Long face syndrome

By Ranjitha s

CONTENTS

O DefinitionO Signs and symptomsO Medical conditions associated with itO Risk factorsO Dental characteristicsO Orthodontic management of long face

syndromeO Surgical correction of long face

syndromeO conclusionO References

Long face syndrome A malocclusion characterized by a long, narrow face, steep mandibular plane angle, and Class II Division 1 dental/skeletal relationship with anterior crowding and associated mouth breathing. A contemporary name for adenoid facies. Mosby’s Medical Dictionary

synonyms•Skeletal open-bite•Extreme clockwise rotation•Adenoid facies•Idiopathic long face•Hyperdivergent face•High angle type•Total maxillary alveolar hyperplasia and •Vertical maxillary excess

Signs and symptoms• Mouth breathing• Suffer from sleep apnea• Malocclusion• Droopy lower lip• Early fatigue• Flattened cheek• Breathing difficulties• Long and narrow head• Difficulties in closing the mouth• Prognathism

Mouth breathing and sleep apnea• If a child is unable to breathe through the

nose- nasal functions are bypassed.  • Air through the nose-warmed, humidified

and cleansed of foreign particles, pollen and bacteria. 

• In addition, dry air carries less oxygen than moist air to the lungs, causing these children to fatigue more rapidly,

• The child’s bite may change too.  Mouth-breathing often causes unbalanced muscle forces which compress the upper jaw. 

• As the palate constricts and creates a smaller space, the tongue may complicate matters by protruding through the front teeth, forcing them outward.  As the upper jaw constricts, it creates a very high vault in the palate and increases the overall length of the lower face, thus the term “long face syndrome”.

•  If the constriction of the upper jaw repositions the molars, expansion of the upper jaw with an orthodontic appliance is recommended, which also often improves breathing.  It is important to catch the problem early ,as this is the easiest time to correct any concern there may be. 

• In some children, a severe upper airway blockage can cause breathing to stop during sleep or sleep apnea.  These children may not grow normally because of the energy they expend trying to breathe during the night.  Also, these children may be hyperactive and experience poor concentration, headaches, nightmares and bedwetting

• A physician may recommend removal of the adenoids if sleep apnea is due to obstruction of the upper airway.

• If allergies are the source of the problem, the causes need to be determined and removed. 

• Hypoallergenic pillows and cover mattresses and pillows with dust mite barrier covers are used. 

• Pediatrician may recommend drugs or allergy shots to reduce allergic responses.

 

BEARS acronym to determine if sleep apnea is a possibility:

•Bedtime problems, such as snoring, sleep apnea or nightmares•Excessive daytime sleepiness•Awakenings at night•Regularity and duration of sleep•Snoring

The following list of medical conditions have 'Long face •Faciodigitogenital syndrome•Fragile-X Syndrome•Marshall-Smith Syndrome•Myasthenic syndrome•Renpenning syndrome•Snyder-Robinson syndrome•Velocardiofacial syndrome•Velofacioskeletal syndrome•WAGR Syndrome•Wilms tumor

• The two most common types of vertical facial dysplasia are generally defined as hyperdivergent and hypodivergent.

• Schende -"long face syndrome“.• Opdebeeck -"short face syndrome.“• As the names suggest, the

hyperdivergent "long face" is characterized by a tendency toward a relatively large lower face, compared with the hypodivergent "short face."

Risk factors

The risk of long face syndrome increasesOAsthmaOEdemaOUnder stressONasal allergyOMalnutrition

Dentofacial characteristics

•with or without dental anterior open-bite. •The upper third of the face -usually within normal limits. •Examination of the middle third of the face typically reveals •Narrow nose,• Narrow alar bases,•A prominent nasal dorsum, and •Depressed paranasal areas.

• Analysis of the lower third of the face commonly reveals

• excessive exposure of the maxillary anterior teeth with the lips in repose, inordinate exposure of the maxillary teeth and gingiva upon smiling,

• Lip incompetency,• Long lower third facial height,• A retropositioned chin, and • An essentially normal or obtuse nasolabial

angle.

• A Class II malocclusion, with or without open-bite, is many times associated with the deformity.

• A high constricted palatal vault with a large distance between the root apices and the nasal floor and a steep mandibular plane are consistent findings.

• These dentofacial-skeletal features are variably manifest with or without dental open-bite.

Orthodontic management of long face syndrome 

Long face syndrome is among the most difficult problems encountered in the practice of orthodontics and unless orthodontic treatments are carefully monitored and controlled, patients with long face syndrome risk developing even more severe characteristics of the syndrome.

Skeletal findings

O Smaller SNB angles- more convex and retrognathic

O Steep mnandibular mandibular plane angle and increased mandiulo-palatal plane angle.

O Increased gonial angleO Increased ANS to ME .

The basic approach to treatment of the long face is to harmonize the length of the bony face with its enveloping soft tissue to restore facial balance and to establish normal overbite and overjet for optimal function.

The objective of orthodontic treatment is to move the malaligned teeth in the best possible position on the individual apical bases.

Monitoring for long face syndrome throughout treatment is an important part of the proper therapy for patients who are at risk.

1.One of the best ways to measure whether long face syndrome characteristics exist is to Measure the cephalometric MM angle-the angle between the palatal plane (ANS-PNS) and the mandibular plane (Go-Gn) . The average MM angle is 26°. Larger MM angles (more than 32°) warn the clinician that further increases in this angle may result in an increase in long face syndrome characteristics.

Frequent (every six to ten months)cephalometric radiography, to monitor changes in the MM angle, is necessary for patients who are at risk of developing characteristics of long face syndrome.

Treatment alternatives :•There are various treatment modifications that reduce the likelihood of the expression of long face syndrome characteristics. •Premolar extractions have proved to be effective and should be carefully considered. Also, closing space by moving molars forward reduces the vertical dimension of occlusion.• This permits the mandible to rotate into a more closed position along its arc of closure, resulting in a more forward positioned chin and a smaller MM angle.

• Long face syndrome also can be controlled by minimizing the extrusion of posterior teeth, particularly maxillary molars.

• They extrude more easily than mandibular molars for two reasons:

The masticatory muscles restrict the posterior mandibular teeth more than their maxillary counterparts and The thin cortices and trabecular bone of the maxilla provide less resistance to movement than the thick cortices and more dense trabeculae of the mandible.

Use of arch wires-Careful force application helps to control extrusion of posterior teeth. Also, using arch wires with a low load-deflection rate greatly reduces tooth extrusion. The load-deflection rate of an arch wire is defined as the force that an arch wire produces per unit of activation.

• Since patients with long face syndrome have relatively weak masticatory muscles, high load-deflection rate arch wires (e.g., stainless steel) easily overpower their masticatory muscles, resulting in posterior tooth extrusion.

• Patients who do not have long face syndrome generally have stronger masticatory muscles, so the same high load-deflection rate arch wires will not cause as much posterior tooth extrusion in such patients. 

Relative material stiffness is directly proportional to load- deflection rate. For practical purposes the material stiffness can be used to determine the relative amount of force that a wire will provide per unit of activation." 

• As a rule, stainless steel arch wires should be avoided in patients with long face syndrome.

• Leveling and aligning can be done with low load-deflection rate arch wires, such as those made of nickel-titanium. However, these arch wires are too flimsy( easily damaged) to be used for space closure and other mechanics.

• An intermediate load-deflection rate arch wire is needed for these procedures.

• TMA, a titanium-molybdenum alloy arch wire (Ormco, Orange, CA) is firm enough for these mechanics, and its load-deflection rate is low enough to prevent unwanted molar extrusion

• Anchorage enhancement is another way that maxillary molar extrusion can be prevented. The enhancement can be accomplished with transpalatal arches (TPA).

• TPAs are fabricated by attaching a heavy wire (.036 ss), with a 5 mm diameter loop at the midline, that has been secured to the mesiolingual surfaces of the maxillary molar bands.

• When a patient talks or swallows, the tongue exerts a palatally directed force against the loop. This, in turn, helps to overcome the extrusive force of most orthodontic mechanics." (Molar crown rotation and root torque can also be accomplished with the use of TPA)

• The more a patient exhibits the characteristics of long face syndrome, the more critical is the need to use a TPA. 

• High-pull headgear - High-pull headgear (HPHg) prevents maxillary molar extrusion even more effectively than a transpalatal arch.

• In patients with long face syndrome, the masticatory muscles do not support the palate.

• This lack of muscular support causes the posterior half of the palate to tip downward and mesially, carrying the maxillary molars downward and mesially as well .

• The direction of force applied by the HPHg helps to prevent this palatal tipping .

Cephalometric x-ray shows the descent of PNS common in patients with long face syndrome. Cephalometric x-ray of a patient with no symptoms of long face syndrome. Note the lack of vertical descent of PNS. 

• HPHg is also used for Class II correction. Fourteen hours of HPHg wear per day helps to correct Class II discrepancies in two ways:

• The maxillary restriction common to all types of headgear ,the restriction of maxillary molar eruption allows the mandible to rotate into a more forward position as it grows.

• A number of clinicians, including Terel Root in the 1970s, recognized the importance of maxillary molar vertical restriction as a method of Class I correction.

• According to Root high-pull facebow is used in individuals in whom increases in vertical dimension are to be avoided.

• As a growth guidance appliance, it (HPHg) can decrease vertical development of the maxilla, thereby allowing for autorotation of the mandible, and maximizing the horizontal expression of mandibular growth." 

High-pull headgear (left). The inner bow of the headgear is attached to the maxillary first molar. The direction of the force applied by the headgear (right) helps prevent the descent of the posterior portion of the palate. 

Twin block appliance - Using a twin block appliance is an alternative method of Class II correction. It consists of repositioning the mandible by using removable maxillary and mandibular splints with acrylic ramps.The ramps measure 5 mm to 8 mm in thickness in the premolar region.

• This ramps impinges on the patient's freeway space, which in turn results in increased masseter tension. This tension not only restricts vertical descent of the maxillary posterior teeth, but also produces a relative intrusion of the posterior aspect of the maxilla in growing patients.This phenomenon, which is called the bite-block effect, provides excellent vertical control.

• Although long-term studies documenting the results of this treatment are not yet available, but the early results are promising.

Initial cephalometric (dotted lines and shaded teeth) and final cephalometric outline (continuous lines) of a patient with long face syndrome whose Class II malocclusion was corrected in 11 months with a twin block appliance

• Surgical correction of long face syndrome

• The need for reduction of vertical facial height in persons with long faces has been long recognized.

• In many adults or adolescents with long faces, it is doubtful whether orthodontic treatment or orthopedic mechanics alone can decrease maxillary height or inhibit its potential growth sufficiently to achieve facial balance and an attractive smile.

• Orthodontic treatment in non growing patients seldom reduces anterior face height or improves the skeletal framework.

If the open-bite is corrected, it is usually accomplished at the expense of facial esthetics by tipping the anterior teeth lingually and/or elongating the teeth. If maxillary incisors are excessively exposed relative to the upper lip, they will probably be exposed even more at the end of orthodontic treatment. Moreover, lip incompetence remains after treatment.

• Many technical modifications of the leFort I osteotomy are feasible to facilitate simultaneous anteroposterior, vertical, or horizontal movements of the anterior and posterior parts of the maxilla.

• The maxilla is easily sectioned sagittally, transversely, or circumpalatally.

• Space closure, arch segment alignment and leveling may be facilitated by vertical interdental osteotomies or ostectomics.

• Palatal cross-bites that cannot be managed by conventional orthodontic appliances are corrected surgically to facilitate widening of the maxilla.

• An excessive curve of Spee in the lower arch may be leveled surgically by simultaneous mandibular subapical osteotomy. This procedure may be accomplished with or without extractions, depending upon arch length requirements for alignment and lower incisor protrusion.

1.Superior repositioning of maxilla in four segments to (a)shorten lower anterior face height,(b) Reduce the amount of lip incompetence by shortening the skeletal framework,(c)Decrease vertical exposure of teeth relative to length of upper lip, (d) Facilitate autorotation of the mandible, closure of open-bite, and maxillomandibular harmony, and (e)Correct maxillary constriction by surgical expansion of the maxilla in four segments.

2. Augmentation of the contour-deficient chin and deep labiomental fold with an alloplastic implant- Genioplasty .3. Reduction of the prominent nasal dorsum by Rhinoplasty.4. Correction of bulging upper and lower eyelids by blepharoplasties

• Summary

• The combined efforts of different specialists are needed for the successful treatment of patients with the long face syndrome.

• Both surgeons and orthodontists who recognize their own capabilities and limitations must combine their skills to achieve the best possible occlusion and facial esthetics.

• The surgical and orthodontic plan of therapy is designed to correct the patient’s dento facial deformity.

• Surgical reduction of facial height and proper alignment of the teeth by orthodontic means are common denominators of successful treatment.

• By properly planned and executed Le Fort I maxillary osteotomies, the vertical dimensions of the face can be shortened to improve the esthetic balance between the nose, upper lip, teeth, and chin and achieve lip competency.

References•General Dentistry, 1997 Vol. 45, No 6, pp. 568-572. Dr. Jim Prittinen, DDS • GraberT, Swain B. Orthodontics: current principles and techniques,•Sehendel, S, A., Eisenfeld, J. H., Bell, 1%‘. H., Epker, B. N., and Mishelevich, I: The long face syndrome-Vertical maxillary excess, AM. J. ORTHOD. 70: 398-408, 1976.•Willmar, K.: On Le Fort I osteotomy, Stand. J. Plast. Reconstr. Surg., Supp. 12, 1974•Schendel, S. A., Eisenfeld, J. H., Bell, W. H., and Epker, B. N.: Superior repositioning of the maxilla: Stability and soft tissue osseous relations, AM. J. ORTHOD. 70: 663-674, 1976. 25.•www.brianpalmerdds.com•Internet sources