
ity of the maxilla, preservation of its viability by proper tlesign of the bony and
Volume 71
Number 1

Fig. 2, D to F. Composite cephalometric tracings before 22 months of orthodontic treatment

and 26 months after treatment. Mandibular plane angle remained unchanged at 42 de-
grees, but anterior height increased 13 mm. Bite started opening slowly after treatment.

soft-tissue incisions, and adequate fixation during the healing phase until there is
osseous union of the sectioned bone. The Le Fort I osteotomy with its many modi-
fications meets these criteria for management of vertical dysplasias.
Inability to move the maxilla the desired amount and relapse were common for
surgeons who initially used this operation. lo The surgeon’s fear that mobilization
of the maxilla would devascularize and devitalize the bone and teeth was the
dominant reason for such problems. Until recent years, the biologic basis and
the surgical principles for maxillary osteotomies remained obscure and were im-
portant reasons why these procedures were considered radical and were given
relatively little use throughout the world. The specter of disaster loomed when
maxillary osteotomies were initially introduced to the American oral surge0n.l’
In 1965, an animal investigation was designed to delineate the biology of maxil-
lary osteotomy wound healing. Since then, more than 150 adult rhesus monkeys
have been used as experimental models to investigate the vascularization, revas-
cularization, and bone healing associated with various maxillary techniques.‘2-‘”
Microangiographic and histologic studies of maxillary osteotomies performed in
 -AGE 15
----AGE 17-b

Fig. 2, G to I. Continued posttreatment growth similar to that seen in pretreatment growth

study. Anterior face height continued to increase more than posterior face height.

adult rhesus monkeys showed transient vascular ischemia, minimal osteonecrosis,

and osseous union when the maxilla, or segments thereof, remained pedicled to
the palatal mucosa and labiobuccal gingiva. The collateral circulation within the
maxilla and its enveloping soft tissue anti the numerous vascular anastonioses in
the anterior and posterior parts of the maxilla permitted many technical varia-
tions of maxillary osteotomy techniques.
The American oral surgeon was initially introduced to surgical procedures for
independent movement of the anterior or posterior portions of the maxilla. How-
ever, these operations lacked versatilit?- and, therefore, casts were freyuentl>
compromised in function and facial esthetics. Gradually, with increasing clinical
experience’“-‘” and improved insight into the surgical and biologic principlcs,lC’
surgical procedures for simultaneous movement of the ant,crior and posterior
maxillae were tlcvelopctl. Now, surgical plans coul~l hc devised and comhincd with
orthodontic techniques to meet the indir*idunJ’s fmctiontr7 cmd cosmetic weeds.
The lie Fort T “down fracturing” technique, with its many modifications, affords
vozume 71
Number 1

Fig. 2 (Cont’d). J to L, Occlusion after 22 months of orthodontic treatment. Maxillary first

premolars were extracted. High-pull face-bow was worn to inhibit posterior maxillary
development. M to 0, Occlusion 41/z years after treatment. The position of the ankylosed
maxillary left first premolar that was in occlusion at completion of treatment indicates the
amount of eruption of the teeth; yet the teeth anterior to the first molars are still not in
occlusion.

great versatility in planning treatment for patients with the long face syndrome
(Fig. 3).
Dentofacial characteristics

Persons wih the long face syndrome have certain dentofacial skeletal features
which are manifest with or without dental anterior open-bite. The upper third
of the face of the affected person is usually within normal limits. Examination
of the middle third of the face typically reveals a narrow nose, narrow alar bases,
a prominent nasal dorsum, and depressed paranasal areas. Analysis of the lower
third of the face commonly reveals excessive exposure of the maxillary anterior
teeth with the lips in repose, inordinate exposure of the maxillary teeth and
gingiva upon smiling, lip incompetency, ion,0~lower third facial height, a retro-
positioned chin, and an essentially normal or obtuse nasolabial angle.
A Class II malocclusion, with or without open-bite, is many times associated
with the deformity. A high constricted palatal vault with a large distance be-
tween the root apices and the nasal floor and a steep mandibular plane are con-
sistent findings. These dentofacial-skeletal features are variably manifest wit,h
or without dental open-bite.
Esthetic considerations

Vertical. The relationship of the upper lip line to the incisor is the keystone to
planning treatment that will achieve an attractive smile. Individual variation in
the anatomy of a smilc,20 length of the incisor clinical crown, and the height of
the upper lip in relation to the gingival margin of the upper incisor teeth are
Fig. 2 (Cont’d). P to R, Facial appearance at age 11 before orthodontic treatment. Lip in-
competence is evident. There is excessive exposure of teeth and gingiva when patient is
smiling. 5 to U, Facial appearance (age 17 years 6 months) 45 years after orthodontic
treatment. Amount of lip incompetence has increased. Upper lip line to incisor relationship
has remained the same. Mandible is more retropositioned.

additional important parameters to consider. With an attractive smile, the upper

lip is usually near or a little below the height of the gingival margin of the maxil-
lary incisors. The upper lip curvature is most desirable when the corners of the
mouth arc above the midline of the upper lip.”
Predictio?l of postopemtive resztlfs. The magnitude and direction of surgical
repositioning of the maxilla and the feasibility of the tentative plan of treatment
are determined from a coordinated study of the patient, his lateral cephalomctric
tracings, and model analysis. A radiograph that delineates both soft and hard
tissues is made with the mandible in centric occlusion and the lip muscles relaxed.
Fig. 3. Surgical technique for correction of long face syndrome with open-bite. Similar
procedure is used for correction of vertical dysplasias without open-bite. A, Typical dental,
skeletal, and facial features of long face syndrome with mandible in centric relation and
lips relaxed. Note prominent nasal dorsum, obtuse nasolabial angle, large distance
between apices of maxillary teeth and nasal floor, excessive curvature of maxillary oc-
clusal plane, high mandibular plane angle, lip incompetency, retropositioned mandible,
open-bite, contour-deficient chin, and Class II malocclusion. B, Plan of surgery: Le Fort I
osteotomy to reduce facial height, close open-bite, level maxillary occlusal plane, reduce
incisor tooth exposure and lip incompetency, and close residual extraction spaces. Hori-
zontal osteotomy of chin designed to increase chin prominence and decrease vertical
height of mental symphysis. Premolar teeth have been extracted to facilitate correction
of crowded and malaligned teeth by orthodontic means. Extraction spaces are closed only
the amount necessary to align anterior teeth. Cross-hatched areas indicate planned hori-
zontal and vertical ostectomy sites. Arrows indicate planned directional movements of an-
terior and posterior maxillae and chin. Amount of bone to be excised is determined from
cephalometric prediction studies and mock sectioning of study casts (Figs. 3 and 4) before
surgical intervention. C, Repositioned maxilla is fixed to the piriform rims and zygomatic
buttresses with transosseous wires; suspension wire from infraorbital rim to maxillary
arch wire provides additional support to maxilla.
 A 1)~. J. Orthod.
Januar~1977

Fig. 4. For legend, see opposite page.

The maxilla is positioned superiorly the amount necessary to achieve 2 to 3 mm.

of maxillary incisor exposure with the upper lip at rest. Because postsurgical
studies have indicated a 20 per cent shortenin g of the upper lip with superior
repositioning of the maxilla, the maxilla is overcorrected a proportional amount.
If, for example, the inferior margin of the upper lip is 10 mm. above the maxil-
lary incisal edge, the maxilla is surgical1.v repositioned superiorly 10 mm. to
achieve esthetic balance between the upper lip and teeth.
 Calculation of ammnt of superior repositioGng of maxilla.
Inferior margin of upper lip to maxillary incisal edge 10 mm.
Desired amount of ma.xillary incisor exposure - 2 mm.
8 mm.
Compensation for upper lip shortening associated with superior
repositioning of maxilla + 2 mm.
Amount of superior repositioning required 10 mm.
Cephalometric prediction of postoperative dmnges. All of the maxillary and
mandibular teeth and bony landmarks and the enveloping soft-tissue profile
(traced from a lateral cephalometric radiograph exposed with the mandible in
centric occlusion and the lips relaxed) are traced on a sheet of acetate tracing
paper (Fig. 4). Simulated maxillomandibular and soft-tissue changes in this
radiograph closely parallel the changes associated with superior repositioning
of the maxilla by surgical means. To simulate the dentoskeletal-facial profile
changes, the maxillary and mandibular teeth and bone arc traced with a differ-
ent-colored pencil onto a second piece of overlaid acetate tracing paper. Cut-out
paper “templates” of the maxilla and mandible are nom moved the amount and
direction necessary to achieve the desired esthetic result and simulate the planned
maxillary movement. On the basis of anticipated changes in the soft tissue as-
sociated with anteroposterior and rcrtical movement, of the dento-osseous seg-
mentP a new soft-tissue profile is traced.
The angle formed bp the nostrils and the upper lip should normally range
between 90 and 110 degrees. When this nasolabial angle is relatively small, the
maxilla is repositioned superiorly and posteriorly to reduce the relative promi-
nence of the upper lip ; the consequent counterclockwise rotation of the mandible
upward and forward increases the chin prominence and decreases the lower an-
terior face height. When there is an obtuse or normal nasolabial angle, the maxilla
is simultaneously moved anteriorly and superiorly to obviate undesirable esthetic

Fig. 4. Cephalometric prediction. All of the maxillary and mandibular teeth and bony land-
marks and the enveloping soft-tissue profile are traced on acetate tracing paper. Then
the maxillary and mandibular dentoskeletal structures and the soft-tissue chin are regis-
tered onto a second piece of overlay tracing paper. After a third piece of tracing paper is
overlaid, the maxillary teeth and bony landmarks are registered (A). The maxilla and
mandible are stippled to help distinguish the template from the image on the tracing
paper. A template of the maxilla is cut out (A). When the anterior and posterior parts of
the maxilla are to be moved independently and simultaneously, the maxillary template
is cut into two pieces to simulate the desired positional changes of the anterior and pos-
terior maxilla. 6, Maxillary template is positioned over the previous cephalometric tracing
to simulate the desired superior maxillary movement. C, Template of mandible is posi-
tioned over the previous tracing. D, The condylar portion of the template is fixed to the
underlying tracing paper with a pin and serves as the axis of mandibular rotation. E,
Simulation of autorotational mandibular movement by anterior and superior movement of
the mandibular template until the mandibular incisors contact the maxillary incisor teeth.
F, The new soft-tissue profile serves as the basis for simulating additional profile changes
by genioplasty or rhinoplasty.
 AWL J. OTthod.
January 1977

changes in the lower third region of the face. After the maxillary template is
moved into the desired position, autorotaticnal mandibular movement is simulatetl
by anterior and superior movement of the mandibular paper “template” until
the lower incisors make contact with the maxillary incisors. The condyle serves
as the axis of rotation. Once the maxillary template is moved into the desired posi-
tion, only relatively small anteroposterior and sagittal adjustments in the posit,ion
of the anterior part of the maxilla can be made without compromise of midfacial
esthetics. Such compromises are only rarely indicated. Mandibular surgery to
advance or retract the mandible into a Class I relation&ip is programmed to
offset a significant, increase or decrease in the amount of overjet. Trial reposition-
ing of the maxillary and mandibular templates is made until a satisfactory over-
bite-overjet and interincisal relationship is achieved consistent with the planned
esthetic objectives. From this new maxillary-mandibular relationship, a new soft-
tissue profile is registered on another piece of tracing paper. This is quite simply
done with respect to all of the soft-tissue contours except the lower lip. IIerc the
surgeon must use his artistic skills to trace in a new lower lip based on the new
position of the incisor teeth and a knowledge of how movement of the underlying
teeth will affect the soft tissue. After a new soft-tissue profile is completed, genio-
plasty or rhinoplasty can be simulated. The surgeon again relies on his artistic
sense of what a balanced facial profile should look like.

Model surgery

The planned movements of the maxilla, determined from clinical and cephalo-
metric studies, arc now simulated on dental study casts. A face-bow transfer is
used to mount the models on an anatomic articulator (Fig. 5) for proper oricn-
tation of the maxillary cast to the glenoid fossae and mandibular hinge axis. The
mandibular cast is oriented in centric relation position by means of a centric r’r-
lation checkbite. The vertical, anteroposterior, and horizontal movements of the
maxilla are determined from positional changes of horizontal and vertical refcr-
encc lines registered on the models before sectioning (Fig. 5)
The entire dento-osseous portion of the maxillary model is sectioned above
the apices of the teeth. Previously made clinical and cephalometric measurements
determine the magnitude and direction of movement, of the maxillary model. The
model can be sectioned into three or four segments to achieve the best possible oe-
clusal result consistent with the planned esthetic objectives. The axial inclination
of the teeth, lip posture, interarch relationship, vertical and anteroposterior facial
proportions, and upper lip-to-tooth relationship are carefully considered before
the sectioned model is repositioned and fixed to the maxillary model base. The rc-
sultant occlusion may indicate the need for concomitant mandibular surgery to
achieve occlusal balance without compromising facial esthetics. For instance,
when full Class II malocclusions arc associated with a satisfactory nasolablial
angle, the maxilla is moved directly superiorly (predicated on proper alignment
and inclination of the maxillary anterior t&h). In these cases it may be neccs-
sary to move the mandible forward surgically to achieve a satisfactory overbite-
overjet relationship ; such movements arc best carried out simultaneously.
Fig. 5. Model surgery. A, Models mounted in centric relationship on Whip-Mix anatomic
articulator. Parallel horizontal lines drawn on the base of the articulated models inter-
sect with perpendicular lines drawn on the canine, premolar, and molar teeth. Horizontal
lines are drawn on the buccal surface of maxillary and mandibular teeth. The amount of
movement of the dento-osseous segments is determined by measuring the distance changes
between the lines before and after model surgery. Transverse and anteroposterior lines
are also drawn on the occlusal surface of the maxillary model. (Model surgery technique
patterned after method presented by Dr. Thomas H. Hohl and Dr. Roger West at Clinical
Congress of the American Society of Oral Surgeons, St. Louis, MO., 1975.) B, After the
dento-osseous portion of the maxillary model is sectioned above the apices of the teeth,
a measured amount (6 mm.) is trimmed from the superior aspect of the anterior maxillary
segment to simulate superior movement of the anterior maxilla. C, After the anterior
maxillary segment is positioned into the best possible occlusal relationship with the
mandibular teeth, the vertical incisal guidance pin on the articulator is loosened to facil-
itate vertical repositioning of the mandibular cast and closure of the space between the
models. The amount of superior repositioning of the anterior maxillary segment is
measured by recording the distance changes between the horizontal base lines. D, The
posterior maxillary dento-osseous segments are positioned into the best possible relation-
ship with the existing occlusion. The distance between the horizontal base lines is
measured to determine the amount of superior movement of the posterior maxillary
dento-alveolar segments. Transverse dimensional changes of the repositioned dento-
osseous segments are measured by recording changes in the intercanine and intermolar
width; anteroposterior positional changes are also measured and recorded.
Fig. 6, A to D. Case 2, a 21-year-old woman with long and narrow face, promine mt nasal
dor: ;um, excessive exposure of teeth, large interlabial gap, contour-deficient chin, narrow
nasc JI alar bases, and flattening of the nasomaxillary area before (A, 8) and 2 years
afte !r maxillary surgery (technique shown in Fig. 5, G) and rhinoplasty. The periol ral mus-
cult Iture, drape of soft tissue, and oral commissures have assumed a balanced appl earance.

An accurate measure of the three-dimensional changes in the position

ma:gilla is made by measuring and comparing the distance between the
hor izontal and vertical refcrcnce lines before and after model surgery. Tf
cal, horizontal, aud antcropostcrior tlimonsional changqcs :lre rwordctl
Volume 71
Nun? her 1

- AGE 21-6
--- AGE 23-6

F
Fig. 6, E to G. E, Composite cephalometric tracings before [solid line-21 years 3 months)
and 3 months after maxillary surgery only (broken line-21 years 6 months) showing
autorotation of mandible, 7 mm. reduction of lower anterior facial height, restoration of
chin contour, improved upper lip line-incisor relationship and lip competency. Maxilla is
superimposed over anterior portion of maxilla; mandible is superimposed over anterior
mandible. F, Two-year cephalometric study [solid line-21 years 6 months; broken line-
23 years 6 months) demonstrating skeletal stability and soft-tissue changes after rhino-
plasty. G, Plan of total maxillary osteotomy technique. Anterior and posterior parts
of maxilla were simultaneously repositioned superiorly to reduce facial height and
facilitate maxillomandibular arch alignment.

models. The model and cephalometric measurements serve as a basis for the planned
maxillary movements and at surgery arc used to sculpture the maxilla to the
dimensions that will effect the desired esthetic and functional changes. Armed
with the results of model and cephalometric prediction studies, the surgeon
should have little difficulty in executing the planned bone incisions, for there is
a very close correlation between these studies and the actual movements of the
maxillary dento-osseous segments at surgery. Fig. 6 shows the actual clinical re-
sults attained in a 21-year-old woman whose cephalometric prediction studies and
mock model surgery are shown in Figs. 4 and 5. The vertical maxillary excess was
treated hy superior repositioning of the maxilla and rhinoplasty. The actual I’C-
suits compared very closely with the preoperative prediction anal simulation
studies.

Treatment

Tn order to plan treatment differentially for any case, the orthodontist and
the oral surgeon must know how each other affects the skeletal, dental, and soft-
tissue framework of the face. With nongrowing patients, if the mandibular plane
angle increases, the mandible rotates open and lengthens the face by increasing
lower face height. This will open the bite if the incisors do not erupt in compc’n-
sation. Con\-ersely, when the mandibular plane angle tIccreases, the mandible ro-
tates closed and shortens the fact by decreasing lower fact height. This will then
close or deepen the bite. When the mandibular plane angle remains constant, there
is no rotation of the mandible and, consequently, no bite-opening or bitt-closing
tendency.
The basic approach to treatment of the Ion,v face is to harmonize the length
of the bony face with its enveloping soft tissue to restore facial balance and to
establish normal overbite and overjet for optimal function. The objective of
orthodontic treatment is to move the malaligned teeth in the best possible position
on the individual apical bases. The jaws are aligned surgically to rcstorc facial
balance and occlusal harmony.

Orthodontic treatment

The aim of presurgical orthodontic treatment is to position the malaligned

teeth over t,heir denture bases so that the maxilla (*an be surgically positionctl
into a satisfactory ovcrbitc-over@ relationship from which postsurgical ortho-
dontic treatment c&anbc completed without problems. Orthodontic management of
high-mandibular-plane-angle cases before surgery may not necessitate coordinatetl
and completely leveled arches if doing so involves the extrusion of teeth, which
invites relapse.
The use of rapid palatal expansion appliances in convert with sclectcd maxil-
lary osteotomies is an effective and predictable means of managing the transverse
maxillary arch discrepancies in the presurgical orthodontic phase of treatment.‘:’
In &her cases, horizontal maxillary deficiencies, manifest as bilateral or unila-
tcral palatal cross-bites, have been managed equally well at the time of thf dc-
finitivc maxillary surgical procedure. Whether palatal expansion shoultl be ac-
complished by surgical means alone or by rapid palatal c~xpansion appliances and
selected maxillary osteotomies is still an open question and must 1~ determinetl
by careful and coordinated treatment planning.
Surgery

Many technical modifications of the 1~ Fort I osteotomy are feasible to fa,cil-

itate simultaneous anteroposterior, vertical, or horizontal movements of the an-
terior and posterior parts of the maxilla. The masilla is easily sectioned sagittally,
transversely, or circumpalatally. SpaccJ closure, arch segment alignment. and
leveling may bc facilitated by vertical interdental ostcotomics or ostcctomics in
Volume 71 Surgical correctio?l of lorlg face syndrovze 55
Number 1

incompletely closed extraction spaces. Palatal cross-bites that cannot be managed

by conventional orthodontic appliances are corrected surgically to facilitate wid-
ening of the maxilla. An excessive curve of Spee in the lower arch may be leveled
surgically by simultaneous mandibular subapical osteotomy. This procedure may
be accomplished with or without extractions, depending upon arch length require-
ments for alignment and lower incisor protrusion.
Since 1973, the Le Fort I osteotomy has been used by one of us (W.H.B.)
to reduce vertical maxillary height in forty adults with the long face syndrome.
The surgical and orthodontic principles used in treating three of these patients
are illustrated by the following case reports.
Case 3 (Fig. 71
ii 3%year-old woman sought correction of an open-bite and treatment to decrease the
prominence of her maxillary incisors. The following problem list was evolved after appropriate
clinical and laboratory examinations :
Esthetics. A full-face examination disclosed excessive exposure of the maxillary anterior
teeth and gingiva in function and repose (Fig. 7, B to C). There was bulging of the upper
eyelids caused by excessive periorbital fat and skin redundancy. Evaluation of the soft-tissue
profile revealed long lower third facial height, a retrognathic mandible, contour-deficient chin,
lip incompetency (10 mm.), and a prominent nasal dorsum.
Cephalometric analysis. Skeletal analysis corroborated the clinical impression of excessive
lower anterior facial height (Fig. 7, G). In addition, there was a high mandibular plane angle
(SN-MP z 45 degrees), and a 9 degree ANB difference. The mandibular incisors were pro-
clined with minimal labial alveolar bone support.
Gcclzrsion. Occlusal analysis disclosed a tapered and constricted maxillary arch with a high
palatal vault (Fig. 7, Z to L). The mandibular left lateral incisor was missing as a result of
a previous extraction. The maxillary and mandibular anterior teeth were crowded and mala-
ligned. In addition, there was a 12 mm. overjet, a Class II malocclusion, and an anterior open-
bite.
Treatment plan. The treatment plan called for the following:
1. Superior repositioning (6 mm.) of maxilla in four segments to (a) shorten lower
anterior face height, (b) reduce the amount of lip incompetence by shortening the
skeletal framework, (c) decrease vertical exposure of teeth relative to length of
upper lip, (d) facilitate autorotation of the mandible, closure of open-bite, and
maxillomandibular harmony, and (e) correct maxillary constriction hy surgical
expansion of the maxilla in four segments.
2. Augmentation of the contour-deficient chin and deep labiomental fold with an
alloplastic implant (Proplast”).
3. Reduction of the prominent nasal dorsum by rhinoplasty.
4. Correction of bulging upper and lower eyelids by blepharoplasties.
5. Orthodontic treatment to (a) improve angulation of mandibular incisors after ex-
traction of the mandibular right lateral incisor. (1)) relieve arch crowding and
correct malaligned teeth after extraction of maxillary first premolars, one lower in-
cisor, and mandibular third molars, and (c) coordinate the dental arches.
Follozc-rq. The patient’s postoperative course was uncomplicated and associated with
virtually no pain or swelling.
Since the mandibular left lateral incisor had been previously extracted, the mandibular
right lateral incisor was also extracted to eliminate a 6 mm. discrepancy in the mandibular
arch. The canines mere L‘slenderir.ed” and reshaped to accommodate the positions of the misa-
ing lateral incisors.
Extraction of the maxillary first premolars provided space to align the six anterior teeth

*Vitek Corporation, Houston, Texas.

 AWL. J. Orthod.
January 1977

t&H
M.H. -AGE 36-6
---AGE 38-2
AGE 36-6

Fig. 7. Case 3. Photographs of 36-year-old woman before (A to C) and after (D to F)

treatment. G, Cephalometric tracing before treatment at age 36 years 6 months). H,
Composite cephalometric tracings before and after treatment showing 5 mm. reduction in
anterior facial height (solid line-36 years 6 months; broken line-38 years 2 months].
 Ptcrgicrd correctio?l of loqtg face syndrome 57

Fig. 7 IICont’d). I to 1, Occlusion before treatment. M to P, Occlusion after treai .ment.

 Am. J. Orthod.
January 1977

Fig. 8. Case 4. Photographs of 15year-old patient with skeletal type of anterior open-
bite and Class II malocclusion before (A and B) and after (C and D) treatment (age 17
years).

before surgery. During the 6-month period of presurgical orthodontic treatment, no attempt
was made to level the maxillary occlusal plane or completely close the extraction spaces. The
anterior maxilla was surgically raised 6 mm., and split into two segments to increase the inter-
canine width; the posterior maxillae were simultaneously repositioned superiorly 7 mm. and ad-
vanced 2 mm. to achieve a Class 1 canine and molar relationship, close the open-bite, and
achieve anteroposterior, horizontal, and vertical maxillomandibular harmony. Final cephalo-
metric records showed a reduction in ANB, SN-MI’, and lower face height. Final space closure
and alignment mere achieved by orthodontic means within 12 months after surgical intraven
tion. Occlusal balance and facial harmony were achieved by the combined efforts of three dis-
ciplines over a period of 20 months (Fig. 7).
Over-all esthetic balance was gained by dimensional changes in the nose and chin associated
with maxillary, nasal, and chin surgery. In addition, esthetic balance between the relaxed upper
vozums71 Stlrgiccd correction of lollg face syndrome 59
Number 1

cc.
AM 14-10

E
Fig. 8 (Cont’d). E, Cephalometric tracing before treatment (age 14 years 10 months). F,
Composite cephalometric tracings before and after treatment show that maxilla was sur-
gically repositioned superiorly and anteriorly; mandible was surgically advanced into
planned maxillomandibular relationship (solid line-l 4 years 10 months; broken line-l 7
years).

lip and incisors, a virtually unchanged nasolabial angle, and improved nose-lip-chin harmony
mere achieved by superior repositioning of the maxilla. With the lips sealed, there was mild
contraction of the perioral musculature because of the 4 mm. residual lip incompetency (Fig.
‘I.
Comment. The degree and permanency of augmenting the labiomental fold area with an
alloplastic material are as yet poorly documented. Quantitative long-term follow-up studies are
needed to document the effectiveness of the procedure and to determine whether or not there
is resorption of bone encasing the incisor roots due to pressure of the overlying implant and
soft tissue. To date, the esthetic results have been good and there has been minimal discern-
ible resorption below the implants in other patients who have been followed over a 2-year post-
operative period.
In the original case analysis, extraction of lower premolnrs in addition to one central in-
cisor was considered to facilitate greater retraction of the lower anterior teeth, Such a treat-
ment plan would have been potentially more problematic and would have necessitated mandibu-
lar advancement; the patient preferred the plan of treatment which included maxillary sur-
gery, genioplasty, and rhinoplasty.

Case 4 (Fig. 81
A 15-year-old female student was initially seen for treatment of a dentofacial deformity
in March, 1974. All study parameters showed the typical facial esthetics commonly associated
with a skeletal type of anterior open-bite. The following problem list was evolved after ap-
propriate clinical and laboratory examination :
Esthetics. Frontal and profile analysis disclosed an obtuse nasolabial angle, excessive ex-
posure of teeth and gingiva in repose and when smiling, lip incompetence as indicated by the
10 mm. interlabial gap at rest, and a long lower anterior facial height (Fig. 8, B and R).
Mandibular retrognathism and a contour-deficient chin were additional findings.
Cephalometric analysis. Cephalometric: evaluation showed excessive angulation of the
maxillary and mandibular incisors (Fig. 8, E) . A high mandibular plane angle, anterior opm-
bite, long lower anterior facial height, supraeruption of the mandibular incisors, and a 12
degree ANB difference mere noted.
Occlusion. Intraoral examination disclosed a tapered and constricted maxillary arch with
a high palatal vault. A full Class JI canine and molar relationship with a 7 mm. overjet and a
 Am. J. O&hod.
January197’i

tely after
Fig. 8 (Co lnt’d). G to J, Occlusion before treatment. K to N, Occlusion immediar
improve
orths odonti c appliances were removed. A positioner was then worn 3 months to
inter rdigito Ition of the maxillary and mandibular teeth.
 \,
‘/
:\ ‘, “/

I
/

0
Fig. 8 (Cont’d). 0, Plan of surgery. Le Fort I osteotomy to reposition maxilla superiorly
and anteriorly; mandibular subapical ostectomy to close residual extraction spaces and
level mandibular occlusal plane; bilateral sagittal split ramus osteotomies to advance
mandible into satisfactory maxillomandibular relationship; horizontal osteotomy of chin
to increase chin prominence and decrease vertical height of mental symphysis. First
premolar teeth are extracted to facilitate orthodontic alignment of crowded and rotated
anterior teeth.

5 mm. anterior open-bite mere associated with crowded and malaligned maxillary and mandib-
ular anterior teeth (Fig. 8, G to J).
Treatment plan. The treatment plan included the following:
1. Superior (6 mm.) and anterior (4 mm.) repositioning of the maxilla (Fig. 8, 0)
to (a) reduce the obtuseness of the nasolabial angle and increase the prominence
of paranasal areas, (b) reduce exposure of teeth and gingiva, (c) shorten lower
anterior facial height, (d) correct lip incompetency, and (e) facilitate autorotation
of the mandible and closure of the open-bite.
2. Surgical advancement of the retropositioned mandible to achieve maxillomandibular
harmony (Fig. 8, 0).
3. Mandibular subapical ostectomy to lower supererupted mandibular anterior teeth
(Fig. 8, 0).
4. Augmentation of the contour-deficient chin by genioplasty (Fig. 8, 0).
5. Orthodontic treatment to (a) reduce angulation of maxillary and mandibular incisors
after extraction of maxillary and mandibular first premolars, (b) relieve arch ir-
regularities, and (c) coordinate the dental arches.
FoZZow-up. The postoperative course was uncomplicated and was associated with relatively
little pain. There were transient right and left hypoesthesias of the lower lip and chin follow-
ing genioplasty and mandibular subapical osteotomy; normal feeling returned within 3 weeks
after surgical intervention.
During the 12.month period of presurgical orthodontic treatment no attempt was made to
level the maxillary and mandibular occlusal planes completely, close the mandibular extraction
spaces, or correct the open-bite. The surgical procedures shown in Fig. 8, 0 mere performed in
two stages. By Le Fort I osteotomy, the maxilla was raised 5 mm. and advanced 4 mm.; simul-
taneously, the mandibular anterior teeth were lowered 4 mm. and retracted 3 mm. by subapical
osteotomy. After bilateral sagittal vertical ramus osteotomies, the mandible was advanced 13
mm. into a Class I occlusal relationship with the maxilla. Two months later the chin was aug-
 AWL. J. Orthod.
January 1977

Fig. 9. Case 5. Photographs of 23-year-old woman with anterior open-bite and Class II
malocclusion before (A to C, age 23 years 2 months) and after (D to F, age 24 years 4
months) treatment.

mented and shortened by genioplasty. Final space closure and alignment of the arches was
completed in another 8 months by orthodontic treatment. Posttreatment dental symmetry,
normal overbite and overjet, and esthetic balance between the nose, lips, teeth, and chin were
attained after approximately 24 months of treatment (Fig. 8).
Cephalometric analysis after surgical intervention revealed minimal positional change of
the surgically repositioned maxilla or mandible over an 18.month period of follow-up. Txo dif-
ferent appliances were used after mandibular advancement to hyperestend the neck muscles
and stabilize the repositioned mandible. A modified Pitkin collar was morn night and day, PX-
cept when eating, for the first 5 months after surgery. 25 Thereafter, a soft cervical collar
was worn at night only for another 4 months. At the time of mandibular advancement, the
digastric, geniohyoid, and mylohyoid muscle insertions were detached in an attempt to mini-
mize the tendency for skeletal relapse.

Case 5 (Fig. 9)
A gradual and progressive open-bite developed in a 23.year-old woman who was initially
seen some 8 years after orthodontic treatment of a Class I deep-bite malocclusion (Fig. 9).
 Rftrgicnl correction of lmg face sywlrme 63

C.C. cc.
- AGE 23-2
AGE 23-2 - IGE 24-4
\\

G
Fig. 9 (Cont’d). G, Cephalometric tracing before treatment (age 23 years 2 months).
H, Composite cephalometric tracings before and after maxillary surgery showing 9 mm.
reduction in anterior facial height, augmentation of chin by genioplasty; reduction of nasal
prominence by rhinoplasty (solid line-23 years 2 months; broken line-24 years 4
months).

The cause of the open-bite was obscure and may have been unrelated to previous orthodontic
treatment. After evaluation of the patient’s clinical records, a problem list was developed.
Esthetics. A large interlabial gap (11 mm.), excessive tooth exposure, a normal nasolabial
angle, and a retropositioned mandible with deficiency of the soft-tissue chin prominence mere
the dominant features revealed by analysis of the patient’s profile with the lips in a relaxed
posture. The most striking clinical feature of the full-face examination was the inadequacy of
upper lip coverage and gingival exposure on smiling (Fig. 9, B to C).
Cephalolnetric analysis. Cephalometric evaluation revealed a steep mandibular plane, an
anterior open-bite, and an excessive lower anterior vertical facial height (Fig. 9, G). The in-
ferior margin of the upper lip in relaxed posture approached the cervical margin of the in-
cisor teeth. The ANB difference was -10 degrees.
Occlusion. Intraoral examination revealed an open-bite between the maxillary and mandibu-
lar teeth, starting in the molar region bilaterally (Fig. 9). Interdental spacing was noted in
the right anterior maxillary quadrant and was associated with constriction of the arch. A
Class II malocclusion was present with a 5 mm. overjet.
Peatment plan. A cephalometric prediction analysis and model surgery indicated the
feasibility of the following treatment plan:
1. Superior repositioning (8 mm.) of the maxilla by Le Fort I osteotomy to (a) reduce
exposure of teeth and gingiva, (b) shorten facial height, (c) correct lip incompeten-
cy, (d) close the open-hite, and (e) facilitate autorotation of the rrtropositioned
mandible.
2. Dento-alveolar surgery to reposition the maxillary right canine (single tooth seg-
ment) and the maxillary central and left lateral incisors (three-tooth segment) to
achieve a Class I canine relationship and correct interdental spacing.
3. Augmentation of contour-deficient chin with a 5 mm. thick implant.
4. Crown and bridge restorative procedures on anterior teeth to improve dental
esthetics and replace the extracted right lateral incisor.
PoZZowup. The patient’s postoperative course was complicated by splaying of the alar bases
and buckling of the nasal septum. Two months after maxillary surgery, good nasal esthetics
was achieved by rhinoplasty.
 Am. J. Orthod.
Jnnuar~ 1977

Fig. 9 (Cont’d). Occlusion before (I to K) and after (L to N) treatment.

 A Class I dental and skeletal relationship, lip competency, and an esthetic nose-lip-tooth-
chin balance were achieved by shortening the lower facial height (Fig. 9). There has been
no discernible change in the skeletal soft tissue or dental structures over a postoperative fol-
low-up period in excess of 2 years.
Comment. Surgical reduction of lower face height by excision of osseous tissue in the
maxilla tends to balance the soft tissue in the lower face and may minimize bone resorption
below the alloplastic chin implant because of reduced tension of the perioral and mentalis
musculature.

Discussion of results

Il’ound healillg. The incisional wounds healed routinely. Postoperative radio-

graphs have shown minimal bone loss in the interdental osteotomy sites and no
periodontal problems which could be related to the surgery as such. Indeed, some
of the patients were positively motivated, at least temporarily, to improve their
oral hygiene. Definitive studies, however, are indicated to determine the long-term
periodontal sequela.
Stablility. There was no discernible postoperative movement of the reposi-
tioned maxilla over an average follow-up period of 13 months. The details of these
studies will be published in another report on the stability and soft-tissue-osseous
relations associated with superior repositioning of the maxilla.24 The maxillary
molars and incisors were moved superiorly in excess of 5 mm. ; as a consequence,
the lower face height was shortened approximately 5 mm. As indicated by the
preoperative cephalometric prediction studies, the mandible rotated clockwise
forward and upward on an arc with the axis of rotation located in the condylar
region (Fig. 5). (This excludes cases in which the mandible was simultaneously
advanced.) Cephalometric monitoring after surgical treatment revealed a slight
tendency for the maxilla to intrude during the period of intermaxillary fixation
and thereafter.
Esthetics. As previously reported,? Le Fort I osteotomy for anterior or supe-
rior repositioning of the maxilla affects nasal esthetics by altering the dimensions
of the nose. Because a narrow nose with a prominent nasal dorsum is typically
associated with the long face syndrome, superior repositioning of the maxilla
usually alters nasal esthetics favorably; the alar bases widen and the nasal tip is
raised. In three of the patients operated on early, however, nasal esthetics was
compromised by excessive bilateral splaying of the alar bases and buckling of the
cartilaginous nasal septum after the maxilla was raised in excess of 10 mm. In
each of these patients, facial balance was achieved after rhinoplasty. The prospec-
tive patient who has a broad nose before surgery must be apprised of the possible
need for rhinoplasty after the maxilla is raised. Buckling of the nasal septum
has been virtually eliminated by modification of the total maxillary osteotomy
down-fracturing technique (Fig. 3) ; the maxillary nasal crest and/or the car-
tilaginous nasal septum are easily reduced an amount which is proportional to
the planned superior movement of the maxilla. There is no practical limitation to
the amount of superior movement of the maxilla. The early critics of this tech-
nique predicted significant reduction in the amount of nasal air flow; accord-
ingly, other techniques have been recommended to obviate change in the intra-
nasal dimensions. These objections, however, have not, been substantiated. Indeed,
 Am. J. Orthod.
January 1977

the postoperative airway and technical problems associated with the Le Fort I
osteotomy are minimal and less problematic than the maxillary and mandibular
surgical techniques that were previously used to reduce facial height. The ma-
jority of patients have little or no postoperative pain and are discharged from the
hospital within 2 or 3 days after surgical intervention.

Summary

The combined efforts of different specialists are needed for the successful
treatment of patients with the long face syndrome. Both surgeons and orthodon-
tists who recognize their own capabilities and limitations must combine their
skills to achieve the best possible occlusion and facial esthetics. The surgical and
orthodontic plan of therapy is designed to correct the patient’s dentofacial de-
formity. Surgical reduction of facial height and proper alignment of the teeth by
orthodontic means are common denominators of successful treatment. By pro-
perly planned and executed Le Fort I maxillary osteotomics, the vertical dimen-
sions of the face can be shortened to improve the esthetic balance between the
nose, upper lip, teeth, and chin and achieve lip competency. Variable open-bitt
and nonopen-bite maxillary deformities in forty adults with the long face syn-
drome were corrected by Le Fort I osteotomy and orthodontic treatment. The
technical problems encountered in planning and executing treatment are dis-
cussed and illustrated by selected case reports.

The authors are indebted to Mrs. Vicky Stinson for her help in preparing this manuscript;
to Mr. William 0. Winn for illustrations of the surgical techniques; to the Photography De-
partment for photographs; to Dr. Larry Snider, Dr. Michael Lehnert, and Dr. Craig Williams,
oral surgery residents at Parkland Memorial Hospital, who participated in the planning and
treatment of Cases 2 and 3; to Dr. Jack Gunter, Dallas, Texas, who performed rhinoplasties
in Cases 2, 3, and 3; to Dr. Joseph N. Bonello, Pittsburgh, Pa., who provided orthodontic
treatment for the patient described in Case 1; and Dr. Martin Sherling for his critical review
of the manuscript. Our special thanks are extended to all of these professionals who have
made interdisciplinary treatment of the patient with the long face syndrome a reality.

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THE JOURN.AL 60 YEARS AGO

January, 1917

Good judgment in the professional man is a valuable asset and one that is essential to
the achievement of signal success. It is, however, an elusive goddess and can only be won
after arduous efforts. Wishing and hoping for judgment is not enough. It must be sought
for with untiring energy and a devotion to one’s work. It must be nurtured in an atmo-
sphere of courage and resolute will. Judgment never set the sign of its approval upon the
coward’s brow. He who would possess it must also wear the badge of absolute honor
because judgment has nothing to do with the dishonorable man. (Martin Dewey: Editor-
ial-Dental Judgment, International Journal of Orthodontia, predecessor of the American
Journal of Orthodontics, 3: 80, 1917.)