Bruce N. Epker

The long face syndrome: Vertical maxillary excess☆

There is a clinically recognizable facial morphology, the long face syndrome, which has been incompletely described in the literature. On the basis of the clinical summary in thirty-one adults with this syndrome, an analysis of esthetics, skeletal morphology, and occlusion was undertaken. Herein we report on these findings, which confirm that this basic dentofacial deformity is associated with excessive vertical growth of the maxilla. Dental open and closed bite are two variants of the syndrome. An increased mandibular ramus height is associated with the closed-bite group.

Surgical-orthodontic expansion of the maxilla

Selected maxillary osteotomies are safe and dependable adjuncts to treatment of bilateral and unilateral maxillary deficiency. Maxillary expansion in fifteen adults was accomplished by separating the maxillary basal bone from the nasal, zygomaticomaxillary, and pterygomaxillary buttresses.

Surgical-orthodontic correction of open-bite deformity

The combined simultaneous anterior and posterior maxillary ostectomy has proved to be a useful method of treating skeletal open-bite. It is indicated primarily in patients with lip incompetence, excessive exposure of maxillary anterior teeth, long lower-face height, contour-deficient chin, and Class II malocclusion. Primary contraindications are the Class III skeletal open-bite and lip competence. We have used the procedure as routine treatment for many open-bites over the past 5 years since we first described it. Clinically, the results have been most gratifying, with marked improvement in facial appearance and stability of the open-bite correction. A preliminary study of stability following this procedure indicated good stability with regard to the vertical repositioning of the maxillary segments. A recently completed study by us on thirty-two patients treated with this procedure and followed for an average of 1.5 years showed excellent stability. This is by no means the only method by which open-bite may be successfully treated, but it is one more method to add to our armamentarium. The surgical procedure must be carefully planned and executed to attain the best possible results. Furthermore, the orthodontic procedures, particularly those involving vertical forces, must be provided at the proper time so that the surgical results are not compromised. Nevertheless, with proper planning, attention to detail, and meticulous execution, the results are rewarding.

Superior repositioning of the maxilla: Stability and soft tissue osseous relations

The skeletal stability and soft-tissue changes associated with superior repositioning of the maxilla by Le Fort I osteotomy or simultaneous anterior and posterior maxillary osteotomies was studied in thirty patients by means of a computerized craniofacial model. Excellent skeletal stability was demonstrated 14 months postoperatively. Postsurgically, the reduction in lower face height and amount of maxillary incisor exposure resulted in improved facial balance. The use of a computerized osseous and soft-tissue craniofacial model has added a new dimension to evaluation of surgical changes associated with correction of dentofacial and craniofacial deformities.

Mechanisms of early skeletal relapse following surgical advancement of the mandible

Despite recent innovative technical and biological advances, surgical advancement of the mandible does not demonstrate uniform skeletal stability. In fact, the results of recent investigations have shown that considerable skeletal relapse occurs quite early in the post-surgical period. This article reviews current literature to implicate the factors primarily responsible for early skeletal relapse following surgical advancement of the mandible via the modified sagittal split ramus osteotomy. Three specific mechanisms which commonly predispose this orthognathic procedure to skeletal relapse are delineated. Prolonged skeletal stabilisation with control of the proximal segment of the mandible is advocated to insure predictably stable results.

Vascular considerations in orthognathic surgery. I: Mandibular osteotomies

Numerous studies have been conducted on the vasculature of the mandible and the effects of its surgical alteration. These illustrations have improved our knowledge considerably. However, much additional information regarding the effects of orthognathic surgery upon the vasculature of the mandible is essential before various mandibular surgical procedures can be casually and categorically stated to be biologically sound. In this article several germane issues regarding vascular considerations in mandibular orthognathic surgery are discussed: (1) What are the shortcomings of published studies addressing the effects of orthognathic surgery on the vascular supply to the mandible and/or the maxilla? (2) What are the potential sequelae of vascular compromise? (3) What is the vascular supply to the mandible? (4) What recommendations are there for minimizing vascular compromise in mandibular orthognathic surgery? In Part II of the study these issues will be discussed as they relate to maxillary orthognathic surgery.

Predictability of upper lip soft tissue changes with maxillary advancement

To improve predictability of the esthetic (soft tissue) results after maxillary advancement surgery, a better understanding of the relationships between the dental osseous movement and overlying soft tissue response is essential. Twenty-one adult patients who underwent isolated maxillary advancement via LeFort I osteotomies without adjunctive nasal soft tissue procedures and/or V-Y closure of the vestibular incision were studied. Homogeneity of the patient population was ensured by selecting cases with less than 2 mm vertical change. The mean maxillary advancement and mean change in Sn was calculated for these 21 patients. Additionally, the 21 patients were subdivided into two groups based on lip thickness: group 1 (lips between 10 and 17 mm thick) and group 2 (greater than 17 mm thick). In each patient group a linear regression (LR) was determined on the magnitude of maxillary advancement (MMA) to the change in soft tissue subnasale (Sn) and on the ratio of Sn change to bone move. The results using mean data showed that the relationships produce significantly high standard deviations; thus, a general correlation between change in soft tissue position to bony advancement cannot be made. Individuals with thin lips (12 to 17 mm) had a good correlation between the magnitude of bony move and amount of soft tissue change. However, increased lip thickness (greater than 17 mm) produced a less predictable correlation between soft and hard tissue changes. All lips thinned around 2 mm when compared with preoperative values. Lip thickness stabilized at approximately 6 months postoperatively.

Clinical neurosensory testing: Practical applications

A relatively large percentage of the practicing oral and maxillofacial surgeons patients experience some degree of neurosensory impairment as a normal concomitant of major surgery. Additionally, some patients develop neurosensory disturbances unexpectedly following routine surgical procedures. This report describes a practical approach to evaluating these individuals, which is essential in making intelligent decisions regarding the objective nature of the nerve injury, potential for recovery, and/or possible need for secondary microneurosurgical intervention.

The alar base cinch: A technique for prevention of alar base flaring secondary to maxillary surgery

The changes in external nasal morphology or nasal esthetics which accompany total maxillary surgery are often favorable. However, select patients who would otherwise benefit optimally from total maxillary surgery experience worsening of nasal esthetics secondary to the surgery. In our experience, this is primarily due to widening of the alar bases. The purpose of the present article is to identify those persons who will undergo undesirable nasal esthetic changes with total maxillary surgery and recommend a method of avoiding these changes.

Velopharyngeal anatomy and maxillary advancement

This study was undertaken to evaluate the radiographic changes in the static velopharyngeal mechanism following total maxillary advancement. Records of 21 patients treated for maxillary retrusion were evaluated. Two groups were present: 13 non-cleft patients and 8 cleft-lip patients. The findings demonstrate an anatomical change in the velopharyngeal mechanism following total maxillary advancement. A similar change occurred in both groups; however, the magnitude is differed. The angle of the soft palate to hard palate increased with surgery (2 degrees per mm. advancement noncleft and 1 degree per mm. cleft). An increase in soft palate length was also seen (.5mm. per mm. advancement non-cleft and .4 mm. per mm. cleft). A pharyngeal need ratio prediction method was established (pharyngeal depth/soft palate length). A ratio of .68--.84 in this study was observed. A ratio greater than one was found to indicate probable velopharyngeal incompetence.