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‘Short-Face’ Patients—Part 3 by Dr. Chad Foster

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Categories: Orthodontics;
‘Short-Face’ Patients—Part 3   

by Dr. Chad Foster

Introduction
Following up on last month’s Part 2, I will present the second of three “short-face” cases this month. They are presented chronologically, and I hope they provide some helpful concepts and mechanics regarding these types of cases.


Case presentation
When I met 12-year-old Jolie in the exam room, I recognized many of the same “little old people” syndrome characteristics I had seen in other short-face kids (Fig. 1). Her overall facial height was obviously deficient, and her frontal facial outline had a squarer form. However, her brachyfacial, over-closed jaw position did more than result in a short facial height. In short-face patients, the over-closure of the mandible also carries the lower lip to a more superior position than ideal. In some patients, this can manifest as over-closure of the lips with two significant aesthetic consequences.
‘Short-Face’ Patients—Part 3
Fig. 1

First, when together at rest, the lips can press into one another more than normal, resulting in compression or redundancy and often a thin or decreased vermilion display (which Jolie showed). Second, the superior position of the lower lip results in a diminished height of the smile window. For Jolie, even when she attempted a large smile, her inter-labial gap was noticeably short, with only enough space to display maybe 60% of her maxillary central incisors.

Relative to the short height of her smile window, her vertical incisor display (VID) and smile arc (SA), which are related but independent traits, appeared to be acceptable. However, it is important to note that her upper lip covered about 40% of her upper incisors. If her vertical were to be opened and her lower jaw descended, the lower lip could also be carried inferiorly a few millimeters. This would both open the height of her smile window and reveal a flat SA and deficient VID.

There was, however, one characteristic feature of the short-face patient that she was missing. Her facial profile did not strike me as overly chin-prominent. In her case, this was because, in addition to having a vertical deficiency (decreased lower facial height), she also had an A-P deficiency (mildly retrognathic mandible with associated Class II occlusion). Had her lower jaw been in a more forward/normal A-P position, her chin would very likely have appeared unfavorably prominent relative to her other facial features.

The previous case (Lea) and the lesson learned about how opening vertically will move the lower jaw not just down but also back were fresh in my mind. For Jolie, I understood that while opening her vertical would benefit her facial balance, it would also result in an even greater iatrogenic Class II occlusal burden. In the absence of orthognathic surgery (which was discussed with Jolie and her mother but declined) to move the mandible forward, attempting to non-surgically compensate for this problem by mesializing the lower dentition would seem to be an unwise decision, especially given the fact that Jolie showed a thin lower anterior periodontal phenotype with visible root scalloping (Fig. 2).
‘Short-Face’ Patients—Part 3
Fig. 2

Within the maxilla, the upper incisors were protrusive and called for retraction to a more ideal position, both aesthetically and functionally. One available option would be to opt for the extraction of two upper bicuspids during her orthodontic treatment. This would allow significant retraction of the protrusive maxillary anterior teeth to bring them all the way back to couple with her pre-treatment lower incisor position. While the would be one reasonable way to treat Jolie that would also avoid any forward movement of her lower incisors, it would unfavorably over-retract the upper incisors within her face. I would not choose to compromise the position of her most important aesthetic teeth (the maxillary incisors) to match the tooth position of an obviously deficient lower jaw.

I also felt that treating her without extractions could potentially benefit my long-term goal of maintaining her vertical dimension if we were able to increase it through orthodontic treatment.1

As it relates to stability, maintaining this type of vertical change post-treatment is a real challenge in these brachyfacial short-face patients. There is obviously nothing wrong with extracting teeth as part of orthodontic treatment, but my preference, when possible, in these types of cases is to maintain the full dentition to attempt to better support the muscle load that unfortunately often acts in opposition to the long-term stability of this increased vertical position.


Chosen treatment plan and mechanics
The treatment plan I eventually chose was tailored to the very unique characteristics of her particular case—a short-face presentation paired with protrusive upper incisors and a slightly retrognathic mandible with associated Class II occlusion. Again, in the absence of surgery, my goal was to attempt to address both the significant vertical and A-P challenges as best as possible. Figure 2 is the start-day records.

The primary mechanical part of my plan was to have her wear cervical pull headgear at night and Class II elastics during the day. In theory, if she was able to comply with this protocol as prescribed, there would be a full-time distalizing force on the maxillary dentition, while the lower incisors (already having a thin periodontal phenotype) would have only a part-time mesializing force on them (less than if elastics were full-time). A lesser duration of mesial force on the lower dentition meant less risk of recession in that already thin anterior area. Additionally, I already anticipated that the lower incisors would procline as her obviously deep curve of Spee was leveled. My preference was not to compound that inevitability with excessive mesial force to the lower dentition.

Regarding her upper incisors, in non-extraction cases that show significant crowding or proclination, I will often flip/invert the four upper incisor brackets to induce a reversed/negative prescription torque on those teeth. It is a great technique that has been popularized by Dr. Tom Pitts. In this case, I chose not to use this technique. I felt that, if she complied with the elastics and headgear combo, there would be a more than sufficient distalizing force on the maxillary dentition to retract and normalize the upper incisor A-P position and inclination. If she did not, I still had extractions or an upper incisor bracket flipping in my back pocket for a mid-treatment course correction if necessary.

Most importantly, there would also be an important vertical component to this chosen plan. With Jolie’s cooperation, there would always be an active force of extrusion on the posterior teeth to support our goal of increasing vertical. While Class II elastics were worn during the day, there would be an extrusive force on the lower first molars. When the cervical pull headgear was worn during the night, there would be an extrusive force on the upper first molars.

In addition to their eruptive effects that benefit increasing vertical, cervical pull headgear and Class II elastics both mechanically favor tipping of the occlusal plane in a clockwise manner. This, in combination with an exaggerated “SAP” bracket positioning (a la Dr. Tom Pitts) that I opted for, would attempt to increase her deficient VID and her flat SA.


‘Short-Face’ Patients—Part 3
Fig. 3

Results
Jolie’s case finished in 26 months total (Figs. 3–9). On a side note, I think it is also important to note that, in cases with vertical gain via posterior extrusion, I am typically in no hurry to finish treatment quickly. There is value in letting them sit for a few extra months in active retention. With intentional education and motivation provided to her during treatment, Jolie understood what was possible regarding her facial and smile improvement with our chosen treatment. That understanding fortunately translated to an engaged patient and great cooperation on her end.

Evaluating the final records from outside-in, there were some noticeable facial changes worth noting. On profile, her lower one-third facial height increased (Figure 4) by way of clockwise rotation of her mandible (the SN-GoGN was increased from 16 to 24, shown in Figure 5). That vertical gain also permitted some other important esthetic improvements.
‘Short-Face’ Patients—Part 3
Fig. 4
‘Short-Face’ Patients—Part 3
Fig. 5
The expression of Jolie’s lip anatomy was one fascinating enhancement to note. While the reduction in maxillary incisor proclination did permit improvement of a slightly everted upper lip, the main soft tissue change of importance was imparted by the increase in vertical (Figure 6). As the lower jaw moved inferiorly because its clockwise rotation, the lower lip was carried down as well. This resulted in two important aesthetic improvements that we previously discussed.
‘Short-Face’ Patients—Part 3
Fig. 6
First, with the lower lip now in a less compressed position, its aesthetic fullness and vermilion display are dramatically on display. Second, the descension of her lower lip has created an increased height of her smile window (Figs. 7–8). This increase in the smiling inter-labial gap distance permits a much fuller vertical display of her beautiful maxillary teeth and, in particular, her improved VID and SA. And they are teeth worthy of that display!
‘Short-Face’ Patients—Part 3
Fig.7
‘Short-Face’ Patients—Part 3
Fig.8

Conclusion
Not every short-face patient should be treated with the same set of tools. While the aesthetic importance of the vertical dimension has been the focus, it cannot be treated in a vacuum—the A-P and transverse dimensions must be conscientiously considered as well with our chosen mechanics. To that point, both Lea and Jolie had noticeable short-face characteristics that contributed to similar areas of aesthetic deficiency. However, had Jolie been treated with the same mechanics that were used in Lea’s treatment, the iatrogenic A-P burden that would have been created would likely have been too substantial to overcome. Likewise, the mechanics used in Jolie’s case would have been very inappropriate in Lea’s case in multiple ways.

Another takeaway from this case is that even if the hard-fought vertical dimension gain is only mild (in Jolie’s case, it was only eight degrees), this can still be strikingly powerful in patients who are significantly vertically deficient. Eight degrees of change might not be as noticeable in a face that is vertically within normal limits. For a patient who is severely deficient outside of the normal range, any degree or incremental improvement toward that normal range creates a much more noticeable qualitative impact compared to a similar quantity of change in a patient already within the normal range. While not as short-faced, post-treatment Jolie is still considered a brachyfacial, low-angle facial type. However, her facial and smile aesthetics speak volumes about the power of those eight degrees.
‘Short-Face’ Patients—Part 3
Fig. 9
References
1. Chua AL, Lim JYS, Lubit EC: The effects of extraction versus non-extraction orthodontic treatment on the growth of the lower anterior face height. Am J Orthod Dentofacial Orthop 104: 361–368, 1993.
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.



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