- Email: [email protected]
Therapeutic, cosmetic effects of oral surgery
0
Thera peut ic, cosmetic effects of oral surgery Robert J Wehner, RN
Robert J Wehner, RN, (IMAJ, A N C ) is supervisor of anesthesia and chief of the respiratory therapy services at the US
Army Hospital in Nurnberg, W Gernzany. He is a graduate of S t Elizabeth Hospital Med-
ical Center, Dayton, Ohio; the US Army School of Anesthesiobgy for Nurses, and the U S Army operating room nursing course.
52
ral surgery ranges from a simple extraction of a tooth to the more complicated surgical correction of mandibular and maxillary deformities. A protruding or receding jaw, a condition called prognathism, is corrected primarily by mandibular or maxillary osteotomy, a common practice for the past ten years. The rectification of a malocclusion and other facial deformities not only aids the patient therapeutically and cosmetically, but also helps him psychologically. The historical development of oral surgery dates back to the early 1800s when Hullihen first described a surgical correction for mandibular protuberance in 1849. His descriptive cure of a patient with severe burns of the neck and a protruding mandible served as a foundation for future mandibular corrections.1 Variations of his surgical correction have been developed, and several reported using a wide range of anatomical sites including the ramus and body of the mandible. Repositioning the maxilla by posterior ostectomy using a two-stage operation was first described by Schuchardt in 1959.2 In 1970, Kufner reported the use of a singlestage ostectomy involving the posterior maxilla.3 These and other procedures are being used today for correction of selected facial deformities. The etiology of mandibular and maxillary facial deformities may be congenital, or they may develop as the individual grows. “In most instances the occlusion and function of the teeth is affected; but in others, the occlusion is normal and the deformities involve parts of the facial skeleton not supplied by teeth.”+ Mandibular prognathism is involved in the craniofacial growth that leads to a disharmony of facial appearance. Hereditary factors influencing this condition could be both endocrine and environmental. Maxillary prognathism is characterized by protruding teeth commonly referred to as “buck teeth.” Like the mandible, the
AORN Journal, July 1975, Vol 22, N o 1
prominent maxilla could be caused by several factors related to both heredity and environment. Protruding front teeth could be the result of an open bite caused by thumbsucking when young or thrusting the tongue while swallowing. “The tongue exerts a pressure of about 60 Ibs during each swallowing reflex. The daily average number of swallows is 1,400.”5This constant pressure causes the maxilla to be pushed upward, and a separation of the front teeth occurs. Surgical correction of this condition is primarily for therapeutic effects. However, the patient sees the correction a s a cosmetic and psychologic effect. Prognathism of the mandible and maxilla cannot be corrected without attention to the anatomical structures involved: the mandible, maxilla, and the blood and nerve supply to the face and skull. A general review of each follows. The mandible is the largest and strongest bone of the face and consists of a curved horizontal portion, the body, and two perpendicular portions, the rami. The
alveolar process border of the body contains cavities for the reception of the teeth. Each ramus has a condyle, which articulates with the mandibular fossa of the temporal bone, and a coronoid process, which gives attachment to the temporal muscle and some fibers of the buccinator. The deep depression between the two processes is called the mandibular notch. The mental foramen, which is just below the first molar tooth, serves as a passage way for the mental nerve, which is a terminal branch of the inferior dental nerve (of the trigeminal nerve) .6 (Fig 1) The maxillae are formed by their union to the whole upper jaw. Each bone helps to form (1) part of the floor of the orbit, (2) the floor and lateral walls of the nasal cavities, and (3) the greater part of the roof of the mouth. Each bone contains a large cavity, the maxillary sinue, which opens into the nose. The alveolar processes are excavated cavities, which vary in depth and size according to the teeth they contain. . .? The two major nerves and their branches which innervate the facial regions are the trigeminal nerve and the facial nerve, commonly referred to as the fifth and seventh cranial nerves. The common carotid arteries provide the major source of blood to the skull. These arteries give off branches to all the vital areas of the skull and brain. Developmental disturbances indicating surgical intervention of prognathism coincide with the etiological factors mentioned previously. They are a maxillary prognathism, which indicates an anteroposterior overdevelopment of the middle region of the face, “. . . a mandibular prog-
AORN Journal, July 1975, Vol 22, No 1
.
53
)\
triaeminal, 5th crania
\
semilunar ganglion
A
-
facial, 7th crbanial nerve
chorc
inferior alveolar
Ann Leonard
Fig 7 . The trigeminal, or fifth cranial nerve, is the great cutaneous sensory nerve of the face, the sensory nerve t o the mucous membranes and other internal structures of the head, and the motor nerve of the muscles of mastication. Its divisions, ophthalmic, maxillary, and mandibular, are numbered in the illustration. The facial, or seventh cranial nerve, innervates the muscles of facial expression, scalp, and inner ear. The sensory part supplies the anterior two-thirds of the tongue with taste and parts of the external acoustic meatus, soft palate, and adjacent pharynx with general sensation. The parasympathetic part supplies secretomofor fibers for the submandibular, sublingual, lacrimal, nasal, and palatine glands.
54
AORN Journal, July 1975, Vol 22, No 1
Ostecfomy in horizontal ramus to’ correct mandibular protrusion. tllustration from Thoma, Kurf H: O r a l Surgery, ed 4, Sf Louis, 7963, C V Mosby Co.
nathism, which is an anteroposterior overdevelopment of the lower third of the face, pseudoprognathism of the mandible, or an anteroposterior underdevelopment of the lower portion of the face.’’s Disturbances of the vertical development of the face include the open bite, involving the long lower portion of the face, or the closed bite, involving the short lower portion of the face. Trauma, crossbite, macroglossia, and cleft palates also are reasons for surgical correcti~n.~
Oral surgeons have added modifications to the basic osteotomy or 0stectomy pioneered by earlier men. Some common surgical procedures for correcting mandibular prognathism that have been tried and proven effective are: the horizontal osteotomy, the sagittal osteotomy, the vertical osteotomy, the sliding 0steotomy, and the oblique osteotomy. (See illustrations.) Methods of approach have been either intraoral or extraoral. The type used by the oral surgeon depends first on the condition of the patient, and second, the preferred method of the surgeon. Operations for the correction of facial deformities are not totally without complications. Although the majority of the complications occur when the intraoral approach is used, other types of procedures also result in complications. Behrman found in his survey of complications after midsaggital splitting that the most frequently reported complications were regression and relapse followed by hemorrhage and disturbances of the mandibular nerve. Some of the less frequent complications reported were edema (airway obstruction),
Simple osteotomy, A, causes V-shaped space to open when anterior fragment is placed in position fo close open bite, while V-shaped ostectomy, B, closes space in correction of open bite. lllustrations from Thoma, Kurt H: O r a l Surgery, ed 4, St Louis, 1963, C V Mosby Co.
AORN Journal, July 1975, VoE 22, No I
55
Reversed V-shaped ostectomy to close open bife in premolar region. A, reversed V excision. 6, anterior fragrnenf tiffed into
fragmentation of the ramus, necrosis or sequestration of bone, and infection.'" Although the incidence of complications is low, their existence must always be considered by the oral surgeon who should use all available means to avoid them. The cosmetic effects realized by oral surgery are gratifying to the patient, who views the operation as a cosmetic improvement rather than improvement of masticatory functions." Women particularly seek cosmetic improvements because of social norms and acceptance.'? Years back, the protruding jaw
56
had several connotations. One was it indicated determined, yet tough and threatening individuals. People expected violence from them. Adults are not the only ones faced with these problems. Young people also have to contend with social problems among their peers because of facial deformities. The receding chin has the opposite effect from the protruding chin. It gives the appearance of a timid, ineffectual person. Business men often find it difficult to promote sales when they have a receding or a protruding chin.13
AORN Journal, July 1975, VoE 22, No I
L-shaped osteotomy for advancing mandible.
\
1.
IF
Osfeofomy ascending ramus of mandible affer Skaloud.
-
\ A /I
\!
I;
3/+
\
Prognathism. A, correction by oblique osteofomy in ramus; 6, correction by ostecforny in horizontal rarnus. lllustrafions from Jhoma, Kurt H: Oral Surgery, ed 4d, St Louis, 1963, C V Mosby Co.
Prognathism, therefore, gives the impression of either a negative person or one who is a bully. By moving the jaw either forward or backward, the oral surgeon can improve the facial appearance of the patient and enable the patient to blend in with the “normal” crowds of people. The accompanying photos demonstrate pre and postoperative views of maxillary prognathism, mandibular
protuberance, and maxillary and mandibular malocclusion. Radiographic examples illustrate changes in facial profiles following osteotomies for correction of prognathisms. Malocclusion of the teeth is one of the greatest prognathic disorders. Functionally, the teeth should meet surface to surface, upper and lower, for food to be properly masticated. In the open bite, the patient can usually bring his posterior teeth (molars) together but is unable to occlude his anterior teeth. This prevents him from “biting” into his food. He usually has to pull his food apart before he can chew i t with his back teeth. People with maxillary protrusion or mandibular protrusion also find it difficult to “bite” into foods. After oral surgical correction, patients find it easier to chew and to bite with their front teeth. Several case reports show that meat, corn on the cob, and lettuce are foods that can be eaten better po~toperatively.~~
AORN Journal, July 1975, Vol 22, No 1
57
Postoperative view, maxillary correction.
Radiographic view showing mandibular protuberance.
58
Postoperative view, mandibular correction.
AORN Journal, July 1975, Vol 22, N o 1
Preoperative view, maxillary malocclusion.
Postoperative view of maxillary correcfion for malocclusion.
Postoperative view of mandibular correction for malocclusion.
Preoperative view, mandibular malocclusion.
AORN Journal, July 1975, Vol 22, N o 1
59
Many patients could once again enjoy foods. Although the types of foods enjoyed did not vary from what was eaten preoperatively, they could be bitten and chewed more easily and more comfortably po~toperatively.~~ Improperly chewed foods, which place a great strain on the digestive system, result in gastric disorders, a fairly common complaint among prognathic patients.l6 Rectification of functional disorders by oral surgery can also eliminate speech defects in some patients who find it difficult to pronounce some consonant and fricative sounds, particularly t, d, 1, n, and s, sh, z, zh. Preoperative and postoperative speech therapy, coupled with surgical correction of the open bite, often gives the patient remission of this condition.“ Before an oral surgeon performs a cosmetic or therapeutic operation, the patient must have a psychiatric evaluation. This is necessary to ascertain if the patient will be able to cope with his new appearance. If the psychiatrist feels the patient is too immature or that he would not be psychologically able to cope with the postoperative improvement, the oral surgeon will usually not perform the operation. I * Most patients who seek aid from an oral surgeon are introverted, shy, and have little self-confidence. They are usually passive and generally remain in a state of depression. Anatomical and functional disturbances not only alter their appearance but also have accompanying psychologic abnormalities. Several of these patients have to withstand great numbers of disadvantages. Reduction of the masticatory
60
function may make one dependent on home cooking and cause digestive problems. One’s appearance may completely bar him from certain types of professions, or may prevent him from advancing in his profession in accord with his mental and manual capabilities. The resultant psychic manifestations, due to the patient’s skeletal disorder alone, may be enough to hinder him in his vocation. Perhaps worst of all for the patient, his personal and private life suffers from these esthetic, psychological and functional abnormalities.19 Many times this psychological problem begins before or at the age of puberty. If surgical correction has not been performed before the patient reaches the age of 20 or 23, the psychic disorder could be so deeply embedded in the patient that in spite of surgical success, the patient may still remain irreversible.20 Beneficial facial improvement by oral surgery not only changes the personality of the patient but also improves him as a social individual. These postoperative patients are outgoing, gain weight, and are no longer the brunt of jokes. The majority of them gain a new selfconfidence, they shed old fears of meeting and talking with people, and they enjoy eating in public. In general, the patient becomes more sociable.*l In summary, the cosmetic, therapeutic, and psychological benefits derived from oral surgery greatly aid the patient in coping with everyday sociological acceptance. Because of oral surgical correction, the patient no longer stands in the “shadows” but becomes a part of the group.
AORN Journal, July 1975, Vol 22, N o 1
0
Notes I. S P Hullihen, "Case o f elongation o f the under iaw and distortion of the face and neck, successfully treated," American Journal of Dental Science, 9 (January 1849) 157-1 85. 2. R A West, B N Epker, "Posterior maxillary surgery: I t s place in the treatment of dentofacial deformities," Journol of O r o l Surgery, 30 (August
1972) 562-575. 3. lbid. 4. Kurt H Thoma, O r a l Surgery Vol 2 ( S t Louis: C V MosbY CO, 1963) 1129-1195. 5. D S Hershman, G L Tinsley, C E Schow, "Apertognathia-an interdisciplinary approach: Report of case,'' Journol of Oral Surgery, 30 (October 1972) 743-747. 6. M A Miller, L C Leavel, Anatomy and Physiology 16th ed (New York: Macmillan Co, 1972)
89. 7. lbid. 8. Maurice Theberge, "Team rapport: I t s value in surgical orthodontics," Journal of O r a l Surgery, 26 ( A p r i l 1968) 277-280. 9. Ibid.
10. S J Behrman, "Complications o f sagittal osteotomy of the mandibular ramus," Journal of O r a l Surgery, 30 (August 1972) 554-561. I I. Theberge, op cit, p 278. 12. H Obwegeser, "Surgical correction o f small or retrodisplaced maxillae," Plastic and Reconstructive Surgery, 43 ( A p r i l 1969) 351.
13. Ibid. 14. N Crowell, H Sazima, S Elder, "Survey of patients' attitudes after surgical correction of prognathism: Study o f 33 patients," Journal of Ora/ Surgery, 28 (November 1970) 820. 15. C E Hutton, "Patients' evaluation o f surgical correction of prognathism: Survey of 32 patients," Journaf of Orul Surgery, 25 ( M a y 1967)
225-228. 16. Thoma, op cit, I 130. 17. Hershman, op cit, 744. 18. Emery Russell, LTC, DC, chief, oral surgery service, US Army Hospital, Fort Campbell, private conversations. 19. Obwegeser. op cit, 351. 20. Obwegeser, op cit. 351. 21. Hutton, op cit, 227.
Ky,
AANA Council on Prucfice members Seven experts in health care have been named to the Council on Practice of the American Association of Nurse Anesthetists (AANA). The new council, which will b e autonomous, will focus on the role of the certified registered nurse anesthetist (CRNA) within the health care field and will have power to act directly on matters involving member discipline and standards of practice. The members are: Thomas Arthur, legal consultant, Gardner, Carton, Douglas, Chilgren & Waud law firm, Chicago; Barbara Brown, RN, EdD, assistant administrator of patient care services, Family Hospital, Milwaukee; Albert E Doubek, CRNA, chief anesthetist, Sioux Valley Hospital, Sioux Falls, SD; Hugh S Mothewson, MD, medical director, respiratory therapy, University of Kansas Medical Center of the College of Health Sciences and Hospital, Kansas City, Kan; Elliott G Roberts, MA, director of hospitals, Detroit General Hospital, Detroit; Helen P Vos, CRNA, BS, director, anesthesia program for nurses,
North Carolina Baptist Hospital, Winston-Salem; and Martha P Belew, CRNA, chief nurse anesthetist, Baptist Memorial Hospital, Memphis, Tenn. The council will have five specific areas of responsibility: 1. develop advisory joint-practice statements pertaining to anesthesia practice (in consultation with the American Society of Anesthesiologists, the American Hospital Association, and the American Nurses' Association) 2. review and revise the standards of practice for nurse anesthetists as required 3. provide for and supervise the ongoing evaluation of the practice of the nurse anesthetist 4.act as the investigating and disciplinary body concerned with grievances and complaints registered against nurse anesthetists pertaining to their practice, including complaints of violations of ethical standards. 5. act as the appeal body in matters of accreditation of train,ing programs for nurse anesthetists.
AORN Journal, July 1975, Vol 22, N o 1
61
Thera peut ic, cosmetic effects of oral surgery Robert J Wehner, RN
Robert J Wehner, RN, (IMAJ, A N C ) is supervisor of anesthesia and chief of the respiratory therapy services at the US
Army Hospital in Nurnberg, W Gernzany. He is a graduate of S t Elizabeth Hospital Med-
ical Center, Dayton, Ohio; the US Army School of Anesthesiobgy for Nurses, and the U S Army operating room nursing course.
52
ral surgery ranges from a simple extraction of a tooth to the more complicated surgical correction of mandibular and maxillary deformities. A protruding or receding jaw, a condition called prognathism, is corrected primarily by mandibular or maxillary osteotomy, a common practice for the past ten years. The rectification of a malocclusion and other facial deformities not only aids the patient therapeutically and cosmetically, but also helps him psychologically. The historical development of oral surgery dates back to the early 1800s when Hullihen first described a surgical correction for mandibular protuberance in 1849. His descriptive cure of a patient with severe burns of the neck and a protruding mandible served as a foundation for future mandibular corrections.1 Variations of his surgical correction have been developed, and several reported using a wide range of anatomical sites including the ramus and body of the mandible. Repositioning the maxilla by posterior ostectomy using a two-stage operation was first described by Schuchardt in 1959.2 In 1970, Kufner reported the use of a singlestage ostectomy involving the posterior maxilla.3 These and other procedures are being used today for correction of selected facial deformities. The etiology of mandibular and maxillary facial deformities may be congenital, or they may develop as the individual grows. “In most instances the occlusion and function of the teeth is affected; but in others, the occlusion is normal and the deformities involve parts of the facial skeleton not supplied by teeth.”+ Mandibular prognathism is involved in the craniofacial growth that leads to a disharmony of facial appearance. Hereditary factors influencing this condition could be both endocrine and environmental. Maxillary prognathism is characterized by protruding teeth commonly referred to as “buck teeth.” Like the mandible, the
AORN Journal, July 1975, Vol 22, N o 1
prominent maxilla could be caused by several factors related to both heredity and environment. Protruding front teeth could be the result of an open bite caused by thumbsucking when young or thrusting the tongue while swallowing. “The tongue exerts a pressure of about 60 Ibs during each swallowing reflex. The daily average number of swallows is 1,400.”5This constant pressure causes the maxilla to be pushed upward, and a separation of the front teeth occurs. Surgical correction of this condition is primarily for therapeutic effects. However, the patient sees the correction a s a cosmetic and psychologic effect. Prognathism of the mandible and maxilla cannot be corrected without attention to the anatomical structures involved: the mandible, maxilla, and the blood and nerve supply to the face and skull. A general review of each follows. The mandible is the largest and strongest bone of the face and consists of a curved horizontal portion, the body, and two perpendicular portions, the rami. The
alveolar process border of the body contains cavities for the reception of the teeth. Each ramus has a condyle, which articulates with the mandibular fossa of the temporal bone, and a coronoid process, which gives attachment to the temporal muscle and some fibers of the buccinator. The deep depression between the two processes is called the mandibular notch. The mental foramen, which is just below the first molar tooth, serves as a passage way for the mental nerve, which is a terminal branch of the inferior dental nerve (of the trigeminal nerve) .6 (Fig 1) The maxillae are formed by their union to the whole upper jaw. Each bone helps to form (1) part of the floor of the orbit, (2) the floor and lateral walls of the nasal cavities, and (3) the greater part of the roof of the mouth. Each bone contains a large cavity, the maxillary sinue, which opens into the nose. The alveolar processes are excavated cavities, which vary in depth and size according to the teeth they contain. . .? The two major nerves and their branches which innervate the facial regions are the trigeminal nerve and the facial nerve, commonly referred to as the fifth and seventh cranial nerves. The common carotid arteries provide the major source of blood to the skull. These arteries give off branches to all the vital areas of the skull and brain. Developmental disturbances indicating surgical intervention of prognathism coincide with the etiological factors mentioned previously. They are a maxillary prognathism, which indicates an anteroposterior overdevelopment of the middle region of the face, “. . . a mandibular prog-
AORN Journal, July 1975, Vol 22, No 1
.
53
)\
triaeminal, 5th crania
\
semilunar ganglion
A
-
facial, 7th crbanial nerve
chorc
inferior alveolar
Ann Leonard
Fig 7 . The trigeminal, or fifth cranial nerve, is the great cutaneous sensory nerve of the face, the sensory nerve t o the mucous membranes and other internal structures of the head, and the motor nerve of the muscles of mastication. Its divisions, ophthalmic, maxillary, and mandibular, are numbered in the illustration. The facial, or seventh cranial nerve, innervates the muscles of facial expression, scalp, and inner ear. The sensory part supplies the anterior two-thirds of the tongue with taste and parts of the external acoustic meatus, soft palate, and adjacent pharynx with general sensation. The parasympathetic part supplies secretomofor fibers for the submandibular, sublingual, lacrimal, nasal, and palatine glands.
54
AORN Journal, July 1975, Vol 22, No 1
Ostecfomy in horizontal ramus to’ correct mandibular protrusion. tllustration from Thoma, Kurf H: O r a l Surgery, ed 4, Sf Louis, 7963, C V Mosby Co.
nathism, which is an anteroposterior overdevelopment of the lower third of the face, pseudoprognathism of the mandible, or an anteroposterior underdevelopment of the lower portion of the face.’’s Disturbances of the vertical development of the face include the open bite, involving the long lower portion of the face, or the closed bite, involving the short lower portion of the face. Trauma, crossbite, macroglossia, and cleft palates also are reasons for surgical correcti~n.~
Oral surgeons have added modifications to the basic osteotomy or 0stectomy pioneered by earlier men. Some common surgical procedures for correcting mandibular prognathism that have been tried and proven effective are: the horizontal osteotomy, the sagittal osteotomy, the vertical osteotomy, the sliding 0steotomy, and the oblique osteotomy. (See illustrations.) Methods of approach have been either intraoral or extraoral. The type used by the oral surgeon depends first on the condition of the patient, and second, the preferred method of the surgeon. Operations for the correction of facial deformities are not totally without complications. Although the majority of the complications occur when the intraoral approach is used, other types of procedures also result in complications. Behrman found in his survey of complications after midsaggital splitting that the most frequently reported complications were regression and relapse followed by hemorrhage and disturbances of the mandibular nerve. Some of the less frequent complications reported were edema (airway obstruction),
Simple osteotomy, A, causes V-shaped space to open when anterior fragment is placed in position fo close open bite, while V-shaped ostectomy, B, closes space in correction of open bite. lllustrations from Thoma, Kurt H: O r a l Surgery, ed 4, St Louis, 1963, C V Mosby Co.
AORN Journal, July 1975, VoE 22, No I
55
Reversed V-shaped ostectomy to close open bife in premolar region. A, reversed V excision. 6, anterior fragrnenf tiffed into
fragmentation of the ramus, necrosis or sequestration of bone, and infection.'" Although the incidence of complications is low, their existence must always be considered by the oral surgeon who should use all available means to avoid them. The cosmetic effects realized by oral surgery are gratifying to the patient, who views the operation as a cosmetic improvement rather than improvement of masticatory functions." Women particularly seek cosmetic improvements because of social norms and acceptance.'? Years back, the protruding jaw
56
had several connotations. One was it indicated determined, yet tough and threatening individuals. People expected violence from them. Adults are not the only ones faced with these problems. Young people also have to contend with social problems among their peers because of facial deformities. The receding chin has the opposite effect from the protruding chin. It gives the appearance of a timid, ineffectual person. Business men often find it difficult to promote sales when they have a receding or a protruding chin.13
AORN Journal, July 1975, VoE 22, No I
L-shaped osteotomy for advancing mandible.
\
1.
IF
Osfeofomy ascending ramus of mandible affer Skaloud.
-
\ A /I
\!
I;
3/+
\
Prognathism. A, correction by oblique osteofomy in ramus; 6, correction by ostecforny in horizontal rarnus. lllustrafions from Jhoma, Kurt H: Oral Surgery, ed 4d, St Louis, 1963, C V Mosby Co.
Prognathism, therefore, gives the impression of either a negative person or one who is a bully. By moving the jaw either forward or backward, the oral surgeon can improve the facial appearance of the patient and enable the patient to blend in with the “normal” crowds of people. The accompanying photos demonstrate pre and postoperative views of maxillary prognathism, mandibular
protuberance, and maxillary and mandibular malocclusion. Radiographic examples illustrate changes in facial profiles following osteotomies for correction of prognathisms. Malocclusion of the teeth is one of the greatest prognathic disorders. Functionally, the teeth should meet surface to surface, upper and lower, for food to be properly masticated. In the open bite, the patient can usually bring his posterior teeth (molars) together but is unable to occlude his anterior teeth. This prevents him from “biting” into his food. He usually has to pull his food apart before he can chew i t with his back teeth. People with maxillary protrusion or mandibular protrusion also find it difficult to “bite” into foods. After oral surgical correction, patients find it easier to chew and to bite with their front teeth. Several case reports show that meat, corn on the cob, and lettuce are foods that can be eaten better po~toperatively.~~
AORN Journal, July 1975, Vol 22, No 1
57
Postoperative view, maxillary correction.
Radiographic view showing mandibular protuberance.
58
Postoperative view, mandibular correction.
AORN Journal, July 1975, Vol 22, N o 1
Preoperative view, maxillary malocclusion.
Postoperative view of maxillary correcfion for malocclusion.
Postoperative view of mandibular correction for malocclusion.
Preoperative view, mandibular malocclusion.
AORN Journal, July 1975, Vol 22, N o 1
59
Many patients could once again enjoy foods. Although the types of foods enjoyed did not vary from what was eaten preoperatively, they could be bitten and chewed more easily and more comfortably po~toperatively.~~ Improperly chewed foods, which place a great strain on the digestive system, result in gastric disorders, a fairly common complaint among prognathic patients.l6 Rectification of functional disorders by oral surgery can also eliminate speech defects in some patients who find it difficult to pronounce some consonant and fricative sounds, particularly t, d, 1, n, and s, sh, z, zh. Preoperative and postoperative speech therapy, coupled with surgical correction of the open bite, often gives the patient remission of this condition.“ Before an oral surgeon performs a cosmetic or therapeutic operation, the patient must have a psychiatric evaluation. This is necessary to ascertain if the patient will be able to cope with his new appearance. If the psychiatrist feels the patient is too immature or that he would not be psychologically able to cope with the postoperative improvement, the oral surgeon will usually not perform the operation. I * Most patients who seek aid from an oral surgeon are introverted, shy, and have little self-confidence. They are usually passive and generally remain in a state of depression. Anatomical and functional disturbances not only alter their appearance but also have accompanying psychologic abnormalities. Several of these patients have to withstand great numbers of disadvantages. Reduction of the masticatory
60
function may make one dependent on home cooking and cause digestive problems. One’s appearance may completely bar him from certain types of professions, or may prevent him from advancing in his profession in accord with his mental and manual capabilities. The resultant psychic manifestations, due to the patient’s skeletal disorder alone, may be enough to hinder him in his vocation. Perhaps worst of all for the patient, his personal and private life suffers from these esthetic, psychological and functional abnormalities.19 Many times this psychological problem begins before or at the age of puberty. If surgical correction has not been performed before the patient reaches the age of 20 or 23, the psychic disorder could be so deeply embedded in the patient that in spite of surgical success, the patient may still remain irreversible.20 Beneficial facial improvement by oral surgery not only changes the personality of the patient but also improves him as a social individual. These postoperative patients are outgoing, gain weight, and are no longer the brunt of jokes. The majority of them gain a new selfconfidence, they shed old fears of meeting and talking with people, and they enjoy eating in public. In general, the patient becomes more sociable.*l In summary, the cosmetic, therapeutic, and psychological benefits derived from oral surgery greatly aid the patient in coping with everyday sociological acceptance. Because of oral surgical correction, the patient no longer stands in the “shadows” but becomes a part of the group.
AORN Journal, July 1975, Vol 22, N o 1
0
Notes I. S P Hullihen, "Case o f elongation o f the under iaw and distortion of the face and neck, successfully treated," American Journal of Dental Science, 9 (January 1849) 157-1 85. 2. R A West, B N Epker, "Posterior maxillary surgery: I t s place in the treatment of dentofacial deformities," Journol of O r o l Surgery, 30 (August
1972) 562-575. 3. lbid. 4. Kurt H Thoma, O r a l Surgery Vol 2 ( S t Louis: C V MosbY CO, 1963) 1129-1195. 5. D S Hershman, G L Tinsley, C E Schow, "Apertognathia-an interdisciplinary approach: Report of case,'' Journol of Oral Surgery, 30 (October 1972) 743-747. 6. M A Miller, L C Leavel, Anatomy and Physiology 16th ed (New York: Macmillan Co, 1972)
89. 7. lbid. 8. Maurice Theberge, "Team rapport: I t s value in surgical orthodontics," Journal of O r a l Surgery, 26 ( A p r i l 1968) 277-280. 9. Ibid.
10. S J Behrman, "Complications o f sagittal osteotomy of the mandibular ramus," Journal of O r a l Surgery, 30 (August 1972) 554-561. I I. Theberge, op cit, p 278. 12. H Obwegeser, "Surgical correction o f small or retrodisplaced maxillae," Plastic and Reconstructive Surgery, 43 ( A p r i l 1969) 351.
13. Ibid. 14. N Crowell, H Sazima, S Elder, "Survey of patients' attitudes after surgical correction of prognathism: Study o f 33 patients," Journal of Ora/ Surgery, 28 (November 1970) 820. 15. C E Hutton, "Patients' evaluation o f surgical correction of prognathism: Survey of 32 patients," Journaf of Orul Surgery, 25 ( M a y 1967)
225-228. 16. Thoma, op cit, I 130. 17. Hershman, op cit, 744. 18. Emery Russell, LTC, DC, chief, oral surgery service, US Army Hospital, Fort Campbell, private conversations. 19. Obwegeser. op cit, 351. 20. Obwegeser, op cit. 351. 21. Hutton, op cit, 227.
Ky,
AANA Council on Prucfice members Seven experts in health care have been named to the Council on Practice of the American Association of Nurse Anesthetists (AANA). The new council, which will b e autonomous, will focus on the role of the certified registered nurse anesthetist (CRNA) within the health care field and will have power to act directly on matters involving member discipline and standards of practice. The members are: Thomas Arthur, legal consultant, Gardner, Carton, Douglas, Chilgren & Waud law firm, Chicago; Barbara Brown, RN, EdD, assistant administrator of patient care services, Family Hospital, Milwaukee; Albert E Doubek, CRNA, chief anesthetist, Sioux Valley Hospital, Sioux Falls, SD; Hugh S Mothewson, MD, medical director, respiratory therapy, University of Kansas Medical Center of the College of Health Sciences and Hospital, Kansas City, Kan; Elliott G Roberts, MA, director of hospitals, Detroit General Hospital, Detroit; Helen P Vos, CRNA, BS, director, anesthesia program for nurses,
North Carolina Baptist Hospital, Winston-Salem; and Martha P Belew, CRNA, chief nurse anesthetist, Baptist Memorial Hospital, Memphis, Tenn. The council will have five specific areas of responsibility: 1. develop advisory joint-practice statements pertaining to anesthesia practice (in consultation with the American Society of Anesthesiologists, the American Hospital Association, and the American Nurses' Association) 2. review and revise the standards of practice for nurse anesthetists as required 3. provide for and supervise the ongoing evaluation of the practice of the nurse anesthetist 4.act as the investigating and disciplinary body concerned with grievances and complaints registered against nurse anesthetists pertaining to their practice, including complaints of violations of ethical standards. 5. act as the appeal body in matters of accreditation of train,ing programs for nurse anesthetists.
AORN Journal, July 1975, Vol 22, N o 1
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