Orthognathic Surgery

741
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
After treatment
E
Prior to retreatment
Pre surgery
E, Occlusal views before retreatment, with orthodontics in progress, and after the completion of
treatment.
• Figure 20-17, cont’d 
Continued

742 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Maxillary advancement
and clockwise rotation
Mandibular
clockwise
rotation
G
F
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 20-17, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
B
A
• Figure 20-18  A 21-year-old woman was referred for surgical evaluation. An orthodontic approach that involved four bicuspid extractions to
neutralize the occlusion had previously been carried out, without success. The Class III negative overjet malocclusion required redo orthodontics
and jaw surgery. Because the patient had a lifelong history of nasal obstruction and consistent physical findings, intranasal procedures were also
beneficial. When the orthodontic decompensation was complete, the patient’s surgery included maxillary Le Fort I osteotomy in segments (arch
expansion, horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies (minimal corrections); osseous
genioplasty (minimal horizontal advancement); and septoplasty and inferior turbinate reduction. A, Frontal views in repose before and after treat­
ment. B, Frontal views with smile before and after treatment.
Continued

744 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
D
C
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-18, cont’d

745
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
E
Prior to surgery after four bicuspid extractions
After treatment
G
F
Arch expansion
Maxillary advancement
and clockwise rotation
E, Occlusal views with orthodontics in progress and after the completion of treatment. F, Articulated dental
casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after treatment.
• Figure 20-18, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
B
A
• Figure 20-19  A 16-year-old high school student was referred by her orthodontist for surgical evaluation. Her Class III negative overjet maloc­
clusion required orthodontics and jaw surgery. Because the patient had a lifelong history of nasal obstruction and consistent physical findings,
intranasal procedures were also beneficial. Presurgical orthodontics were completed without extractions, and the maxillary dental root crowding in
the alveolar bone and the incisor procumbency remained. The patient’s surgery included maxillary Le Fort I osteotomy (horizontal advancement,
vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies (clockwise rotation); osseous genioplasty (minimal horizontal advance­
ment); and septoplasty and inferior turbinate reduction. Note the aesthetic advantage of the maxillomandibular clockwise rotation. A, Frontal views
in repose before and after treatment. B, Frontal views with smile before and after treatment.

747
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
D
C
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-19, cont’d 
Continued

748 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
E
Prior to treatment
Pre surgery
After treatment
E, Occlusal views before treatment, with orthodontics in progress, and after the completion of treatment.
Note that the maxillary dental roots are crowded in the alveolus, which resulted in labial gingival recession.
• Figure 20-19, cont’d

749
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
G
F
F, Articulated dental casts before analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 20-19, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
B
A
• Figure 20-20  A 16-year-old high school student was referred by her orthodontist for surgical evaluation. The Class III negative overjet maloc­
clusion required orthodontics and jaw surgery. Because the patient had a lifelong history of nasal obstruction and consistent physical findings,
intranasal procedures were also beneficial. Presurgical orthodontics was completed without extractions, and the maxillary incisor procumbency
remained but without dental root crowding in the alveolar process. The patient’s surgery included maxillary Le Fort I osteotomy in segments (hori­
zontal advancement, vertical lengthening, arch expansion, and clockwise rotation); sagittal split ramus osteotomies (clockwise rotation); osseous
genioplasty (minimal horizontal advancement); and septoplasty and inferior turbinate reduction. Note the aesthetic advantage of the maxilloman­
dibular clockwise rotation in the presence of baseline excess incisor inclination. A, Frontal views in repose before and after treatment. B, Frontal
views with smile before and after treatment.

751
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
D
C
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-20, cont’d 
Continued

752 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
E
Prior to treatment
Pre surgery
After treatment
E, Occlusal views before retreatment, with orthodontics in progress, and after the completion of treatment.
• Figure 20-20, cont’d

753
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
study also suggested that, when a limited mandibular set-
back is carried out in combination with maxillary Le Fort
I advancement, significant negative effects on the posterior
airway space are likely prevented.
Postsurgical Orthodontic Maintenance
and Detailing
The surgeon’s effective management of the patient’s
in-hospital and at-home convalescence during the initial
healing period (i.e., 5 weeks) is essential for a successful
outcome (see Chapter 11). Cephalometric and Panorex
radiographs and facial and occlusal photographs are obtained
at standard postoperative intervals to document progress.
We prefer to take these records at the 5-week postoperative
interval as a matter of routine.
If segmental maxillary osteotomies were carried out, a
prefabricated surgical splint will have been secured to the
characterized by maxillary deficiency in combination with
relative mandibular excess. The patients were divided into
two groups. All patients underwent mandibular ramus oste­
otomies with a degree of set-back. The Group 1 study
patients (n = 13) underwent mandibular set-back of 5 mm
or more without simultaneous Le Fort I osteotomy. The
Group 2 study patients (n = 13) underwent limited man­
dibular set-back, but their procedures were performed in
combination with Le Fort I advancement. All study patients
underwent preoperative and postoperative lateral cephalo­
metric radiographs at standard intervals. Any changes that
occurred in the position of the hyoid bone, the distance of
the palate to the posterior nasal spine, the retrolingual space,
and the hypopharyngeal space were measured from the
postoperative radiographs. Preoperative and postoperative
portable polysomnography were also carried out. The study
confirmed that mandibular retropositioning of 5 mm or
more can significantly decrease the posterior airway space
and cause mild to moderate obstructive sleep apnea. The
G
F
Arch expansion
Maxillary advancement
and clockwise rotation
Mandibular clockwise rotation
F, Articulated dental casts before analytic model planning. G, Lateral cephalometric radio­
graphs before and after treatment.
• Figure 20-20, cont’d

754 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Chapter 17). Significant condylar resorption after orthog­
nathic surgery is rarely seen in the skeletal Class III patient
(see Chapter 36).
Proffit and colleagues make a compelling argument that
for the Class III patient, when the orthognathic procedure
is a mandibular set-back only versus two-jaw surgery then
relapse at the ramus osteotomy site is a common occur­
rence.79,80 Research confirms better long-term skeletal and
occlusal stability when two-jaw surgery (i.e., maxillary
advancement with limited mandibular setback) is per­
formed for the management of most Class III skeletal
patterns.81
All of these factors must be taken into account to best
achieve and then maintain the desired results.
Temporomandibular Disorders:
The Effects of Orthodontics and
Orthognathic Surgery
It is estimated that an average of 32% of the population
reports at least one symptom of TMD, whereas an average
of 55% demonstrate at least one clinical sign. TMD includes
various signs and symptoms of the temporomandibular
joint, the masticatory muscles, and related structures. The
signs and symptoms may include a spectrum of referred
head and neck pain; joint noise (e.g., popping, clicking,
crepitus); reduced or altered mandibular movements as a
result of muscle spasm or disc displacement, with or without
reduction; condylar head erosion, and pain on direct palpa­
tion of either of the temporomandibular joints or the mas­
ticatory muscles.3,5
Occlusal factors (i.e., degrees of malocclusion) are often
claimed to be associated with TMD. Interestingly, the cor­
rection of a skeletal Class III jaw deformity through ortho­
dontics and orthognathic surgery often relieves the signs
and symptoms of TMD, but this is not predictable for each
individual patient (see Chapter 9).
Suboptimal Facial Aesthetics after
Orthognathic Surgery
An accurate pretreatment facial analysis should limit the
incidence of suboptimal aesthetics after surgery. Many of
the aesthetic treatment planning pitfalls for the correction
of skeletal Class III patterns were reviewed earlier in this
chapter. Clearly stated and realistic objectives that are dis­
cussed and agreed upon by all parties are essential. Com­
prehensive and meticulous treatment planning, accurate
surgical execution, and good patient cooperation further
ensure a favorable result. Despite the following of these
steps, patient and family dissatisfaction are to be expected
in a small percentage of cases.40,41,56,68,103,115 Maintaining
open lines of communication, reasonable patient and family
flexibility, and clinician responsiveness to ongoing needs
and concerns will generally result in the satisfactory resolu­
tion of these issues (see Chapter 7).
maxillary occlusal surfaces during the operation. The ortho­
dontist sees the patient within 24 hours of splint removal
at approximately 5 weeks after surgery, and he or she
replaces the maxillary sectional wires with a rigid continu­
ous arch wire. The teeth are then ligated together to main­
tain the arch form. The use of a transpalatal wire or an
acrylic palatal plate may also be used to stabilize the arch
form if significant transverse expansion was carried out.
Close orthodontic monitoring for skeletal and dental shifts
and detailing during the first 6 months after surgery is
essential.
Complications, Informed Consent, and
Patient Education
The orthodontist and the surgeon are frequently asked to
evaluate jaw disharmonies and malpositioned teeth and
then to attempt to alter nature’s events. With an under­
standing of the natural progression of the uncorrected skel­
etal Class III dentofacial deformity and knowledge of how
specific interventions will affect head and neck function and
facial aesthetics, predictable results are generally achieved.
Complications and patient dissatisfaction will always
occur in a small percentage of individuals.4,23,44,46,47,53,54,120
The clinician’s ability to communicate the potential risks
and complications, the alternative approaches available, and
the benefits of the recommended treatment plan to the
patient and the family is essential to achieve a favorable
result. When the patient, the family, and all treating clini­
cians are fully informed, shared responsibility for the treat­
ment outcome is more likely (see Chapter 16).
Malocclusion after Orthodontics and
Orthognathic Surgery
There are inherent biologic challenges to the orthodontic
movement of the teeth in the alveolar process and to the
surgical repositioning of the jaws or jaw segments in the
individual with maxillary deficiency and relative mandibu­
lar excess. These include the technical aspects of the repo­
sitioning, the initial healing requirements, and the difficulties
associated with the long-term maintenance of the mechani­
cally relocated teeth, jaws, and jaw segments. When follow­
ing sound biomechanical and aesthetic principles, clinicians
carry out orthodontic treatment and surgical procedures
and then effectively maintain the results, in most cases.
Potential intraoperative technical difficulties associated with
sagittal split ramus osteotomies of the mandible and maxil­
lary Le Fort I osteotomies can result in an immediate (i.e.,
early) malocclusion; however, these difficulties are generally
preventable (see Chapter 17).*
Timing the surgery to limit ongoing mandibular growth
afterward is usually possible, but it is more problematic for
the skeletal Class III patient than the Class II patient (see
*References 19, 34, 35, 43, 45, 55, 59-61, 67, 69, 79, 80, 82, 96, 100-
102, 107, 108, 111, 116, 118

755
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
the jaws to establish a functional occlusion, an improved
upper airway, and enhanced facial aesthetics.
A Le Fort I advancement (beyond cephalometric norms)
with vertical adjustment and clockwise rotation in combi­
nation with mandibular ramus osteotomies and chin reshap­
ing is the key to the achievement of favorable maxillofacial
convexity, A-point to B-point relationships, and enhanced
aesthetics in most patients. As a result, the soft-tissue enve­
lope is stretched; this results in the loss of unattractive skin
folds and distortions as well as the lessening of the deep
creases that would otherwise occur with age.
Conclusions
When evaluating the developmental dentofacial deformity
of maxillary deficiency in combination with relative mandibu­
lar excess, attention to both the skeletal anomalies and the
soft-tissue envelope distortions is essential. The orthodon­
tist’s immediate goal in preparation for jaw reconstruction
is to remove all dental compensations and to place the teeth
solidly in the alveolar process. If extractions are required to
uncrowd the alveolar arch and to ensure the patient’s peri­
odontal health, so be it. The surgeon will then reposition
References
1. Alexander AEZ, McNamara JA, Jr, Franchi
L, Baccetti T: Semilongitudinal
cephalometric study of craniofacial growth
in untreated Class III malocclusion. Am J
Orthod Dentofacial Orthop 135:700.e1–700.
e14, 2009.
2. Angle EH: Treatment of malocclusion of the
teeth: Angle’s system, ed 7, Philadelphia, 1907,
SS White.
3. Athanasiou AE: Number and intensity of
occlusal contacts following surgical
correction of mandibular prognathism.
J Oral Rehabil 19:145, 1992.
4. Athanasiou AE: Morphologic and
functional implications of the surgical-
orthodontic management of mandibular
prognathism: A comprehensive review.
Am J Orthod Dentofacial Orthop 103:439,
1993.
5. Athanasiou AE, Mavreas D: Tomographic
assessment of alterations of the
temporomandibular joint after surgical
correction of mandibular prognathism. Int J
Adult Orthodon Orthognath Surg 6:105,
1991.
6. Baccetti T, McGill JS, Franchi L, et al:
Skeletal effects of early treatment of Class III
malocclusion with maxillary expansion and
face-mask therapy. Am J Orthod Dentofacial
Orthop 113:333–343, 1998.
7. Baccetti T, Reyes BC, McNamara JA, Jr:
Craniofacial changes in Class III
malocclusion as related to skeletal and dental
maturation. Am J Orthod Dentofacial Orthop
132:171.e1–171.e12, 2007.
8. Bailey LJ, White RP, Proffit WR, et al:
Segmental Le Fort I osteotomy for
management of transverse maxillary
deficiency. J Oral Maxillofac Surg 55:728,
1997.
9. Becker R: Results in the treatment of
prognathism and open bite with
simultaneous tongue reduction. Dtsch
Zahnarztl Z 17:892, 1960.
10. Bell WH: Le Fort I osteotomy for correction
of maxillary deformities. Oral Surg
33:412–426, 1975.
11. Bell WH, Creekmore DC: Surgical
orthodontic correction of mandibular
prognathism. Am J Orthod 63:256, 1973.
12. Bell WH, Jacobs JD: Surgical orthodontic
correction of horizontal maxillary deficiency.
J Oral Surg 37:897, 1979.
13. Bell WH, White RP, Hall HP, et al:
Mandibular excess. In Bell WH, Proffit WP,
White R, editors: Surgical correction of
dentofacial deformities, Philadelphia, 1980,
WB Saunders, pp 234–441.
14. Betts NJ, Vanarsdale RL, Barber HD, et al:
Diagnosis and treatment of transverse
maxillary deficiency. Int J Adult Orthodon
Orthognath Surg 10:75, 1995.
15. Blair VP: Surgery of the mouth and jaws,
St Louis, 1914, Mosby.
16. Bloomquist DS: The stability of
segmentalized Le Fort I osteotomies with
miniplate fixation in patients with maxillary
hypoplasia [discussion]. J Oral Maxillofac
Surg 53:1412, 1995.
17. Broadbent HB, Broadbent HB, Jr, Golden
WH: Bolton standards of dentofacial
developmental growth, St Louis, 1975, CV
Mosby.
18. Brunell JA, Bhat M, Lipton JA: Prevalence
and distribution of selected occlusal
characteristics in the US population.
1988–1991. J Dent Res 75:706, 1996.
19. Busby BR, Bailey LJ, Proffit WR, et al:
Long-term stability class III treatment: A
study of 5-year postsurgical results. Int J
Adult Orthodon Orthognath Surg 17:159,
2002.
20. Capelozza L, Martins A, Mazzotini R,
da Silva HG: Effects of dental
decompensation on the surgical treatment
of mandibular prognathism. Int J Adult
Orthodon Orthognath Surg 11:165–180,
1996.
21. Cevidanes L, Baccetti T, Franchi L, et al:
Comparison of two protocols for maxillary
protraction: Bone anchors versus face mask
with rapid maxillary expansion. Angle Orthod
80:799–806, 2010.
22. Chamberland S, Proffit WL: Short-term and
long-term stability of surgically assisted rapid
palatal expansion revisited. Am J Orthod
Dentofacial Orthop 139:815–822, 2011.
23. Cho HJ: Effect of rigid fixation on
orthodontic finishing after mandibular
bilateral sagittal split setback: The case for
miniplate monocortical fixation. J Oral
Maxillofac Surg 70:e310–e321, 2012.
24. Chong Y, Ive JC, Årtun J: Changes following
the use of protraction headgear for early
correction of Class III malocclusion. Angle
Orthod 66:351–362, 1996.
25. De Clerck H, Cevidanes L, Baccetti T:
Dentofacial effects of bone-anchored
maxillary protraction: A controlled study of
consecutively treated Class III patients.
J Oral Maxillofac Surg 138(5):577–581,
2010.
26. Demetriades N, Chang DJ, Laskarides C,
Papageorge M: Effects of mandibular
retropositioning, with or without maxillary
advancement, on the oro-naso-pharyngeal
airway and development of sleep-related
breathing disorders. J Oral Maxillofac Surg
68:2431–2436, 2010.
27. Downs WB: Variations in facial
relationships: Their significance in treatment
and prognosis. Am J Orthod Dentofacial
Orthop 34:812, 1948.
28. El-Gheriani AA, Maher BS, El-Gheriani AS,
et al: Segregation analysis of mandibular
prognathism in Libya. J Dent Res 82:523–
527, 2003.
29. Ellis E, III, McNamara JA, Jr: Components
of adult Class III open bite malocclusion.
Am J Orthod Dentofacial Orthod 86:277,
1984.
30. Epker BN, Fish LC: The surgical-
orthodontic correction of class III skeletal
open bite. Am J Orthod Dentofacial Orthop
73:601, 1978.
31. Epker BN, Fish LC, Paulus PJ: The
surgical-orthodontic correction of maxillary
deficiency. Oral Surg Oral Med Oral Pathol
46:171, 1978.
32. Epker BN, Turvey TA, Fish LC: Indications
for simultaneous mobilization of the maxilla
and mandible for the correction of
dentofacial deformities. Oral Surg Oral Med
Oral Pathol 54:369, 1982.
33. Farkas LG, Sohm P, Kolar JC, et al:
Inclinations of the facial profile: Art versus
reality. Plast Reconstr Surg 75:509, 1985.
34. Gu G, Gu G, Nagata J, et al: Hyoid
position, pharyngeal airway and head posture
in relation to relapse after the mandibular

756 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
setback in skeletal Class III. Clin Orthod Res
3:67–77, 2000.
35. Hirdnaka D, Kelly J: Stability of
simultaneous orthognathic surgery on the
maxilla and mandible: A computer assisted
cephalometric study. Int J Adult Orthodon
Orthognath Surg 2:193, 1987.
36. Hohl TH, Epker BN: Macrogenia: A study
of treatment results with surgical
recommendations. J Oral Surg 41:545,
1976.
37. Ishii H, Morita S, Takeuchi U, Nakamura S:
Treatment effect of combined maxillary
protraction and chincap appliance in severe
skeletal Class III cases. Am J Orthod
Dentofacial Orthop 92:304–312, 1987.
38. Jabaley ME, Edgerton ME: Surgical
correction of congenital midface retrusion in
the presence of mandibular prognathism.
Plast Reconstr Surg 44:1, 1969.
39. Jacobson A, Evans WG, Preston CB,
Sadowsky PL: Mandibular prognathism. Am
J Orthod 66:140–171, 1974.
40. Joss CU, Joss-Vassalli IM, Bergé SJ,
Kuijpers-Jagtman AM: Soft tissue profile
changes after bilateral sagittal split osteotomy
for mandibular setback: A systematic review.
J Oral Maxillofac Surg 68:2792–2801, 2010.
41. Kawamoto HK, Jr: Reduction mentoplasty
[discussion]. Plast Reconstr Surg 70:151,
1982.
42. Kelly JE, Harvey C: An assessment of the teeth
of youths 12-17 years. Department of Health,
Education, and Welfare Publication No (HRA)
77-1644, Washington, DC, 1977, National
Center for Health Statistics.
43. Kim YG, Oh SH: Effect of mandibular
setback surgery on occlusal force. J Oral
Maxillofac Surg 55:121, 1997.
44. Kobayashi T, Honma K, Nakajima T, et al:
Masticatory function in patients with
mandibular prognathism before and after
orthognathic surgery. J Oral Maxillofac Surg
51:997, 1993.
45. Kobayashi T, Watanabe I, Ueda K, et al:
Stability of the mandible after sagittal ramus
osteotomy for correction of prognathism.
J Oral Maxillofac Surg 44:693, 1986.
46. Kondo E: The course of treatment of a class
III skeletal open bite case and its analysis.
Aust Orthod J 12:217, 1993.
47. LaBlanc JP, Turvey TA, Epker BN: Results
following simultaneous mobilization of the
maxilla and mandible for the correction of
dentofacial deformities: Analysis of 100
consecutive patients. J Oral Surg 54:607,
1982.
48. Lew KK, Foong WC, Loh E: Malocclusion
prevalence in an ethnic Chinese population.
Aust Dent J 38:8, 1993.
49. Liao YF, Chiu YF, Huang CS, et al:
Presurgical orthodontics versus no presurgical
orthodontics: Treatment outcomes of
surgical-orthodontic correction for skeletal
class III open bite. Plast Reconstr Surg
126:2074–2083, 2010.
50. de Lira Ade L, de Moura WL, de Barros
Vieira JM, et al: Surgical predication of
skeletal and soft tissue changes in Class III
treatment. J Oral Maxillofac Surg 70:e290–
e297, 2012
51. Luhr HG: Zur stabilen osteosynthese bei
unterkiefer–frakturen. Dtsch Zahnarztl Z
23:754, 1968.
52. Luhr HG: Skelettverlagernde operationen
zur harmonisierung des gesichtsprofils––
probleme der stabilen fixation von
osteotomiesegmenten. In Pfeifer G, editor:
Die asthetik von form und funktion in der
plastischen und wiederherstellungschirurgie,
Berlin, 1985, Springer-Verlag, p 87.
53. Magnusson T, Ahlborg G, Svartz K:
Function of the masticatory system in
20 patients with mandibular hypo- or
hyperplasia after correction by a sagittal split
osteotomy. Int J Oral Maxillofac Surg 19:289,
1990.
54. McHugh M, Van Sickels JE: Effect of
stabilization of a bilateral sagittal split on
orthodontic finishing after mandibular
setback: A case for bicortical fixation. J Oral
Maxillofac Surg 70:e301–e309, 2012.
55. McNance AM, Moss JP, James DR: Stability
of surgical correction of patients with skeletal
III and skeletal II anterior open bite, with
increased maxillary mandibular plane angle.
Eur J Orthod 14:198, 1992.
56. McNance AM, Moss JP, Wright WR, et al:
A three-dimensional soft tissue analysis of
16 skeletal class III patients following
bimaxillary surgery. Br J Oral Maxillofac Surg
30:221, 1992.
57. Milicesco V: La valeur de la photographie,
de la crâniometrie et de la téléradiographie
dans le prognathisme mandibulaire
anatomique. Rev Stomatol 69:474–480,
1968.
58. Miotti A: Rassegna bibliografica sull’eziologia
ed epidemiologia del prognatismo
mandibolare. Dent Cadmos 50:29–32,
1982.
59. Moser K, Freihofer HP: Long-term
experience with simultaneous movement of
the upper and lower jaw. J Oral Maxillofac
Surg 8:271, 1980.
60. Nagai I, Tanaka N, Noguchi M, et al:
Changes in occlusal state of patients with
mandibular prognathism after orthognathic
surgery: A pilot study. Br J Oral Maxillofac
Surg 39:429, 2001.
61. Nagamine T, Kobayasgi T, Nakajima T, et al:
The effects of surgical-orthodontic correction
of skeletal class III malocclusion on
mandibular movement. J Oral Maxillofac
Surg 51:385, 1993.
62. Norholt SE, Sindet-Pedersen S, Jensen J: An
extended Le Fort I osteotomy for correction
of midface hypoplasia: A modified technique
and results in 35 patients. J Oral Maxillofac
Surg 54:1297, 1996.
63. Obwegeser HL: The surgical correction of
mandibular prognathism and retrognathia
with consideration of genioplasty. Part 1.
Oral Surg 10:677, 1957.
64. Obwegeser HL: Eingriffe am overkiefer zur
korrektur des progenen zustandsbildes.
Schweiz Monatschr Zahnheilkd 75:365–373,
1965.
65. Obwegeser HL: Surgical correction of small
or retrodisplaced maxillae. Plast Reconstr Surg
43:352–365, 1969.
66. Obwegeser HL: Die einzeitige vorbewegung
des oberkiefers and ruckbewegung des
unterkiefers zur korrektur der extremen
“progenie.” Schweiz Monatschr Zahnheilkd
80:547–555, 1970.
67. Ohkura K, Harada K, Morishima S, et al:
Changes in bite force and occlusal contact
area after orthognathic surgery for correction
of mandibular prognathism. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 91:141,
2001.
68. Papadopoulos MA, Lazaridou-Terzoudi T,
Oland J, et al: Comparison of soft and hard
tissue profiles of orthognathic surgery
patients treated recently and 20 years earlier.
Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 108:e8, 2009.
69. Pepersack WJ, Chausse JM: Long-term
follow-up of the sagittal split technique for
correction of mandibular prognathism.
J Maxillofac Surg 6:117–140, 1978.
70. Perthes G: Operative korrektur der progenie.
Zentralbl Chir 49:1540–1541, 1922.
71. Phillips C, Medland WH, Fields HW, Jr:
Stability of surgical maxillary expansion. Int
J Adult Orthodon Orthognath Surg 7:139,
1992.
72. Posnick JC: Mandibular excess and maxillary
deficiency. In Posnick JC, editor: Craniofacial
and maxillofacial surgery in children and
young adults, Vol 38, Philadelphia, 2000,
WB Saunders Co, pp 1004–1024.
73. Posnick JC, Agnihotri N: Managing chronic
nasal airway obstruction at the time of
orthognathic surgery: A twofer. J Oral
Maxillofac Surg 69(3):695–701, 2011.
74. Posnick JC, Fantuzzo J, Orchin J: Deliberate
operative rotation of the maxillo-mandibular
complex to alter the A-point to B-point
relationship for enhanced facial esthetics.
J Oral Maxillofac Surg 64:1687–1695,
2006.
75. Posnick JC, Fantuzzo JJ, Troost T:
Simultaneous intranasal procedures to
improve chronic obstructive nasal breathing
in patients undergoing maxillary (Le Fort I)
osteotomy. J Oral Maxillofac Surg 65:2273–
2281, 2007.
76. Proffit W, Fields H, Jr: Contemporary
orthodontics, ed 3, St Louis, 2007, Mosby.
77. Proffit WR, Fields HW, Moray LJ:
Prevalence of malocclusion and orthodontic
treatment need in the United States:
Estimates from the N-HANES III survey. Int
J Adult Orthodon Orthognath Surg 13:97–
106, 1998.
78. Proffit WR, Phillips C, Dann C, IV: Who
seeks surgical orthodontic treatment? Int J
Adult Orthodon Orthognath Surg 3:153,
1990.
79. Proffit WR, Phillips C, Dann C, IV, et al:
Stability after surgical-orthodontic correction
of skeletal class III malocclusion: 1.

757
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Mandibular setback. Int J Adult Orthodon
Orthognath Surg 6:7, 1991.
80. Proffit WR, Phillips C, Dann C, Turvey TA:
Stability after surgical-orthodontic correction
of skeletal class III malocclusion: 3.
Combined maxillary and mandibular
procedures. Int J Adult Orthodon Orthognath
Surg 6:221, 1991.
81. Proffitt WR, Phillips C, Turvey TA: Stability
after mandibular setback: Mandible-only
versus 2-jaw surgery. J Oral Maxillofac Surg
70:e408–e414, 2012.
82. Reitzik M: Skeletal and dental changes after
surgical correction of mandibular
prognathism. J Oral Surg 38:109, 1980.
83. Reyes BC, Baccetti T, McNamara JA, Jr: An
estimate of craniofacial growth in Class III
malocclusion. Angle Orthod 76:577–784,
2006.
84. Reyneke JP, Evans WG: Surgical
manipulation of the occlusal plane. Int J
Adult Orthodon Orthognath Surg 5:99–110,
1990.
85. Rosen H: Facial skeletal expansion:
Treatment strategies and rationale. Plast
Reconstr Surg 89:798, 1992.
86. Rosen H: Aesthetics in facial skeletal surgery.
Perspect Plast Surg 6:1, 1993.
87. Rosen HM: Porous block hydroxyapatite as
an interpositional bone-graft substitute in
orthognathic surgery. Plast Reconstr Surg
83:985, 1989.
88. Rosen HM: Segmental osteotomies of the
maxilla. Clin Plast Surg 16:785, 1989.
89. Rosen HM: Maxillary advancement for
mandibular prognathism: Indication and
rationale. Plast Reconstr Surg 87:823, 1991.
90. Sakamoto E, Sugawara J, Umemori M,
Mitani H: Craniofacial growth of
mandibular prognathism during pubertal
growth period in Japanese boys: Longitudinal
study from 10–15 years of age. Jpn J Orthod
Soc 55:372–386, 1996.
91. Samman N, Tong AC, Cheung LK, et al:
Analysis of 300 dentofacial deformities in
Hong Kong. Int J Adult Orthodon
Orthognath Surg 7:5, 1992.
92. Sar C, Arman-Özçirpici A, Uçkan S, Yazici
AC: Comparative evaluation of maxillary
protraction with or without skeletal
anchorage. Am J Orthod Dentofacial Orthop
139:636–649, 2011
93. Sassouni V, Nanda S: Analysis of dentofacial
vertical proportions. Am J Orthod 50:801,
1964.
94. Scholssmann A: Cited by G Perthes:
Operative korrektur der progenie. Zentralbl
Chir 49:1540–1541, 1922.
95. Silverstein K, Quinn PD: Surgically-assisted
rapid palatal expansion for management of
transverse maxillary deficiency. J Oral
Maxillofac Surg 55:725, 1997.
96. Simpson W: The results of surgery for
mandibular prognathism. Br J Oral Surg
12:166, 1974.
97. Singh GD: Morphologic determinants in the
etiology of class III malocclusion: A review.
Clin Anat 12:382–405, 1999.
98. Singh GD, McNamara JA, Jr, Lozanoff S:
Procrustes, Euclidean and cephalometric
analysis of the morphology of the mandible
in human class III malocclusions. Arch Oral
Biol 43:535–543, 1998.
99. Skaloud F: New surgical method for
correction of prognathism of the mandible.
Oral Surg Oral Med Oral Pathol 4:689–694,
1951.
100. Sorokolit CA, Nanda RS: Assessment of the
stability of mandibular setback procedures
with rigid fixation. J Oral Maxillofac Surg
48:817, 1990.
101. Stea G: Notre experience dans le transientdu
prognatism. Rev Stomatol 72:559, 1971.
102. Stella JP, Astrand P, Epker BN: Patterns and
etiology of relapse after correction of class III
open bite via subcondylar ramus osteotomy.
Int J Adult Orthodon Orthognath Surg 1:91,
1986.
103. Stella JP, Streater MR, Epker BN, Sinn DP:
Predictability of upper lip soft tissue changes
with maxillary advancement. J Oral
Maxillofac Surg 47:697, 1989.
104. Stiles KA, Luke JE: The inheritance of
malocclusion due to mandibular
prognathism. J Hered 44:241–245,
1953.
105. Sugawara J, Tsuchikawa T, Soya T, Mitani
H: Late adolescent growth of skeletal Class
III craniofaces in Japanese girls: Average
growth from 14–17 years of age based on
longitudinal data [Japanese]. Nihon
Kyosei Shika Gakkai Zasshi 42:399–408,
1983.
106. Thompson EM, Winter RM: Another family
with the “Habsburg jaw.” J Med Genet
25:838–842, 1988.
107. Throckmorton GS: Masticatory function in
patients with mandibular prognathism before
and after orthognathic surgery [discussion].
J Oral Maxillofac Surg 51:1002, 1993.
108. Throckmorton GS: Effect of mandibular
setback surgery on occlusal force
[discussion]. J Oral Maxillofac Surg 55:126,
1997.
109. Tollaro I, Baccetti T, Franchi L: Class III
malocclusion in the deciduous dentition: A
morphological and correlation study. Eur J
Orthod 16:401–408, 1994.
110. Tornes K: Extraoral and intraoral vertical
subcondylar ramus osteotomy for correction
of mandibular prognathism. Int J Oral
Maxillofac Surg 16:671, 1987.
111. Tornes K, Wisth PJ: Stability after vertical
subcondylar ramus osteotomy for correction
of mandibular prognathism. Int J Oral
Maxillofac Surg 17:242, 1988.
112. Trauner R, Obwegeser H: The surgical
correction of mandibular prognathism and
retrognathia with consideration of
genioplasty. II. Operating methods for
microgenia and distoocclusion. Oral Surg
Oral Med Oral Pathol 10:787–792, 1957.
113. Turvey TA, Hall DJ, Fish LC, Epker BN:
Surgical orthodontic treatment planning for
simultaneous mobilization of the maxilla and
mandible in the correction of dentofacial
deformities. Oral Surg Oral Med Oral Pathol
54:491, 1982.
114. Vanarsdale R, White R: Three-dimensional
analysis for skeletal problems. Int J Adult
Orthodon Orthognath Surg 9:159, 1994.
115. Van der Dussen FN, Egyedi P: Premature
aging of the face after orthognathic surgery.
J Craniofac Surg 18:335, 1990.
116. Wardrop RW, Wolford LM: Maxillary
stability following downgraft and/or
advancement procedures with stabilization
using rigid fixation and porous block
hydroxyapatite implants. J Oral Maxillofac
Surg 47:336, 1989.
117. Watanabe M, Suda N, Ohyama K:
Mandibular prognathism in Japanese families
ascertained through orthognathically treated
patients. Am J Orthod Dentofacial Orthop
128:466–470, 2005.
118. Westwood P, McNamara JA, Jr, Baccetti T,
et al: Long-term effects of Class III treatment
with rapid maxillary expansion and facemask
therapy followed by fixed appliances. Am J
Orthod Dentofacial Orthop 123:306–320,
2003.
119. Williams MD, Sarver DM, Sadowsky PL,
et al: Combined rapid maxillary expansion
and protraction facemask in the treatment of
class III malocclusion in growing children: A
prospective long-term study. Semin Orthod
3:10, 1997
120. Wisth PJ: Mandibular function and
dysfunction in patients with mandibular
prognathism. Am J Orthod 85:193–198,
1984.
121. Wolfe SA, Berkowitz S: Combined maxillary
and mandibular procedures: Sequential or
simultaneous. In Plastic surgery of the facial
skeleton, Boston, 1989, Little, Brown,
p 417.
122. Wollf G, Wienker TF, Sander H: On the
genetics of mandibular prognathism: Analysis
of large European noble families. J Med
Genet 30:112–116, 1993.
123. Wilhelm-Nold I, Droschl H: Die
frühbehandlung der progenie im milchgebiß
im vergleich zur behandlung im
wechselgebiß. J Orofacial Orthopedics/Fortschr
Kieferorthop 51(3):165–179, 1990.
124. Yamaguchi T, Park SB, Narita Maki K,
Inoue I: Genomewide linkage analysis of
mandibular prognathism in Korean and
Japanese patients. J Dent Res 84:255–259,
2005.
125. Zhou Y, Hagg U, Rabie AB: Severity of
dentofacial deformity, the motivations and
the outcome of surgery in skeletal Class III
patients. Chin Med J (Engl) 115:1031,
2002.

758

21
Long Face Growth Patterns:
Maxillary Vertical Excess with
Mandibular Deformity
JEFFREY C. POSNICK, DMD, MD
• Functional Aspects
• Clinical Characteristics
• Dental Findings
• Radiographic Findings
• Etiologic Considerations
• The Role of Growth Modification in the
Preadolescent Patient
• The Orthodontic Camouflage Approach
• An Orthodontic Molar Intrusion Approach
• Definitive Reconstruction
• Surgical Planning Pitfalls
• Postsurgical Orthodontic Maintenance and
Detailing
• Complications, Informed Consent, and
Patient Education
• Malocclusion after Orthodontics and
Orthognathic Surgery
• Temporomandibular Disorders: Effects of
Orthodontics and Orthognathic Surgery
• Conclusions
in a personal and family decision to seek treatment more
frequently than most other patterns of dentofacial defor­
mity (e.g., mandibular deficiency alone).112 Halfway around
the world, in South Africa, Reyneke estimated that, in his
orthognathic practice, approximately 30% of those seeking
treatment have a long face with complaints about a gummy
smile and concerns caused by malocclusion.117
The basic diagnostic criteria for a long face growth
pattern include an excessive anterior facial height (i.e., the
elongation of the lower third) that leads to disproportion
between facial height and width.26,28,69,70 Studies confirm
that the excessive eruption of the posterior maxillary denti­
tion causes the mandible to rotate downward and backward
(clockwise rotation) and results in increased lower facial
height.24,34 This makes any baseline mandibular anteropos­
terior deficiency seem worse and any true mandibular prog­
nathism seem better.31,123 As the mandible rotates down and
back during facial development, the lower incisors often
adapt by becoming more upright, with crowding. The man­
dibular clockwise rotation tends to separate the upper and
lower incisors vertically, thereby creating an open bite with
an accentuated curve of Spee.76 Not all long face growth
patterns involve an anterior open bite. The maxillary inci­
sors also supra-erupt.111,139 The anterior bite may stay closed
or even become deep, depending on the extent of max­
illary and mandibular incisor supra-eruption.5,23,71,93-97,133
Whether the incisor relationship remains deep, normal, or
open, lip incompetence (i.e., ≥4 mm of lip separation at
rest) occurs, with mentalis strain that results from attempts
to achieve lip closure.27,99,100
Functional Aspects
• Wide lip separation occurs, with excessive effort required
during attempts to achieve lip seal.
• Chronic obstructive nasal breathing as a result of
increased intranasal airway resistance (e.g., septal
The prevalence of a long face growth pattern at a prominent
U.S. maxillofacial center was documented as representing
22% of jaw deformity evaluations as judged from the
parameter of excessive anterior facial height.114 The lower
anterior facial height was specifically long in 88% of the
affected individuals.54,74,75 The term long face is generally
used to describe a maxillofacial growth pattern that typically
also includes a gummy smile, an anterior open bite, and a
lack of chin prominence. This combination of problems
seems to be harder for the individual to live with; it results

759
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
deviation, enlarged inferior turbinates, tight nasal aper­
ture, elevated nasal floor) is frequent (see Chapter 10).
• Classic articulation errors in speech as a result of the
anterior open bite and lip incompetence are expected
(see Chapter 8).
• Chewing and swallowing difficulties caused by the
anterior open-bite malocclusion are expected (see
Chapter 8).
• Detrimental effects on the dentition and the periodon­
tium as a result of long-term traumatic malocclusion, the
displacement of the teeth outside of the alveolar bone
housing, or previous camouflage orthodontic and restor­
ative treatments may be seen.
• The incidence of temporomandibular disorder may be
higher than it is among individuals with normal jaw
harmony and occlusion (see Chapter 9).
Clinical Characteristics
• Excessive anterior facial height, primarily in the lower
third of the face
• Lip incompetence (i.e., resting lip separation of ≥4 mm)
• Increased exposure of the gingiva with a broad smile (i.e.,
a gummy smile)
• Increased frequency of anterior open bite (although one
third of patients present with a normal or deep bite and
only 15% have an open bit of >4 mm)
• Mandibular deficiency with Class II malocclusion is fre­
quent (this can range from Class I to Class III)
• A mandible that is rotated downward and backward (i.e.,
clockwise rotation)
• An excessively full, curled lower lip when in a relaxed
position
• Increased vermillion exposure of the lower lip
• A constricted or narrow alar base width, with depressed
paranasal regions
• The appearance of a flat or sunken midface, without
aesthetically pleasing facial curves or contours
• A negative vector relationship of the ocular globe to the
lower eyelid
Dental Findings
• Anterior open bite (may be normal or deep)
• Excessive alveolar height in the anterior maxillary region
(this will raise the floor of the nose and partially obstruct
nasal airflow)
• Mandibular incisors that are upright, with crowding
• Accentuated curve of Spee as a result of the overeruption
of the mandibular incisors
• Tendency toward a narrow, V-shaped maxillary arch with
posterior crossbites (this is seen in approximately 50%
of patients)
• Occlusal surface enamel wear on the posterior teeth as a
result of grinding (secondary occlusal trauma) or previ­
ous occlusal equilibration performed in an attempt to
close the anterior open bite
Radiographic Findings
• Excessive eruption of the maxillary posterior teeth (i.e.,
the distance from the palatal plane to the cusps of the
molars)
• Maxillary horizontal deficiency
• Clockwise rotation of the maxilla (i.e., an increased
palatal plane angle)
• Increased lower anterior facial height
• Clockwise rotation of the mandible (i.e., an increased
mandibular plane angle)
• Normal or short mandibular ramus height
• Mandibular posterior teeth not excessively erupted
• Excessive eruption of the maxillary and mandibular inci­
sors: with enough anterior hypereruption, a normal or
deep overbite is more likely
• Measurable excessive eruption of the maxillary incisors
(i.e., the distance from the floor of the nose to the incisal
edge)
• Measurable excessive eruption of the mandibular incisors
(i.e., the distance from the menton to the incisal edge)
Fields and colleagues presented simplified cephalometric
diagnostic criteria.44 If a patient has all three of the follow­
ing criteria, he or she can be considered to have a long face
growth pattern:
1. An increased mandibular plane angle
2. An increased total anterior facial height
3. A decreased percentage of upper to lower facial height
Etiologic Considerations
Current thinking is that both environmental influences and
inherited tendencies play a role in the development of a long
face.53,66,67,85-87 A significant percentage of patients with long
faces have been found to have an increased oral and decreased
nasal breathing pattern.25,33,37,52,59,82,134,146,150 Interestingly,
nasal obstruction is not always present with long face
growth patterns, but an open-mouth posture during devel­
opment is typical. Other causes of an open-mouth posture
in the preadolescent patient have been shown to result
in similar long face dysmorphology.1,2,4,51,61,78,80,140 This in­
cludes muscle weakness syndromes (e.g., Moebius syn­
drome, facial nerve palsy, cerebral palsy, muscular dystrophy)
and the presence of a large tongue (e.g., Beckwith-
Wiedemann syndrome, hemangioma, vascular malforma­
tions, neurofibromatosis, Proteus syndrome; see Chapter 4).
There is experimental animal model research to support
the theory that a long face anterior open-bite malocclusion
is a physiologic adaptation to an open-mouth protrusive
tongue posture that is present during facial development
(see Chapters 4 and 10).62-65 It has also been clarified that,
in humans, a resting open-mouth protrusive tongue posture
is an etiologic factor in the development of a long face with
an anterior open bite. Interestingly, the intermittent occur­
rence of tongue thrust during speech and swallowing is not

760 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
functional appliance be worn for 14 to 16 hours per day.
When headgear is used, it is designed to apply direct exter­
nal force to the teeth through a fixed maxillary appliance.
Unfortunately, true vertical pull is almost impossible to
achieve, and this results in a degree of added backward pres­
sure. Because the majority of patients with long faces do
not have protrusion of the maxilla, this unavoidable poste­
rior force is counterproductive and results in further hori­
zontal maxillary deficiency. The combination of vertical
intrusion vectored headgear and an intra-oral functional
appliance to affect the posterior dentition—when initiated
during childhood and sustained through the teenage years
in a compliant child—is thought to have the potential to
produce improvement in the patient with a long face growth
pattern. In all but borderline long faces, which are recog­
nized during childhood, growth modification is not likely
the preferred approach.
The Orthodontic Camouflage
Approach
The patient with a long face often perceives a visual promi­
nence of his or her upper incisors. For this reason, it is
apparently tempting for the orthodontist to proceed with a
camouflage treatment plan to neutralize the occlusion via
the retraction of the upper incisors. This approach seems to
be especially difficult for the orthodontist to avoid when
viewing the problem primarily as a Class II malocclusion
without fully considering the vertical and horizontal skeletal
disharmony, the lip incompetence, the upper airway dys­
function, and the overall facial aesthetics. The extraction of
the maxillary first premolars followed by the retraction of
the anterior teeth will improve and may even neutralize the
occlusion, but it does nothing to relieve the vertical facial
problem, and it will further accentuate the horizontal facial
deficiency. As the incisors are orthodontically retracted, they
are also elongated (i.e., extruded), and the nasolabial angle
opens, which results in unattractive effects on the lips and
the nose.
Before embarking on an orthodontic camouflage
approach, the clinician should confirm that the patient and
his or her family understand the aesthetic limitations of
closing the anterior open bite by extruding the incisors
(i.e., residual or worsening gummy smile, residual lip
incompetence with mentalis strain, lack of facial aesthetic
improvement). The patient’s long-term dental stability and
periodontal health must also be considered. In addition, the
maxilla, the mandible, and the chin will remain horizontally
deficient and vertically long, thereby further accentuating
lip incompetence and the long, flat, retrusive appearance of
the profile.
An Orthodontic Molar
Intrusion Approach
Sato and colleagues believe high-angle Class II malocclu­
sions can be corrected with the use of “multiloop edgewise
thought to be the cause of an open bite. In fact, periodic
tongue thrusting is an adaptive response to an open bite
rather than the cause.47 When the incisors overlap in an
average way (i.e., with a normal overbite), the normal-sized
tongue is naturally placed behind the teeth to create the
necessary anterior seal for successful swallowing and the
articulation of specific consonant sounds (see Chapter 8).
In the presence of anterior open bite, the normal tongue
must protrude past the teeth to seal against the lips. This is
an expected adaptive mechanism to assist with swallowing
and speech. Confirmation that the protrusive tongue posi­
tion during swallowing and speech is a reversible adaptation
has been routinely documented after the individual with a
long face and an anterior open bite undergoes successful
orthognathic surgery and orthodontic treatment.89,142,155
When the open bite is closed with the use of sound biologic
mechanics (i.e., without orthodontic dental compensation)
and when lip competence is achieved through surgery (i.e.,
there is no longer excess lower facial height), there is a fairly
reliable elimination of the tongue thrust without the need
for active myofunctional physical therapy retraining.
However, if a skeletal anterior open bite has been closed
with the use of unsound orthodontic maneuvers (i.e., exces­
sive eruption of the anterior teeth or buccal tipping of the
molars outside of the alveolar bone housing) and if lip
competence is not achieved (i.e., inadequate facial height
shortening), dental relapse is to be expected. In this case,
tongue thrusting should not be blamed for the recurrent
malocclusion.
The Role of Growth Modification in the
Preadolescent Patient
When standard growth modification maneuvers for a long
face growth pattern are attempted in the preadolescent
patient, the primary objective is to restrain the hypererup­
tion of the posterior maxillary teeth. In theory, this would
limit the abnormal downward and backward rotation of the
mandible. Unfortunately, effective and practical methods
for accomplishing this seemingly limited objective have
been difficult to orchestrate. It has also been shown that the
natural progression of the deformity may persist through
adolescence. This means that the effective containment of
the maxillary posterior dental hypereruption would need to
continue throughout the teenage years. The two traditional
methods that are used to impede excessive vertical growth
of the posterior maxilla are 1) the use of high-pull headgear
connected to a complete or partial maxillary fixed appliance
and 2) the use of a functional intra-oral appliance that
incorporates a bite-block device (i.e., an activator) between
the teeth.
The intraoral functional appliance is usually designed to
exert force on the posterior teeth when the masticatory
muscles contract. The occlusal force is then transferred
through the biting surfaces of the upper and lower posterior
teeth to the periodontal ligaments to limit molar eruption.
To be effective, most clinicians recommend that the

761
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
were to continue, it should occur in both the mandible and
the maxilla in a proportionate way.
If the individual with a long face is either a normal
mandibular grower (i.e. Class I) or a mandibular-deficient
grower (i.e. Class II), then after he or she is in the perma­
nent dentition and the teeth are orthodontically aligned,
ongoing horizontal jaw growth after reconstruction is
unlikely.
Horizontal jaw growth maturation may be analyzed with
the use of serial lateral cephalometric radiographs. These
sequential radiographs can be used to make direct mandibu­
lar measurements. Surgery is delayed until the deceleration
of growth can be documented. The best evidence available
indicates that, when orthognathic surgery is undertaken in
the mandibular-deficient patient as early as completion of
the adolescent growth spurt, forward growth of the man­
dible almost never occurs.135 Further horizontal growth of
the maxilla at this age is also not expected.
For all of these reasons, proceeding with definitive
orthognathic and intranasal surgery for the patient with a
Class II long face growth pattern when he or she is as young
as 14 years old is generally safe from a growth perspective,
but only after the eruption and orthodontic alignment of
the teeth (Fig. 21-4).
Preorthodontic Periodontal Considerations
Assessing the individuals biologic and anatomic risk factors
for periodontal injury should be undertaken before starting
orthodontic treatment.
Orthodontic attempts to compensate the occlusion in
the patient with a long face growth pattern may result in
gingival recession along the labial aspect of the lower inci­
sors and the buccal aspect of the posterior maxillary teeth.
The advantage of bicuspid extractions in the mandible or
the maxilla should always be considered to achieve full
positioning of the dental roots solidly in the alveolar bone
(see Chapter 6).
When lip competence and an improved nasal airway
have been achieved as a result of jaw and intranasal proce­
dures, the dryness of the gingiva (ex. inflammation) will also
diminish (see Chapter 6).
Orthodontic Preparation for
Orthognathic Surgery
The orthodontic mechanics should be oriented toward posi­
tioning of the teeth solidly in the alveolar housing within
each arch and specifically within each maxillary segment as
indicated.128,132,145,149,151 A goal is for the teeth to occlude
together appropriately at the time of surgery and after fin­
ishing orthodontics. The preferred and anticipated occlu­
sion is best confirmed via the periodic review of dental
models (see Chapter 5).
From the beginning, the orthodontist and the surgeon
make joint decisions concerning the treatment approach.
One aspect that they will consider is whether the maxilla is
arch wires.”124 With the use of tip-back mechanics and verti­
cal elastics, the researchers believe that the occlusal plane
inclination can be altered by intruding the molars via the
autorotation of the mandible and the closure of the open
bite. Unfortunately, scientific evidence in support of this
method of treatment for a patient with a long face and an
anterior open bite has not been forthcoming.
With the use of skeletal temporary anchorage devices,
the intrusion of the molars has been recommended by
some to close an open bite.105,157,158 Man-Suk and colleagues
completed a study to examine the long-term stability of
anterior open-bite correction via the intrusion of the maxil­
lary posterior teeth in adults.88 In the first group (n = 5
adults), mini-screw implants were placed on the buccal and
palatal sides, between the roots of the maxillary second
premolars and first molars and between the roots of the
maxillary first and second molars. Intrusion forces were
directly applied to the molars with elastomeric chains. In
the second group (n = 4 adults), mini-screw implants were
placed on the buccal side only between the roots of the
maxillary second premolars and first molars and between
the roots of the maxillary first and second molars. A rigid
transpalatal arch was placed before applying the intrusive
forces to prevent the buccal tipping of the teeth. Lateral
cephalograms were taken at the initial evaluation and again
at 1 and 3 years after treatment. The cephalograms were
traced and analyzed. The study documented that the maxil­
lary first molars were intruded on an average of 2.39 mm
during treatment, with relapse of 0.45 mm at the 3-year
follow up (i.e., 22.9% relapse). A majority of the relapse
occurred during the initial posttreatment year. The molar
relapse had a significant effect on the eventual incisal over­
bite. There was no significant difference in molar relapse or
the maintenance of overbite between the two different
methods of skeletal anchorage used. It would appear as
though there is currently no known way to fully retain an
orthodontically intruded molar.
For patients with borderline long face growth patterns
in whom the open bite has been successfully closed with the
use of orthodontic mechanics and in whom the remaining
gummy smile and lip incompetence is only mild, a vertical
reduction with horizontal advancement genioplasty may
improve the profile aesthetics and lip competence enough
to be a satisfactory compromise for the patient (see Chapter
37 and 40).
Definitive Reconstruction
Timing of Orthognathic Surgery
Orthodontic or surgical interventions undertaken in the
individual with a long face growth pattern will not be
definitive if significant jaw growth continues after treat­
ment. In our experience, when the increased intranasal
airway resistance is simultaneously managed as part of the
definitive jaw reconstruction, excessive ongoing vertical
growth ceases.108,110 Even if minor degrees of vertical growth

762 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
posterior teeth have not been orthodontically posi­
tioned fully within the alveolar housing (e.g., if there
is buccal tipping of molars), dental relapse after
surgery with a return of the narrow maxillary arch
width and the open-bite malocclusion is more likely
to occur (see Chapter 17).
Basic Mandibular Arch Mechanics
• Routine orthodontic mechanics are used to level, align,
close up spaces, and achieve appropriate arch form in the
lower jaw.
• Extraction of a bicuspid in each quadrant (or of a single
incisor, in rare cases) or interproximal reduction may be
needed in the lower arch to uncrowd the dental crowns,
to set the roots solidly in the alveolar housing, and to
correct incisor inclination.
Basic Maxillary Arch Mechanics
• In the presence of vertical skeletal discrepancies, presur­
gical orthodontic stabilization may be achieved with sec­
tional finishing wires that conform to the arch shape of
each segment.
• If no vertical segmental skeletal discrepancies exist, then
the maxillary arch is leveled with a continuous arch wire.
Care is taken to prevent the forward flaring of the inci­
sors. Posterior intrusion mechanics are also avoided,
because they predispose the patient to late dental relapse.
• The advantage of bicuspid extractions to position the
remaining roots solidly in alveolar housing should always
be considered.
• In our experience, planning the interdental osteotomies
between the canines and the first bicuspids is rarely pre­
ferred. Segmentation in this location is technically more
time-consuming for the orthodontist (i.e., precise inter­
canine width orthodontic detailing becomes necessary),
and it is more prone to dental injury and periodontal
sequelae (i.e., pocketing and gingival recession) from the
interdental osteotomy at surgery.
• Segmentation between the lateral incisors and the canines
is generally preferred. When segmenting in this location,
it is not necessary or advantageous for the orthodontist
to create space at the planned osteotomy sites, because
the roots are naturally divergent. The advantages of seg­
menting the maxilla in this location (i.e., between the
lateral incisor and the canine) on each side and then
parasagittally (i.e., down the hard palate) include the
simplification of orthodontic mechanics, the prevention
of periodontal sequelae, and the ability to positively
influence incisor inclination without negatively affecting
the vertical facial height.
Basic Surgical Approach
The surgical approach for the treatment of a classic long face
is best carried out through a combination of osteotomies,
including Le Fort I osteotomy in segments, bilateral sagittal
split ramus osteotomies, and oblique osteotomy of the
to remain in one piece or to be segmented; if segmentation
is planned, they will determine at what locations this will
occur. The decision for or against segmentation of the
maxilla is driven by the baseline skeletal deformity and not
for reasons of clinical expedience. A patient with a long face
and a moderate or severe anterior open bite will generally
have an excessive curve of Spee in the upper arch. Vertical
steps in the maxillary arch exist that are coincident with the
degree of dentoalveolar dysplasia. The more severe the verti­
cal alveolar and dental step-offs, the more exaggerated the
curve of Spee and the more obvious the need for segmental
orthodontic mechanics and segmental surgical reposition­
ing as part of the overall correction.
With maxillary surgical segmentation planned, the
orthodontist’s presurgical goal is to level the teeth indepen­
dently within each segment. With a decision made to also
defer arch expansion to the surgical phase (i.e., segmental
osteotomies with widening), the orthodontic alignment of
the teeth within each segment becomes the preoperative
objective. Furthermore, there is no need or advantage for
the orthodontist to create a space at the planned interdental
osteotomy sites (i.e., between the lateral incisor and canine
on each side or between the central incisors), because the
roots are naturally divergent (see Chapter 17). The orth­
odontic preparation before surgery should incorporate the
following basic concepts:
1. The mandibular arch is leveled with the use of standard
orthodontic mechanics before surgery. A patient with a
long face does not generally have a severely exagger­
ated curve of Spee in the lower arch. Therefore, com­
plete leveling is generally carried out before surgery
(with or without the need for extractions).
2. The presence of an excessive reverse curve of Spee in the
maxillary arch is an indication of a skeletal problem
rather than a dental one. Orthodontic leveling of the
arch in segments (i.e., four incisors, the canine
through the second molar on the left side, and the
canine through the second molar on the right side) is
generally consistent with the skeletal dysmorphology,
and it is carried out before surgery. With the curve of
Spee orthodontically leveled in each of the three com­
ponents, segmental Le Fort I osteotomies will allow
for the placement of the three individually leveled
components over the orthodontically leveled man­
dibular arch to achieve the preferred occlusion at
operation.
3. The presence of a narrow maxilla is an indication of
skeletal dysplasia rather than dental malposition. Orth­
odontic tooth movement should remain consistent
with the narrow skeletal width. Each posterior
segment (i.e., the canine through the second molar
on the left side and the canine through the second
molar on the right side) should be independently
orthodontically leveled. Segmentation of the down-
fractured maxilla will then adjust the arch width to
the orthodontically leveled mandibular arch. If the

763
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
17, I recommend a single-stage orthognathic approach in
most cases. This includes a Le Fort I down-fracture oste­
otomy with segmentation to simultaneously correct the
curve of Spee; any transverse discrepancy; vertical dysplasia;
horizontal dysplasia; canting (i.e., roll orientation); any
midline discrepancies (i.e. yaw orientation); and A-point to
B-point discrepancies (i.e., pitch orientation).
chin (Figs. 21-1 through 21-10).* Management of the ante­
rior neck soft tissues—including cervical soft-tissue flap
elevation, neck defatting, and vertical platysmal muscle
plication—can also be carried out, if desired (see Chapter
40). The removal of the impacted wisdom teeth is fre­
quently recommended for long-term dental health. If this
is planned, it can be accomplished at the same time (see
Chapters 15 and 16).
If septoplasty, inferior turbinate reductions, or both are
required to improve nasal airflow, then the procedures are
carried out simultaneously (see Chapter 10).108-110 For the
patient with a long face growth pattern, an important aspect
of nasal aesthetics and airway management is to also simul­
taneously lower and recontour the floor of the nose, the
pyriform rims, and the anterior nasal spine region. In 1985,
Ellis used lateral cephalometric radiographs to study the
specific regions of vertical maxillary excess in mature indi­
viduals (i.e., >17 years old) with long faces.36 In the study
patients, the linear distance between the incisal edge and
the floor of the nose (i.e., the upper incisal edge to the
anterior nasal spine) was found to be significantly increased.
In other words, the anterior floor of the nose was excessively
high, which at least partially accounted for the diminished
nasal aperture opening. Ellis recognized that, when a stan­
dard Le Fort I maxillary intrusion is carried out to decrease
the gummy smile, the elimination of any excessive alveolar
bone in the area of the pyriform fossa should also be con­
sidered. In these cases, I recommend that the floor of the
nose and the anterior nasal spine regions be recontoured to
lower the floor. When this is done, the nasal airway is
improved, and the “bunching” of the nasal and paranasal
soft tissues is avoided. I agree with Ellis and Westermark
that the popular use of an alar cinch stitch is generally
carried out as a soft-tissue attempt to solve a skeletal
problem.36,154 Although the alar cinch stitch will have effects
on the nasal base width, it will also have secondary effects
on the nasolabial angle and the nasal tip projection that may
not be positive.118 In addition, if the cinch stitch is com­
pleted without fully correcting the skeletal aspects (i.e.,
lowering the nasal floor and recontouring the anterior nasal
spine), suboptimal nasal aesthetics and further airway
obstruction are likely.55,92,144
One of the indications for the segmenting of the
maxilla is to correct transverse dental width deficien­
cies.7,9,10,22,56,77,79,129,130 In the past, problems of stability with
transverse expansion have led some clinicians to recom­
mend a two-stage surgical approach to maxillary reconstruc­
tion for a long face growth pattern. The first stage involves
surgically assisted rapid palatal expansion to widen the
maxilla during the presurgical orthodontic phase of treat­
ment. Approximately 6 to 18 months later, a Le Fort I
down-fracture osteotomy is carried out as part of the defini­
tive orthognathic correction to reposition the maxilla verti­
cally and horizontally, as indicated. As discussed in Chapter
*References 6, 11-21, 29, 32, 38, 40, 41, 48, 57, 58, 68, 72, 73, 83, 84,
100, 101, 118-121, 125, 138, 148, 152, 17, 102
Text continued on p. 801
*References 39, 43, 46, 60, 98, 107, 116, 122, 127, 141, 143, 147,
153, 156
NOTE:  The literature does not confirm a better
outcome with a two-stage surgical approach to maxillary
deficiency in individuals with long faces.30 The potential
for increased morbidity as well as the increased time and
financial costs of a two-stage surgical approach cannot
be justified in most cases (see Chapter 17).
Immediate Presurgical Planning
The immediate presurgical planning takes into account
collaborative clinical efforts among the orthodontist, the
surgeon, the patient, and the family that will have been
ongoing since the initial consultation visits.* Depending on
the condition of the dentition and the supporting struc­
tures, the restorative dentist and the periodontist may also
have been intricately involved.
The patient’s specific medical and dental records are
reviewed, including radiographs (e.g. computed tomogra­
phy scans; panoramic, lateral, and posteroanterior cephalo­
metric images and periapical radiographs); facial and
occlusal photographs; and dental models. Immediate pre­
surgical records (i.e., within 2 to 6 weeks of surgery) will
most importantly include facial measurements taken during
a direct visual examination of the patient; alginate impres­
sions of the maxilla and the mandible; centric relation bite
recording; and face-bow registration.
First, broad-stroke decisions are made regarding the pre­
ferred vector changes for each jaw; only then are the precise
millimeter distances and angular changes required in each
jaw to achieve the desired end result determined (see
Chapter 12). Analytic model planning is carried out on the
articulated dental casts with use of the Erickson Model
Table. Splints are constructed to assist with the achievement
of the precise occlusion and preferred facial aesthetics in the
operating room (see Chapters 13 and 14).
The basic vector changes required in the maxilla to
correct a long face growth pattern frequently include
maxillary horizontal advancement; the shortening of the
anterior (vertical) height; transverse widening; and the cor­
rection of the curve of Spee to match the mandibular arch.
Basic vector changes often incorporate counterclockwise
rotation of the maxillary plane (i.e., pitch orientation)
as needed to achieve a preferred A-point to B-point

Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 21-1  A 15-year-old girl arrived with her parents for surgical evaluation. Her history and physical examination confirmed nasal obstruction,
heavy snoring, lip incompetence, difficulty chewing, and frequent speech articulation errors. The facial aesthetic concerns included an awareness
of a weak chin, a gummy smile, and the impression of having a large nose. The patient had been under an orthodontist’s care since the mixed
dentition. Rapid palatal expansion and full bracketing with attempted closure of the anterior open bite were not successful. Further evaluations
were carried out by a speech pathologist and an otolaryngologist, and a fresh look was taken at the patient’s ortho­dontic needs. Orthodontic
decompensation in combination with orthognathic and intranasal surgery was chosen. The simultaneous procedures carried out included Le Fort
I osteotomy in segments (horizontal advancement, and vertical shortening, counterclockwise rotation, arch expansion, and the correction of the
curve of Spee); sagittal split ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical shortening
and horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal views in repose before and after
reconstruction. B, Frontal views with smile before and after reconstruction.

765
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 21-1, cont’d 
Continued

766 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to retreatment
After treatment
Pre surgery
E
E, Occlusal views before retreatment, with orthodontic decompensation in progress, and after the completion
of treatment.
• Figure 21-1, cont’d

767
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
F
Maxillary counter-
clockwise rotation
Mandibular counter-
clockwise rotation
Arch expansion
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
surgery.
• Figure 21-1, cont’d

768 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 21-2  A 15-year-old girl arrived with her parents for surgical evaluation. Her history and physical examination confirmed lifelong nasal
obstruction, heavy snoring, and lip incompetence. The facial aesthetic concerns included an awareness of a weak chin, a gummy smile, wide lip
separation, and a deep lip curl. The patient had been under orthodontic observation since the mixed dentition. Further evaluations were carried
out by a speech pathologist and an otolaryngologist. Orthodontic decompensation in combination with orthognathic and intranasal surgery was
chosen. The simultaneous procedures carried out included Le Fort I osteotomy in segments (horizontal advancement, vertical shortening, arch
expansion, the correction of the curve of Spee, and counterclockwise rotation); sagittal split ramus osteotomies (horizontal advancement and
counterclockwise rotation); osseous genioplasty (vertical shortening and horizontal advancement); and septoplasty, inferior turbinate reduction, and
nasal floor recontouring. A, Frontal views in repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.

769
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C
C, Profile facial views before and after reconstruction. D, Oblique views before and after reconstruction.
• Figure 21-2, cont’d 
Continued

770 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to treatment
After treatment
Pre surgery
E
E, Occlusal views before treatment, with orthodontic decompensation in progress, and after the completion
of treatment.
• Figure 21-2, cont’d

771
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
F
Maxillary counter-
clockwise rotation
Mandibular counter-
clockwise rotation
Arch expansion
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
surgery.
• Figure 21-2, cont’d

772 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 21-3  A 15-year-old girl arrived with her parents for surgical evaluation. Her history and physical examination confirmed lifelong nasal
obstruction and lip incompetence. The facial aesthetic concerns included an awareness of a weak chin, a gummy smile, and wide lip separation.
The patient had been under an orthodontist’s care since the mixed dentition and underwent a full course of treatment. Further evaluations were
carried out by a speech pathologist and an otolaryngologist, and a fresh look was taken at the patient’s orthodontic needs. Orthodontic decom­
pensation in combination with orthognathic and intranasal surgery was chosen. The simultaneous procedures carried out included Le Fort I oste­
otomy in segments (horizontal advancement, vertical); sagittal split ramus osteotomies (horizontal advancement and counterclockwise rotation);
osseous genioplasty (vertical shortening and horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring.
A, Frontal views in repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.

773
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
Continued
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 21-3, cont’d

774 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to retreatment
After treatment
Pre surgery
E
E, Occlusal views before retreatment, with orthodontic decompensation in progress, and after the completion
of treatment.
• Figure 21-3, cont’d

775
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
F
Maxillary counter-
clockwise rotation
Mandibular counter-
clockwise rotation
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
surgery.
• Figure 21-3, cont’d

776 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 21-4  A 13-year-old girl arrived with her parents for surgical evaluation. Her history and physical examination confirmed lifelong nasal
obstruction, heavy snoring, lip incompetence, and persistent gingivitis despite good home care. The facial aesthetic concerns included an aware­
ness of a weak chin, a gummy smile, and severe lip strain. Further evaluations were carried out by a speech pathologist and an otolaryngologist,
and a fresh look was taken at the patient’s orthodontic needs. Orthodontic decompensation in combination with orthognathic and intranasal surgery
was chosen. The simultaneous procedures carried out included Le Fort I osteotomy (horizontal advancement, and vertical shortening); sagittal split
ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical shortening and horizontal advancement);
and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal views in repose before and after reconstruction. B, Frontal
views with smile before and after reconstruction.

777
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
Continued
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 21-4, cont’d

778 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to treatment
After treatment
Pre surgery
E
E, Occlusal views before treatment, with orthodontic decompensation in progress, and after the completion
of treatment.
• Figure 21-4, cont’d

779
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs
before and after surgery.
• Figure 21-4, cont’d

Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 21-5  A 21-year-old woman arrived for surgical evaluation. Her history and physical examination confirmed lifelong nasal obstruction, lip
incompetence, difficulty chewing, and frequent speech articulation errors. The facial aesthetic concerns included an awareness of a weak chin, a
gummy smile, lip strain, and the impression of having a larger nose. The patient had been under an orthodontist’s care since the mixed dentition
and through the high school years. Growth modification attempts followed by rapid palatal expansion and full bracketing with four bicuspid extrac­
tions were unsuccessful to close the anterior open bite. Early periodontal and dental deterioration were evident. Further evaluations were carried
out by a speech pathologist, an otolaryngologist, and a periodontist, and a fresh look was taken at the patient’s orthodontic needs. Orthodontic
decompensation in combination with orthognathic and intranasal surgery was chosen. The simultaneous procedures carried out included Le Fort
I osteotomy in segments (horizontal advancement, vertical shortening, counterclockwise rotation, arch expansion, and the correction of the curve
of Spee); sagittal split ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical shortening and
horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal views in repose before and after
reconstruction. B, Frontal views with smile before and after reconstruction.

781
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
Continued
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 21-5, cont’d

782 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
4 bicuspid extractions and dental compensation carried out earlier in life
After treatment
Pre surgery
E
E, Occlusal views before retreatment, with orthodontic decompensation in progress, and after the completion
of treatment.
• Figure 21-5, cont’d

783
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
F
Maxillary counter-
clockwise rotation
Mandibular counter-
clockwise rotation
Arch expansion
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
surgery.
• Figure 21-5, cont’d

Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 21-6  A 15-year-old girl arrived with her parents for surgical evaluation. Her history and physical examination confirmed lifelong nasal
obstruction, heavy snoring, lip incompetence, difficulty chewing, and frequent speech articulation errors. The facial aesthetic concerns included an
awareness of a weak chin, a gummy smile, and difficulty holding the lips together. The patient had been under an orthodontist’s care since the
mixed dentition. Rapid palatal expansion and full bracketing with attempted closure of the anterior open bite were unsuccessful. Further evaluations
were carried out by a speech pathologist and an otolaryngologist, and a fresh look was taken at the patient’s ortho­dontic needs. Orthodontic
decompensation in combination with orthognathic and intranasal surgery was chosen. The simultaneous procedures carried out included Le Fort
I osteotomy in segments (horizontal advancement, vertical shortening, counterclockwise rotation, and arch expansion); sagittal split ramus osteoto­
mies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical shortening and horizontal advancement); and septo­
plasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal views in repose before and after reconstruction. B, Frontal views with
smile before and after reconstruction.

785
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
Continued
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 21-6, cont’d

786 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
Mandibular counter-
clockwise rotation
Arch expansion
G
After treatment
Pre surgery
E
E, Occlusal views with orthodontic decompensation in progress and after the completion of treatment.
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after surgery.
• Figure 21-6, cont’d

787
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 21-7  A high-school girl arrived with her parents for evaluation. She refused an orthognathic approach at the time but then returned during
her college years to request correction. Her history and physical examination confirmed nasal obstruction, lip incompetence, and difficulty chewing.
The facial aesthetic concerns included an awareness of a weak chin, a gummy smile, lip strain, and the impression of having a larger nose. The
patient had been under an orthodontist’s care since the mixed dentition. Rapid palatal expansion and full bracketing with attempted closure of the
anterior open bite were not successful. Further evaluations were carried out by a speech pathologist and an otolaryngologist, and a fresh look was
taken at the patient’s orthodontic needs. Orthodontic decompensation that included four bicuspid extractions in combination with orthognathic
and intranasal surgery was chosen. The simultaneous procedures carried out included Le Fort I osteotomy in segments (horizontal advancement,
vertical shortening, and arch expansion); sagittal split ramus osteotomies (horizontal advancement); osseous genioplasty (vertical shortening and
horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal views in repose before and after
reconstruction. B, Frontal views with smile before and after reconstruction.
Continued

788 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 21-7, cont’d

789
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
After treatment with four bicuspid extractions
Pre surgery just prior to 4 bicuspid extractions
E
F
Arch expansion
G
E, Occlusal views with orthodontic decompensation in progress and then after the completion of treatment.
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after surgery.
• Figure 21-7, cont’d