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Mandibular prognathism
Mandibular prognathism Two unusual cases John G. Whinery, Amarillo,
Texas
M
ost private practitioners have experienced the marvel of seeing several rare or unusual casesat one time or in quick succession.Such was the case in the third week of May 1980, when two casesof mandibular prognathism were referred to me. One patient was 5 years old (Fig. l), and the other was 79 years of age (Fig. 2). These two casesare unusual by reason of age, but they merit discussion because of the holistic considerations which they evoked. CASE 1
The chief complaint which brought the 5-year-old to me was his refusal to speak, especially at preschool, and enuresis. He had begun to wet his pants and his bed. The other children at school were mimicking his speech impediment, which resulted from the too-forward position of his tongue. The child had a marked mandibular prognathism which was confirmed by cephalometric x-ray analysis (Fig. 3). Physical examination by a pediatrician revealed no other abnormality. The patient’s weight was in the 80th percentile for his age, and his height was in the 90th percentile for his age. Both parents are large. Speech and language evaluation was reported in part as follows: “An articulation analysis reveals a consistent thrusting of the tongue between the teeth for the sibilants ‘S’ , ‘z’, ‘sh’, ‘ch’, and ‘j’. Periodically a lateral emission of air audible for some of these sounds. Other sounds affected include the ‘th’, ‘r’, and ‘v’ sounds. The ‘t’ and ‘d’ phonemes are acoustically correct; however, they are made by using compensatory movements of the tongue which is either the lateral side ridges of the tongue against the teeth or the midtongue against the hard palate. It does not appear that the environmental accommodation of the upper arch is sufficient to accommodate the entire surface of the tongue, restricting the tongue in making a comfortable contact with the alveolar arch but instead contacting the edges of the maxillary teeth. ‘K’ is substituted for ‘ch’ and ‘g/j’ in initial positions of words. “Stimulability of the sibilants was judged to be poor due to the severe mandibular protraction, causing the tongue to be forced either between the teeth or resulting in poor linguo-alveolar valving which results in a lateral lisp. Although he could produce a correct ‘r’ sound in isolation 0030.422OjX2,‘070007
+ 05%00.50/O
@ 1982 The
C. V. Mosby
Co
it was not easy or natural for him to retract the tongue, possibly due to lack of space in the upper arch. “It is the examiner’s impression that M. is having great difficulty making adaptive articulatory movements for his misarticulations and that the severe malocclusion interferes with the correction of speech.“’ Pertinent observations by the child psychiatrist were that the child showed good emotional responsiveness and there was no evidence of emotional withdrawal or break from reality. The child showed rather poor use of speech and a tendency to talk in telegraphic fashion. He was reticent about attempting either a written or a verbal task. The general impression of the examiner was that the child showed rather severe problems in speech, developmental delays in cognitive and social areas, and evidences of unsureness and poor self-concept. A search of the literature failed to report a similar case involving so young a patient. The speech and psyche problems mandated prompt surgery. The usual policy of waiting for complete growth was not considered; however the alarming growth potential was taken into consideration. From the lateral cephalometric radiograph, four factors have been identified with portend abnormal mandibular growth.2 These factors are (1) upper and lower first molar relationship measured from the pterygoid vertical line to the distal surface, (2) a “forward” porion location measured along Frankfort from the vertical pterygoid line, (3) cranial deflection-a downward and forward basion measured by the angle of basion-nasion intersection with Frankfort, and (4) a forward ramus position measured by the angle of Frankfort to a line drawn from pterygoid vertical to Xi point. Deviations from normal for these four factors in this patient’s original x-ray film were measured by the Rocky Mountain Data Systems Corporation: Molar relation -~ I .3 clinical deviation Povion location-l .2 clinical deviation Cranial deflection-O. 1 clinical deviation Ramus position-l .6 clinical deviation These deviations are of low magnitude and do not predict the large growth experienced in the nearly 2 years since surgical intervention. The corpus length of the mandible relative to the length of the middle and anterior cranial fossae (basion to nasion) is a clear indication of mandibular growth. However, an 7
Oral Surg. July. 19x2
Fig. 1
Fig. 2
Volume
Mandibular
54
prognathism
9
Number I
Fig. 3
abnormality found here can serve only as a factor for extension of the established growth pattern, not as a predictor of growth not yet demonstrated. Determination of when to operate must still be made on the basis of the patient’s social, psychological, and physical well-being. During summer vacation a bilateral extraoral mandibular ramus vertical oblique osteotomy and coronoidotomy was performed. This procedure and the postoperative course were uneventful. The child spoke little while in intermaxillary fixation. Speech and behavior were evaluated 1 month after the start of school. The report stated: “Contrary to the first evaluation, which was on May 23, 1980, M. was verbal throughout the testing situation, outgoing, with a constant smile and cooperative in the stimulability testing. It is very apparent that his self-image is markedly improved, as he related with confidence to the examiner all during the evaluation. The patient’s mother reports that this is also evident at school. “An articulation analysis reveals that the pronounced, existing frontal lisp and lateral lisp which occurred before surgery have been reduced to a slight frontal lisp and the lateral lisp has been eliminated. Although Michael continues to produce the ‘1’ ‘n’ ‘t’, and ‘d’ sounds either by thrusting the tongue or by using the lateral ridges of the tongue against the teeth, stimulability testing reveals that
Fig. 4
the tongue tip can be easily placed on the alveolar ridge and the sounds can be produced rapidly in succession. This, of course, could not be accomplished prior to surgery. M. also continues to rest the tongue between the teeth in repose. This evaluation reveals that the environmental accommodation for the tongue is now adequate for the
10
Whinery
Fig.
5
The patient’s mother reported that the enuresis had stopped except for rare occasions. The parents, both of whom had slightly prominent jaws, were advised that additional surgical intervention will probably be necessary as the child grows. They also understand the importance of remedying the child’s developing psychologic problems. CASE 2
Fig.
6
production of speech sounds with no restrictions, as was demonstrated by his performance at this evaluation. “His habitual speech patterns and habitual thrusting of the tongue and tongue position at rest will need to be re-established through intensive speech therapy”’
The chief complaint of the 79-year-old female patient was that chewing was difficult and painful. Plaster casts furnished by the referring dentist illustrate the malrelationship of the teeth and jaws (Fig. 4). A panoramic film illustrated the extensive bone resorption which occurred under the maloccluding partial denture (Fig. 5). The patient had a long-standing habit of holding her teeth together-a possible cause of bone 10~s.~The referring dentist felt unable to develop an occlusion which would function and which would be pain free. Physical evaluation revealed moderate osteoarthritis, but otherwise all systems were functioning normally. Blood chemistries, chest x-ray, and an electrocardiogram were normal. There was no significant history of previous illness. The patient was exceptionally bright, alert, and communicative. She created the impression of being much younger than 79, despite her first words to me: “I’ll bet you never saw an older or uglier woman.” There was no apparent physical finding to contraindicate mandibular surgery. Because the patient lived a considerable distance from this city, the referring dentist was asked to tell her of the “downside” aspects of corrective surgery, that is, length of intermaxillary fixation, extent of surgery, etc. The patient promptly returned to this office asking that the surgical procedure be performed. After thorough discussion, the treatment was put off until cooler weather. Her continued desire for surgical correction was evidenced by a number of
Mandibular phone calls and letters during the next several months. After thorough evaluation of the patient’s problem, her health, and desire, it was apparent that the only reason for not operating was that she was “too old.” I could not say that to her. The geriatric assessment was that she was more fit for surgery than for suffering the pain of eating and substandard nutrition. Although it is well recognized that tooth-removal wounds may heal more slowly in old persons, bone fractures generally heal at the same rate as in younger adults.’ The ongoing resorption and formation of bone are in essentially the same amounts during the third and fourth decades. Subsequently, resorption increases while formation of bone remains the same. The result is osteoporosisthe depletion of bone mass. After about age 80, resorption decreases to a balance with bone deposition.6 Women loose twice as much bone in absolute terms and three times as much percentagewise.’ Loss of bone tissue is accompanied by progressive calcification and concomitant loss of water and organic tissue in normal aging human beings.” The bone is lost from the inside out, not subperiosteally. The large area of periosteum available for repair of ramus fractures/osteotomies relative to the mass of bone must account for the consistent healing of the mandibular ramus. An increase in the number of occluded Haversian canals in old bone must represent an interruption of blood supply.* The surgeon is well advised to preserve periosteal attachment maximally. The mandibular vertical ramus osteotomy requires periosteal stripping on the medial surface to allow internal pterygoid muscle release and for overlap of the distal bone segment. The ramus must also be stripped on the facial surface to permit coronoidotomy and the vertical osteotomy. However, the periosteal attachment should be preserved on the posterior edge and much of the medial surface. Other considerations for cutting old bone must include its diminished elasticity and the loss of bone strength. Cutting, levering, and the drilling of holes must be done with gentleness. A bilateral mandibular ramus vertical oblique osteotomy and coronoidotomy was performed on Oct. 8, 1980.
prognathism
II
Stabilization of the posterior mandible (edentulous) was achieved with figure of eight wiring of the proximal and distal fragments, thus avoiding the discomfort and sepsis of an intraoral splint (Fig. 6). The surgery went easily and without problem. The postoperative course was not remarkable, except for the patient’s slowness in regaining her preoperative vigor, which took about 3 weeks. SUMMARY
In the first case we were obliged to operate because of social-psyche problems. In the second case extensive “elective” surgery was approached with hesitation. The patient was 80 years old the day her sutures were removed. To have denied her the surgery because of her age would have constituted a severe insult and hurt to the lady’s psyche, that is, her spirit for living. Further, it would have cast the doctor in a Godlike role of determining who is “too old.” Each of these surgical procedures resulted in much satisfaction to all concerned. REFERENCES I. Scholl. 2.
3. 4. 5. 6. I.
8.
K. L. (Amarillo Speech Hearing and Language Center): Personal Communication, May 23, 1980. Schulhof, R. J., Nakamura, S., and Williamson, W. V.: Prediction of Abnormal Growth of Class III Malocclusions, Am. J. Orthod. 71:421-430, 1977. Scholl, K. L.: Personal Communication, Oct. 29, 1980. Whinery. J. G.: Mandibular Atrophy: A Theory of Its Cause and Prevention. J. Oral Surg. 33~120, 1975. Devas, Michael: Geriatric Orthopaedics, London, 1977, Academic Press, p. 105. Turek, Samuel L.: Orthopaedics, Principals and Their Application, Philadelphia, J. B. Lippincott Company, p, 135. Garn, Stanley M., et al.: Population Similarities in the Onset and Rate of Adult Endosteal Bone Loss, Clin. Orthop. 65~5 l-59. 1969. Detcnbcck. Lee C., and Jow’scy. Jenifer: Normal Aging in the Boric of the Adult Dog, Clin. Orthop. 65:76-80. 1969.
Reprint
requests
10:
Dr. John G. Whinery 2412 Line Ave. Amarillo. Texas 79106
Texas
M
ost private practitioners have experienced the marvel of seeing several rare or unusual casesat one time or in quick succession.Such was the case in the third week of May 1980, when two casesof mandibular prognathism were referred to me. One patient was 5 years old (Fig. l), and the other was 79 years of age (Fig. 2). These two casesare unusual by reason of age, but they merit discussion because of the holistic considerations which they evoked. CASE 1
The chief complaint which brought the 5-year-old to me was his refusal to speak, especially at preschool, and enuresis. He had begun to wet his pants and his bed. The other children at school were mimicking his speech impediment, which resulted from the too-forward position of his tongue. The child had a marked mandibular prognathism which was confirmed by cephalometric x-ray analysis (Fig. 3). Physical examination by a pediatrician revealed no other abnormality. The patient’s weight was in the 80th percentile for his age, and his height was in the 90th percentile for his age. Both parents are large. Speech and language evaluation was reported in part as follows: “An articulation analysis reveals a consistent thrusting of the tongue between the teeth for the sibilants ‘S’ , ‘z’, ‘sh’, ‘ch’, and ‘j’. Periodically a lateral emission of air audible for some of these sounds. Other sounds affected include the ‘th’, ‘r’, and ‘v’ sounds. The ‘t’ and ‘d’ phonemes are acoustically correct; however, they are made by using compensatory movements of the tongue which is either the lateral side ridges of the tongue against the teeth or the midtongue against the hard palate. It does not appear that the environmental accommodation of the upper arch is sufficient to accommodate the entire surface of the tongue, restricting the tongue in making a comfortable contact with the alveolar arch but instead contacting the edges of the maxillary teeth. ‘K’ is substituted for ‘ch’ and ‘g/j’ in initial positions of words. “Stimulability of the sibilants was judged to be poor due to the severe mandibular protraction, causing the tongue to be forced either between the teeth or resulting in poor linguo-alveolar valving which results in a lateral lisp. Although he could produce a correct ‘r’ sound in isolation 0030.422OjX2,‘070007
+ 05%00.50/O
@ 1982 The
C. V. Mosby
Co
it was not easy or natural for him to retract the tongue, possibly due to lack of space in the upper arch. “It is the examiner’s impression that M. is having great difficulty making adaptive articulatory movements for his misarticulations and that the severe malocclusion interferes with the correction of speech.“’ Pertinent observations by the child psychiatrist were that the child showed good emotional responsiveness and there was no evidence of emotional withdrawal or break from reality. The child showed rather poor use of speech and a tendency to talk in telegraphic fashion. He was reticent about attempting either a written or a verbal task. The general impression of the examiner was that the child showed rather severe problems in speech, developmental delays in cognitive and social areas, and evidences of unsureness and poor self-concept. A search of the literature failed to report a similar case involving so young a patient. The speech and psyche problems mandated prompt surgery. The usual policy of waiting for complete growth was not considered; however the alarming growth potential was taken into consideration. From the lateral cephalometric radiograph, four factors have been identified with portend abnormal mandibular growth.2 These factors are (1) upper and lower first molar relationship measured from the pterygoid vertical line to the distal surface, (2) a “forward” porion location measured along Frankfort from the vertical pterygoid line, (3) cranial deflection-a downward and forward basion measured by the angle of basion-nasion intersection with Frankfort, and (4) a forward ramus position measured by the angle of Frankfort to a line drawn from pterygoid vertical to Xi point. Deviations from normal for these four factors in this patient’s original x-ray film were measured by the Rocky Mountain Data Systems Corporation: Molar relation -~ I .3 clinical deviation Povion location-l .2 clinical deviation Cranial deflection-O. 1 clinical deviation Ramus position-l .6 clinical deviation These deviations are of low magnitude and do not predict the large growth experienced in the nearly 2 years since surgical intervention. The corpus length of the mandible relative to the length of the middle and anterior cranial fossae (basion to nasion) is a clear indication of mandibular growth. However, an 7
Oral Surg. July. 19x2
Fig. 1
Fig. 2
Volume
Mandibular
54
prognathism
9
Number I
Fig. 3
abnormality found here can serve only as a factor for extension of the established growth pattern, not as a predictor of growth not yet demonstrated. Determination of when to operate must still be made on the basis of the patient’s social, psychological, and physical well-being. During summer vacation a bilateral extraoral mandibular ramus vertical oblique osteotomy and coronoidotomy was performed. This procedure and the postoperative course were uneventful. The child spoke little while in intermaxillary fixation. Speech and behavior were evaluated 1 month after the start of school. The report stated: “Contrary to the first evaluation, which was on May 23, 1980, M. was verbal throughout the testing situation, outgoing, with a constant smile and cooperative in the stimulability testing. It is very apparent that his self-image is markedly improved, as he related with confidence to the examiner all during the evaluation. The patient’s mother reports that this is also evident at school. “An articulation analysis reveals that the pronounced, existing frontal lisp and lateral lisp which occurred before surgery have been reduced to a slight frontal lisp and the lateral lisp has been eliminated. Although Michael continues to produce the ‘1’ ‘n’ ‘t’, and ‘d’ sounds either by thrusting the tongue or by using the lateral ridges of the tongue against the teeth, stimulability testing reveals that
Fig. 4
the tongue tip can be easily placed on the alveolar ridge and the sounds can be produced rapidly in succession. This, of course, could not be accomplished prior to surgery. M. also continues to rest the tongue between the teeth in repose. This evaluation reveals that the environmental accommodation for the tongue is now adequate for the
10
Whinery
Fig.
5
The patient’s mother reported that the enuresis had stopped except for rare occasions. The parents, both of whom had slightly prominent jaws, were advised that additional surgical intervention will probably be necessary as the child grows. They also understand the importance of remedying the child’s developing psychologic problems. CASE 2
Fig.
6
production of speech sounds with no restrictions, as was demonstrated by his performance at this evaluation. “His habitual speech patterns and habitual thrusting of the tongue and tongue position at rest will need to be re-established through intensive speech therapy”’
The chief complaint of the 79-year-old female patient was that chewing was difficult and painful. Plaster casts furnished by the referring dentist illustrate the malrelationship of the teeth and jaws (Fig. 4). A panoramic film illustrated the extensive bone resorption which occurred under the maloccluding partial denture (Fig. 5). The patient had a long-standing habit of holding her teeth together-a possible cause of bone 10~s.~The referring dentist felt unable to develop an occlusion which would function and which would be pain free. Physical evaluation revealed moderate osteoarthritis, but otherwise all systems were functioning normally. Blood chemistries, chest x-ray, and an electrocardiogram were normal. There was no significant history of previous illness. The patient was exceptionally bright, alert, and communicative. She created the impression of being much younger than 79, despite her first words to me: “I’ll bet you never saw an older or uglier woman.” There was no apparent physical finding to contraindicate mandibular surgery. Because the patient lived a considerable distance from this city, the referring dentist was asked to tell her of the “downside” aspects of corrective surgery, that is, length of intermaxillary fixation, extent of surgery, etc. The patient promptly returned to this office asking that the surgical procedure be performed. After thorough discussion, the treatment was put off until cooler weather. Her continued desire for surgical correction was evidenced by a number of
Mandibular phone calls and letters during the next several months. After thorough evaluation of the patient’s problem, her health, and desire, it was apparent that the only reason for not operating was that she was “too old.” I could not say that to her. The geriatric assessment was that she was more fit for surgery than for suffering the pain of eating and substandard nutrition. Although it is well recognized that tooth-removal wounds may heal more slowly in old persons, bone fractures generally heal at the same rate as in younger adults.’ The ongoing resorption and formation of bone are in essentially the same amounts during the third and fourth decades. Subsequently, resorption increases while formation of bone remains the same. The result is osteoporosisthe depletion of bone mass. After about age 80, resorption decreases to a balance with bone deposition.6 Women loose twice as much bone in absolute terms and three times as much percentagewise.’ Loss of bone tissue is accompanied by progressive calcification and concomitant loss of water and organic tissue in normal aging human beings.” The bone is lost from the inside out, not subperiosteally. The large area of periosteum available for repair of ramus fractures/osteotomies relative to the mass of bone must account for the consistent healing of the mandibular ramus. An increase in the number of occluded Haversian canals in old bone must represent an interruption of blood supply.* The surgeon is well advised to preserve periosteal attachment maximally. The mandibular vertical ramus osteotomy requires periosteal stripping on the medial surface to allow internal pterygoid muscle release and for overlap of the distal bone segment. The ramus must also be stripped on the facial surface to permit coronoidotomy and the vertical osteotomy. However, the periosteal attachment should be preserved on the posterior edge and much of the medial surface. Other considerations for cutting old bone must include its diminished elasticity and the loss of bone strength. Cutting, levering, and the drilling of holes must be done with gentleness. A bilateral mandibular ramus vertical oblique osteotomy and coronoidotomy was performed on Oct. 8, 1980.
prognathism
II
Stabilization of the posterior mandible (edentulous) was achieved with figure of eight wiring of the proximal and distal fragments, thus avoiding the discomfort and sepsis of an intraoral splint (Fig. 6). The surgery went easily and without problem. The postoperative course was not remarkable, except for the patient’s slowness in regaining her preoperative vigor, which took about 3 weeks. SUMMARY
In the first case we were obliged to operate because of social-psyche problems. In the second case extensive “elective” surgery was approached with hesitation. The patient was 80 years old the day her sutures were removed. To have denied her the surgery because of her age would have constituted a severe insult and hurt to the lady’s psyche, that is, her spirit for living. Further, it would have cast the doctor in a Godlike role of determining who is “too old.” Each of these surgical procedures resulted in much satisfaction to all concerned. REFERENCES I. Scholl. 2.
3. 4. 5. 6. I.
8.
K. L. (Amarillo Speech Hearing and Language Center): Personal Communication, May 23, 1980. Schulhof, R. J., Nakamura, S., and Williamson, W. V.: Prediction of Abnormal Growth of Class III Malocclusions, Am. J. Orthod. 71:421-430, 1977. Scholl, K. L.: Personal Communication, Oct. 29, 1980. Whinery. J. G.: Mandibular Atrophy: A Theory of Its Cause and Prevention. J. Oral Surg. 33~120, 1975. Devas, Michael: Geriatric Orthopaedics, London, 1977, Academic Press, p. 105. Turek, Samuel L.: Orthopaedics, Principals and Their Application, Philadelphia, J. B. Lippincott Company, p, 135. Garn, Stanley M., et al.: Population Similarities in the Onset and Rate of Adult Endosteal Bone Loss, Clin. Orthop. 65~5 l-59. 1969. Detcnbcck. Lee C., and Jow’scy. Jenifer: Normal Aging in the Boric of the Adult Dog, Clin. Orthop. 65:76-80. 1969.
Reprint
requests
10:
Dr. John G. Whinery 2412 Line Ave. Amarillo. Texas 79106