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The aim of this chapter is to review the indications and biomechanics of intraoral mandibular distraction and focus on the clinical outcomes and innovations utilizing intraoral distraction devices.

Objective The purpose of this study was to biomechanically evaluate the stability of a T-shaped miniplate fixation of a modified sagittal split ramus osteotomy (MSSRO) with buccal step and to compare it with single or double-parallel straight miniplates fixing a standard sagittal split ramus osteotomy (SSRO). Study design Eighteen Synbone mandibular replicas were used in the study and divided into 3 groups. Standard SSRO was applied in the first and second groups, and the third group was cut for MSSRO with buccal step. After 7 mm of advancement, fixation modalities for the 3 groups included a single straight miniplate, double-parallel straight miniplates, and a T-shape miniplate, respectively. Each model was secured in a jig and subjected to vertical load on the anterior teeth. Results The T miniplate group showed a significantly higher value for stability than the group with a single straight miniplate. There was no significant difference in stability between the T miniplate and the double-parallel straight miniplate groups. Conclusion For mandibular advancement surgery of 7 mm in a laboratory environment, a T-shaped miniplate used with MSSRO and buccal step as a combination significantly optimize the resistance and stability of the fixation compared with a standard SSRO fixed with a single straight miniplate.

This article focuses on the emergence of the small edentulous osteoperiosteal flap.

Purpose: The purpose of this study was to analyze the skeletal and dental positional changes and histomorphology of the distraction regenerates and mucogingival periosteal tissues that occurred after simultaneous widening and bilateral lengthening of the mandible in baboons by a miniaturized intraoral bone-borne distraction appliance. Materials and Methods: Distraction appliances were activated 5 days after vertical ramus and symphyseal osteotomies at a rate of 0.9 mm/d for 10 days. The appliances were then stabilized for 8 weeks, after which the animals were killed. The distraction gaps and gingival tissues were analyzed clinically, histologically, and by standardized radiographic studies. Results: Positional changes of the canines and incisor apices were proportional to the skeletal movements. Tipping of both incisors toward the center of the distraction gap was observed. Proportionate movement of the superior and inferior portion of the distracted segments was noted. Newly formed longitudinal trabecular columns parallel to the vector of distraction originated from the intact margins of alveolar bone contiguous with the adjacent teeth. Active histogenesis occurred in the stretched mucogingival periosteal tissues located in the distraction gaps. Conclusions: The results of this investigation support the clinical use of the miniaturized intraoral bone-borne distraction appliance to selectively widen and lengthen the mandible. The orientation of the mandibular distractors must be parallel to the common vector of distraction, which should be parallel to the maxillary occlusal plane. The formation of a bone regenerate in the alveolar region depends on the presence of an adequate bone interface on either side of the distraction gap.

Transverse mandibular deficiency with crowding of the mandibular anterior teeth is frequently present in patients with Class I and II malocclusions. The hallmarks of treatment by compensating orthodontics, functional appliances or orthopaedic devices are instability, compromised periodontium and compromised facial aesthetics. A new surgical technique has been developed to widen the mandible. The method is based upon gradual osteodistraction following vertical interdental symphyseal osteotomy. Ten patients with transverse mandibular deficiency and significant dental crowding were treated by symphyseal distraction and subsequent non-extraction decompensating orthodontic treatment. Either an intraoral tooth-borne Hyrax appliance or a new custom-made bone-borne osteodistractor was used to gradually widen the mandible. The surgical procedures were accomplished under local anaesthesia and intravenous sedation in an ambulatory surgical setting using an individualized distraction protocol. The appliances were activated 7 days after symphyseal osteotomies, once each day at a rate of 1 mm per day and stabilized for 30-40 days after distraction. After the segments were distracted, non-extraction orthodontic alignment of the mandibular anterior teeth was accomplished. The symphyseal distraction gaps were bridged by new bony regenerate. Distraction osteogenesis provided an efficient surgical alternative to orthognathic surgery for widening the mandible and treatment of transverse mandibular deficiency without extraction of teeth.

Purpose: Vascular ischemia has been associated with improper soft tissue flap design, stretching of the palatal vascular pedicle, bony segmentation, transection of the descending palatal vessels, or hypotension. This study examined Le Fort I osteotomy wound healing after some of these surgical maneuvers. Materials and Methods: Clinically analogous four-segment Le Fort I osteotomies were accomplished through circumvestibular incisions in nine adult rhesus monkeys and the animals were killed at 0, 3, 7, 14, and 28 days after surgery. Revascularization and bone healing were studied by microangiographic and histologic techniques. Results: The findings indicated that the palatal mucosa or labial-buccal gingiva and mucosa provide adequate nutrient pedicles for Le Fort I osteotomies accomplished through a circumvestibular type incision. Conclusions: It was concluded that segmentalization, stretching of the vascular pedicles, or transection of the descending palatine vessels have only transitory discernible effects on revascularization and bone healing.

To evaluate systematically the biomechanical properties of 13 popular screw designs, ranging from 0.8 to 2.0 mm in diameter.Screws were characterized in terms of external, core, and drill diameter; cutting flute and head design; material; pitch, thread depth; and height of shank (unthreaded portion) and shank with plate. They were tested in standardized bone specimens (2 x 2.5cm slabs of fresh bovine femur) 1, 2, 3, and 4-mm thick. For each screw-bone thickness combination, 10 trials were conducted to determine push-out force (POF) and another 10 trials to determine insertion (IT) and maximum torque (MT) yielding a total of 1,040 tests.Among the 13 different screws, in 1-mm thick bone, both the lowest (108.5 N) and highest (294.9 N) POF were created by 2-mm screws (P.001); that with the lowest POF had a long unthreaded shank and pitch, that with highest POF had a short unthreaded shank and pitch. Screws with 0.8- to 1.5-mm diameters showed no differences in POF. The 2-mm screw with the lowest POF also had the lowest MT in 1-mm thick bone compared with the other 2-mm screws (P.001). In thicker bones (2 mm), two 2-mm screws showed 30% to 50% lower MT than the other same size screws (P.001) because their head slots stripped easily. When all screws were considered together for a particular bone thickness, torque was strongly predicted by screw diameter (MT: r = .94, P.001; IT: r = 0.92, P.001). Screws with the same diameters varied significantly in IT because of differences in self-tapping cutting flute design.External diameter, unthreaded shank height, head slot, and self-tapping cutting flute design had the greatest impact on screw strength and efficiency in thin cortical bone. Thread depth, core diameter, and metal type did not affect performance significantly. Under these highly standardized in vitro conditions, the ideal 2-mm screw has an unthreaded shank that is as short as possible, and the pitch is about 0.8 mm. Additional aspects of a clinical situation beside holding strength must, however, be considered when choosing a screw.

Summary When a large chin advancement is performed and a broad musculo-periosteal pedicle is preserved, excessive stretching of the suprahyoid musculature may occur, leading to instability or resorption of the advanced genial segment. The present study was designed to evaluate long-term osseous and soft tissue changes after large advancement genioplasties (greater than 10 mm), achieved by horizontal osteotomy of the inferior border of the mandible, with preservation of a musculo-periosteal pedicle to the advanced genial segment. Bone remodeling and the inherent soft tissue changes were radiographically assessed in a long-term follow-up period (mean = 26.8 months), with attention to observe progressive osseous changes. Despite the observed 17% bone resorption, the enveloping soft tissues of the chin followed the bony movement in a ratio of 1:0.83. Osseous resorption was not progressive, and the soft tissue changes remained unaltered. A broad musculo-periosteal pedicle consistent with the surgical objective should remain attached to the advanced genial segment to minimize osseous resorption and achieve more predictable soft tissue changes. We emphasize the need for a longer follow-up period (25–30 years) to determine the effect of the stabilization devices and osseous remodeling, specially in younger patients.

Regional odontodysplasia is an uncommon condition of variable expression and unknown etiology. A case of unilateral maxillary regional odontodysplasia associated with asymmetric maxillary and mandibular development and consequent facial asymmetry is reported.

A 55-year-old black man, an intravenous substance abuser who had an acute arterial embolus to the distal aorta originating from his mitral valve, was noted on pathologic examination of the clot to have aspergillosis emboli. The infective endocarditis also resulted in emboli to the brain with subsequent death.

Of 72 consecutive patients needing abdominal aortic surgery, the transperi toneal approach (TA) was used in 34 patients. In this TA group, with a mean age of fifty-eight years, 28 patients had aortoiliac or aortobifemoral grafts. Of the 38 patients operated via the retroperitoneal approach (RA), 27 had aortoiliac disease and 11 had aneurysms. In the RA group, the mean age was fifty-nine years; 32 patients in this group had aortofemoral grafts. The groups were simi lar with regard to hypertension, heart disease, obstructive pulmonary disease, previous myocardial infarction, and stroke. The TA was associated with the larger intraoperative blood loss (1,100 mL) when compared with the RA (mean: 400 mL). Intraoperative crystalloid re quirements were significantly higher for the TA (5,500 mL) versus the RA (3,000 mL). Similarly, the intraoperative blood requirements were higher for the TA (3.0 units packed red blood cells [PRBC]) than the RA (1.0 unit PRBC). The numbers of units of PRBC transfused after surgery were significantly less with the RA (1.25 units) compared with the TA (0.5 unit). The total operative time for the TA was 225 minutes; the time for the RA was 165 minutes (p < 0.01). The number of hospitalized postoperative days in the TA was 11.5 compared with 6 days in the RA; average number of days of nasogastric intubation was 4 days for the TA compared to 0.25 day for the RA; and tolerance for regular food was initiated at 5.5 days in the TA compared with 1.5 days in the RA. The number of hours of postoperative intubation for the TA was an average of 19.5 compared with 4.5 for the RA; the number of postoperative verbal orders in the TA was 14.0 compared with 4.5 in the RA; and complications in the TA were six times greater than in the RA. Most of the TA complications were pulmonary; these were not present in the RA. The incidence of wound infection was zero in both groups; mortality was zero in both groups. The average hospital cost of the TA was $20,125.26 compared with $5,164.05 for the RA. The RA for abdominal aortic vascular surgery is more cost effective than the TA.

Carotid surgery without preoperative arteriography was performed in 101 consecutive patients with an average age of 68.5 years and almost equal sex distribution. This prospective study analyzed risk factors, operative approach, bruits, indications for surgery, and outcome. All patients were studied by real-time B-mode ultrasound and spectral analysis and none were referred for arteriogram. The majority of patients had a standard carotid endarterectomy, and the findings at surgery correlated with noninvasive imaging. No mortality was recorded in this series of patients; a 1% rate of neurologic morbidity was noted. These results suggest that one can safely operate on the basis of a duplex scan. A preoperative arteriogram is not always necessary for carotid evaluation.

Purpose This preliminary study assesses the positional changes of the maxilla after simultaneous 3-dimensional Le Fort I osteotomy and distraction osteogenesis (3D-LFI/DO). Patients and Methods The records of 18 patients, 17.7 years of age (range, 12-38 years) at the time of surgery, manifesting transverse maxillary deficiencies and variable sagittal/vertical deformities were evaluated presurgically and 3 years postsurgery (range, 1 to 10 years). All patients underwent midsagittal 2-piece Le Fort I osteotomies. The planned sagittal and vertical positional changes were immediately performed by the Le Fort I surgery. After a latency period of 5 to 7 days, maxillary expansion was slowly achieved by distraction osteogenesis using a Hyrax appliance activated 1-mm/day. Once the planned transverse expansion had been attained, the Hyrax device served as a retention appliance for 8 to 12 weeks, after which the distraction gap was orthodontically closed. The morphological changes were assessed by comparing standardized preoperative and postsurgical models, posterior-anterior radiographs, and lateral cephalograms. Results Class I canine and molar relationships, along with satisfactory sagittal and vertical skeletal relationships, were observed at follow-up. The maxilla was advanced (1.5-1.8 mm) and positioned either superiorly or inferiorly (1.2-2.9 mm), depending on the original deformity. The arch perimeter increased 5.4 mm and the arch width increased between 4.2 and 6.6 mm. The maxillary expansion was nonparallel, greater anteriorly and inferiorly. Conclusions The 3D-LFI/DO can be used to simultaneously and selectively widen, lengthen and vertically reposition the maxilla, producing acceptable post-treatment skeletal and dental relationships, without healing problems observed clinically.

The purpose of this study was to analyse the skeletal changes and stability of the distracted segments during and after simultaneous widening and bilateral lengthening of the mandible in baboons with a miniaturized intraoral bone-borne osteodistractor. Distraction appliances were activated 5 days after vertical posterior body and midsymphyseal osteotomies at a rate of 0.9 mm/day for 10 days. The appliances were then stabilized for a period of 8 weeks, after which the animals were killed. The distraction gaps and gingival tissues were studied clinically and on standardized radiographs. The proportional movement of the distracted segments that we found supports the clinical use of the miniaturized intraoral bone-borne distraction appliance to widen and lengthen the mandible selectively. It also supports the concept of positioning the mandibular osteodistractors parallel to the common vector of distraction, which should parallel the corrected maxillary occlusal plane.

The purpose of this study was to evaluate the effects of mandibular symphyseal distraction osteogenesis using a tooth-borne expansion device. The sample included 20 Hispanic nonsyndromic patients (11 males and 9 females) between 13.5 years and 37.3 years of age. Predistraction (1.5 months before surgery), postdistraction (1 month after surgery), and long-term follow-up (1.3 year after surgery) records included posteroanterior, lateral, and panoramic radiographs and models. Postdistraction radiographic evaluation showed that symphyseal distraction osteogenesis produced insignificant increases in the bicondylar, bigonion, and biantegonion widths; intermolar and, especially, intercanine widths increased significantly and a distraction gap was observed in the symphyseal region. Follow-up model analysis showed the largest width increases between the first molars and second premolars and the smallest width increases between canines and first premolars. The difference between the postdistraction and long-term follow-up width changes was explained by the postdistraction orthodontic effect, which modified the shape of the dental arch. A disproportionate pattern of distraction, characterized by significantly greater dental than skeletal widening, was observed in the second molar and antegonion region. Distraction osteogenesis without presurgical orthodontic treatment produced significant proclination of the mandibular incisors; no proclination was observed in cases with predistraction orthodontic treatment. Dental crowding was resolved by the movement of teeth into the distraction regenerate and concomitant orthodontic treatment. Follow-up radiographs showed transverse skeletal stability of the distraction procedure. We conclude that mandibular symphyseal distraction osteogenesis increased mandibular arch width and partially corrected dental crowding, with a potential for disproportionate distraction patterns and proclination of the mandibular incisors.

This study was designed to examine whether the use of electrical stimulation during mandibular lengthening accelerates new bone formation. Twenty adult female rabbits weighing between 2800 g and 3200 g underwent left mandibular body osteotomy. After a 3 day latency period, an external fixation device was activated at a rate of 0.7 mm per day for 10 days. Direct current electrical stimulation of 10 microA was applied to 10 rabbit mandibles. Two of the screws were used as electrodes during the distraction phase. The other 10 rabbits (control group) were not stimulated. The device was then stabilized for periods of 10, 20, 30 and 60 days in both groups. The distraction segment was evaluated radiographically by assessing the proportion of bone mineral density using a dichroma scan. The amount of new bone formation was studied histologically with an image analyzer to evaluate the bone formation in the distraction gap. Histological examination showed that the new bone formation 10 and 20 days after distraction was greater in the electrical stimulation group than in the control group. Ten and 20 days after distraction, image analysis and analysis of bone mineral density in areas of newly formed bone indicated that there was a greater amount of new bone formation in the stimulation group than in the control group. The radiographic evaluation, however, did not demonstrate significantly different images between the stimulation group and the control group. Thirty and 60 days after distraction, no difference in the amount of new bone formation was noted in either the experimental or the control groups. These results indicate that electrical stimulation during gradual distraction promotes new bone formation in the early retention period in a rabbit model.

The purpose of this study was to evaluate the histologic changes within the condyle in response to mandibular widening using osteodistraction. Mandibular midline osteotomies were made in nine Macaca mulatta monkeys and tooth-borne distraction devices were bonded to the mandibular dentition. Distraction was continued until a 3-5 mm widening was achieved. The appliances were then stabilized for a period of 4 weeks. Non-decalcified sagittal sections of the lateral, middle and medial thirds of the condyles were analyzed. Although three of the seven animals showed no unusual morphology, four others exhibited morphologic differences within the fibrous layer, cartilage layer or bone/cartilage interface. Histologic changes were seen to occur in the fibrous layer, cartilaginous layer and cartilage/bone interface. The severity of these changes were correlated with the likely rotational forces directed at the condyle on the postero-lateral and antero-medial surfaces.

The purpose of this investigation was to elucidate the biology of distraction osteogenesis during mandibular widening. Midsymphyseal vertical interdental osteotomies were performed in nine Macaca mulatta monkeys. After a latency period a tooth-borne appliance was activated at a rate of 0.5 mm twice a day for 7-10 days. The appliance was then stabilized for a period of 4 or 8 weeks. The distraction gap at the inferior portion of the symphysis was bridged completely by new bony trabeculae. Bone formation in the interdental area was apparently related to the surgical technique. Newly formed bony trabeculae were oriented parallel to the direction of distraction. The location of the osteotomy site with an adequate margin of alveolar bone contiguous with the adjacent teeth was necessary for the induction of the distraction osteogenesis. Disproportional movement between superior and inferior portions of the distracted segments was noted.

A cephalometric analysis of the submental-cervical region was carried out by examining and comparing 16 white adults who had ideal submental-cervical esthetics with 16 adult orthognathic surgery patients who were treated by submental lipectomy or liposuction and various orthognathic surgical procedures. A normative data base of the submental-cervical region was derived from the ideal subject group. The submental-cervical morphology of the preoperative patients differed significantly from the ideal subjects. The submental-cervical angle (Sm-Ce) and the submental soft tissue thickness at C point (IBM-Sm) presented the greatest disparity between the ideal subjects (118.0 degrees, 28.0 mm) and the preoperative patients (158.3 degrees, 42.1 mm, each P.001). After surgery, Sm-Ce and IBM-Sm decreased to 132.8 degrees (P.001) and 28.7 mm (P.001), respectively. By the end of 6 months postoperative, the mean values of Sm-Ce and IBM-Sm were 131.1 degrees and 28.6 mm. The submental soft tissue thickness of the patients 6 months after surgery was not statistically different from the ideal subjects (each P.05). Orthognathic surgical procedures with concomitant submental lipectomy or liposuction had a significant effect on the contour of the submental and cervical soft tissues.

The positional relationship between the high-level Le Fort I osteotomy and the nasolacrimal canal was studied in standard posteroanterior and lateral cephalograms made of 100 adult dry skulls after orienting the Frankfort horizontal of each skull to the natural horizontal plane. The simulated high-level Le Fort I osteotomy in all of the 100 skulls was under the level of the inferior orifice of the nasolacrimal canal by a mean distance of 5.2 mm (range, 0.5 to 11.5 mm). The average distance between the canal orifice and a line which extended from the lacrimal fossa to the anterior attachment of the inferior turbinate was 0.7 mm (range, 2.0 mm medially to 3.5 mm laterally). The maxillary height was strongly correlated to the height of the infraorbital foramen (r = .59, P less than .001) and the simulated osteotomy (r = .57, P less than .001). The results indicate that the osteotomy, when made just beneath the infraorbital foramen and extending into the piriform rim at the level of anterior attachment of the inferior turbinate, will usually not jeopardize the nasolacrimal duct within its bony canal. A line drawn from the lacrimal fossa to the anterior attachment of the inferior turbinate on the anterior aspect of the maxilla is a good approximation of the course of the nasolacrimal canal.

Treatment of adults with vertical maxillary deficiency (short faces) has continually been an intriguing challenge for surgeons and orthodontists. For this category of patients, the introduction of simultaneous bone grafting and Le Fort I osteotomy has opened the door for improved treatment. However, despite the improved surgical techniques, surgeons have been reluctant to increase the vertical dimension of the maxilla by Le Fort I osteotomy with interpositional bone grafts because of inconsistent and variable stability after surgery. This study examines structural and functional adaptation of the adult temporomandibular joint and stability in a primate model following surgical lengthening of the maxilla in the vertical dimension. Results suggest that maxillary surgery and autorotation can alter condylar stress within physiologic ranges. However, further studies are indicated to clarify the surgery's long-term effect.

Large advancement genioplasties were performed in 10 patients (mean advancement, 11.7 mm) by horizontal osteotomy of the inferior border of the mandible, with preservation of a musculoperiosteal pedicle to the advanced genial segment. Preoperative, immediate postoperative, and long-term follow-up lateral cephalometric radiographs were retrospectively analyzed to evaluate the osseous and soft-tissue changes of the chin. After a mean follow-up period of 15 months, 76% of the initial advancement was preserved, representing 24% osseous resorption. The enveloping soft tissues of the chin followed the bony movement in a ratio of 1:0.88. Horizontal osteotomy of the inferior border of the mandible was a relatively stable procedure when used for large chin advancements. The broadcast possible musculoperiosteal pedicle should remain attached to the advanced genial segment to minimize osseous resorption and to achieve more predictable soft-tissue changes.

This volume details leading edge orthognathic and reconstructive surgery procedures. Coverage explains the "why's" of maxillary and mandibular and combined surgical procedures, how to perform the techniques and their results. The book also stresses diagnosis and treatment planning.

Ten adult midsagittaly sectioned cadaver heads were used to measure the distance between the apex of the central incisor or canine teeth and the attachment of the genioglossus or geniohyoid muscles. Measurements were made on both cadaver specimens and radiographs. The results of the two methods showed no statistically significant difference. The results indicate that there is a relatively small chance (5.6%) of including the genioglossus attachment in the lingual pedicle if an anterior mandibular subapical osteotomy is positioned 3 to 5 mm below the incisor apex but a large chance (65%) of including the genioglossus muscle when the osteotomy procedure includes the canine teeth.

Inferior repositioning of the atrophic maxillary edentulous alveolar ridge by LeFort I osteotomy and simulataneous bone grafting, and superior repositioning of the atrophic mandibular edentulous ridge by horizontal osteotomy of the mandibular body and simultaneous bone grafting have been accomplished successfully. These two new surgical procedures add a new dimension to treatment of severe atrophy of the alveolar ridges in edentulous or partially edentulous patients.

A two-dimensional model which allows calculation of mechanical advantage of the human temporalis and masseter muscles is presented. The model is manipulated to demonstrate how selected differences in facial morphology affect the mechanical advantage of the muscles. The model is then used to evaluate the differences in mechanical advantage between patients with the long face syndrome and those with the short face syndrome. Differences in facial morphology between these two groups result in significant differences in the mechanical advantages of their muscles. Mechanical advantage may, in part, explain observed differences in bite force between the two groups. The model suggests that some surgical procedures used to correct facial disharmonies may have a significant effect on the mechanical advantage of the jaw muscles.

Transient pulpal vascular ischemia and direct injury to the apices of the teeth have been implicated as the causes of degenerative and atrophic pulpal changes in experimental animals after Le Fort I osteotomy despite the presence of collateral circulation. The long-term clinical effect of these pathologic changes in human teeth has not been studied. Seventeen maxillary third molar teeth from 10 patients whose postsurgical follow-up ranged from 6 months to 78 months (mean, 40 months) were extracted. The long-term biologic effects of Le Fort I osteotomy on the pulp and on the development of teeth were retrospectively evaluated with clinical and standard histologic techniques. Normal teeth from patients who were not operated on were used as controls. Histologic examination revealed an intact pulpal circulation and minimal pathologic changes in the pulpal tissue. Clinical and radiographic studies showed that the growing teeth developed normally after surgery. The Le Fort I downfracture procedure had little discernible long-term effect on the pulp and on the development of human third molar teeth.

Summary Cephalometric prediction tracings are used in concert with biomechanical modelling to simulate jaw movements and soft tissue profile changes associated with the surgical correction of vertical maxillary excess and absolute mandibular deficiency. Cephalometric prediction studies are used to identify positional changes which have a known propensity to relapse or be stable and when used in concert with biomechanical modelling, serve as an adjunct in designing surgical procedures to achieve skeletal stability, good facial profile aesthetics, biomechanical efficiency and long-term skeletal stability.

A retrospective study of the osseous and soft tissue changes of the chins of ten patients treated for vertical maxillary excess by Le Fort I osteotomy and advancement genioplasty was undertaken. The patients were characterized by excessive lower anterior facial height, obtuse or normal nasolabial angles, prominent maxillary incisors, lip incompetence, everted lower lips, anterior open bites, lack of chin prominence, and excessive chin height. A change in the proportion of osseous to soft tissue of 1.0 to 0.87 was obtained by advancement genioplasty and concomitant superior repositioning of the maxilla by Le Fort I osteotomy.

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 dentofacial 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. Variable open-bite and nonopen-bite maxillary deformities in forty adults with the long face syndrome were corrected by Le Fort I osteotomy and orthodontic treatment. The technical problems encountered in planning and executing treatment are discussed and illustrated by selected case reports.