Vertical skeletal dysplasia can lead to excessive lower facial height and maxillary teeth elongation with gum exposure. Patients usually have long face, steep mandibular plane angle, usually with mandibular retrognathism. The clinical manifestations include narrow nose, narrow upper dental arch, excessive incisal display, a significant backward and downward rotated mandible as well as vertical maxillary excess (VME). Traditional classifications which mainly based on sagittal jaw relation is inadequate in describing the vertical skeletal discrepancy. The patient also suffered from multiple missing posterior teeth, that requires an interdisciplinary dental care. The main treatment objectives are to normalize overjet and overbite, improve chin projection, reduce the gummy smile, and establish satisfactory occlusion with stable posterior support. A three-pieces Le Fort I with a unilateral posterior segmental maxillary impaction was done to correct the over-erupted molars. In the mandible, sagittal split osteotomies with genioplasty were performed. An esthetic improvement and balanced oral function were both achieved after all teeth being restored. The benefit of this comprehensive approach among orthodontist, oral surgeon and prosthodontist to correct a severe dentofacial deformity were also discussed.

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Pre-treatment facial photographs showed classic features of VME: long face, incompetent lips, excessive incisal display, broad buccal corridor and reduced chin prominence (a-c).

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Pre-treatment intraoral photographs revealed narrow maxillary arch form with posterior end-on bite (arrow in b), elongated maxillary left molars (arrow in c), multiple missing posterior teeth and lingually tilted mandibular second premolars (arrows in e).

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Pre-treatment panoramic radiograph showed mandibular left molars were recently extracted (arrow in a). Lateral cephalogram demonstrated an excessive lower anterior facial height with extremely high mandibular plane angle (b).

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Space was created between maxillary central and lateral incisor before surgery (arrow in a). Mandibular TADs were used to assist tooth alignment (circle in c).

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Panoramic radiograph (a) and lateral cephalogram (b) taken after pre-surgical orthodontic tooth movement. Overjet remained large for further surgical mandibular advancement.

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Post-surgical panoramic radiograph (a) and lateral cephalogram (b) demonstrated significant skeletal changes and an enlarged airway.

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Total movements of the three segments in maxillary osteotomy were illustrated in the occlusal view. Segment ①②③ were differentially impacted; 2 mm expansion between segment ② and ③; 3 mm of bone was trimmed (shaded area) mesial to the segment ③ for advancement.

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Superimposition of the cephalometric tracings immediately before surgery and 2 weeks after surgery. Maxillary left molars were drawn in dotted line, while right molars were in solid line. Note that part of the maxillary bone was removed.

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Mandibular removable occlusal plate for maintaining vertical dimension.

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Intraoral photographs in 2 months after surgery. Lower left lingual buttons were added for crisscross elastics (c and e).

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Panoramic radiograph taken 3 months after surgery. Maxillary lateral incisors received root canal treatment. Root resorption of mandibular anterior teeth was noted (dotted circle).

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Facial photographs after active treatment showed that the profile was greatly improved.

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Profile change was illustrated with superimposition of initial and final lateral facial images.

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Intraoral photographs after active treatment demonstrated that normal overjet and overbite. Sufficient space was left for restoration of maxillary right premolar and mandibular left molar.

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Final panoramic radiograph and lateral cephalogram after combined orthodontic and orthognathic surgical treatment.

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Lateral cephalometric tracing superimpositions of before and after treatment. Maxillary left molars were drawn in dotted line, while right molars were in solid line.

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Two-year follow up facial and intraoral photographs. Stable result was demonstrated after all restorations were completed.

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After 2 years of retention, panoramic radiograph (a) and lateral cephalogram (b) exhibited minimal skeletal change.