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The influence of tongue asymmetries on the development of jaws and the position of teeth
Int. J. Oral Surg. 1974: 3:261-265 (Key words: laws, development; tongue)
The influence of tongue asymmetries on the development of jaws and the position of teeth K.H. AUSTERMANN AND E. MACHTENS
Department o/ Maxillo-Facial Sttrgery, University Hospital, Muenstep, and Department of Maxillo-Facial Surgery, Knappschaftskrankenhaus, Bochum, Federal Republic o/ Germany
ABSTRACT--Seven patients with a unilateral enlargement of the tongue were analyzed with a view to the consequences for the tooth-jaw system. In two cases, the reason for the tongue asymmetry was a unilateral tongue tumor; in three cases the reason was a hemihypertrophy along with unilateral glossoplegia, while in two more cases the asymmetry had been caused by a congenital hyperplasia of one half of the tongue. The open bite was larger on the unaffected side in patients with tongue tumors, while in those showing a unilateral glossoplegia the bite was wider on the affected side. The congenital hemihyperplasias were corrected by operation before the patients were 12 months old.
A balance must exist between the forces exercised by outer and by inner soft parts and this balance is a prerequisite for the harmonious formation of the maxillo-mandibular apparatus. P r o o f of this is provided by a multitude of cases in which this balance is impaired. BBCKER~, RHEIr~WAZD & BECK.ERa, and also BECKER & PALM2 have described the consequences of symmetricaI anomalies of the tongue. Taking a different point of depature, MACHTENS & MARXKOR3 3, and also SCHLEGEL5 were able to show the influence of the outer soft parts on the firm tissues in cases of paralyses of the motor facial nerve. T h e aim of this report is to analyze how unilateral enlargement of the tongue influences the firm tissues of the jaw.
Material and methods The cases of unilateral enlargement of the tongue recorded in the past 5 years at the Department of Maxillo-Facial Surgery, University Hospital, Muenster, were collected. Seven cases could fulfill the conditions of no previous orthodontic treatment and of a definite difference in volume between the two halves of the tongue. According to etiologic criteria, the m~terial was divided into three groups: Group 1: tongue asymmetries due to unilateral tumors (two cases). Group 2: tongue asymmetries due to unilateral glossoplegia (three cases). Group 3: tongue asymmetries due to congenital, unilateral hyperplasia of the muscle (two cases). The causes for the unilateraI tongue enlargement of the first group were a congenital lymphangioma and a hemangioma. The asymmetries grouped together in Group 2 were due to unilateral glossoplegia con-
262
A U S T E R M A N N AND MACHTENS
tracted in preschool age subsequent to a tonsillectomy. In both cases of Group 3, a congenital hypertrophy paralleled an overdevelopment of single parts of the body on the same side. The surgical technique depended on the extent, the cause and the localization of the asymmetry. The operation was aimed at removing the cause wherever possible and at achieving tongue symmetry. According to the individual indications, the following procedures were chosen: (1) asymmetrical wedge-shaped excision of the tip of the tongue (Fig. 4), used in one case of Group 2, (2) a combination of frontal and latera[ wedge-shaped excision (Fig. 5), used in cases of Group 3, and (3) lateral e;ccision, preserving the tip of the tongue (Fig. 6), used in cases of Group 1.
Results TONGUE ASYMMETRIES DUE TO UNILATERAL TUMORS T h e enlarged tongue entailed in both cases an open bite dependent in size on that of the tumor. On the healthy, non-affected side, the resulting open bite was m u c h wider than on the tumor-affected side. This open bite was due, above all, to the m a n dible's alveolar process being forced away f r o m the n o r m a l curve (Figs. 1 A - B ) . T h e open bite closed after operation without any additional orthodontic t r e a t m e n t (Figs. 1 C - D ) , as demonstrated by Case 1.
Fig. I. Case 1. A, a 4-year-old boy with an enlargement of the tongue on the right side, caused by a hemangioma. The chosen line of intersection is indicated. B, occlusion in the same patient showing the large open bite before surgery. Open especially on the left side. C, occlusion 6 months postoperatively. D, occlusion 24 months postoperatively.
TONGUE ASYMMETRY AND JAW DEVELOPMENT
263
Fig. 2. Case 2. A, a 13-year-old girl. with a glossoplegia on the right side along with hypertrophia of the healthy half of the tongue and deviation towards the right. B, frontat view of dental cast in occlusion showing a moderately open bite on right side. C, cross-section of maxillary dentat cast at level of second premolar, viewed from the rear.
TONGUE ASYMMETRIES DUE TO U N I L A T E R A L G L O S S O P L E G I A The consequence of this unilateral paralysis was a muscular hypotrophy on the affected side, along with a deviation of the outstretched tongue towards the paralyzed side. To compensate, the healthy side developed a hypertrophy (Fig. 2 A ) . The corresponding findings in the tooth-jaw system, as demonstrated in Case 2, were: (a) lateral open bite on the paralyzed side, (b) shortened apical base of the paralyzed side, (c) subnormal eruption of teeth on the paralyzed side, (d) flattening of the palate arch on the affected side, and (e) deviation of the midline of the maxilla towards the healthy side (Figs. 2 B - C ) . In one case of unilateral glossoplegia the enlarged healthy side was reduced. The open bite decreased within a few weeks, without, however, attaining perfect occlusion.
TONGUE ASSYMMETRIES DUE TO C O N G E N I T A L , U N I L A T E R A L HYPERPLASIA OF THE MUSCLE The two patients of this group were brought to us for treatment before they were 1 year old (Fig. 3). They underwent an operation at the age of 5 months (Case 3) and 10 months of age, respectively. Up to that time, no conspicuous malformation of the alveolar process or the partly erupted primary teeth had been observed. In b o t h cases perfect occlusion could be obtained by a well-timed operation without further need for orthodontic treatment.
Discussion The pressure effect of the tongue (W), composed of several factors, was expressed by BECKERt by means of the following formula:
AUSTERMANN AND MACHTENS
264
the value of the single factors affecting the formation of the tooth-jaw system. Regarding the cases of Group 1, the interpretation of this observation departs from the fact that - due to lack of muscle tissue - the tumor is functionally more or less inactive, thereby, however, exercising an increased pressure Oll the functionally active part of the healthy side. As a result, the tone and the functional activity come to bear more intensely on the teeth and the alveolar processes, thus causing the open bite.
~
f
I
Fig. 3. Case 3. A 4-month-old boy with a congenital hyperplasia of the right-hand half of the tongue.
W = f (volume, size) + f (tone) + f (attitude, position) -t-f (function). In our opinion, a similar formula might be found to express factors of the outer soft parts. The problem is how to define
Fig. 5. Diagram of tongue reduction by means of a combination of frontal and lateral wedge-shaped excision of tip of tongue.
1
111 Fig. 4. Diagram of tongue reduction by means of an asymmetrical wedge-shaped excision of tip of tongue.
I,
j4
f J
///
Fig. 6. Dia ram of tongue reduction by means of lateral excision with preservation of tip of tongue.
TONGUE ASYMMETRY AND JAW DEVELOPMENT As for the cases of Group 2, we are convinced that the open bite does not result from a deformation of the normal curve of the jaws subsequent to increased tongue pressure, as in the cases of Group 1, but rather from an insufficient development of the alveolar processes and a shortening of the length of the crowns, the latter two factors being in turn a consequence of reduced functional stimulation of the affected half of the jaw. Most probably, a certain importance must also be accorded to an elevated bite on the healthy side. Th e elevated bite can be the result of tone and function of the tongue as well as os an increased chewing action on the healthy side, all exercising a cumulative effect. These observations support the theory that the functional component of the tongue exercises a far more powerful influence on the jaws than does the tongue volume. This view does not, however, exclude the
Address: Abteilung fiir Mund- und Kieferchirurgie der Universitiit Miinster 44 Miinster Robert-Koch-Str. 27 a Federal Republic o)~ Germany
265
possibility that an extremely large tongue volume may cause an open bite.
References 1. BECrd~R, R.: Die Wachstumxst~rungen des Unterkiefers. Dr. Alfred I-[uethig Verlag, Heidelberg 1966, p 138. 2. B~Crd~R, R. & PAr~M, D.: Zur kausalen und formalen Genese des Pierre-Robin-Syndroms. Dtsch. Zahnaerzll. Z. 1966: 21: 1.3211338. 3. MACnTaNS, E. & MaRXt
The influence of tongue asymmetries on the development of jaws and the position of teeth K.H. AUSTERMANN AND E. MACHTENS
Department o/ Maxillo-Facial Sttrgery, University Hospital, Muenstep, and Department of Maxillo-Facial Surgery, Knappschaftskrankenhaus, Bochum, Federal Republic o/ Germany
ABSTRACT--Seven patients with a unilateral enlargement of the tongue were analyzed with a view to the consequences for the tooth-jaw system. In two cases, the reason for the tongue asymmetry was a unilateral tongue tumor; in three cases the reason was a hemihypertrophy along with unilateral glossoplegia, while in two more cases the asymmetry had been caused by a congenital hyperplasia of one half of the tongue. The open bite was larger on the unaffected side in patients with tongue tumors, while in those showing a unilateral glossoplegia the bite was wider on the affected side. The congenital hemihyperplasias were corrected by operation before the patients were 12 months old.
A balance must exist between the forces exercised by outer and by inner soft parts and this balance is a prerequisite for the harmonious formation of the maxillo-mandibular apparatus. P r o o f of this is provided by a multitude of cases in which this balance is impaired. BBCKER~, RHEIr~WAZD & BECK.ERa, and also BECKER & PALM2 have described the consequences of symmetricaI anomalies of the tongue. Taking a different point of depature, MACHTENS & MARXKOR3 3, and also SCHLEGEL5 were able to show the influence of the outer soft parts on the firm tissues in cases of paralyses of the motor facial nerve. T h e aim of this report is to analyze how unilateral enlargement of the tongue influences the firm tissues of the jaw.
Material and methods The cases of unilateral enlargement of the tongue recorded in the past 5 years at the Department of Maxillo-Facial Surgery, University Hospital, Muenster, were collected. Seven cases could fulfill the conditions of no previous orthodontic treatment and of a definite difference in volume between the two halves of the tongue. According to etiologic criteria, the m~terial was divided into three groups: Group 1: tongue asymmetries due to unilateral tumors (two cases). Group 2: tongue asymmetries due to unilateral glossoplegia (three cases). Group 3: tongue asymmetries due to congenital, unilateral hyperplasia of the muscle (two cases). The causes for the unilateraI tongue enlargement of the first group were a congenital lymphangioma and a hemangioma. The asymmetries grouped together in Group 2 were due to unilateral glossoplegia con-
262
A U S T E R M A N N AND MACHTENS
tracted in preschool age subsequent to a tonsillectomy. In both cases of Group 3, a congenital hypertrophy paralleled an overdevelopment of single parts of the body on the same side. The surgical technique depended on the extent, the cause and the localization of the asymmetry. The operation was aimed at removing the cause wherever possible and at achieving tongue symmetry. According to the individual indications, the following procedures were chosen: (1) asymmetrical wedge-shaped excision of the tip of the tongue (Fig. 4), used in one case of Group 2, (2) a combination of frontal and latera[ wedge-shaped excision (Fig. 5), used in cases of Group 3, and (3) lateral e;ccision, preserving the tip of the tongue (Fig. 6), used in cases of Group 1.
Results TONGUE ASYMMETRIES DUE TO UNILATERAL TUMORS T h e enlarged tongue entailed in both cases an open bite dependent in size on that of the tumor. On the healthy, non-affected side, the resulting open bite was m u c h wider than on the tumor-affected side. This open bite was due, above all, to the m a n dible's alveolar process being forced away f r o m the n o r m a l curve (Figs. 1 A - B ) . T h e open bite closed after operation without any additional orthodontic t r e a t m e n t (Figs. 1 C - D ) , as demonstrated by Case 1.
Fig. I. Case 1. A, a 4-year-old boy with an enlargement of the tongue on the right side, caused by a hemangioma. The chosen line of intersection is indicated. B, occlusion in the same patient showing the large open bite before surgery. Open especially on the left side. C, occlusion 6 months postoperatively. D, occlusion 24 months postoperatively.
TONGUE ASYMMETRY AND JAW DEVELOPMENT
263
Fig. 2. Case 2. A, a 13-year-old girl. with a glossoplegia on the right side along with hypertrophia of the healthy half of the tongue and deviation towards the right. B, frontat view of dental cast in occlusion showing a moderately open bite on right side. C, cross-section of maxillary dentat cast at level of second premolar, viewed from the rear.
TONGUE ASYMMETRIES DUE TO U N I L A T E R A L G L O S S O P L E G I A The consequence of this unilateral paralysis was a muscular hypotrophy on the affected side, along with a deviation of the outstretched tongue towards the paralyzed side. To compensate, the healthy side developed a hypertrophy (Fig. 2 A ) . The corresponding findings in the tooth-jaw system, as demonstrated in Case 2, were: (a) lateral open bite on the paralyzed side, (b) shortened apical base of the paralyzed side, (c) subnormal eruption of teeth on the paralyzed side, (d) flattening of the palate arch on the affected side, and (e) deviation of the midline of the maxilla towards the healthy side (Figs. 2 B - C ) . In one case of unilateral glossoplegia the enlarged healthy side was reduced. The open bite decreased within a few weeks, without, however, attaining perfect occlusion.
TONGUE ASSYMMETRIES DUE TO C O N G E N I T A L , U N I L A T E R A L HYPERPLASIA OF THE MUSCLE The two patients of this group were brought to us for treatment before they were 1 year old (Fig. 3). They underwent an operation at the age of 5 months (Case 3) and 10 months of age, respectively. Up to that time, no conspicuous malformation of the alveolar process or the partly erupted primary teeth had been observed. In b o t h cases perfect occlusion could be obtained by a well-timed operation without further need for orthodontic treatment.
Discussion The pressure effect of the tongue (W), composed of several factors, was expressed by BECKERt by means of the following formula:
AUSTERMANN AND MACHTENS
264
the value of the single factors affecting the formation of the tooth-jaw system. Regarding the cases of Group 1, the interpretation of this observation departs from the fact that - due to lack of muscle tissue - the tumor is functionally more or less inactive, thereby, however, exercising an increased pressure Oll the functionally active part of the healthy side. As a result, the tone and the functional activity come to bear more intensely on the teeth and the alveolar processes, thus causing the open bite.
~
f
I
Fig. 3. Case 3. A 4-month-old boy with a congenital hyperplasia of the right-hand half of the tongue.
W = f (volume, size) + f (tone) + f (attitude, position) -t-f (function). In our opinion, a similar formula might be found to express factors of the outer soft parts. The problem is how to define
Fig. 5. Diagram of tongue reduction by means of a combination of frontal and lateral wedge-shaped excision of tip of tongue.
1
111 Fig. 4. Diagram of tongue reduction by means of an asymmetrical wedge-shaped excision of tip of tongue.
I,
j4
f J
///
Fig. 6. Dia ram of tongue reduction by means of lateral excision with preservation of tip of tongue.
TONGUE ASYMMETRY AND JAW DEVELOPMENT As for the cases of Group 2, we are convinced that the open bite does not result from a deformation of the normal curve of the jaws subsequent to increased tongue pressure, as in the cases of Group 1, but rather from an insufficient development of the alveolar processes and a shortening of the length of the crowns, the latter two factors being in turn a consequence of reduced functional stimulation of the affected half of the jaw. Most probably, a certain importance must also be accorded to an elevated bite on the healthy side. Th e elevated bite can be the result of tone and function of the tongue as well as os an increased chewing action on the healthy side, all exercising a cumulative effect. These observations support the theory that the functional component of the tongue exercises a far more powerful influence on the jaws than does the tongue volume. This view does not, however, exclude the
Address: Abteilung fiir Mund- und Kieferchirurgie der Universitiit Miinster 44 Miinster Robert-Koch-Str. 27 a Federal Republic o)~ Germany
265
possibility that an extremely large tongue volume may cause an open bite.
References 1. BECrd~R, R.: Die Wachstumxst~rungen des Unterkiefers. Dr. Alfred I-[uethig Verlag, Heidelberg 1966, p 138. 2. B~Crd~R, R. & PAr~M, D.: Zur kausalen und formalen Genese des Pierre-Robin-Syndroms. Dtsch. Zahnaerzll. Z. 1966: 21: 1.3211338. 3. MACnTaNS, E. & MaRXt