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The management of macroglossia when associated with prognathism
T H E M A N A G E M E N T OF MACROGLOSSIA W H E N ASSOCIATED W I T H PROGNATHISM By MILTON EDGERTON, M,D.
From the Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore IT is a common clinical fact that prognathism of the ~mandible is frequently associated with macroglossia of varying degrees. It is difficult to guess whether the large tongue is a result of natural growth processes attempting to fill the abnormally large floor of the mouth created by the mandible, or whether abnormal development of the tongue is an etiological factor in the development of the prognathism. Consideration of surgical correction of the malocclusion and appearance of the patient must take this macroglossia into account. I f the tongue is very large and it is necessary to remove a large segment of mandible for correction, the surgeon runs the danger of reducing the size of the floor of the mouth to such an extent that it will no longer accommodate the large tongue and the physiology of a micrognathia will be produced surgically (Fig. I). In such patients the difficulties are congenital rather than surgical, but are also due to the fact that the symphysis of the mandible is so far posterior that the tongue is carried backward as a result. Breathing, talking, and swallowing may all be interfered with because of pressure of the base of the tongue against the epiglottis (Douglas, I946). Surgical removal of part of the macroglossic tongue in prognathic patients constitutes an obvious approach to the problem. At the same time the surgeon is anxious not to upset the speech or taste perception of the patient by reducing the length of the tongue or removing excessive taste buds. Fro. The amount of required mandibular Shows infant with typical micrognathia, resection in one of our patients was 2o The normally sized tongue is too large for mm. on one side and I8 mm. on the other the floor of the mouth and encroachesposteriorly on the epiglottis, causing cyanosis (Figs. 2 and 3). This would result in a and great difficultyin takingliquids. reduction of the area of the floor of the mouth by approximately 6o per cent. (Fig. 4, A). The patient was a young girl with an extremely large tongue and a low vault to the palate. There was no place for the tongue to go but downward and backward. II7
118
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
A
FIG. 2 A and B, Views of patient with marked prognathism and associated extreme macroglossia, C shows some open bite and severe prognathic malocclusion.
C
A
B FIG. 3 A and B show dental models of teeth in preoperative occlusion. (Made by D r T. E. Sikes of the Johns Hopkins Hospital dental department.)
MACROGLossIA WHEN ASSOCIATED WITH PROGNATHISM
119
We had planned to use a two-stage Dingman type operation with intraoral cuts on the mandible as the first stage (Fig. 4, B). If the tongue size could be reduced at this first stage, no extra surgical steps would be required. ,
Third
Molars
~
t
'Lm2"~'gsq ......doc
FLOOR OF MOUTH
A
B FIG. 4 A, Diagram of required mandibular resection to give normal occlusion. B~ Bone cuts being made in mandibular body as in first stage procedure, as described by Dingman.
After a consideration of several plans the elliptical excision, shown in Fig. 5, A, was used because of (a) the symmetry and minimal disturbance of muscle attachment, (b) the distribution of taste buds, and (c) the absence of the reduction in length of tongue. Removal of this segment proved quite easy at operation (Fig. 5, B). Endotracheal anmsthesia was used and large ha:mostatic sutures were passed
I20
BRITISH
JOURNAL
OF
pLASTIC
Bitter
SURGERY
. Vallate Papillae
of Excised Area
S
a
l
t
y
~
DORSUM OF TONGUE A
B
FIG. 5 A, Diagram of approximate amount of tongue removal to accompany the 60 per cent. reduction in floor of mouth. B, Operative removal of median ellipse of tongue. T h i s is carried out at same operation as Fig. 4, B.
MACROGLOSSIA
WHEN
ASSOCIATED
WITH
PROGNATHISM
121
beneath the area to be excised before the cuts were made. It was not necessary to ligate either lingual artery, and no secondary hmmorrhage occurred post-operatively. The intraoral bone cuts were then made and the mucosa closed. After about ten days all the oedema had subsided, and it was very evident that the tongue size had been greatly reduced. Speech remained unchanged.
Fro. 6 Second stage of mandibular resection carried out three weeks later through cervical incisions. T h e mandible has been removed in two plates, and the preserved inferior alveolar nerve can be seen spanning the bone ends.
A
B FI~. 7 A, Immediate post-operative wiring of the teeth used to supplement fixation obtained by internal wiring of mandible fragments with steel wire. B shows final occlusion obtained after union was firm and spot-grinding was completed.
At the second stage (Fig. 6) the mandible was resected through cervical incisions, and the inferior alveolar nerve preserved in the manner suggested by Dingman (I948). Good union and occlusion resulted. It was noted that the tongue once more appeared to fill the oral cavity after the symphysis was displaced backward. However, no difficulty in breathing or swallowing followed.
122
BRITISH JOURNAL
OF PLASTIC
SURGERY
Speech remained clear. Taste sensations were interesting. For almost six weeks following operation there was complete absence of the bitter taste as tested by codeine or quinine on the tongue. Salty and sweet taste were markedly exaggerated, but as time passed they became less noticeable. At present there is only slight diminution in bitter taste perception.
FIG. 8 Post-operative views of patient with pleasing gnathic index.
The mobility of the tongue was at first reduced considerably, possibly due to residual discomfort, but after a few weeks of use the patient stated she could move it as well as before operation (Figs. 7 and 8). SUMMARY Most cases of prognathism will not require associated surgery on the tongue. A simple method is suggested for possible use in the occasional case which may have such a large tongue that a sudden gross change in the location of the jaw will have undesirable effects on the breathing or swallowing mechanism. A single case is presented in which the post-operative upset in the physiology of the tongue was both temporary and minimal.
REFERENCES DINGMAN, R. O. (1948). Plast. 6" Recons. Surg., 3, 124. DOUGLAS, B. (1946). Ibid., I, 300.
From the Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore IT is a common clinical fact that prognathism of the ~mandible is frequently associated with macroglossia of varying degrees. It is difficult to guess whether the large tongue is a result of natural growth processes attempting to fill the abnormally large floor of the mouth created by the mandible, or whether abnormal development of the tongue is an etiological factor in the development of the prognathism. Consideration of surgical correction of the malocclusion and appearance of the patient must take this macroglossia into account. I f the tongue is very large and it is necessary to remove a large segment of mandible for correction, the surgeon runs the danger of reducing the size of the floor of the mouth to such an extent that it will no longer accommodate the large tongue and the physiology of a micrognathia will be produced surgically (Fig. I). In such patients the difficulties are congenital rather than surgical, but are also due to the fact that the symphysis of the mandible is so far posterior that the tongue is carried backward as a result. Breathing, talking, and swallowing may all be interfered with because of pressure of the base of the tongue against the epiglottis (Douglas, I946). Surgical removal of part of the macroglossic tongue in prognathic patients constitutes an obvious approach to the problem. At the same time the surgeon is anxious not to upset the speech or taste perception of the patient by reducing the length of the tongue or removing excessive taste buds. Fro. The amount of required mandibular Shows infant with typical micrognathia, resection in one of our patients was 2o The normally sized tongue is too large for mm. on one side and I8 mm. on the other the floor of the mouth and encroachesposteriorly on the epiglottis, causing cyanosis (Figs. 2 and 3). This would result in a and great difficultyin takingliquids. reduction of the area of the floor of the mouth by approximately 6o per cent. (Fig. 4, A). The patient was a young girl with an extremely large tongue and a low vault to the palate. There was no place for the tongue to go but downward and backward. II7
118
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
A
FIG. 2 A and B, Views of patient with marked prognathism and associated extreme macroglossia, C shows some open bite and severe prognathic malocclusion.
C
A
B FIG. 3 A and B show dental models of teeth in preoperative occlusion. (Made by D r T. E. Sikes of the Johns Hopkins Hospital dental department.)
MACROGLossIA WHEN ASSOCIATED WITH PROGNATHISM
119
We had planned to use a two-stage Dingman type operation with intraoral cuts on the mandible as the first stage (Fig. 4, B). If the tongue size could be reduced at this first stage, no extra surgical steps would be required. ,
Third
Molars
~
t
'Lm2"~'gsq ......doc
FLOOR OF MOUTH
A
B FIG. 4 A, Diagram of required mandibular resection to give normal occlusion. B~ Bone cuts being made in mandibular body as in first stage procedure, as described by Dingman.
After a consideration of several plans the elliptical excision, shown in Fig. 5, A, was used because of (a) the symmetry and minimal disturbance of muscle attachment, (b) the distribution of taste buds, and (c) the absence of the reduction in length of tongue. Removal of this segment proved quite easy at operation (Fig. 5, B). Endotracheal anmsthesia was used and large ha:mostatic sutures were passed
I20
BRITISH
JOURNAL
OF
pLASTIC
Bitter
SURGERY
. Vallate Papillae
of Excised Area
S
a
l
t
y
~
DORSUM OF TONGUE A
B
FIG. 5 A, Diagram of approximate amount of tongue removal to accompany the 60 per cent. reduction in floor of mouth. B, Operative removal of median ellipse of tongue. T h i s is carried out at same operation as Fig. 4, B.
MACROGLOSSIA
WHEN
ASSOCIATED
WITH
PROGNATHISM
121
beneath the area to be excised before the cuts were made. It was not necessary to ligate either lingual artery, and no secondary hmmorrhage occurred post-operatively. The intraoral bone cuts were then made and the mucosa closed. After about ten days all the oedema had subsided, and it was very evident that the tongue size had been greatly reduced. Speech remained unchanged.
Fro. 6 Second stage of mandibular resection carried out three weeks later through cervical incisions. T h e mandible has been removed in two plates, and the preserved inferior alveolar nerve can be seen spanning the bone ends.
A
B FI~. 7 A, Immediate post-operative wiring of the teeth used to supplement fixation obtained by internal wiring of mandible fragments with steel wire. B shows final occlusion obtained after union was firm and spot-grinding was completed.
At the second stage (Fig. 6) the mandible was resected through cervical incisions, and the inferior alveolar nerve preserved in the manner suggested by Dingman (I948). Good union and occlusion resulted. It was noted that the tongue once more appeared to fill the oral cavity after the symphysis was displaced backward. However, no difficulty in breathing or swallowing followed.
122
BRITISH JOURNAL
OF PLASTIC
SURGERY
Speech remained clear. Taste sensations were interesting. For almost six weeks following operation there was complete absence of the bitter taste as tested by codeine or quinine on the tongue. Salty and sweet taste were markedly exaggerated, but as time passed they became less noticeable. At present there is only slight diminution in bitter taste perception.
FIG. 8 Post-operative views of patient with pleasing gnathic index.
The mobility of the tongue was at first reduced considerably, possibly due to residual discomfort, but after a few weeks of use the patient stated she could move it as well as before operation (Figs. 7 and 8). SUMMARY Most cases of prognathism will not require associated surgery on the tongue. A simple method is suggested for possible use in the occasional case which may have such a large tongue that a sudden gross change in the location of the jaw will have undesirable effects on the breathing or swallowing mechanism. A single case is presented in which the post-operative upset in the physiology of the tongue was both temporary and minimal.
REFERENCES DINGMAN, R. O. (1948). Plast. 6" Recons. Surg., 3, 124. DOUGLAS, B. (1946). Ibid., I, 300.