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Mandibular micrognathia and vertical maxillary excess correction with

combination LeFort I and inverted L osteotomies

Article  in  American Journal of Orthodontics and Dentofacial Orthopedics · May 2020

DOI: 10.1016/j.ajodo.2019.02.021

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CASE REPORT

Mandibular micrognathia and vertical

maxillary excess correction with
combination LeFort I and inverted
L osteotomies
Hunter Boss,a,b Jae Hyun Park,b,c Albert Carlotti,a,c Michael Papademetriou,c and John Grubbc
Austin, Tex, Seoul, Korea, and Mesa, Ariz

A 34-year-old woman with mandibular micrognathia, vertical maxillary excess, and an open bite characterized by
a “bird-face” deformity was treated with orthodontics combined with LeFort I and bilateral inverted L osteotomies.
The total treatment time was 16 months. Her occlusion and facial appearance were significantly improved by a
surgical-orthodontic plan. This case report presents the discussion of a unique and complex orthognathic surgi-
cal case and the myriad of orthodontic and surgical considerations that it involved. (Am J Orthod Dentofacial
Orthop 2020;157:704-18)

“B
ird-face” deformity (Vogelgesicht) has been
used to describe a dentofacial abnormality
that is characterized by a Class II skeletal
malocclusion with severe mandibular retrognathism, short
posterior facial height, diminutive condyle-ramus
complex, microgenia, and a steep mandibular plane angle
with or without an anterior open bite.1-3 The exact
etiology of this dentoskeletal deformity is often
unknown but can be caused by idiopathic arthritis,
reactive arthritis, condylar trauma, craniofacial
microsomia, craniofacial dysostosis, idiopathic condylar
resorption, or mandibular hypoplasia resulting in an
underdeveloped vertical height of the posterior condyle-
ramus complex with concomitant dentofacial changes.1,2
Patients with a phenotypical bird-face deformity pre-
sent challenges to the orthodontist and the surgeon
beyond the typical Class II surgical treatment plan. Their
mandibles are underdeveloped in all dimensions and
a
Private Practice, Austin, Tex.
b
Graduate School of Dentistry, Kyung Hee University, Seoul, Korea.
c
Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health,
A.T. Still University, Mesa, Ariz.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Jae Hyun Park, Postgraduate Orthodontic Program,
Arizona School of Dentistry & Oral Health, A.T. Still University, 5835 E Still Circle,
Mesa, AZ 85206; e-mail, JPark@atsu.edu.
Submitted, December 2018; revised and accepted, February 2019.
0889-5406/$36.00
Ó 2020 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.02.021
704
often exhibit diminutive condyles and short posterior
rami.1 This can lead to compensatory changes in devel-
opment such as excessive downward growth of the
maxilla and a narrow transverse dimension. This facial
abnormality presents with severe overjet, a steep
mandibular plane, and long lower facial third with the
maxillary anterior segment continuing to passively
move inferiorly, creating a vertical maxillary excess
owing to a lack of opposing tooth contacts.1,2
A patient presenting with a bird-face deformity re-
quires significant advancement of the mandible and
lengthening of the posterior face; therefore, the conven-
tional bilateral split ramus osteotomy (BSSO) is unable to
properly correct this skeletal deformity.1-4 This case
report presents a protocol that includes orthodontic
and surgical treatment with LeFort I and the lesser-
known bilateral inverted L osteotomy to correct the pa-
tient's severe Class II malocclusion, well characterized by
the bird-face deformity. A functional and esthetic result
was achieved.
DIAGNOSIS AND ETIOLOGY
A 34-year-old woman was self-referred for an ortho-
dontic evaluation. Her chief complaint was that her
“lower jaw was too far back.” She had previously
received orthodontic treatment in her late adolescence,
but when she was ready for the orthognathic surgery,
her family could not afford it. The patient was always
aware that she would need surgery to correct her jaw
Boss et al
Fig 1. Pretreatment facial and intraoral composite.
relationship, but she waited until she could personally
pay for the surgery. The patient presented to the ortho-
dontic clinic with a phenotypical bird-face deformity
(Fig 1). Clinically, she demonstrated (1) dolichocephalic
facial type, (2) convex soft-tissue profile, (3) mandibular
micrognathia, (4) long lower anterior facial height, (5)
vertical maxillary excess, (6) obtuse nasolabial angle,
(7) short chin throat length, and (8) lip incompetence
with a reverse resting lip line.
Intraorally, she had a beyond full-step Class II maloc-
clusion bilaterally at the molar and canine (Fig 2). Her
overjet was 20.7 mm with an open bite of 0.8 mm. She
had mild crowding in the maxillary arch and moderate
crowding in the mandibular arch with a mild curve of
Spee. Compared with her facial midline, her maxillary
midline was centered, whereas her mandibular midline
was 0.5 mm to the right. Further diagnosis revealed a
slight Bolton discrepancy with an anterior ratio of 82%
and an overall ratio of 95% (norms 77.2% and 91.3%,
American Journal of Orthodontics and Dentofacial Orthopedics
705
respectively).5 This was most likely the result of mandib-
ular excess both in the anterior and premolar areas.
When smiling, the patient showed a high smile line
with excessive gingival display, revealing 4 mm of
contiguous gingival display.6 The patient also presented
with a reverse resting lip line in which her upper lip
measured from subnasale to stomion was shorter than
her commissure height (Fig 3).6 This led to an upward
and reverse curvature to her upper lip. In our patient's
case, this reverse resting lip line and her vertical maxillary
excess resulted in significant lip incompetence. It is also
important to note that she presented with an absolute
maxillary transverse discrepancy, which was expressed
when the dental casts were advanced to a Class I rela-
tionship.7 This was likely because of the posterior maxilla
occluding with the narrower portion of her mandibular
arch, owing to the anteroposterior discrepancy.
A clinical examination of the anatomy of her head
and neck revealed that she had slight myofascial pain
May 2020  Vol 157  Issue 5
706 Boss et al

Fig 2. Pretreatment models.

Fig 3. Normal lip length at rest. Sn, subnasale; Ls, labialis superior; St, stomion.

of her right and left masseteric musculature on palpa-
tion. Further assessment revealed no joint pain, popping,
or clicking in either temporomandibular joint (TMJ). The
irregular and diminutive shape of her condyles was seen
on her 3-dimensional (3D) cone-beam computed to-
mography (CBCT) slices (Fig 4). This necessitated further
TMJ testing to ensure there would be a stable surgical
outcome. Her oral maxillofacial surgeon ordered bone
scintigraphy of her TMJs using a technetium diphosph-
onate (99 mTc) bone scan to ensure there was no active
bony remodeling (condyle or fossa) present.8-16 Bone
scintigraphy has the advantage of showing active bony
changes where traditional radiography can only
capture the present bony architecture.9,12,17 Results
from bone scintigraphy using 99 mTc does not guar-
antee a stable TMJ; therefore, the process should be
used as a supplemental index when looking for degener-
ative joint disease.12 This type of imaging should be
combined with other radiographic and clinical findings
to assure the correct clinical diagnosis.12 The patient's
bone scan was negative, demonstrating no active bony
remodeling. Her symptomology was considered
muscular in origin because of the constant need to pro-
trude her mandible for it to function. The radiology
report combined with our clinical examination deemed
that the joints were stable for surgery. Although the scin-
tigraphy and the clinical assessment were favorable, the
patient was informed that she could still be at risk for
joint remodeling or idiopathic condylar resorption
because of her anatomic characteristics.
A panoramic radiograph showed no caries or other
pathologies, but it also revealed several amalgam

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Boss et al 707

Fig 4. Pretreatment TMJ slices from the CBCT.

Fig 5. Pretreatment lateral cephalogram, tracing, and panoramic radiograph.

restorations on her posterior teeth and that all her third 10.2 mm) with a hyperdivergent skeletal pattern
molars had been extracted (Fig 5). (SN-MP, 52.6 ). Her maxillary and mandibular inci-
The lateral cephalometric analysis indicated a sors were within the normal range (U1-SN, 102.1 ;
skeletal Class II pattern (ANB, 14.3 ; Wits appraisal, IMPA, 87.2 ) (Fig 5; Table), and her American

American Journal of Orthodontics and Dentofacial Orthopedics May 2020  Vol 157  Issue 5
708 Boss et al

The surgeon preferred an alternate plan that used a

Table. Cephalometric measurements
single piece LeFort I because of the patient's relatively
Measurement Norm Pretreatment Posttreatment small maxillomandibular transverse discrepancy and to
SNA ( ) 82.0 82.2 80.5 simplify the already complex surgery, which would
SNB ( ) 80.0 67.5 75.5 only be further complicated by a 3-piece LeFort I. The
ANB ( ) 2.0 14.7 5.0
transverse discrepancy would therefore need to be cor-
Mp-SN ( ) 32.0 51.1 41.6
FMA ( ) 25.0 42.5 26.0 rected orthodontically. After autorotation of her
SN-U1 ( ) 104.0 102.1 92.4 mandible from the impaction of the maxilla, bilateral in-
U1-NA (mm) 4.0 0.7 2.5 verted L osteotomies would be completed to advance her
IMPA ( ) 90.0 87.2 102.4 mandible and correct her short posterior face height us-
L1-NB (mm) 4.0 7.0 7.9
ing iliac crest bone grafts. An accompanying advance-
Upper lip (mm) 4.0 1.4 8.5
Lower lip (mm) 2.0 3.5 6.7 ment genioplasty would improve the position of her
soft-tissue pogonion. A computer-aided surgical simu-
lation using NemoFAB software (Nemotec, Madrid,
Spain) would be used to simulate the movements of
Board of Orthodontics Discrepancy Index score was the bony segments and to visualize the results (Fig 7).
63 (Fig 6). This simulation would then be used to discuss the skel-
etal movements to be accomplished on the model block
TREATMENT OBJECTIVES surgery with the surgeon. The surgeon's expertise and
The following treatment objectives were established: experience with model block surgery has yielded excel-
lent results in the past. The model block surgery would
1. Advance the mandible. be used to fabricate the interim and final surgical splints.
2. Decrease the vertical maxillary excess. The patient, the oral maxillofacial surgeon, and the
3. Establish Class I molar and canine relationship. orthodontist selected this option.
4. Establish normal overbite and overjet. Other possible options included a similar 2-jaw sur-
5. Relieve crowding. gery with a prosthetic joint and condylar replacement.
5. Improve facial profile and smile esthetics. However, the patient and the surgeon did not choose
this option owing to the relatively young age of the pa-
TREATMENT ALTERNATIVES tient and the eventual need for multiple surgeries to
replace the prosthesis over the patient's life span. Joint
Orthognathic surgery was definitely necessary on the replacement was deemed a last resort but still a viable
basis of the patient's clinical history, chief complaint, option, if the patient's natural joints fail at any time.
and the clinical findings. The phenotypical bird-face Another approach could have been mandibular distrac-
deformity was well characterized in this patient's clinical tion osteogenesis followed by a revision surgery, if
presentation. needed. Although the literature supports combination
The most ideal surgical option would have been maxillary and inverted L osteotomy surgery for patients
bilateral inverted L osteotomies (mandible first) to who present with a bird-face deformity, a traditional
advance the mandible and lengthen the posterior BSSO with LeFort I (single or 3 piece) impaction could
ramus-condyle complex using iliac crest bone grafts to also have been used. Theoretically, this option would
fill the osteotomy gap.2 This would be followed by a have yielded less advancement of pogonion.
3-piece LeFort I with differential impaction to expand
her posterior segments, impact her anterior segment,
and allow a counterclockwise rotation of her maxillary TREATMENT SELECTION AND PROGRESS
occlusal plane, which would allow greater horizontal After acceptance of preorthodontic and surgical con-
advancement of her mandible.2 This treatment plan sultations, the patient was bonded and banded using
would correct the vertical maxillary excess, transverse MBT preadjusted appliances with 0.022 3 0.028-inch
discrepancy, and the excessive maxillary incisor display. slots (3M Unitek, Monrovia, California). Her mandibular
In addition, it could be accompanied by a lip length- right central incisor was brought into the arch using a
ening procedure, advancement genioplasty, and elective combination of a nickel titanium open coil spring and
rhinoplasty to improve overall facial balance. This treat- a “slingshot elastic” using a power chain. Her teeth
ment plan was not selected because of the surgeon's were leveled and aligned with a progression of archwires
preferred surgical technique and because the patient up to 0.019 3 0.025-inch stainless steel. Differential
was only interested in correcting her jaw disharmony. interproximal reduction using air rotor stripping of the

May 2020  Vol 157  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Boss et al 709

Fig 6. ABO Discrepancy Index score. ABO, American Board of Orthodontics.

maxillary and mandibular anterior dentition was used to
resolve the crowding, improve the inclination of the
teeth in their respective jaws, and correct the Bolton
discrepancy. When the patient was finished with presur-
gical orthodontics, surgical hooks were attached to both
archwires (Figs 8 and 9).
Surgical planning and model block surgery were
completed. Movements by means of a model block
were to be 1-2 mm short of a Class I molar and canine
relationship owing to the perceived surgical limitations
in the magnitude of advancement of the bony segments
and the subsequent osteotomy gap of the mandible.
Thus, the remaining Class I correction was to be accom-
plished orthodontically.
Surgery proceeded without complications with
the following surgical movements: the maxilla was
impacted 6.0 mm as measured from the maxillary
incisors using a LeFort I procedure and the mandible
was advanced at pogonion by 21.0 mm, which was
followed by a genioplasty that advanced pogonion
by another 4.0 mm and raised it superiorly by
4.0 mm. Postsurgical stability was achieved using a

American Journal of Orthodontics and Dentofacial Orthopedics May 2020  Vol 157  Issue 5
710
Fig 7. Virtual treatment objectives and model block surgery setup.
surgical splint for 14 days postoperatively. After
splint removal, posterior up-and-down elastics (3/
16 inch, 6 oz) with a Class II vector were used to
close the bite and improve interdigitation of the
buccal segments.
The treatment was completed in 16 months. A maxil-
lary Hawley retainer with an acrylic labial bow and a
lower permanent 3-3 retainer were delivered. The pa-
tient was instructed to wear the maxillary Hawley full
time for 6 months and thereafter at night only. Selected
laser gingivectomy was performed to improve the sym-
metry of the gingival margins in accordance with
adequate biological widths.
TREATMENT RESULTS
Evaluation of the patient's posttreatment records
demonstrated the following (Figs 10 and 11):
1. Patient's facial esthetics improved.
2. Smile esthetics enhanced.
3. Vertical maxillary excess improved.
4. Acceptable overbite and overjet created.
5. Class I canine and molar relationship developed.
6. Lip augmentation or lengthening procedure was not
accepted by the patient, so a reverse resting lip line
and slight lip incompetence is still present.
A posttreatment panoramic radiograph cut from
the patient's CBCT revealed proper root alignment
with no evidence of significant root resorption (Fig
12). Lateral cephalometric analysis showed significant
May 2020  Vol 157  Issue 5
Boss et al
skeletal improvement of (ANB, from 14.7 to 5 ;
Wits appraisal from 9.7 mm to 3.4 mm). Her maxil-
lary incisors showed retroclination (U1-SN from 102.1
to 92.4 ), and her mandibular incisors showed procli-
nation (IMPA from 87.2 to 102.4 ; Table). The maxil-
lary incisor retroclination and mandibular incisor
proclination were the result of correcting the remain-
ing Class II with elastics, resolving mandibular crowd-
ing, and leveling the curve of Spee. Whereas the
mandibular incisors were proclined, the interincisal
angle was improved (U1-L1 from 118 to 125.2 ;
norm 129.7 ). The mandibular intercanine width was
maintained (pretreatment 25.5 mm to 25.1 mm post-
treatment). These compromises in incisor inclination
were considered necessary and acceptable because of
the limitations of surgery. Posttreatment CBCT slices
and 3D reconstruction images of the bone were
created to evaluate the periodontal support of the
lower anterior segment (Fig 13). These images reveal
a continuous labial and lingual cortical plate without
bony dehiscence and with proper interalveolar height
in the lower anterior region. These images and the pa-
tient's healthy thick gingival biotype and immaculate
oral hygiene improves the probability for long-term
stability. Improvement of her facial profile is best
shown by the decrease in facial convexity, improve-
ment of neck throat length, and increased projection
of pogonion. The magnitude of the dental and skel-
etal movements can be appreciated based on the
lateral cephalometric superimpositions (Fig 14).
American Journal of Orthodontics and Dentofacial Orthopedics
Boss et al 711

Fig 8. Presurgical orthodontic composite.

Fig 9. Presurgical lateral cephalogram, tracing, and panoramic radiograph.

American Journal of Orthodontics and Dentofacial Orthopedics May 2020  Vol 157  Issue 5
712 Boss et al

Fig 10. Posttreatment composite.

Fig 11. Posttreatment models.

May 2020  Vol 157  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Boss et al 713

Fig 12. Posttreatment lateral cephalogram, tracing, and panoramic radiograph.

The patient reported no TMJ pain or discomfort after
treatment. Her temporomandibular series showed well-
positioned condyles with some apparent bony changes
or remodeling of both TMJs. On comparing the pretreat-
ment TMJ slices with the posttreatment TMJ slices, the
posttreatment shows some changes in joint space and
slight alterations to the condylar architecture. The pre-
treatment TMJ slices show subjective excessive joint
space with diminutive “pencil thin” condyles, whereas
the posttreatment series shows centered condyles with
slightly altered shape and a relative reduction in joint
space (Fig 15). The radiographic changes in the patient's
joint were explained to her in detail, and options moving
forward were provided. Since the completion of her
treatment, no significant changes in her bite have been
observed. The patient was made aware that continued
changes in TMJ including resorption could necessitate
further therapy and even surgical procedures, which

Fig 13. Lower anterior segment CBCT slices and bone reconstruction images.

American Journal of Orthodontics and Dentofacial Orthopedics May 2020  Vol 157  Issue 5
714
Fig 14. Pretreatment (black), presurgical (blue), and
posttreatment (red) lateral superimposition.
could be as extensive as total joint replacement. Given
the asymptomatic nature and no observable changes
in her occlusion, the patient elected for close follow-
up and sequential CBCT imaging with TMJ cuts to
monitor for changes.
Overall, the patient is extremely satisfied with her
treatment outcome. Her American Board of Orthodon-
tics Cast-Radiograph Evaluation score was a 13 (Fig 16).
DISCUSSION
Patients who present with a bird-face deformity
often require large mandibular advancements (15-
20 mm measured at B-point), lengthening of the short
condyle-ramus complex, and counterclockwise rotation
Fig 15. Comparison of TMJ slices (A) pretreatment and (B) posttreatment.
May 2020  Vol 157  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Boss et al
of the maxillomandibular complex, which allows for the
normalization of the occlusal plane.2,4 Advancing the
mandible with an unaltered steep occlusal plane reduces
the amount of forward projection of pogonion. This is a
result of advancing along the occlusal plane, which goes
in a downward and forward direction. Flattening the
occlusal plane allows a more horizontal movement of
the mandible and produces a greater projection of po-
gonion.18 Surgical correction with counterclockwise
rotation of the maxillomandibular complex allows for
an increased positive advancement of the mandible as
registered at pogonion. Counterclockwise maxilloman-
dibular advancement surgery has been considered very
controversial in the classic literature.2,18-20 The
controversy is predicated on research that was
completed in the pre–rigid fixation era. Now, prudent
surgeons are able to use internal rigid fixation and pre-
vent lengthening of the pterygomasseteric sling,
achieving a stable surgical result.2,18-20
BSSO has been the “workhorse” for mandibular ad-
vancements, but it has some limitations.3 It cannot pro-
duce the magnitude of movement required for patients
such as this one. Although some authors have cited sta-
ble results with BSSO advancement .10 mm, most au-
thors would consider the limitation of a stable
mandibular BSSO advancement to be \10 mm
measured at B-point.21-24 This is far short of the
required 15-20 mm of advancement that is often
needed to treat patients with this type of dentofacial
deformity.2 BSSO also relies on fixation of the overlap-
ping proximal and distal segments of the mandible of
the sagittal split. The overlapping region where these
cuts are made and fixed limits the amount of forward
advancement and does not allow for appreciable length-
ening of the posterior face height. BSSO is unable to
significantly increase posterior face height and falls short
of achieving the magnitude of advancement required.
Therefore, the inverted L osteotomy technique is
Boss et al 715

Fig 16. ABO Cast-Radiograph Evaluation score. ABO, American Board of Orthodontics.

preferred.2,3 Inverted L osteotomies have shown stability
in the literature with movements of $10 mm2,3,18
The inverted L osteotomy was introduced by Caldwell
et al25 in 1968, but BSSO had been introduced by Trau-
ner and Obwegeser26 a decade earlier, in 1957, and it
quickly became the preferred method for mandibular
advancement because of its predictability and stabil-
ity.2,27 Inverted L osteotomy most likely never really
gained any widespread use because of the extraoral
incision required, morbidity associated with additional
bone harvest for grafting, potential injury of the mar-
ginal mandibular nerve, and need for fixation.2
Currently, with improvements in internal rigid fixation,
virtual surgical treatment planning, surgical cutting
guides, inadequate correction with BSSO, and even
some use of an intraoral approach, there has been a re-
newed interest in inverted L osteotomy for patients such
as the one we are presenting.2,3

American Journal of Orthodontics and Dentofacial Orthopedics May 2020  Vol 157  Issue 5
716
Fig 17. Inverted L osteotomy diagram.
There is some variation in inverted L osteotomy, but
it is typically done through an extraoral approach with a
3-cm retromandibular or “Risdon incision” made below
the angle of the mandible.2 A surgical cut is made hori-
zontally from the anterior border of the ramus superior
to the mandibular foramen.2 This cut joins a vertical
cut posterior to the mandibular foramen.2 This osteot-
omy leaves the coronoid process and the posterior
portion of the angle of the mandible in the proximal
segment (Fig 17).2 This allows for passive lengthening
of the ramus while it frees the fibers of the pterygomas-
seteric sling and sphenomandibular ligament.2 Although
there are some articles demonstrating an intraoral
approach for inverted L osteotomy using custom instru-
mentation,3 traditionally the procedure is accomplished
with an extraoral approach.2 This is due to the
complexity of the osteotomies, the need for large inter-
positional grafting, and plating difficulties.2 Because of
these complications, inverted L osteotomy is most often
reserved for those Class II patients who require signifi-
cant lengthening of the posterior ramus.1-3
The LeFort I osteotomy was completed before the in-
verted L osteotomy. Whether to operate on the maxilla or
mandible first is a topic of controversy in the literature.28
The current evidence is not preferential, but there are
some theoretical advantages to operating on the
mandible first.28 The 2 main advantages cited for doing
this are the ability to use the stable or fixed position of
the maxilla to position the freely movable mandible
and to properly seat the condyles, even if the preoperative
centric relation was incorrect. An incorrect centric in a
mandible-first surgery could still allow for correct
occlusal positioning with only a difference in the osteot-
omy gap.28-31 Even with these theoretical advantages,
maxillary first surgery is still the predominant way of
doing bimaxillary surgery.28 With this patient, model
May 2020  Vol 157  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Boss et al
block surgery was used to simulate the surgical move-
ments and create the surgical splints. Undergoing a
mandible-first approach when creating the simulated
cuts on the models would have resulted in opening of
the bite on the articulator. This would potentially compli-
cate calculating the exact movements. Therefore, the
surgeon treated this patient with maxillary surgery first.
Some additional techniques could have been em-
ployed with our patient to correct her reverse resting
lip line, gingival display, and slight lip incompetence.
To understand properly how to correct the upper lip, a
correct diagnosis is essential. The upper lip is a dynamic
structure, varying a great degree with speaking, smiling,
and other functions. Therefore, diagnosing the position
of the upper lip should rely not only on the static posi-
tion of the lip at rest but also on the dynamic move-
ment.32 To make a proper diagnosis, the following
needs to be determined: incisor display at rest (1-
3 mm in males and 2-4.5 mm in females),33 upper lip
length from subnasale to stomion (20 mm in females
and 23 mm in males), commissure height, correct vertical
position of the maxillary incisor, and whether there is
hypermobility of the upper lip (.80% lip shortening
on smiling).6 When the static position of the upper lip
is shorter than the commissure height, the upper lip
has a reverse resting lip line.6 This can be corrected dur-
ing the patient's LeFort I procedure. There is a method
called a V-Y advancement closure to close the maxillary
vestibule with sutures, which can result in lengthening
of the lip after a maxillary LeFort I.34 If the procedure
is not done at the time of orthognathic surgery, another
lip lengthening procedure called the V-Y plasty can be
used to correct a short upper lip and improve lip compe-
tence.35 If the patient had adequate lip length but it is
hypermobile with smiling, there is a simple surgical pro-
cedure in which the maxillary anterior buccal vestibule is
lowered by removing an elliptical piece of tissue that re-
duces the lip elevation with smiling.36-40 A nonsurgical
approach using BOTOX (Allergan, Inc, Irvine,
California) has also been used to aid in correction of
hypermobility of the lip.39,41,42
Our patient presented with a reverse resting lip line,
which was not corrected with surgery. A V-Y advance-
ment closure could have improved the final results.
The patient and her surgeon selected a more youthful
look, and they were very pleased with the results (Fig
18). A 3D Neo optical scanning system (Morpheus Co,
Seoul, Korea) scan was performed on the patient after
treatment with her lips at rest to evaluate her soft tissue
more carefully (Fig 19). Her measurements revealed a
slightly short upper lip of 18.4 mm with commissural
heights of 24.2 mm and 24.5 mm. Approximately
5.5 mm of her incisors showed with her lips at rest. If
Boss et al 717

Fig 18. (A) Pretreatment repose three-quarter view (B) Posttreatment repose three-quarter view (C)
Posttreatment smiling three-quarter view.

results. In this case study, the following results were

observed:
1. Skeletal disharmony and malocclusion were signifi-
cantly improved.
2. Dentofacial esthetics were greatly enhanced.
3. The patient's subjective overall satisfaction with the
final results was excellent.

ACKNOWLEDGMENTS
We thank Dr Jorge Villanueva and the Nemotec Com-
pany for help with the computer-aided surgical simula-
tions and Dr Ivan Halim for manuscript preparation.

SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2019.02.021.

REFERENCES
Fig 19. 3D Morpheus lip measurements of final treatment
results.
her lip was within the reference range, her incisor display
at rest would be within the normal limit of 2-4.5 mm,
demonstrating her maxillary incisors were positioned
correctly in the vertical dimension. The patient was satis-
fied with the final results and had no interest in further
surgical procedures. She did, however, elect to have a
minimal gingivectomy to correct her gingival height
symmetry.
CONCLUSIONS
Class II malocclusions presenting with a bird-face
phenotype can be treated with an inverted L osteotomy
surgical approach to achieve the most acceptable
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