British Journal of Oral Surgery (1981) 19, 231-257 0007-117X/81/00380237$02.

00
@ The British Association of Oral Surgeons

THE VERTICAL DIMENSION IN ORTHOGNATHIC SURGERY

D. HENDERSON, M.B., B.S., B.D.s., F.D.s.R.c.s.(ENG.), M.R.C.S.

Consultant in Oral and Maxilla-Facial Surgery,
St Thomas’ Hospital, London

Summary. The vertical dimension has been shown in recent years to be very important in the assess-
ment, diagnosis, treatment planning and surgery of facial skeletal deformity and disproportion. The
clinical and cephalometric evaluation of vertical facial dysplasia is discussed, and the management of
vertical deficiency or excess in the mandible and maxilla is outlined. The relevance to anterior open
bite cases is indicated. Cases are shown which illustrate the problems and the results of treatment.

Introduction
In the assessment of cases for orthognathic surgery individuals are encountered who
exhibit imbalance betweenthe vertical and horizontal components of the facial skeleton
and other parts of the face. Some of these cases involve primary vertical dysplasia
whilst in others vertical disproportion complicates horizontal and transverse abnor-
malities of growth. Recently more attention has been directed to the recognition and
correction of these vertical problems, especially in the United States; little discussion
has taken place in this country, however, and the pupose of this paper is to review the
management of the vertical dimension in general, illustrating the problems from
selected cases.

a:b

VERTICAL PROPORTION

FIG. 1. Proportional relationships in the full face view.

(Received 13 March 1981: accepted 5 June 1981)

237
238 BRITISH JOURNAL OF ORAL SURGERY

Assessment of the vertical relationships of the face

As with all orthognathic assessment, recognition is partly clinical and partly radio-
graphic. Cephalometric radiography is particularly useful in determining the site or
sites of disproportionate skeletal development.

1. Full face assessment

The well-proportioned face shows (in addition to the familiar division into approxi-
VERTICAL FACIAL HEIGHT

DENTOALVEOLAR HEIGHT

FIG. 2. Vertical facial height-lateral cephalometric measurements in (a) (above) overall facial skeleton,
(b) (below) dentoalveolar area.
 VERTICAL DIMENSION IN ORTHOGNATHIC 239
mately three equal thirds) several markers of vertical balance which have been well
described by Epker et al. (1978) and are illustrated in Figure 1.
(a) The distance fron the outer canthus of the eye to the angle of the mouth should
about equal the distance from the nasal columella to the chin, i.e. A should equal B in
Figure 1.
(b) The lateral edge of the alar rim should lie vertically below the medial canthus of
the eye, or slightly lateral to this position.
(c) The medial limbus of the eye should lie vertically above the angle of the oral
commissure.
(d) The vermillion exposure of the lips should be equal, that is, a should equal b in
Figure 1. Some writers emphasise that the distance from the subnasale to the lip
stomion should be one third of the distance from the stomion to the menton, but in
the author’s experience this is not always essential to good full face aesthetics and is
particularly variable in different races. The intrinsic size of the lip itself and the tone of
the orbicularis oris muscle is important before imbalance is blamed on the underlying
dentoalveolar position. Vertical or anteroposterior abnormality can both affect the
vertical balance of lips and chin in the lower,third. The relationship of the upper incisors
to the upper lip at rest is most important. About 3 mm of incisor exposure is desirable
for good balance, and much treatment planning centres on this relationship.
These features will be altered by anteroposterior movement of the maxilla or man-
dible. Maxillary advancement brings the nasal tip forwards and tilts it upwards, and
this effect is increased if the maxilla is simultaneously shortened vertically. Both
advancement and shortening also widen alar flare and enhance the convexity of the
para-alar regions. Shortening also widens the oral commissure, increasing lip ver-
million exposure in centric occlusion of the teeth. Reverse effects follow facial length-
ening by maxillary elongation. The alar flare is reduced, the lips are ‘thinned’, and the
mouth narrows from side to side. Treatment should always be planned to correct the
anomalous marks of vertical disproportion and to avoid their accentuation, and this
depends on attentive pre-operative assessment plus a knowledge of the effects of the
different facial osteotomies on vertical as well as anteroposterior relationships.

2. Cephalometric assessment
The simple ‘in clinic’ determination of anterior facial height and the balance between
upper and lower components is by the measurement of NA relative to APO, which

\
\

(a) LOW ANGLE (b) HIGH ANGLE

FIG. 3. Mandibular advancement in (a) Low angle, and (b) High angle cases.
240 BRITISH JOURNAL OF ORAL SURGERY

should be about 8 : 7 (McIntosh, 1970). This is subject to considerable error and if any
suspicion exists from the clinical evaluation that there may be vertical disproportion a
full vertical cephalometric analysis should be carried out. The A point is liable to
vertical plotting error as is the pogonion, and considerable errors may therefore be
compounded into the proportion NA : APO. The anterior nasal spine (ANS) and the
menton (Me) are reliable vertically although the ANS is subject to horizontal plotting
error.
The analysis presented in Figure 2 is becomimg generally accepted. Problems exist
in selecting a reference plane. The Frankfurt horizontal is too subject to plotting error
to be reliable, and the SN plane offers variable upward inclination from the horizontal
The latter is nevertheless the most suitable and norms for comparison are available

FIG. 4. Case 1. Low Angle Class 2 Div.1 case treated by mandibular advancement alone. (a) (top left)
and (b) (top right) Profile pre- and post-op (3/12 post-op); (c) (bottom left) and (d) (bottom right)
Full face (pre- and post-op).
 VERTICAL DIMENSION IN ORTHOGNATHIC 241

Preop 3/12 Postop

ATFH 107 IIL

AUFH 57 57

ALFH 50 97

FPI -6.5 0.0

SM. LOW ANGLE CLASS 2. Div.1

treated by -. FSS only

Fig. 4(e). Tracing of Case 2.

Table I.
Useful linear and angular
measurements in vertical
facial analysis. Bolton
standards (see Broadbent
et al., 1976)

Mean SD.

ATFH 119.8 7.00

AUFH 54.3 3.48
ALFH 65.4 4.96

RH 56.3 3.92

OP-PP 21.0
OP-MP 32.0

AUDH 28.5
ALDH 39.0

PTFH 79.0
PUFH 46.0
PLFH 43.0

SN-MP 29.7

from the Bolton standards (Broadbent et al., 1976). Vertical relationships are best
studied in profile cephalometry as the site of abnormality may be in the posterior face
(e.g. maxilla too high posteriorly) or the anterior face (e.g. mandible too high an-
teriorly), and is often panfacial.
242 BRITISH JOURNAL OF ORAL SURGERY

Interest centres in three sets of measurements, shown in Table I, and in two derived
proportional relationships. As with all cephalometry it is important to evaluate the
figures as a whole and not to pay too much attention to variations of individual
measurements from established norms.
The two proportional relationships derived from the figures are,
1. The SN : MP angle which relates posterior facial height to anterior facial height
and presents a mean of 29.7” in Caucasian adults. The FMA is too variable in plotting
and should be dropped from use, except in general discussion of lip profile relation-
ships, which are subject to other cross checks.
2. The Facial Proportion Index (FPI), introduced by Opdebeeck and Bell (1978),
is a useful way of expressing upper and lower anterior facial height in proportion to
total anterior facial height. Normally the anterior lower facial height (ALFH) is 55
per cent of the total anterior facial height (ATFH), the remaining 45 per cent being
midfacial (AUFH).
FPI (Facial Proportion Index) is calculated as ALFH expressed as a percentage of
ATFH minus AUFH expressed as a percentage of ATFH (normally 55 per cent
minus 45 per cent) and should about equal 10 regardless of the absolute measure-
ments.

The FPI is less than 10 in the Short Face Syndrome and more than 10 in the Long
Face Syndrome (see below).

Table II.
Classification of vertical dysplasias

Vertical Mandibular Deficiency

Low angle type
High angle type
Vertical Mandibular Excess
Vertical Maxillary Deficiency
Vertical Maxillary Excess
Bimaxillary Vertical Disproportion

FIG. 5. Increasing anterior lower facial height by sup-apical Proplast insert.

 VERTICAL DIMENSION IN ORTHOGNATHIC 243
The surgical significance of these estimations, and the different clinical problems
they indicate will be considered under a simple classification (Table II) dividing the
subject into maxillary and mandibular vertical excess or deficiency; but it must be
strongly emphasised that most cases fall to some extent into the last category of
bimaxillary (or panfacial) disproportion. Herein lies the difference between theoretical
correction and practical limitation both in terms of the extent of justifiable surgery in
relatively minor cases and of the restraint set by the soft tissue environment, which is
less susceptible to surgery and may therefore contraindicate otherwise logical skeletal
correction.

FIG. 6. Case 2. Low angle Class 2 Div.1 case treated by mandibular advancement (FSS) with vertical
augmentation and forward sliding genioplasty. (a) (top left) and (b) (top right) Profile pre-op and 3/12
post-op; (c)(bottom left) and(d) (bottom right) Full face (pre-and post-op).
244 BRITISH JOURNAL OF ORAL SURGERY

Fig. 6(e). Case 2. Lateral cephalogramone year post-op.

Vertical mandibular deficiency

Space allows only a few general comments on the correction of mandibular height
and the subject will be discussed further in the associated paper on anterior man-
dibuloplasty. Lower facial height, particularly anterior lower facial height, often reflects
maxillary abnormality, but primary vertical deficiency also occurs in the subapical
basal bone of the body and symphysis and in the mandibular rami. Ramus height
must always be seen in conjunction with the pterygo-masseteric soft tissue investment.
Where the soft tissue is deficient correction is rarely possible with stability, and the
masseteric and pterygoid activity should be assessed in the accepted manner (muscular
contraction by palpation, the presence or absence of antegonial notching, electro-
myography).
The distinction between ‘High angle’ and ‘Low angle’ cases is significant. Advance-
ment of the mandible in ‘low angle’ Class 2 cases produces the so-called clockwise
rotation under incisal guidance, and therefore an increase in ALFH (Fig. 3a). The same
manoeuvre in ‘high angle’ cases produces counterclockwise rotation without increase
in ALFH as a rule, but with increased forward projection of the chin (Fig. 3b).
Wolford et al. (1978) have presented an excellent analysis of these cases, defining a
third or ‘Median angle’ group, but the exercise does little more than demonstrate the
wide spectrum of abnormality. The differing effect of clockwise and counterclockwise
rotation on ALFH is important and predictable on photocephalometric planning.
 VERTICAL DIMENSION IN ORTHOGNATHIC 245
(a) LOW Angle Cases. It is always important to assess whether maxillary vertical
height is deficient with overclosure of the mandible in these cases - one type of short
face syndrome. Clockwise rotation may leave an open bite laterally. In the writer’s
experience it is not always true that this closes by the eruption of the cheek teeth as
stated by some authorities; on the contrary this rarely occurs in the over twenties, and
is prevented in the presence of premolar crowding. This can pose difficult occlusal
problems and anterior mandibuloplasty with depression of the lower anteriors and
increase in anterior mandibular height (ALDH) by bone graft or proplast implant to
compensate would be more logical in addition to mandibular advancement. The com-
combination is rarely necessary provided longitudinal orthodontic/surgical planning

FIG. 7. Case 3. High angle Class 2 Div. 1 case treated by mandibular advancement (FSS) with forward
sliding genioplasty. (a) (top left) and (b) (top right) Profile pre-op and 3/12 post-op; (c) (bottom left)
and (d) (bottom right) Full face pre- and 3/12 post-op.
246 BRITISH JOURNAL OF ORAL SURGERY

Fig. 7(e). Case 3. Tracing.

and treatment is carried out. Case 1 illustrates the problem well (Fig. 4). The increase
in ALFH obtained by clockwise rotation, whilst significant, is inadequate to restore
the FPI to 10. In this patient the pre-operative FPI was -6.5 and the post-operative
figure was 0. In other words there remains a 10 per cent disproportion between AUFH
and ALFH, something a little less than 10 mm of deficiency in this girl. Low angle
cases are stable, and this patient has shown no relapse five years post-operatively.
How can the extra 10 mm of lower facial height be added? Either a subapical bone
graft or proplast insert (Fig. 5) is simple and effective following a standard sliding
genioplasty bone cut and depression of the anterior lower border. This has been per-
formed with proplast on seven occasions all stable from one to six years in follow-up.

FIG. 8. Vertical reduction genioplasty by sub-apical wedge resection. (a) (left) Wedge outlined,
(b) (right) Wedge excised and lower border repositioned.
 VERTICAL DIMENSION IN ORTHOGNATHIC 247

FIG. 9. Short Face Syndrome. (a) (top left) Full face, (b) (top right) Occlusion, (c) (bottom left) Profile -
rest position, (d) (bottom right) Profile - in occlusion.

Case 2 (Fig. 6) shows a similar case to the first but treated additionally with vertical
subapical augmentation by proplast implant and the improved vertical balance is
clearly seen.
(b) High Angle Cases. These force a compromise onto the surgeon. Typically the
ramus height and posterior facial height is short, but to lengthen it would stretch the
pterygomasseteric soft tissues and induce relapse. Anterior upper facial height is often
a little increased and logically should be reduced with concomitant alteration in the
gonial angle of the mandible, involving complex bimaxillary surgery rarely justified by
the case. The price is paid in producing a balanced but overlong face in relation to its
width, which looks better in profile than in the full face view. Counterclockwise rotation
fortunately does not increase the ALFH but the patient usually requires a genioplasty
to correct labiomental contour. Case 3 (Fig. 7) illustrates the problem, having a
248 BRITISH JOURNAL OF ORAL SURGERY

SHORT FACE SYNDROME A.S. PREOP

FPI = 5.7

SN:MP 26’

Fig. 9(e). Short Face Syndrome. Tracing of Case.

slightly increased AUFH, high SN : MP angle, short posterior facial height, and
reduced lower facial height. Mandibular advancement (FSS) combined with forward
sliding genioplasty produces a pleasing profile but a long narrow look to the lower
face in full face view. If the latter is unacceptable the patient must be persuaded to
undergo bimaxillary correction, which will be stable but is rarely justified for this
group.

Vertical mandibular excess

Although excessive length in the ramus occurs bilaterally, it is more commonly a
problem in asymmetries and will not be discussed here. Increased subapical bone in
the anterior mandible is a very common problem, sometimes associated with over
eruption of the lower incisors in high angle cases with or without anterior open bite.
Whilst this can be reduced by simply removing bone from the lower border, a much
better chin contour is assured if the more time-consuming technique of removing a
sub-apical wedge of bone is employed (Fig. 8). The lower border is then brought up
(and if indicated can also be brought forward) and wired into place. The procedure
can be combined with lower labial segmental procedures (anterior mandibuloplasty)
and will be discussed in depth in the second paper.

Vertical maxillary deficiency

Bell and co-workers in Dallas have done much to define the characteristics of the
so-called Short Face Sydrome (Bell, 1977; Opdebeeck & Bell, 1978). Clinically there
is a square, broad face, with reduced anterior lower facial height and a low SN : MP
angle. The nose is broad, with increased alar flare, the nasolabial angle is decreased,
the lips are narrow and the mouth broad, with a deep over bite (Fig. 9). Several
 VERTICAL DIMENSION IN ORTHOGNATHIC 249
features described by Bell are not consistent in the cases described here, reflecting more
the degree of antero-posterior malrelation between the jaws (for example, maxillary
hypoplasia antero-posteriorly). The outstanding feature is the inability of the patient
to show the teeth during smiling, as they are hidden behind the upper lip. There is
always an increased freeway space. In occlusion therefore the mandible is overclosed
and appears more protrusive and the chin more prominent than in fact is the case. In
the relaxed position the patient may appear relatively well proportioned in profile.
Cephalometrically the reduced ALFH may not be associated with a reduced SN : MP
angle in one group of cases (Opdebeeck & Bell, 1978). These writers found that the
ramus height is more significant in determining lower facial height than is the SN : MP
angle, and they distinguish two groups. In the first the FPI is a little less than 10, the
ramus height is markedly increased and the SN : MP angle very low (one form of ‘low
angle case’). Posterior dental height is increased or normal. In the second group the
FPI is very reduced, the ramus is short, the SN : MP angle is normal or a little
reduced, but there is marked reduction in posterior dental height. In my experience
the distinction between ‘Long ramus’ and ‘Short ramus’ cases is valid, but the maxil-
lary features are very variable. In the presence of inadequate incisor display and an
increased freeway space, maxillary elongation is the correct treatment.
The technique of maxillary lengthening has been described by several authors. A
horseshoe incision is made around the maxillary vestibule and the tissues are reflected
from the maxilla to display the vertical deficiency (Fig. lOa). The maxilla is down-
fractured, no special precautions being necessary in the management of the nasal
septum, but the nasal floor mucosa is carefully preserved to provide additional protec-

FIG. 10. Mid-facial lengthening,(a) (top left) Short maxilla exposed, (b) (top right) Subcrestaliliac
bone graft, (c) (bottom left>Lateral maxillary interpositional full thicknessiliac graft, (d) (bottom
right) Supra-apicalbone graft betweenpremaxillaand nasal floor.
250 BRITISH JOURNAL OF ORAL SURGERY

FIG. 11. Case 4. Short face syndrome treated by maxillary lengthening and advancement, Le Fort 1
level. (a) (top left) and (b) (top right) Full face views in occlusion, pre-op and 3/12 post-op; (c)
(bottom left) and (d) (bottom right) Pre-op and post-op incisor display.

tion for the bone graft at its most vulnerable site. A large full thickness subcrestal bone
graft is cut with a bur (Fig. lob), and sectioned into strips for lateral interpositional
grafts, together with a contoured piece to restore height below the nasal floor and to
reconstruct the anterior nasal spine and nasal sill, after extraskeletal craniomaxillary
fixation of the displaced maxilla (Figs. 1Oc & d).
Case 4 (Fig. 11) shows the results. The maxilla has been brought down into the large
freeway space area, increasing AUFH by 9 mm. The teeth can now be seen during
smiling, whereas it was necessary to raise the lip to see them preoperatively.

Vertical maxillary excess

Consideration of vertical problems in the maxilla brings the long face syndrome and
its variants into focus, and with it the solution to the problems of the more severe
 VERTICAL DIMENSION IN ORTHOGNATHIC 2.51

Fig. 11(e).Case 4. Tracing.

anterior open bite cases. The story started with Schuchardt’s two-stage posterior
maxillary ostectomy (Schuchardt, 1959) for raising the posterior maxillary alveolar
segments. This operation fell into disrepute in this country in recent years because of
the high incidence of relapse. West and Epker (1972) and others have shown that
proper case selection and modern operative techniques allow posterior maxillary
ostectomies (either alone or in combination with anterior maxillary ostectomies) to be
performed with longterm stability. Subsequently total maxillary shortening has been
extensively described (Schendel et al., 1976a; Schendel et al., 1976b; Bell et al., 1977;
Bell & McBride, 1977).
The so-called ‘long face syndrome’ is characterised by increased ALFH with or
without anterior open bite (Fig. 12). The alar flare is narrowed and the naso-labial area
recessed. There is excessive incisor display on smiling, with a generally elongated and
narrowed lower third of the face. The width of the oral commissure is reduced with
thin vermillion exposure. The nasolabial recession is more marked in profile, the chin
may be retropositioned or, if relatively prognathic, the labiomental curve will be flat-
tened and displeasing, as in the case illustrated. Cephalometrically there is an increased
SN : MP angle, normal or reduced SNA (more commonly reduced in my cases), and
similar variability in the SNB. This contrasts with Bell’s figures and may indicate that
he is describing a particular sub-group of the syndrome whilst we regard the pattern
as common to a wider range of deformities. The common factor is vertical maxillary
excess, mainly in the posterior maxilla, with increased ALFH. There is increased
ramus height if there is no anterior open bite. Anterior dentoalveolar height is always
increased. Schendel(l976) regards the condition as one of increased maxillary height
with greater ramus growth in those cases showing no anterior open bite, but with
19/4-B
252 BRITISH JOURNAL OF ORAL SURGERY

normal ramus height in those developing AOB. In both instances correction is limited
by the requirement that ramus height cannot be increased surgically without the
danger of unstable pterygomasseteric tension.
Correction of vertical excess in the maxilla is technically simple (Fig. 13). A planned
section is removed from the lateral maxillary wall, giving easy access during down-
fracture to the medial and posterior walls of the antrum. A section of the nasal septum
is removed, including a vertical triangle of bone in the anterior septum to prevent undue
prominence of the nasal tip. During downfracture the palate may be narrowed or
slightly widened by appropriate cuts in the palate from the superior surface, and
differential movement of the anterior and posterior segments may also be combined
from the superior access. If the inferior turbinate bones obstruct superior movement
they can be cut short with scissors, either through the vestibule of the nose or by open-
ing the nasal floor to give direct access. The latter is preferable if the obstruction is
more posterior. This is an important part of the surgery as there is a danger of reducing
the nasal airway unacceptably without it. The superior aspect of the palate may be
grooved to locate the nasal septum after upward displacement has taken place. Fixa-
tion is by internal skeletal suspension without bone grafting (unless there has been
much forward movement of the maxilla at the same time). Sometimes the maxilla

FIG. 12. Long Face Syndrome. (a) (top left) Full Face, (b) (top right) Profile, (c) (bottom) Occlusion.
 VERTICAL DIMENSION IN QRTHOGNATHIC 253

LONG FACE SYNDROME

FPI = 22.5

A.R. PREOP

Fig. 12(d).Long Face Syndrome.Tracing of Case.

requires upward positioning posteriorly and downward movement anteriorly to estab-

lish good lip to upper incisor balance. Hedemark and Freihofer, (1978) have shown
that this may be unstable, but in my experience extraskeletal fixation, plus a nine-week
period of fixation will maintain the height gained less one fifth in the anterior region.
Over-correction by one fifth is therefore recommended, with extraskeletal fixation for
the whole of the nine-week period.
Case 5 (Fig. 14) illustrates the changes obtained with vertical maxillary shortening
combined with forward movement of the mandible by bilateral sagittal splitting and an
augmentation genioplasty. Note the increased alar width.
When dealing with vertical correction of the maxillary plane in asymmetries the

FIG. 13. Mid-facial shortening. (a) Planned segment of maxilla removed; (b) Maxilla superiorly
repositioned.
254 BRITISH JOURNAL OF ORAL SURGERY

work of Brami et al. (1974) is followed. They advise distributing the correction
between the short side of the maxilla (lengthening from a high trans-zygomatic osteo-
tomy) and the normal side (shortening to reduce the stretch in the short side soft
tissues). This seems to be more stable than pure lengthening of one side by rotation
downwards from the opposite molar region.

Bimaxillary correction
As the cases shown have already illustrated the correction of vertical dysplasias
frequently requires bimaxillary surgery. This in itself probably helps to stabilise the

FIG. 14. Case 5. Long face syndrome treated by shortening maxilla at Le Fort 1 level. (a) (top left) and
(b) (top right) Profile pre-op and 3/12 post-op; (c) (bottom left) and (d) (bottom right) Full face
pre- and post-op.
 VERTICAL DIMENSION IN ORTHOGNATHIC 255

FIG. 15. Long face syndrome treated by maxillary repositioning, shortened posteriorly and lengthened
anteriorly, with mandibular set-back (BSS) and forward sliding genioplasty. (a) (top left) and (b) top
right) Profile pre-op and 3/12 post-op,(c) (centre left) and (d) (centre right) Full face (pre-and post-op),
(e) (bottom left) and (f) (bottom right) occlusion.
256 BRITISH JOURNAL OF ORAL SURGERY

-\ I

i
I
I
I
\
\

P.T PREOP ________

3112 POSTOP ------ ---
Fig. 15(g). Tracing of Long Face Syndrome Case.

results by the distribution of tissue stresses over a wide and balancing area. My exper-
ience has been that the stability of associated anteroposterior movements, particularly
advancement of the maxilla is less than seen in routine Le Fort I advancements and
this is more true with increasing vertical maxillary height than vice versa. Case 6 (Fig.
15) shows a typical severe anterior upen bite case treated by vertical rotation of the
maxilla, bilateral sagittal split to set back the mandible, and genioplasty (see the
 VERTICAL DIMENSION IN ORTHOGNATHIC 257
cephalometric tracing). This approach is a considerable advance on the former in-
adequate and unstable results of mandibular surgery based on a false view of the site
of primary abnormality.
Several questions remain to be satisfactorily answered. Why is interference with the
freeway space stable? Is prolonged fixation, preferably extraskeletal, the answer to
relapse reported from some centres? Why should tilting movements be less stable than
even vertical displacements? Will there ever be an answer to the short ramus/high
angle combination allowing stable reconstruction of the ramal deficiency?

Acknowledgements
I am indebted to the photographic departments of the Royal Dental Hospital, London, and St.
Thomas’ Hospital, London, for the photographic illustrations; and to the several Registrars and
House Surgeons involved in the cases shown. The extensive occlusal rehabilitation and other con-
servative work involved in Case 2 was planned and undertaken by Professor E. Levinson of London.
Finally I am grateful to the many orthodontic colleagues at the Royal Dental Hospital for their
valued presurgical and postsurgical collaboration.

References
Bell, W. H. (1977). Correction of the short face syndrome - vertical maxillary deficiency: a prelimi-
nary report. Journal of Oral Surgery, 35, 110.
Bell, W. H., McBride, K. L. (1977). Correction of the long face syndrome by Le Fort 1 osteotomy.
Oral Surgery, Oral Medicine, Oral Pathology, 44,493.
Bell, W. H., Creekmore, T. D., & Alexander, R. G. (1977). Surgical correction of the long face
syndrome. American Journal of Orthodontics, 71, 40.
Brami, S., Lamarche, J. P. & Souyris, F. (1974). Treatment of facial asymmetries by one-stage
maxillary and mandibular bilateral osteotomies. International Journal of Oral Surgery, 3, 239.
Broadbent, B. H. Sr., Broadbent, B. H. Jr. & Golden, W. H. (1976). Bolton Standards of dentofacial
developmental growth’. C. V. Mosby Company, St. Louis.
Epker, B. N., Fish, L. C. & Paulus, P. J. (1978). The surgical-orthodontic correction of maxillary
deficiency. Oral surgery, Oral Medicine, Oral Pathology, 46, 171.
Hedemark, A. & Freihofer, H. P. (1978). The behaviour of the maxilla in vertical movements after
Le Fort 1 osteotomy. Journal of Maxillofacial Surgery, 6, 244.
McIntosh, R. B. (1970). Orthodontic surgery: comments on diagnostic modalities. Journal of Oral
Surgery, 28, 249.
Opdebeeck, H., & Bell, W. H. (1978). The short face syndrome. American Journal of Orthodontics,
73, 499.
Schendel, S. A., Eisenfeld, J., Bell, W. H., Epker, B. N. & Mishelevich, D. J. (1976a). The long face
syndrome: vertical maxillary excess. American Journal of Orthodontics, 70, 398.
Schendel. S. A.. Eisenfeld. J.. Bell. W. H. & Enker. B. N. (19766). Suuerior reoositioning of the
maxilla: stability and ioff tissue relations. kmerhan Jourial of ‘Orthodontics, $0, 663. -
Schuchardt, K. (1959). ‘Experiences with the surgical treatment of deformities of the jaws; prognathia,
micrognathia, and open bite.’ Chapter in Wallace, A. B. (Editor). International Society of Plastic
Surgeons, 2nd Congress. London, E. & S. Livingstone.
West, R. A. & Epker, B. N. (1972). Posterior maxillary surgery: its place in the treatment of dento-
facial deformities. Journal of Oral Surgery, 30, 562.
Wolford, L. M., Walker, G., Schendel, S. A., Fish, L. C. & Epker B. N. (1978). Mandibular deficiency
syndrome. 1. Clinical delineation and therapeutic significance. Oral Surgery, Oral Medicine, &
Oral Pathology, 45, 329.