Message Boards
Today's Active Topics Today's Active Cases Browse Forum Categories My Recent Activity My Messages Private Groups My Marked Threads My Subscriptions
Today's Active Images Today's Active Polls Most Active Topics Global Townie Map Advanced Message Board Search Message Board Terms of Use

‘Short-Face’ Patients—Part 2 by Dr. Chad Foster

View Comments (1) More by this author (47)
Orthotown Magazine 

Aesthetic implications and treatment strategies

by Dr. Chad Foster

Introduction
Following up on last month’s Part 1, this month I will present the first of three full-record “short-faced” cases. They are presented chronologically, and I hope they can provide some helpful concepts and mechanics regarding these types of cases.


Case presentation
This 13-year-old girl (Fig. 1) shows many of the negative aesthetic traits correlated with a short lower one-third facial height that I laid out in Part 1.
‘Short-Face’ Patients—Part 2
Fig. 1

Placing bite turbos (even before braces are placed) can immediately simulate how increasing the lower one-third facial height will impact facial aesthetics. When I initially placed temporary bite turbos on Lea to simulate an increase in vertical, I was struck by the changes that were imparted (Fig. 2). There was a decrease in chin prominence, the frontal facial form became longer and more ovoid and the smile window increased in height. After seeing what the vertical looked like when normalized, my aim was then to erupt the posterior teeth to set the occlusion to that new vertical goal that was simulated by the bite turbos.
‘Short-Face’ Patients—Part 2
Fig. 2

The desired eruption of posterior teeth to set the new vertical position in this case was wholly dependent on strategic positioning of bite turbos and excellent elastic compliance. Lea’s initial start day records are shown in Figure 3. Bondable hooks were placed on the lingual surface of all upper and lower first molars. Cross elastics were worn from U6s to L6s full time. One day the elastics were worn from the lingual of the U6s to the buccal of the L6s and the next day they were worn from the buccal of the U6s to the lingual of the L6s. It is extremely important that these types of eruptive posterior elastics have their buccal/lingual direction alternated regularly to avoid unfavorably altering the buccolingual inclination of the molars as they erupt. This allows for more pure vertical eruption.
‘Short-Face’ Patients—Part 2
Fig. 3

Bite turbos were placed on Lea’s U4s. I have found that this specific bite turbo position is a good one in cases where you are attempting to both permit molar extrusion and also tilt the occlusal plane with maxillary incisor extrusion and mandibular incisor intrusion via “SAP” bracket positioning (a la Tom Pitts). In this way, the force from the bite turbos is closer to the center of rotation of the occlusal plane that is attempting to be tipped. Once that bracket position has been leveled out (often after the rectangular NiTi stage), turbos can be more safely placed on U1s to allow for greater posterior eruption. In Lea’s case, that is what we did—at four months into treatment, the bite turbos were moved to the lingual of the U1s (Fig. 4). With good cooperation with the vertical molar elastics, by month eight the molars had erupted enough for them to begin contacting.
‘Short-Face’ Patients—Part 2
Fig. 4

In pursuit of extra-oral (facial) aesthetics, by attempting to change the vertical, I was presented with some intra-oral (occlusal) problems. The new vertical position was a result of the lower jaw rotating both down and back. This clockwise rotation helped the facial balance but instantly created a half step Class II occlusion. This was problematic on several fronts. First, a much greater amount of Class II elastics would now need to be relied upon in addition to the planned vertical elastics. This whole plan was going to depend on an extremely motivated and compliant patient, which is not always the best strategy. For my initial bite turbos on the U4s, I also gave them a Class II ramp shape (the ramps sloped down and back) so that they contacted the distal of the L4s but did not touch the L5s (Fig. 5). For those interested, check out my December 2022 column on Class II ramps. In this manner, occlusal forces on the U4s and L4s could be partially redirected in an AP direction (slight distal force U4s and slight mesial force L4s).
‘Short-Face’ Patients—Part 2
Fig. 5

A side effect of the reliance on Class II mechanics to fit the occlusion to the new vertical facial height was that it was very challenging to give proper torque to the upper incisors (which were already a bit deficient in positive labiolingual inclination pretreatment). In the end, the incisors finished still a bit under-torqued. Had I forced more positive torque into those teeth in finishing, however, this would have necessitated that the lower incisors be even further proclined to couple with the uppers. The lower incisors were already proclined because of the Class II elastics, so this further compromise was not deemed appropriate, given the thin lower anterior gingival phenotype.


Additional notes
There were other interesting findings during the 20 months of treatment. I initially chose a mild version of SAP bracket positioning in Lea’s case. Her pre-treatment smile arc and vertical incisor display were reasonably acceptable since her maxillary incisors were in a slightly over-erupted position relative to the occlusal plane (which was aesthetically favorable in her smile). As I previously mentioned, four months into treatment, I felt that the bracket height positions were sufficiently leveled with rectangular NiTi wires, so I moved the bite turbos to the lingual of the U1s to allow better eruption of all posterior teeth (molars and bicuspids). What I noticed at six months in was that despite what I thought was sufficient SAP bracket placement, her smile was now beginning to actually show a reverse smile arc from the bite turbos on the lingual of the U1s (Fig. 6). In response to this finding, I repositioned the upper incisors even further gingivally and the lower incisors more incisally to exaggerate the SAP effect (these new positions are shown in Figure 6). Fortunately, through good elastic wear on her part, I was able to remove the bite turbos on the U1s at 12 months into treatment and also performed archwire step-down bends to the anterior teeth in both arches to help recover smile arc and vertical incisor display.
‘Short-Face’ Patients—Part 2
Fig. 6

Results
The case finished in 20 months. (Figs. 7–10) The SN-GoGn had improved from 14 degrees to 20 degrees, and the FMA improved from 12 degrees to 18 degrees. There was better balance on profile with a subtle but noticeable decrease in chin prominence. On the frontal aspect, the increase in vertical dimension allowed for better facial taper when compared to her squarer facial form from pre-treatment. With less soft tissue compression, her smile window had increased to a more normal height. The mini-aesthetics (smile) show good arch width and ideal smile arc and vertical incisor display. Importantly, her deep bite was corrected, but not at the expense of the aesthetic display of her beautiful maxillary incisors.
‘Short-Face’ Patients—Part 2
Fig.7
‘Short-Face’ Patients—Part 2
 
‘Short-Face’ Patients—Part 2
Fig.8
‘Short-Face’ Patients—Part 2
Fig.9
‘Short-Face’ Patients—Part 2
Fig. 10


Conclusion
There were two major takeaways from this case for me. First, as grateful as I was for Lea’s efforts, I also realistically understood that I would not likely be able to depend on this degree of compliance with most patients. Second, I also came to understand, as stated earlier, that taking a Class I patient and setting them to an increased vertical position by rotating the lower jaw down and back meant that there would be a significant Class II occlusal burden to now deal with. Case selection is critical in vertical cases and it may not always be wise to trade a vertical problem for an AP problem.

Look for Part 3 of our short-faced case journey in the upcoming January/February 2025 issue!
Author Bio
Dr. Chad Foster Dr. Chad Foster is Orthotown’s editorial director, a board-certified orthodontist and owner of Butterfly Orthodontics in Phoenix. A graduate of Chapman University, he earned a Doctor of Dental Surgery and a master’s degree in craniofacial biology, and completed his orthodontic residency at the University of Southern California. Foster writes and lectures internationally on the topic of orthodontic aesthetics.



Orthotown Magazine
September 2025
Orthotown Magazine September 2025 Read Current Issue Read Archived Issues
Sponsors
Townie® Poll
Do you have a dedicated insurance coordinator in your office?
  
Site Menu
Message Boards Magazine Continuing Education Podcasts Blogs Classifieds News Events Townie® Poll Ebooks Townie Choice Awards
Company Info
Contact Us Advertise With Us Howard Farran DDS, MBA Policies and Agreements
Site Help
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Orthotown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450