Long face syndrome

DEPARTMENT OF
ORTHODONTICS
AND
DENTO FACIALwww.indiandentalacademy.com

LONG FACE SYNDROME
www.indiandentalacademy.com

‘A person is always remembered by his face and deeds’. The human face is
the area of our interest. The human face has been the subject of study since
man could first express himself. Beautiful faces are always eye catching. The
terms beauty, attractiveness and harmony are all included under the umbrella
of esthetics
The law of the equal tripartite, which applies to the entire face, is usually
considered first. This guideline requires that the distance from the point
trichion to the point glabella, the point glabella to the point subnasal, and
the point subnasal to the point menton all be equivalent.

Vertical skeletal dysplasia can either be due to increase in vertical
dimension or a decrease in vertical dimension.
The “Long face syndrome” includes multiple anomalies like open bite,
hyperdivergent face, maxillary alveolar hyperplasia, maxillary vertical
excess, anterior vertical excess of the lower face level, high angle facial
type.

Schudy FF (1964) studied that the vertical dimension is the most important
dimension to the clinical orthodontist, and that vertical dysplasias are inseparably
related to both open and closed bites. It was shown that vertical dysplasias are due
to inharmonious vertical growth, that many of these inharmonies are reflected in the
SN-MP angle. These dysplasias have a direct bearing on treatment procedures and
that they can be pinpointed and measured in millimeters. Morphological types of
human face should be based on the angle of facial divergence.
Lundstorm A, Woodside DG (1981) based their study on the Burlington and Ann
Arbor longitudinal samples, compared selected dentofacial characteristics in cases
with predominantly vertical and horizontal growth directions at the chin, the
investigation tested a number of hypotheses on possible relationship between the
chin growth direction and the dentofacial variations studied. It was found that
cases with vertical and horizontal growth differed in several respects, the former
showing greater facial height, a more retrognathic chin, a steeper mandibular
plane, a larger gonial angle and less skull base flexure than the latter.www.indiandentalacademy.com

DEVELOPMENT OF VERTICAL SKELETAL DYSPLASIA
NATURE V/S NURTURE
Essentially all aspects of normal and abnormal development are in
some way a result of the interaction of genetic and environmental
factors; thus there is no compelling reason to label a trait or condition
as either genetic or environmental.
Most of the anomalies have a multi factorial basis of existence, there
fore the effects of both the nature and nurture should be considered.

Characteristics Forward Rotator Backward Rotator
Inclination of the condylar head Curves forward and back Straight or slopes up
Curvature of the mandibular canal Curved Straight
Shape of the mandibular lower border Curved downward Notched
Inclination of the symphysis (Anterior
aspect just below “B” point)
Slopes backward Slopes forward
Interincisal angle Vertical or obtuse Acute
Interpremolar or intermolar angles Vertical or obtuse Acute
Anterior lower face height Short Tall
Bjork in 1969, in his implant studies showed the 7 structural signs of mandibular
growth

Clinical
- Dolichofacial face
- Increased lower anterior face height and
decreased posterior face height
- Gummy smile
- Incompetent lips
- Anterior open bites
- Weak musculature
Sassouni’s Analysis
Diagnosis of Long Face Syndrome:

• High mandibular plane angle & hyperdivergent jaws
• Short ramal length
• Increased symphyseal height
• Antigonial notching
• Hypsomaxilla
• Hypsogenia
• Downward backward rotated mandible
• Extruded Molars
CEPHLOMETRIC FINDINGS:

It has been noted that vertical dimension affects the sagittal
relation between the maxilla and the mandible.
Eg: A Class III vertical grower will be rotated to Class I and like
wise a Class I vertical grower will be rotated to Class II
Therefore these compensations should be taken into consideration
while planning the treatment for the patient
Effect of Vertical component on Sagittal relation:

TREATMENT OF LONG FACE SYNDROME
Treatment can be divided into :
• Early treatment which includes growth modification like
head gears, chin cups, bite blocks, vertical holding apliance,
TPA etc.
• Late treatment which includes mechanotherapy and surgical
treatment. Surgical treatment usually done in adults.

SKELETAL FACTORS IN THE DEVELOPMENT OF AN OPEN
BITE TYPE :
The combination of :-
excessive development of the
upper mid-face heights (cranial
base to molars)
a lack of development of
posterior facial heights (S-Go)
results in the downward and
backward rotation of the
mandible.

The posterior half of the
palate is tipped downward,
carrying the molars further
downward. This gives rise
to a large palatomandibular
plane angle.

Because of the short ramus and the lower palate, the
pharyngeal space is constricted. In order to breathe,
these persons keep their tongues forward. Further
enhanced by the dental open-bite, there is a tongue-
thrusting tendencies.

When enlarged tonsils are
present, the tongue is further
confined anteriorly. As the
narrow palatal vault reduces
the necessary space, there is a
tendency towards tongue
protrusion. This, in turn, may
be a factor in the creation of
bi-dental protrusion

In vertical growth pattern
the dentoalveolar symptoms
include a protrusion in the
upper anterior teeth with
lingual inclination of the
lower incisors.

Extractions
Wedge Principle Coupled With The Extraction Of Teeth
Two major approaches of applying the wedge principle by extraction of
teeth to control the vertical dimensions.
1. Loss of posterior anchorage so that the anchor teeth move
mesially and are located farther anteriorly in the arch in an
area of greater vertical dimension.
2. Extraction of first or second molars in both arches to decrease
the posterior dentoalveolar height.
 Pearson stated that after the extraction of premolar teeth, there is some mesial drift of the
posterior teeth (out of the wedge) and this permits the mandible to hinge closed.
 Yamaguchi and Nanda concluded that the changes in horizontal and vertical position of the
molars were dependent on the type of force application and not on the extraction or non-
extraction strategy
 Recent studies have shown and the evidence has proven that extraction does not help in
reducing the mandibular plane angle

High pull headgear
Centre of resistance of
dentition
Centre of resistance of
Maxilla
Direction of force passing through
the resistance of the maxilla

Vertical Pull Chin cup
Four possible mechanisms of (action at work)
a) maxillary sutures are pressure sensitive and some intrusion of the maxilla could
occur.
b) The posterior teeth tend to move forward mesially.
c) A slight change in the shape of the condylar neck, with many tending to be curved
more forward than previously.
d) A retardation of eruption of the posterior teeth.www.indiandentalacademy.com

MANDIBULAR BITE BLOCK THERAPY WITH
VERTICAL PULL CHIN CUP THERAPY
Similar effect to vertical pull chin cup, it brings about intrusion of posteriors

MAGNETIC BITE BLOCKS
Although we get rapid results, two difficulties arise with bite blocks:-
Extreme mouth opening and patience to tolerate the appliance.
Lateral movement of the mandible, that can cause some
temporomandibualr joint strain.

SURGICAL MODIFICATION OF LONG FACE PROBLEMS
When the severity of vertical deformity is so great that reasonable correction
cannot be obtained by growth modification or camouflage, the combination of
orthodontic And orthognathic surgery may provide the only viable treatment option.
Careful planning involving both the orthodontist and the oral maxillofacial Surgeon
now provide patients with an option that result in both desirable esthetics and occlusion.
 One method of surgical correction is to extract second and/or third molars if they are the
only source of centric contacts.
 Glossectomies have been used to correct open bite problems associated with abnormal
tongue habits. Their effectiveness in closing anterior or posterior open bite problems has
not been substantiated.

IMPACTION
The most common indication for maxillary surgery is vertical
skeletal dysplasia
The maxilla can be moved upwards by 10 – 15 mm with
excellent stability

Clinical presentation:-
Increased lip to tooth relation
Increased gingival display
Increased inter labial gap relation
Relative mandibular deficiency
Anterior open bite (may be compensated
by hyper eruption of teeth)
COGS analysis indications include:-
Increased upper and lower facial height (N-ANS & ANS-Gn)
Increased mandibular plane angle (MP-HP)
Increased posterior facial height (N-PNS )
Increased gonial angle (Ar-Go-Gn)
Increased facial height ratio (N-ANS/ANS-Gn)
Divergent occlusal planes

Biomechanical factors
Minimize orthodontic extrusion –occurs rapidly with mechanics such
as the placement of low modulus continuous archwires
Segmented arch mechanics are an excellent way to predictably control
the point of force application and the magnitude of force applied
When divergent occ. planes exist the treatment occ. plane must be
selected first , then appropriate force system designed .(typically
a functional occlusal plane is drawn)

CONCLUSION
Diagnosis of the long face syndrome is a complex problem.
The orthodontic clinician must make a careful differential
diagnosis for each patient who seeks his or her care. The
diagnosis must analyze all three components of
malocclusion- facial, dental and skeletal. Each component
must be carefully studied and understood so that the proper
questions are asked and the correct diagnostic decisions are
made to lead to an effective treatment plan.
Though it must be remembered that the treatment of long
face syndrome will always remain a challenge for the
orthodontist.

Long face syndrome

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