Long and Short Faces
Long and short faces present the ultimate challenge to the orthodontist. The malocclusions which accompany these distinct facial types are some of our most formidable treatment problems. Obviously both excessive and deficient vertical facial growth are the principal causes of long and short faces.
Specifically, where are the growth increments which cause a long face and specifically, where are the growth increments, the lack of which cause a short face? It is basic that we locate and measure these increments in order to discover the cause of long and short faces.
It is basic that we recognize the reciprocal nature of the reaction between vertical and horizontal growth. Effective condylar growth (horizontal growth) moves the chin forward, not downward. The vertical growth of the molar teeth moves the chin downward, sometimes backward. Vertical and horizontal growth increments functioning against one another cause the mandible to rotate.
When vertical effective condylar growth, in mm, exceeds the vertical growth of the molar teeth, in mm, the mandible rotates forward. When the vertical growth of the molar teeth exceeds the vertical effective condylar growth, the mandible rotates posteriorly. In other words, the long and short face problem revolves around the vertical growth of the molar teeth. This is a physical action not related to biology. It is important to clarify these principles of function early in this discussion.
In the treatment of patients with long faces we try to inhibit the growth of the molar teeth, particularly the upper molars. In treating the patient with a short face we always try to stimulate the vertical growth of both upper and lower molar teeth.
Following are some characteristics of the patient with a long face:
1. A high SN/mandibular plane angle,
2. A high occluso/mandibular plane angle,
3. A high palatal to mandibular plane angle,
4. An open bite,
5. A tongue thrust,
6. Paraoral muscle strain when swallowing,
7. Display of gum of upper arch when smiling,
8. Mouth breathing, and
9. Upper incisors may be either crowded or protrusive.
The following characteristics characterize the patient with a short face:
1. A low SN to mandibular plane angle,
2. A low occluso/mandibular plane angle,
3. A low palatal to mandibular plane angle,
4. A deep bite,
5. A deficiency of lower face height,
6. Maxillary incisors may be inclined forward or reclined posteriorly. They may be crowded,
7. Lower lip may curl down, and
8. May have a Class II molar relation.
In treating the long face, the greatest hazard is fear of producing more facial height. The objectives in treatment are:
1. Try to inhibit the downward growth of the upper molars.
2. Use care in correcting the lower curve of Spee. May be wise to only partially correct this curve. The Japanese who use the MEOW technique have shown some successful treatment of open bites.
3. In closing an open bite it is very important to move the lower incisors upward more than the upper incisors downward. This is because the lower incisors are the "great bite closers and the upper molars are the great bite openers." Rarely a patient may be found who has an open bite but the upper incisors need to be intruded to improve aesthetics. In such a case the upper incisors may first be intruded and held up while the lower incisors are moved upward to close the open bite. We have successfully corrected open bites in this way. The lower incisors are more stable than the upper incisors, when moved occlusally.
When treating the patient with a short face, the objectives are as follows:
1. Stimulate as much molar height as possible.
2. Avoid intrusion of lower incisors, because intruded lower incisors are very unstable We are talking about 8 to 11 mm of overbite. Please see Article 16 of the Schudy Chronicles.
3. A bite plate and posterior vertical elastics may be necessary in the early months of treatment.
4. Molars need time to grow. Must go slowly.
5. Avoid the extraction of teeth if possible.
6. Be sure to accomplish ample torque (24° to SNA), and ample interincisal angle (130°).
7. Always reduce overbite to 1 mm without intruding lower incisors.
8. Place a fixed retainer for lower cuspid to cuspid.
If these objectives are completely accomplished, then retention should be a small problem.
It has been postulated that, by heredity, the jaws first grow apart a given amount and then the teeth fill in the space between the jaws, and that the growth of the teeth do not "jack the jaws" apart. A more reasonable postulation is that the teeth do in fact force the jaws apart. Without treatment the jaws grow apart a given amount, but with treatment they usually grow apart an additional amount. This is observed consistently. Please see Article 12 of the Schudy Chronicles.
I was so happy when I heard that a world conference was planned for October, 1997. The subject to be discussed was "Long and Short Faces," a subject near and dear to my heart. I looked forward with much anticipation to receiving the proceedings of the meeting in book form.
When the book arrived, to my utter amazement not one of the speakers at the conference measured condylar growth and vertical molar growth. There was no attempt to measure growth increments and relate these increments to one another in the same individual. There was no attempt to show what particular growth increments cause a long face. There was no attempt to show what particular increments are lacking in a short face. There was no attempt to show what combination of growth increments causes the mandible to rotate posteriorly, and what combination causes the forward rotation of the mandible. There was no attempt to explain "cause and effect." In fact, the word "increment" I don't think was mentioned at the conference. Since these pertinent concepts were not discussed, the conference did not seem to accomplish the purpose for which it was convened.
I must be fair and reasonable about my attitude toward the participants in the conference. I am aware of the important contribution of the European orthodontic community. They have taught the Americans, among other concepts, that removable appliances can produce valuable orthopedic changes. There were innovative procedures and concepts shown which were effective in treatment.
All of this is well and good, but in addition, there must be a reasonable understanding of basic anatomical relationships, and a reasonable understanding of cause and effect so that we can correctly interpret the changes that we observe. In other words, we must have a good road map so that we can get to where we are going. We do not have a good road map unless we regularly measure growth increments and can interpret their effect on the jaws and teeth. It was perfectly obvious that none of the speakers understand the principles of growth and function associated with long and short faces.
For the European orthodontic community to hold a world conference on a subject, first recognized by myself in 1960, and never give any credit, and never even mention me in the bibliography is UNTHINKABLE.
As I gave some thought to how I should react to this travesty, I began to see some weird humor in it. Then I thought of how few American orthodontists have ever published anything pertaining to the subject, and I thought, why not have the Europeans join the Americans and make it unanimous?? I have given my life and my best to my profession, so with love and good will toward all and malice toward none, I will leave it there-history will judge!!
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