CHAPTER 17
Vertical Maxillary Deformities
Stephen A. Schendel
Vertical maxillary deformities were rarely recognized
or treated before the early 1970's. Their recognition is
based on changing aesthetic mores and increasing so-
phistication of cephalometric analyses. Classical cepha-
lometric analyses paid little attention to vertical facial
changes. During the 1940's and 1950's, surgeons concen-
trated on mandibular deformities and, thus, most proce-
dures were performed on the mandible even when the
basic deformity was found in the maxilla. This was par-
tially due to the difficulties inherent in maxillary sur-
gery such as vascularization and subsequent difficulty
in mobilizing the maxilla. Until the advent of more
sophisticated anesthetic techniques, antibiotics, and the
biologic studies of Bell, complete maxillary surgery was
uncommon and fraught with relapse. Hogeman was
one of the first to correct the vertical maxillary deformi-
ties, but it was not until the work of Bell, Epker, and
Schendel that the techniques were popularized.
Vertical Maxillary Excess: Long
Face Syndrome
Vertical maxillary excess, or long face syndrome, was
first recognized as such by Schendel and coworkers in
1976. Surgical correction of this deformity was based on
a vertical impaction of the maxilla. Stability of this pro-
cedure, long thought to be prone to relapse, was demon-
strated first in 1976 and was subsequently confirmed by
numerous other studies. Skeletal open bite mayor may
not be a component of the long face syndrome and is
one of its variants. This is due to a disproportion of the
vertical excess, more vertical growth occurring in the
posterior aspect of the maxilla versus the anterior, and
an associated shortness of the ramus of the mandible.
284
J. W. Ferraro (ed.), Fundamentals of Maxillofacial Surgery
© Springer-Verlag New York, Inc. 1997
Physical Findings
• Long vertical facial height, especially noted in the
lower third
• Frequently narrow constricted alar bases
• Lip incompetence with an excessive interlabial gap
• Excessive gingival and upper incisor show at rest and
during smiling
• Frequently an obtuse nasolabial angle >3110 degrees
• Retruded and vertically long chin
• Retrognathic mandible secondary to backward auto-
rotation or to a true retrognathism
Cephalometric anaylsis
• Increased lower anterior facial height
• Smaller than normal SNA and SNB angles
• Larger than normal ANB angle (>3 degrees)
• Maxillary incisor show of >3 mm
• A steep mandibul!lr plane angle
• Open antegonial angle
• Increased distance from the palatal plane to the oc-
clusal surface
• Increased axial incisor angulation to the palatal plane
>110 degrees
• A skeletal open bite may be present
• Retruded chin
• Usually decreased cranial base angle (basion-sella-
nasion)
• Occlusion: Class II, occasionally Class I
• Frequent anterior open bite
• Constricted transverse maxillary arch, resulting in
cross-bite
• Flat or accentuated Curve of Spee
• Frequent dental crowding
17. Vertical Maxillary Deformities
Outline of Treatment
Presurgical Orthodontics
• Determine extraction versus non-extraction
• Orthodontic treatment
• Evaluate the amount of transverse maxillary deficien-
cy; whether this can be corrected orthodontically or
by multiple segmental mandibular osteotomies or by
a separate transverse maxillary orthopedic expansion
associated with surgical assistance
• Level and align the arches
• Eliminate dental compensation by aligning the teeth
axially in their correct plane of alveolar bone
• No attempt to close any open bite should be done
orthodontically
Surgical Orthodontic Assessment
• Assess facial aesthetics
• Definitive cephalometric prediction tracing
• Model surgery on a semiadjustible anatomic articula-
tor with face bone transfer
• Splint construction
Surgical Plan
1. Maxillary Le Fort I osteotomy
• ± multiple segments to correct any transverse or
vertical problems
• usual maxillary osteotomy is an impaction
2. Genioplasty
• ± horizontal advancement
• ± vertical reduction
3. Mandibular osteotomy
• If auto-rotation alone is inadequate to correct the
Class II malocclusion without significant posterior
maxillary repositioning, the mandible should be
advanced by bilateral sagittal split ramus osteo-
tomies. Also, if any facial asymmetry is present,
bimaxillary surgery will be required.
Vertical Maxillary Deficiency:
Short Face Syndrome
Vertical maxillary deficiency was originally described
by Hogeman but popularized after the article by Opde-
beeck and Bell in 1978. Subsequent papers concerned
the surgical correction of this condition by lengthening
the maxilla vertically using interpositional graft materi-
al. Early reports were prone to high relapse with this
procedure, but with rigid fixation, stability has been
greatly improved.
Physical Findings
• Vertically decreased facial height
• Lack of maxillary incisor show with an edentulous
look
285
• Frequently flat upper lip that appears short
• Concave facial profile with acute nasolabial angle
<110 degrees
• Appearance of overclosure of the mandible with ex-
cessive projection of the chin
• Large gonial angles with appearance of large mass of
muscles
• Wide alar bases
Cephalometric Analysis
• Decreased lower anterior facial height
• Decreased vertical height of the chin with frequent
anterior projection
• A decreased distance from the occlusal plane to the
palatal plane, indicative of shortening of maxillary al-
veolar height
• Increased maxillary incisor to palatal plane angle, in-
dicative of proclined teeth
• Acute mandibular plane angle
• .A skeletal Type ill malocclusion
• Negative ANB angle
• A larger than normal to normal SNB angle
• Increased cranial base angle (basion-selia-nasion)
Occlusal Analysis
• Frequent deep bite
• Class II malocclusion to Class I
• Large transverse maxillary arch
• Frequently the mandibular teeth bite inside the max-
illary dentition
• Frequent crowding of the mandibular dentition
• Reverse Curve of Spee
Outline of Treatment
Presurgical Orthodontics
• Level and align the arches
• Assess the need for extractions versus non-extraction
treatment. More than likely with this malocclusion,
extractions are not needed.
• The mandibular Curve of Spee may be accentuated.
This needs to be leveled.
• The incisor should be placed over the alveolar bone
with the correct axial inclination.
Surgical Orthodontic Treatment
• Reassess facial aesthetics
• Definitive surgical prediction tracing
• Model surgery on articulated dental casts by
semiadjustable articulator
• Construction of occlusal splint
286
Surgical Plan
1. Maxillary Le Fort I
• Frequently in one segment as most maxillas are
sufficiently wide and level with this deformity
• Vertical lenthening is most frequently done with
an inteipositional graft to improve the lip-to-tooth
aesthetics
• Occasional horizontal advancement of the maxilla
to improve the profile and overjet relationship
2. Genioplasty
• Vertical lengthening with interpositional graft to
improve the lower facial height
• Occasional retrusion of the chin if insufficient
downward autorotation of the mandible has not
occurred
Mandibular Surgery
Occasional mandibular advancement can be concomi-
tantly done to improve overall facial projection, al-
though this is infrequent with this type of deformity.
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