At a glance
- Vertical maxillary excess (VME) is a dentofacial deformity characterised by an overgrowth of the maxilla (the upper jawbone) in the vertical dimension.
- The development of vertical maxillary excess is multifactorial, arising from a combination of genetic predisposition and environmental influences during childhood growth phases.
- Patients presenting with vertical maxillary excess typically display a distinct constellation of clinical signs.
- Accurate diagnosis of vertical maxillary excess requires a systematic, multidisciplinary evaluation combining clinical measurements, radiographic imaging, and three-dimensional planning.
- Vertical maxillary excess is broadly classified according to the anatomical zone of vertical elongation and its interaction with the dental occlusion.
Understanding Vertical Maxillary Excess and Facial Anatomy
Vertical maxillary excess (VME) is a dentofacial deformity characterised by an overgrowth of the maxilla (the upper jawbone) in the vertical dimension. In a balanced facial profile, the upper lip covers the upper front teeth at rest, revealing only two to four millimetres of dental enamel, and shows minimal gingiva (gum tissue) during a full, natural smile. When the maxilla grows excessively downwards, this delicate proportion is disrupted, leading to what clinicians call 'long face syndrome' and patients often describe as a pronounced gummy smile. The underlying anatomy involves not just the alveolar bone supporting the teeth, but the entire maxillary basal bone, the nasal aperture, and the associated facial musculature.
The condition fundamentally affects the relationship between the skeletal framework and the overlying soft tissues. Because the vertical height of the middle and lower thirds of the face is disproportionately elongated, the lips often cannot meet naturally when the facial muscles are relaxed. This inability to seal the lips without conscious muscular effort is known as lip incompetence. Vertical maxillary excess surgery addresses this structural disharmony directly by altering the skeletal foundation, creating an anatomically stable base that allows both proper oral function and natural facial aesthetics.
Clinicians distinguish pure vertical maxillary excess from isolated dental or soft-tissue variations. While excessive gingival display can arise from short upper lips, hyperactive lip muscles, or delayed eruption of the teeth, true VME is rooted in skeletal dysplasia. The downward vertical position of the maxilla alters the trajectory of the mandibular arc of closure, often rotating the lower jaw downwards and backwards, which further exaggerates facial elongation and compromises bite function.
Aetiology and Developmental Risk Factors
The development of vertical maxillary excess is multifactorial, arising from a combination of genetic predisposition and environmental influences during childhood growth phases. Familial inheritance plays a primary role; craniofacial growth patterns, bone morphology, and jaw proportions are heavily influenced by polygenic inheritance. If parents or close relatives exhibit elongated facial patterns or significant skeletal open bites, the propensity for excessive vertical maxillary descent increases markedly in the offspring as facial growth accelerates during the adolescent growth spurt.
Environmental and functional factors during active development can substantially aggravate skeletal discrepancy. Chronic upper airway obstruction—commonly caused by hypertrophic adenoids, chronic allergic rhinitis, or deviated nasal septa—forces habitual mouth breathing. To facilitate oral airflow, the tongue drops to the floor of the mouth, lowering the intraoral pressure that normally balances the inward forces of the cheek muscles. This altered neuromuscular equilibrium allows the posterior maxillary teeth to over-erupt vertically, driving the maxilla further downwards and promoting posterior vertical excess.
Prolonged non-nutritive sucking habits, such as thumb or pacifier sucking extending past early childhood, can similarly disrupt normal dentofacial growth vectors. In certain regions, including South Asia, untreated childhood airway infections and nutritional factors can compound developmental discrepancies. Additionally, prolonged use of tobacco, betel quid, or paan during young adulthood impairs local tissue health and bone turnover, complicating both developmental assessments and subsequent surgical intervention.
Clinical Presentation and Functional Symptoms
Patients presenting with vertical maxillary excess typically display a distinct constellation of clinical signs. The most prominent aesthetic feature is significant gingival exposure—frequently exceeding five to eight millimetres—both during dynamic smiling and at rest. The lower third of the face appears elongated in frontal and profile views, and the chin often appears retruded or weak. When attempting to close the mouth, the mentalis muscle over the chin contracts excessively, producing a characteristic dimpled or strained appearance known as 'mentalis strain'.
Beyond facial aesthetics, VME frequently induces functional debilities. Because the lips remain parted at rest, chronic mouth breathing ensues, predisposing the patient to dry mouth (xerostomia), chronic marginal gingivitis, and an increased risk of dental caries due to reduced salivary protection. The posterior maxillary elongation often causes the back teeth to contact prematurely during chewing, which prevents the front teeth from meeting properly and results in an anterior open bite. This malocclusion complicates the incision and mastication of food, placing abnormal mechanical loads on the temporomandibular joints (TMJs).
Speech articulation can also be subtly impaired, particularly for sibilant sounds ('s' and 'z') and labiodental consonants ('f' and 'v'), as the tongue and lips struggle to achieve precise contact against elongated skeletal targets. Over time, these combined physical and functional challenges can lead to muscle fatigue, TMJ clicking or pain, and considerable psychosocial distress related to facial appearance.
Diagnostic Assessment and Cephalometric Analysis
Accurate diagnosis of vertical maxillary excess requires a systematic, multidisciplinary evaluation combining clinical measurements, radiographic imaging, and three-dimensional planning. The clinical examination begins with facial anthropometry, measuring facial thirds, the intercanthal distance, lip length at rest, and the exact millimetres of incisor and gingival display during both static rest and dynamic animation. The examining maxillofacial surgeon and orthodontist must differentiate skeletal VME from hypermobile upper lip (which elevates excessively without skeletal overgrowth) and altered passive eruption (where gum tissue covers too much of the tooth crown).
Standardised radiographic evaluation includes lateral and posterior-anterior cephalograms. Lateral cephalometric analysis allows the clinician to quantify skeletal landmarks, evaluating the sella-nasion-A point (SNA) angle, upper anterior facial height (UAFH), and lower anterior facial height (LAFH). An elevated ratio of lower anterior facial height to total facial height strongly correlates with vertical excess. Cone-beam computed tomography (CBCT) provides high-resolution 3D visualization of the maxillary sinuses, bone volume, root anatomy, and the precise position of the descending palatine arteries.
Contemporary surgical planning relies heavily on Virtual Surgical Planning (VSP) software. Intraoral digital scans of the dentition are merged with CBCT data to create a virtual composite skull. Surgeons simulate the precise osteotomy cuts, measure bone collisions in fractions of a millimetre, and fabricate computer-aided design and computer-aided manufacturing (CAD/CAM) surgical splints or customized titanium fixation plates. This meticulous workflow eliminates guesswork and ensures predictable skeletal repositioning.
Classification and Clinical Subtypes
Vertical maxillary excess is broadly classified according to the anatomical zone of vertical elongation and its interaction with the dental occlusion. The primary division separates total vertical maxillary excess from segmental (anterior or posterior) excess. In total VME, the entire maxilla is uniformly overdeveloped vertically, resulting in excessive gingival show across the entire dental arch while the occlusal plane remains relatively horizontal. These patients generally present with lip incompetence and a proportionate, albeit elongated, middle and lower face.
Posterior vertical maxillary excess occurs when vertical overgrowth is concentrated predominantly in the molar and premolar regions. This posterior descent prevents the mandible from closing completely in the front, resulting in a skeletal anterior open bite and a downward-backward rotation of the lower jaw. Conversely, anterior vertical maxillary excess is restricted to the front segment of the jaw, often causing a deep bite (overbite) where the upper front teeth cover the lower teeth completely, accompanied by excessive anterior gum display.
VME is also classified according to its co-occurrence with sagittal and transverse discrepancies. It frequently presents alongside transverse maxillary constriction (a narrow upper arch with a high-arched palate) or sagittal anomalies, such as Class II malocclusions (retrusive lower jaw) or Class III malocclusions (underbite). Identifying the specific subtype dictates whether surgery must involve single-piece maxillary repositioning or a multi-piece segmented osteotomy to address width and alignment simultaneously.
Treatment Modalities: Orthodontic and Surgical Options
The management of vertical maxillary excess depends heavily on the severity of the skeletal discrepancy and the developmental age of the patient. In growing children, interceptive orthodontics combined with airway management can sometimes guide vertical growth. In adults with mild vertical excess (one to two millimetres), non-surgical camouflage using temporary anchorage devices (TADs)—tiny titanium micro-screws inserted into the alveolar bone—can achieve modest intrusion of the upper dentition. However, skeletal intrusion via TADs has strict biological limits and cannot correct significant basal bone excess or soft-tissue disproportion.
Adjunctive soft-tissue procedures, such as crown lengthening (gingivectomy) or lip-repositioning surgery, are suitable only when the excess gingival display is caused by localized dental or muscular factors. For true moderate-to-severe vertical maxillary excess (three millimetres or more of skeletal discrepancy), orthognathic surgery represents the established, definitive standard of care. Surgical correction alters the underlying bony architecture, producing structural stability that orthodontic tooth movement alone cannot replicate.
The definitive approach combines presurgical orthodontics, vertical maxillary excess surgery (most commonly a Le Fort I superior repositioning), and postsurgical orthodontic refinement. Presurgical orthodontics decompensates the teeth—aligning them correctly within their respective jawbones rather than letting them tilt to mask the skeletal defect. This ensures that when the maxillofacial surgeon repositions the jawbone during surgery, the teeth interlock into a stable, functional, and harmonious occlusion.
The Surgical Procedure: Step-by-Step Le Fort I Osteotomy
Orthognathic surgery for vertical maxillary excess is routinely executed using a Le Fort I osteotomy with superior repositioning (maxillary impaction). The procedure is performed under general anaesthesia with nasotracheal intubation, leaving the oral cavity completely unobstructed for surgical access and occlusal verification. Local anaesthetic containing adrenaline is infiltrated into the maxillary vestibule to minimise intraoperative bleeding and assist tissue hydrodissection.
The surgeon makes a horizontal incision in the buccal mucosa above the roots of the upper teeth, extending from the first molar on one side to the first molar on the other. The periosteum is carefully elevated to expose the anterior and lateral walls of the maxilla, the piriform aperture of the nasal cavity, and the zygomatic buttresses. Using reciprocating or piezoelectric saws, horizontal bone cuts are made several millimetres above the tooth root apices, extending from the piriform rim posteriorly through the lateral maxillary walls to the pterygomaxillary junction.
To allow superior repositioning (impaction), a pre-calculated strip of bone is resected from the maxillary walls. The nasal septum and lateral nasal walls are freed, and the maxilla is down-fractured to mobilize it fully from the skull base. The bone excess is removed, and any bony interferences around the descending palatine neurovascular bundles and nasal floor are carefully sculpted. The maxilla is then positioned superiorly into its planned location using CAD/CAM splints and rigidly secured to the stable cranial framework using bio-inert titanium miniplates and monocortical screws. Soft-tissue handling, including an alar cinch suture to control nasal width and a V-Y mucosal closure, completes the operation.
Postoperative Recovery and Rehabilitation
The recovery phase following vertical maxillary excess surgery requires adherence to structured clinical protocols to optimize healing and avoid displacement of the osteotomised bone segments. Immediate postoperative care involves close monitoring of the airway, facial oedema management with intravenous corticosteroids and head elevation, and the application of cold packs to the cheeks. Facial swelling typically peaks around 48 to 72 hours post-surgery before gradually subsiding over the subsequent two to three weeks.
Rigid internal fixation with titanium plates generally avoids the historical requirement of wiring the jaws completely shut (intermaxillary fixation). Instead, light guiding elastics are placed between the upper and lower orthodontic brackets to guide the bite into the new position while allowing the patient to open their mouth for speech, oral hygiene, and nutritional intake. Patients must adhere strictly to a non-chew, liquid-to-purée diet for the first four to six weeks to ensure initial bony union without mechanical disruption.
Sensory changes in the upper lip, anterior cheeks, and palate are expected due to traction on the infraorbital and greater palatine nerves during surgery. In the vast majority of patients, normal sensation gradually returns over three to six months. Gentle oral hygiene with chlorhexidine mouth rinses and ultra-soft toothbrushes is commenced on the first postoperative day. Light cardiovascular activity can usually resume after three weeks, while contact sports and strenuous lifting must be avoided for at least three months.
Potential Complications and Risk Management
While Le Fort I superior repositioning for vertical maxillary excess is a safe and highly predictable procedure when performed by trained maxillofacial surgeons, inherent surgical risks exist. Intraoperative risks include significant haemorrhage from the descending palatine artery or pterygoid venous plexus, which is mitigated through meticulous surgical technique, hypotensive anaesthesia, and prompt electrocautery or vessel ligation. In rare instances, asymmetric bone removal can result in an unintentional cant of the occlusal plane, requiring intraoperative re-alignment.
Postoperative complications may include infection around the titanium hardware, delayed bone healing, or avascular necrosis of maxillary segments, particularly if extensive multi-piece segmentations were performed. These risks are heightened in individuals who smoke, use gutka or betel nut, or have poorly managed systemic conditions like diabetes. Hardware infection may necessitate the removal of loose miniplates once bony union is secured.
Aesthetic complications involve unintended widening of the nasal base (alar flaring) or upturning of the nasal tip as the maxilla is moved superiorly. Surgeons routinely counteract these forces by placing an alar cinch suture to cinch the alar fibrocartilages together and performing a V-Y advancement closure of the upper lip to maintain lip fullness. Relapse, defined as the gradual vertical descent of the maxilla post-surgery, is remarkably low with superior impaction compared to other orthognathic movements, provided proper fixation and retention protocols are followed.
Red Flags and When to Seek Immediate Medical Attention
Following discharge from the hospital, patients and their carers must remain vigilant for warning signs indicating acute surgical complications. While mild nasal oozing, facial bruising, and moderate discomfort are expected components of normal healing, certain symptoms demand urgent clinical re-evaluation by the surgical team or emergency department.
The most critical red flag is respiratory difficulty or acute shortness of breath, which can signify severe airway compromise from delayed retropharyngeal oedema, haematoma, or accidental aspiration. Sudden, active, bright-red haemorrhage from the oral cavity or nose (epistaxis) that does not stop with light pressure is another major emergency requiring immediate medical intervention to prevent significant blood loss.
Other warning signs include a rapidly worsening, unilateral, tense swelling accompanied by severe throbbing pain and fever above 38°C (100.4°F), indicative of acute postoperative infection or abscess formation. Patients should also seek prompt evaluation if they experience a sudden change in their bite—such as teeth no longer fitting into the surgical splint—or if they feel a clicking, mobility, or crunching sensation in the upper jawbone, which could signal hardware failure or micro-movement of the bone.
Evidence and further reading
The clinical protocols and surgical techniques governing vertical maxillary excess surgery are underpinned by decades of rigorous maxillofacial research and prospective clinical trials. Professional bodies such as the British Association of Oral and Maxillofacial Surgeons (BAOMS), the American Association of Oral and Maxillofacial Surgeons (AAOMS), and the International Journal of Oral and Maxillofacial Surgery consistently recognize Le Fort I maxillary superior repositioning as the definitive, gold-standard intervention for moderate-to-severe skeletal vertical maxillary excess.
Long-term stability studies published in leading literature, including the Journal of Oral and Maxillofacial Surgery and Cochrane reviews on orthognathic surgery, demonstrate that superior maxillary impaction is among the most stable orthognathic surgical movements. Skeletal relapse rates are exceptionally low when rigid internal fixation using titanium miniplates and monocortical screws is employed, especially when compared with mandibular advancements or downward maxillary movements.
Modern advances in virtual surgical planning and CAD/CAM cutting guides have further improved translational accuracy, significantly reducing operating times and post-surgical morbidity. Professional consensus stresses that successful management of VME requires coordinated multidisciplinary planning between certified specialist orthodontists and oral and maxillofacial surgeons, ensuring optimal functional occlusion, airway patency, and long-term facial harmony.
Questions patients ask us
- What is the primary difference between a gummy smile and vertical maxillary excess?
- A gummy smile is a descriptive symptom showing excessive gum display upon smiling. It can stem from dental factors (short teeth), muscular factors (a hyperactive upper lip), or skeletal issues. Vertical maxillary excess is the specific skeletal diagnosis where the upper jawbone itself has grown excessively long in the vertical dimension, requiring skeletal correction rather than just soft-tissue management.
- Is vertical maxillary excess surgery painful?
- Patients generally report moderate discomfort rather than severe pain. During surgery, general anaesthesia prevents any sensation, while local anaesthetics and intravenous pain medications manage immediate postoperative pain. Most discomfort arises from facial swelling, nasal congestion, and mild stretching sensations rather than sharp pain, and is well managed with standard oral analgesics.
- Will vertical maxillary excess surgery change the appearance of my nose?
- Yes, superior repositioning of the maxilla directly affects the nasal base. Moving the jaw upward can widen the nostril base and slightly elevate the nasal tip. To prevent excessive widening, surgeons routinely place an internal 'alar cinch' suture and sculpt the anterior nasal spine to ensure a balanced, aesthetically pleasing nasal profile.
- How long will my jaws be locked or wired shut after surgery?
- Modern vertical maxillary excess surgery rarely involves wiring the jaws completely shut. Instead, rigid internal fixation with titanium miniplates and screws stabilizes the bones. Surgeons typically place light, removable orthodontic rubber bands (elastics) between the teeth to guide your bite, allowing you to open your mouth for speaking and cleaning.
- Can braces or orthodontic aligners alone correct vertical maxillary excess?
- Orthodontics alone cannot correct moderate-to-severe vertical maxillary excess because braces move teeth within the bone, but cannot alter the basal jawbone height. While minor cases may be managed with temporary skeletal anchorage devices (TADs) to intrude teeth slightly, significant skeletal excess requires combined orthognathic surgery for definitive and stable results.
- How long is the recovery period before I can return to work or school?
- Most patients take two to three weeks off work or academic studies. By the end of the second week, acute swelling and fatigue have significantly subsided. However, desk work can often be resumed sooner, while strenuous occupations, heavy lifting, or contact sports must be avoided for at least six to twelve weeks.
- Are the titanium plates and screws removed after the jaw heals?
- In the majority of patients, the titanium plates and screws remain permanently integrated into the jawbone without causing any harm or triggering metal detectors. They are only removed in a minor secondary procedure if they become infected, exposed through the gum, or cause localized discomfort, which occurs in a small percentage of cases.
- What are the lifestyle and dietary requirements during healing?
- For the first six weeks, patients must strictly adhere to a liquid and soft, non-chew diet (such as smoothies, soups, mashed potatoes, and scrambled eggs) to prevent bone displacement. Strict tobacco, paan, and alcohol cessation is essential, as nicotine and toxic compounds severely compromise blood supply, bone healing, and soft-tissue closure.
When to see us
Get examined without waiting if any of the following applies to you:
- Swelling that spreads, restricts mouth opening or affects swallowing or breathing
- Numbness, altered sensation, or bleeding that will not stop after surgery
- Jaw locking, an ulcer or lump lasting more than two weeks, or a white or red patch that does not heal
Get a written plan and cost before you commit
If this is what you are dealing with, the next step is a consultation with radiographs — surgery & jaw cases are seen by the specialist who handles that field. You get a written plan and staged cost before anything begins.
reception@dramitsharmahospital.comThis article is general education and does not replace an in-person examination, radiographs or a diagnosis by a qualified dentist.
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