DEPARTMENT OF ORTHODONTICS

AND 1
DENTOFACIAL ORTHOPAEDICS

SRI AUROBINDO COLLEGE OF DENTISTRY AND

P.G. INSTITUTE

JOURNAL CLUB-1
Comparative Study Between The SFS And LFS Rotation As A
Possible Morphogenic Mechanism
H. OPDEBEECK, M.D., D.D.S, W.H.BELL, D.D.S, J.EISNFELD,PH.D., AND D. MISHELEVICH,
M.D.,PH.D. (LOUVAIN, BELGIUM, AND DALLAS, TEXAS)
BY- ANKITA RAWAT (P.G. 1ST YEAR)
Introduction: 2

 Vertical facial dysplasias may be due to increase or decrease in vertical

dimensions.

 According to this it can be classified as :

1. Short Face Syndrome
2. Long Face Syndrome

 In both dysplasias, alteration in the lower anterior facial height was the
common denominator.
Short Face Syndrome
3
 Also mentioned as Low Angle Type.

 On the basis of four parameters:

1. FPI (facial proportion index)
2. The RH (ramus height)
3. The OP-PP distance (or posterior maxillary height)
4. The SN: MP angle

 It is divided into two sub groups:

1. Subtype I
2. Subtype II
 4

Short Face Syndrome

Subtype I –
5
1. Long ramus
2. An extremely low SN:MP angle
3. Slightly reduced posterior maxillary dentoalveolar height
4. Normal FPI

Subtype II-
1. Short ramus
2. Dominant VMD (vertical maxillary deficiency)
3. Slightly reduced SN:MP angle
4. Very low FPI
6
Long face syndrome
7
 High angle type.

 It is manifested primarily by excessive lower vertical facial height.

 Middle third of the face-

- narrow nose
- narrow alar bases
- depressed nasolabial areas.
 Lower third of the face – 8
- excessive exposure of maxillary anterior teeth
- poor upper-lip-to-tooth relationship,
- large inter-labial distance
- long lower third of the face, and
- exposure of the maxillary teeth and gingiva upon smiling
- large inter-labial distance,
- a retro-positioned chin
 9

Variable clinical
manifestations of the long face
syndrome.
 Occlusal analysis – 10
- mostly Class II malocclusion
- with or with- out open-bite deformity
- a high palatal vault
- a large distance between the root apices and the nasal floor.
 Aim of the study 11

 The study was done to investigate whether a subdivision similar to

Short Face Syndrome .

 The parameters used were same used in dividing SFS, i.e.,

1. FPI (facial proportion index)
2. The RH (ramus height)
3. The OP-PP distance (or posterior maxillary height)
4. The SN: MP angle
 12

 Rotation of mandible in both cases in concern with different

reference points.

 Comparison of SFS and LFS.

 Material and Methods 13

 Sample size- 36 patients.(Caucasians race)

 13 males and 14 females of age group 17 to 55 years

 The 27 patients were previously studied for SFS.

 The 9 subjects were added with clinical impression of LFS.

 Modified ‘natural head position’ was used.(by Bench)

 14
 The cephalogram were traced according to computerized
craniofacial model of Walker.

 Hyoid bone, the outline of inner cortex of the occipital bone and
the spine was added to the model.

 The model consist of 220 points.

15
Cephalometric measurements: 16

Linear and angular

measurements were used in
this study.
Measurements related to pharyngeal area: 17
 Results and Discussion 18

1. Rotation of mandible ‘in concern’ with the hyoid bone, the cervical
spine and the pharynx.

• There was overall rotation of the mandible in concern to hyoid, pharynx and
spine.

• Long face syndrome - clockwise or posterior direction rotation.

• Short face syndrome - counter-clockwise or anterior direction rotation.
 19
• There was rotation of entire mandible i.e., the ramus, corpus and the
condyle.

• The corpus bends towards the ramus in anterior rotation.

• In posterior rotation, the ramus and corpus bend away from each other.

• A significant larger SN:HP angle was found in LFS.

• It was indicated that hyoid bone was involved in overall rotation of the
‘movable parts’ of the craniofacial complex.
20
• The posterior wall of the pharynx:
21

In Short Face Syndrome- rotation in counter-clockwise direction.

In Long Face Syndrome- significant decrease in pharynx depth.

• The cervical spine:

In Short face syndrome- the angle between A3-A4 vertebra and cranial base
was smaller.
In Long face syndrome- rotation of the spine backward and upward against
the cranial base
 22
 The simultaneous rotation of all the structures can be explained on the
following anatomic basis:

1. Pharynx is the link between mandible and the hyoid on one side and spine
on the other.

2. The major muscles around pharynx meet at pharyngeal raphe and

intimately relate to the anterior longitudinal fibres of the spine.
 23
3. The hyoid bone and the mandible are linked to pharynx by middle
and upper constrictor muscles.

4. The hyoid bone is connected to mandible by geniohyoid, anterior

belly of digastric and mylohyoid muscle.

5. Hyoid bone is also connected to tongue by hyoglossus and

genioglossus muscle.
• The tongue also show rotation : 24

• In short face syndrome- tongue is positioned posteriorly and superiorly

against the palate.

• In mild long face syndrome- tongue is positioned anteriorly with base

higher and the tip lower then the normal at the level of the incisal tip.

• In extreme clockwise rotation- tongue was slightly retruded, with very

high root position and tip down in the mandible.
2. Comparative study between the SFS and the LSF:
25
Vertical dimensions:

 In Short face syndrome, reduction of ATFH is mainly due to reduction of

ALFH.

 And ALFH is responsible for over all increase in facial height in Long
face syndrome.

 The mid facial height was common in both the cases.

26
 27
 In LFS, the ramus was short and condyle was close to cranial
base (reduced PTFH) as compared to SFS.

 OP-PP height(posterior dentoalveolar height) was greater in

LFS group than in SFS group.

 OP-MP(Posterior mandibular height) was shorter in SFS than in

LFS.
Sagittal Dimensions: 28

 SNB angle value was significantly smaller in LFS than for SFS.

 Significantly reduced S-PNS distance in the LFS as compared to

LFS.

 Length of cranial base and maxilla was same for both cases.(ANS-
PNS)
Dental Characteristics: 29

 The upper first molar was at more mesial position in SFS than in LFS.

 Degree of overbite was more pronounced in SFS and overjet was same for
both.

 A positive correlation was found between posterior maxillary height(OP-PP)

and anterior lower facial height and ramus length.(primarily due to rotation)
 30
 The relation between ramus length and SN-MP angle was of inverse
proportionality.

 It indicates that the long ramus length will display extreme

counterclockwise rotation.

 The short ramus length will have reduced or normal SN-MP angle.
 So on the basis of all the four parameters, the LFS was also divided into two
subtypes: 31

Subtype I – characterized by
- long ramus
- an increased OP-PP distance
- moderately increased SN:MP angle
- long faces i.e., FPI above 10
- more gingival display upon smiling
- ANS-PNS plane is not angulated
- Upright upper and lower incisors
- Reserve curve is present in lower arch
- Increased height of anterior and posterior maxilla
32
Subtype II- characterized by
33
- short or extremely short ramus
- normal or slightly increased OP-PP distance
- anterior lower facial height is increased
- FPI value is above 10 but less than subtype I
- angulates ANS-PNS plane at the level of incisive canal
- reverse curve of maxillary occlusal plane
- upper and lower incisors are flared labially
- crowding space problems and arch irregularities, open bite
present
 34
Why short ramus favors posterior rotation in LFS ?

1. Vital need to maintain adequate space between the mandible and the cervical
spine.

2. Short ramus is accompanied with lower pharynx.

3. Hyoid bone is closer to cervical spine.

 35
4. Stretching of cervical spine, hyperextension of head, backward of
rotation of cervical spine prevents the ‘encroachment of pharynx’ as the
pharyngeal space is narrowest at the base of tongue.

5. Pharyngeal depth and soft tissue factors(tongue volume) may also play
a role.
36
Effect of Environmental obstructive factors on rotation of
37
mandible…..

1. This include factors like adenoids or experimental protracted nasal

obstruction.

2. It causes downward and backward rotation of mandible and hyoid

bone again reducing vital space.

3. The encroachment of vital pharyngeal space again leads to same

compensatory mechanisms as in short ramus.
 38
4. The cervical spine pulls hyoid bone and pharynx posteriorly and
superiorly and tongue also rotates similarly.

5. This brings about mouth breathing pattern.

6. Maxilla also increases in height – vertical maxillary excess.

7. And ultimately it causes LONG FACE SYNDROME

Summary 39

 Cephalometric tracings of 27 untreated adults Caucasians with reduced

lower facial height and 9 untreated adult Caucasians with increased
lower facial height were compared.

 Linear and angular measurements of both groups were analyzed and

compared.

 Like SFS, the LFS was also divided into sub-groups.

 Subtypes I was characterized by:
40
1. long ramus
2. Increased OP-PP
3. Increased SN-MP angle
4. Excessive lower facial height

 Subtype II was characterized by:

1. Extreme backward and downward rotation of mandible
2. Short or extremely short ramus
3. Increased lower anterior facial height
 It is demonstrated that many characteristics of LFS and SFS 41
were due to clockwise and anticlockwise rotation of mandible
with respect to hyoid bone tongue pharynx and cervical spine.

 The vital need to maintain patency of upper airway at the level

of the base of the tongue may account for rotation in LFS.
References 42

1. Bell, W. H., Creekmore, T. D.. and Alexander, R. G.: Surgical correction

of the long face syndrome, AM. .I. ORTHOD. 71: 40-67, 1977.
2. Opdebeeck, H. M., and Bell, W. H.: The short face syndrome, AM. J.
ORTHOD. 73: 499-511, 1978.
3. Walker, G. F. A.. and Kowalski, C. J.: A two dimensional coordinate
model to the quantification, description, analysis, prediction and
simulation of craniofacial growth, Growth 35: 191-21 I, 1971.
4. Pernkopf, E.: Atlas of topographical and applied human anatomy,
Philadelphia, 1963, W. B. Saunders Company, vol. I.
 43
3. Koski, K., and Landemaki, P.: Adaptation of the mandible in children
with adenoids. AM. J. ORIHOIX 68: 660-665, 1975.

4. Droel, R., and Isaacson, R. J.: Some relationship between the glenoid
fossa position and various skeletal discrepancies, AM. J. ORTNOD.
61: 64-78, 1972.

5. Cuttler, B. S.. Hassig. F. H., and Turpin. D. L Dentofacial changes

produced during and after use of a modified Milwaukee brace on
Macucu mulnrrcr, AM. J. ORTHOD. 61: 115-137, 1972.