973032

review-article20202020
FACXXX10.1177/2732501620973032FACE: Journal of the American Society of Maxillofacial SurgeonsPosnick and Kinard

Article

FACE

Common Patterns of Developmental

2020, Vol. 1(2) 131­–139
© The Author(s) 2020
DOI: 10.1177/2732501620973032
https://doi.org/10.1177/2732501620973032

Dentofacial Deformities: A Biologic journals.sagepub.com/home/fac

Classification System

Jeffrey C. Posnick1-4 and Brian E. Kinard1,5

Abstract
Jaw disharmonies that are recognized after birth and that present in association with the pre-pubertal growth spurt are called
developmental dentofacial deformities. These deformities occur during the normal growth phase of the face with degrees
of either excess or deficiency in one or more vectors of the jaws. Clinical observation combined with radiographic analysis
confirms that developmental dentofacial deformities tend to occur in 6 distinct and repetitive biologic patterns. Once the
individual’s jaw growth pattern is known, the natural progression of their deformity, the functional consequences on speech
articulation, chewing ability, swallowing mechanism, and breathing, and the locations of skeletal dysmorphology that require
surgical intervention fall into place. The purpose of the manuscript is to review the 6 common patterns.

Keywords
orthognathic, dentofacial, deformity, short face, long face

In humans, jaw disharmonies that are recognized after birth and
that present in association with the pre-pubertal growth spurt
are called developmental dentofacial deformities. This excludes
jaw deformities that are due to: malformations, trauma, cleft
lip/palate, and auto-immune disorders. Developmental dento-
facial deformities occur during the normal growth phase of the
face with degrees of either excess or deficiency in one or both
jaws. A biologic basis for the observed common patterns of
developmental jaw deformities may be a combination of hered-
itary (ie, race or familial predisposition) and/or due to environ-
mental factors (ie, open mouth posture due to nasal obstruction
or masticatory muscle hypotonia).
Over the last many thousands of years, the human cranial
capacity has increased in volume with an upright shaped
forehead to accommodate an expanding brain while the jaws
have become smaller.1 As the sinus cavities have reduced in
volume and the jaws have become retrusive, the number and
size of the teeth have remained relatively constant. This
means that in a retrusive jaw there is less available dentoal-
veolar bone to support a full complement of dental roots. For
many humans, this results in intra-arch dental crowding with
tipping, rotation, and displacement of the teeth outside of an
insufficient volume of supporting dentoalveolar bone.2-6
Even when jaw size is in the “normal” range, humans typi-
cally have insufficient arch volume for the third molars.
Also, over the millennia, with the mixing of diverse popula-
tions there is a greater degree of mismatch in upper to lower
jaw size resulting in increased prevalence of interarch
malocclusion.7,8
The resulting developmental dentofacial deformities seen
in humans limit the ability of the lips, tongue, soft palate, and
the teeth in each jaw to optimally approximate each other
during speech, swallowing, and chewing.7-9 Also, when the
maxilla is retrusive and deficient, the intranasal anatomy (ie,
septum, turbinates, nasal floor, pyriform width) is typically
negatively impacted. The resulting increased intranasal air-
way resistance affects ease of breathing causing chronic
obstructive nasal breathing (CONB) and may also limit sinus
drainage.10 Another evolutionary finding is that the human
head has become more upright which alters the relationship
of the craniofacial complex to the cervical spine. This rela-
tionship further limits the retropalatal and retroglossal upper
airway spaces. When combined with weight gain due to a
sedentary lifestyle, this has led to a dramatic increase in the
incidence of obstructive sleep apnea (OSA) in humans.11
Recognizing these evolutionary human anatomic findings
help to set the objectives for successful orthognathic surgical
outcomes. Treatment may include (1) The need to expand the
upper airway space to relieve OSA and to correct CONB. (2)
1
Posnick MD consulting, Potomac, MD, USA
2
Georgetown University Washington, DC, USA
3
University of Maryland School of Dentistry, Baltimore, MD, USA
4
Howard College of Dentistry, Washington, DC, USA
5
University of Alabama Birmingham, Birmingham, AL, USA
Corresponding Author:
Jeffrey C. Posnick, 10100 Counselman Road, Potomac, MD 20854,
USA.
Email: jposnick@drposnick.com
132 FACE 1(2)

Figure 1. A 15-year-old Caucasian girl with a long face jaw growth pattern. The history and physical examination confirmed lifelong
nasal obstruction and mild OSA, both jaws are long, retrusive and clockwise rotated. Her facial aesthetic concerns included an
awareness of a weak chin, a gummy smile, wide lip separation, and a deep lip curl. She underwent a coordinated non-extraction
orthodontic and segmental bimaxillary orthognathic and intranasal surgery approach (from Posnick, JC: Long Face Growth Patterns:
Maxillary Vertical Excess with Mandibular Deformity. Orthognathic Surgery: Principles and Practice. 1st Edition (J. C. Posnick ed) St.
Louis, Elsevier. Ch. 21, Figure 21–2, pp. 768-770, 2014).

The need to expand the maxillofacial skeleton to optimize •• – Hemi-Mandibular Hyperplasia

facial aesthetics and to limit visual perceptions of facial aging.
(3) The need to extract expendable teeth (ex, premolars)
allowing the remaining dental roots to be centered into den-
toalveolar housing in support of long term dental health.
Developmental jaw deformities are also known to have nega-
tive effects on the social perceptions of others. The implica-
tions for this on the individual’s body image and self-esteem
are additional important considerations.12-16
Clinical observation combined with radiographic analysis
confirms that developmental jaw deformities tend to occur in
6 distinct and repetitive biologic patterns. Once the individu-
al’s jaw growth pattern is recognized, the natural progression
of their deformity, the functional consequences (ie, effects on
speech, chewing, swallowing, breathing), and the locations
of skeletal dysmorphology that require surgical intervention
fall into place.13,17-22 This biologic classification system
assists the clinician towards an accurate and comprehensive
diagnosis which takes into account the patients: upper air-
way, facial aesthetic, and long-term dental health needs. The
6 common jaw growth patterns include:
•• Long Face Growth Patterns
•• Short Face Growth Patterns
– Short Face Type I
– Short Face Type II
•• Primary Maxillary Deficiency Growth Patterns
•• Primary Mandibular Deficiency Growth Patterns
•• Asymmetric Mandibular Excess Growth Patterns
•• – Hemi-Mandibular Elongation
•• Bimaxillary Dental Protrusive Growth Patterns
Long Face Jaw Growth Patterns
The long face dentofacial deformity was first described as a
distinct pattern by Schendel et al in 1976.23 It is a pattern of
facial disharmony that presents with marked lower anterior
facial height (LAFH) (see Figure 1). In this deformity,
assessing the ratio of the LAFH to the upper anterior facial
height (UAFH) will confirm that the lower height is exces-
sive. The height of the alveolar process in both jaws is
increased. There is frequently an anterior bite with excess
overjet malocclusion.
•• Long face jaw deformities have marked excess in
lower anterior facial height (LAFH).
•• The ratio of the LAFH to the upper anterior facial
height (UAFH) will confirm that the lower height is
excessive.
•• The height of the dentoalveolar process in both jaws is
increased.
•• Both jaws are typically long, retrusive, and clockwise
rotated which limits the retropalatal and retroglossal
upper airway spaces and predisposes to OSA.
•• A hypoplastic arch form is typical which results in
crowding of the dental roots and predisposes to peri-
odontal sequalae if not addressed.
Posnick and Kinard
Figure 2. Facial profile, lateral cephalometric radiograph and occlusion views demonstrating classic Short Face Type I maxillofacial
findings. (From Posnick JC, Kinard BE, Singh N, Ogunsanya O: Short Face Dentofacial Deformities: Changes in Social Perceptions,
Facial Esthetics, and Occlusion after Bimaxillary and Chin Orthognathic Correction. Journal of Craniofacial Surgery 31:633, 2020.
Figure 1).
•• The maxillary incisors are often fully exposed below
the upper lip causing a “toothy” appearance in repose
and excess gingival show during smile. The lips are
widely separated when at rest with strain at attempted
closure.
•• An open mouth posture often due to chronic nasal
obstruction (ie, blocked intranasal airway space) is
typical.
•• An anterior open bite is frequent, but a closed bite can
also occur.
•• The Angle class of malocclusion is typically class II
with excess overjet but may be class I or class III with
negative overjet.
•• The maxillary arch form is typically narrow and with
an excess reverse curve of Spee.
•• When associated with a class II excess over jet, the
chin will lack prominence.
•• The neck to chin angle is often obtuse with “bunch-
ing” of the anterior neck soft tissues.
•• The nose appears prominent and the cheekbones
appear flat.
Short Face Jaw Growth Patterns
The short face dentofacial deformity is a pattern of facial
disharmony that presents with significant vertical and hori-
zontal deficiency in the maxilla and mandible (see Figures 2
and 3). In this deformity, the lower anterior facial height is
decreased, as measured by the ratio of the LAFH to the
133
UAFH.24 The height of the alveolar process in both jaws is
reduced. The Angle class of malocclusion (class I vs class
II) and extent of overjet and overbite discrepancy in short
face jaw growth patterns will vary according to the 2 sub-
types (see below).
•• Short face jaw deformities are most common in
Caucasians and rarely occur in Africans.
•• In short face dentofacial deformities both jaws must
have significant vertical and horizontal deficiency.
•• The ratio of the LAFH to the UAFH will confirm that
the lower facial height is decreased.
•• The height of the dentoalveolar process in both jaws is
decreased.
•• Hypoplastic arch forms risk crowding of the dental
roots within limited dentoalveolar bone which predis-
poses to periodontal sequelae if not addressed.
•• Both jaws are typically short, retrusive and counter-
clockwise rotated (ie, flat occlusal plane) which limits
the retropalatal and the retroglossal upper airway
spaces, predisposing to OSA.
•• The maxillary incisors are often completely covered
by the upper lip creating an edentulous appearance in
repose and an unfavorable smile with no gingival
show.
•• A sad or unhappy look is created due to the down-
turned oral commissures and closed oral aperture.
•• An Angle class I deep bite or mild class II without
excess overjet malocclusion (Short Face Type I) is
134
Figure 3. Facial profile, lateral cephalometric radiograph, and occlusion views demonstrating classic Short Face Type II maxillofacial
findings. (From Posnick JC, Kinard BE, Singh N, Ogunsanya O: Short Face Dentofacial Deformities: Changes in Social Perceptions, Facial
Esthetics, and Occlusion after Bimaxillary and Chin Orthognathic Correction. Journal of Craniofacial Surgery 31:633, 2020. Figure 1).
common which reflects closely matched horizontal
deficiency of both jaws (see Figure 2).
•• In Short Face Type I, there will be a flat occlusal
plane (ie, counterclockwise rotated jaws) with a
prominent appearing pogonion. This results in the
appearance of square-shaped jaws and prominent
appearing cheekbones.
•• An Angle class II with excess overjet malocclusion
(Short Face Type II) is also a common presentation of
short face. This pattern reflects a greater degree of
horizontal deficiency in the mandible than in the max-
illa (see Figure 3).
•• In Short Face Type II, pogonion will lack prominence,
the labio-mental fold will be deep, and the lower lip
will be everted.
Primary Maxillary Deficiency Jaw
Growth Patterns
Maxillary deficiency developmental jaw deformities are
often casually referred to as mandibular prognathism (see
Figure 4). Primary maxillary deficiency is a pattern of facial
disharmony that presents with horizontal retrusion of the
upper jaw as an essential component of the deformity. This
should be differentiated from others patterns of dentofacial
deformity typically associated with class III malocclusion
(eg, unilateral condylar hyperactivity) and those that are
occasionally associated with a class III malocclusion (eg,
long face and bimaxillary dental protrusion). In primary
maxillary deficiency jaw growth patterns, there is always a
class III malocclusion with negative overjet and the dental
midlines are coincident. This pattern of malocclusion limits
FACE 1(2)
any confusion with unilateral condylar hyperactivity as the
cause of the class III (see section to follow on asymmetric
mandibular excess).
•• Primary maxillary deficiency dentofacial deformities
can occur in any race but they are most prevalent in
the Asian population.
•• Horizontal maxillary deficiency is an essential com-
ponent of the deformity which is often misinterpreted
as mandibular prognathism.
•• An Angle class III negative overjet malocclusion with
coincident dental midlines is always present which
essentially rules out unilateral condylar hyperactivity.
•• Procumbent maxillary incisors and retrusive mandib-
ular incisors are common dental compensations.
•• Deformity of the mandible is also expected with need
to adjust the pitch, roll, yaw orientation, or simultane-
ously adjust the horizontal dimension as part of the
orthognathic correction.
•• A prominent appearing chin in profile and a thick
appearing lower lip are both reflections of the degree of
maxillary deficiency and reverse over jet malocclusion.
•• The nose may appear prominent and the cheekbones
may appear flat with a sunken midface and a hypo-
tonic upper lip.
Primary Mandibular Deficiency Jaw
Growth Patterns
Primary mandibular deficiency dentofacial deformities pres-
ent with horizontal retrusion of the lower jaw as an essential
component (see Figure 5). It should be differentiated from
Posnick and Kinard 135

Figure 4. A 19-year-old of Asian descent with a primary maxillary deficient growth pattern. He has an Angle class III negative overjet
anterior open bite malocclusion with coincident dental midlines. The mandible is also involved and requires surgical repositioning. He
has a lifelong history of obstructed nasal breathing. The upper facial skeleton is symmetric and proportionate; the soft-tissue envelope
is distorted but not malformed. He underwent a coordinated non-extraction orthodontic and segmental bimaxillary orthognathic
approach. (From Posnick, JC: Standard Analytic Model Planning for Orthognathic Surgery. Orthognathic Surgery: Principles and Practice.
1st Edition (J. C. Posnick ed) St. Louis, Elsevier. Ch. 13, Figure 13–1, pp. 375-376, 2014).

Figure 5. A 14-year-old Caucasian girl with a primary mandibular deficiency growth pattern. She is with an Angle class II excess overjet
malocclusion with coincident dental midlines. The maxillary arch width is narrow and the upper jaw also lacks full projection. She
underwent a coordinated non-extraction orthodontic and segmental bimaxillary approach.(From Posnick, JC: Definition and Prevalence
of Dentofacial Deformities. Orthognathic Surgery: Principles and Practice. 2nd Edition (J. C. Posnick ed, B. Kinard, assoc. ed.) St. Louis,
Elsevier. Ch. 3, Figure 3–7, 2021 (In Press)).

other patterns of DFD also associated with horizontal defi- modification attempts) the pattern of malocclusion will be a
ciency of the mandible including short face, long face, and class II excess overjet with coincident dental midlines. This
bimaxillary dental protrusion. In untreated primary mandib- pattern of malocclusion prevents confusion with unilateral
ular deficiency (ie, no previous orthodontics or growth condylar injury as a cause of the class II.
136 FACE 1(2)

Figure 6. A teenage girl with right side Hemi-Mandibular Hyperplasia (HMH) that occurred during the prepubertal growth spurt. She
demonstrates a typical phenotype for HMH as described within the text. (From Posnick, JC: Asymmetric Mandibular Excess Growth
Patterns. Orthognathic Surgery: Principles and Practice. 1st Edition (J. C. Posnick Ed) St. Louis, Elsevier. Ch. 22, Figure 22–2, pp. 810, 2014).

Figure 7. A teenage boy with right sided Hemi-Mandibular Elongation (HME) that occurred during the prepubertal growth spurt.
He demonstrates a typical phenotype for HME as described in the text. He underwent a coordinated non-extraction orthodontic and
segmental bimaxillary orthognathic approach. (From Posnick, JC: Asymmetric Mandibular Excess Growth Patterns. Orthognathic Surgery:
Principles and Practice. 2nd Edition (J. C. Posnick ed, B. Kinard, assoc. ed.) St. Louis, Elsevier. Ch. 22, Figure 22–8, 2021 (In Press)).

•• Primary mandibular deficiency dentofacial deformi-
ties can occur in any race but they are most commonly
seen in Caucasians.
•• Horizontal mandibular deficiency is an essential
component.
•• An Angle class II excess overjet malocclusion with
coincident dental midlines is always present which
essentially rules out unilateral condylar trauma.
•• The maxillary arch width is frequently constricted
with a degree of upper jaw horizontal deficiency while
the vertical dimension is generally acceptable (ie not
Long Face or Short Face).
Asymmetric Mandibular Excess Jaw
Growth Patterns
Asymmetric mandibular excess growth patterns describe a
specific type of dentofacial deformity that occurs after birth
and results from unilateral condylar hyper activity that occurs
during the prepubertal growth spurt (see Figures 6 and 7).
Posnick and Kinard 137

Figure 8. A 16-year-old girl of African descent with a bimaxillary dental protrusion growth pattern associated with a jaw disharmony.
There is excess lower anterior vertical height and horizontal retrusion of both jaws. She is with lip incompetence, gummy smile,
chronic nasal obstruction, and a weak profile. There is an Angle class II anterior open bite malocclusion with procumbent incisors. She
underwent a coordinated non-extraction orthodontic and segmental bimaxillary orthognathic and intranasal surgery approach. (From
Posnick, JC: Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony. Orthognathic Surgery: Principles and Practice.
1st Edition (J. C. Posnick ed) St. Louis, Elsevier. Ch. 24, Figure 24–1, pp. 900-902, 2014).

Obwegeser et al believe that two unique growth regulars acting
from within the condyle explain the two distinct physical pre-
sentations of this pattern of dentofacial deformity25 (see below).
•• Asymmetric mandibular excess growth patterns occur
during the pre-adolescent growth spurt and should be
differentiated from jaw asymmetries which are pres-
ent at birth. They primarily affect the low jaw and are
caused by unilateral condylar hyperactivity.
•• The first of two clinical patterns of asymmetric man-
dibular excess are a rarer form (5% of case). It results in
what is called Hemi-Mandibular Hyperplasia (HMH).
•• HMH is characterized by an increase in volume of all
parts of the hemimandible with involvement ending
exactly at the midline of the symphysis (see Figure 6).
•• In HMH there is a downward and medial thrust/rota-
tion of the entire hemimandible without a lateral shift
of the mandible to the contralateral side.
•• In HMH, the downward and medial thrust of the man-
dible creates an ipsilateral posterior open bite, which
is at least partially offset by hyper-eruption of the pos-
terior maxillary dentoalveolar complex. This results
in a varied degree of maxillary cant (ie, roll orienta-
tion deformity).
•• The anterior occlusion remains relatively normal
without either a lateral shift of the mandibular dental
midline or a negative overjet or open bite.
•• The second clinical pattern of asymmetric mandibular
excess is the more common form (95% of cases). It
results in what is called Hemi-Mandibular Elongation
(HME).
•• HME is characterized by an “elongation” of the
affected condyle-condylar neck complex with a con-
sistent lateral shift of the mandible to the contralateral
side. This lateral shift of the mandible is best visual-
ized at the chin (see Figure 7).
•• In HME, this also results in a lateral shift of the man-
dibular dental midline and a posterior crossbite on the
contralateral side. It creates a greater molar class III
malocclusion on the ipsilateral side and a lesser molar
class III (or class I) on the contralateral side. Depending
on the extent of condylar hyperactivity the anterior
overjet may be normal or negative and the overbite may
be normal or open.
•• The extent of skeletal dysmorphology for both sub-
types (ie, HMH and HME) is dependent on multiple
factors including: the intensity of the cellular hyperac-
tivity of the condyle, the patient’s age when the abnor-
mal hyperactivity began, the length of time that it
remained active; any underlying hereditary dentofa-
cial deformity (ie, short face growth pattern), environ-
mental factors (ie, mouth breathing), and any treatment
previously rendered (ie, orthodontics or growth modi-
fication attempts) before arrival for evaluation.
Bimaxillary Dental Protrusive Jaw
Growth Patterns
Distorted vertical and horizontal growth of the maxillo-man-
dibular skeleton (excess or deficiency) in association with
bimaxillary dental protrusion is a pattern of dentofacial
deformity that results in both facial and dental disharmony
138
(see Figure 8). This abnormal jaw growth pattern may be
associated with a class I, class II, or class III molar relation-
ship but it always occurs with mandibular and maxillary inci-
sor procumbency and anterior open bite malocclusion.
•• Bimaxillary dental protrusive jaw deformities can
occur in any racial group, but facial convexity and lip
prominence are strongly influenced by race and ethnic
characteristics. Greater degrees of lip and incisor
prominence tend to occur in Africans, Asians, and
Latinos than in Caucasians.
•• Common physical findings include flaccid lips (ie,
limited muscle tone), protrusive tongue (ie, strong lin-
gual muscle tone), procumbent maxillary and man-
dibular incisors (typically with adequate dentoalveolar
housing), and an anterior open bite.
•• For bimaxillary dental protrusion to also be part of a
developmental dentofacial deformity, marked vertical
and horizontal jaw growth distortion must also be pres-
ent. The extent of vertical and horizontal jaw disharmony
will result in variable degrees of functional disturbance
with speech, chewing, swallowing, and breathing.
•• The jaw disharmony may present with an Angle class
I, class II, or class III molar relationship but always
with bimaxillary incisor procumbence and usually
with anterior open bite.
•• Expect varied degrees of lip incompetence and men-
talis strain that result from the excess lower anterior
facial height.
•• Also expect excess anterior dental show in repose and
gingival show with smile; and chin dysmorphology.
In the era of computer-aided three-dimensional CBCT
planning in orthognathic surgery it is easy to lose track of the
patient’s comprehensive clinical needs and the extent of
facial dysmorphology that requires reconstruction. Applying
a biologic classification system to the analysis of develop-
mental dentofacial deformities is a useful way to clarify the
diagnosis and then stay on the right clinical track.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Brian E. Kinard https://orcid.org/0000-0002-8780-0670
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