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Surgical correction of micrognathia and microgenia
Ord SURGERY OralMEDICINE PATH 0 10 GY
AND ord
VOLUME
29
NUMBER
2
FEBRUARY,
1970
Operative oral surgery Surgical correction of micrognathia and microgenia Report
of a case
Stuart M. Goldberg, D.D.S.,’ Jamaica, N. Y. DEPARTMENT HOSPITAL
OF DENTISTRY, CENTER
and Robert L. Himmelfarb, LONG
ISLAND
D.D.X.,“’
JEWISH-QUEENS
AFFILIATION
T
he deformities of micrognathia and microgenia produce a significant disproportionate relationship between the hard and soft tissues of the lower and middle thirds of the face. Usually accompanying this is a severe malocclusion, which creates a functional disability of the stomatognathic system with respect to mastication and speech. The basic concern in the correction of these deformities is the achievement of satisfactory function and stability of the hard tissues and a balanced harmony of the overlying soft tissues. Although cosmetics is not our primary concern, facial appearance is extremely important since disfiguring deformities have the potentiality of producing serious social handicaps with psychic overtones. The surgical approach to micrognathia and microgenia are many, and each must be carefully designed to meet the requirements of the individual patient. Attempts at lengthening the mandible to correct micrognathia include various *Formerly **Attending
Chief Resident in Oral Surgery. Oral Surgeon.
At present
Assistant
Attending
Oral Surgeon.
163
164
Goldberg and Himmelfarb
Oral Surg. February,
Fig.
1. Preoperative
1970
profile.
types of sliding osteotomies of both the body and the ramus of the mandible, with and without interposed bone grafts. 1p2*4l ~-17 In a like manner, a deficiency of the mentum, or microgenia, has been corrected by a sliding osteotomy or by the insertion of autogenous, heterogenous, or alloplastic onlay grafts.2y 3, 6 CASE REPORT A 17-year-old boy was referred by an orthodontist to the oral surgery clinic and possible correction of his severe micrognathia and microgenia (Fig. 1). Past
for evaluation
history
The patient’s mother related that the facial deformity did not manifest itself until the child was recuperating from a prolonged hospitalization for the treatment of body burns sustained at the age of 7. She attributed the facial deformity to the “prolonged use of body bandages which extended up to and around t.he lower portion of the face.” All other elements of the past medical history and the review of systems were essentially negative. Regional
examination
Extraoral examination of the head and neck was essentially negative except for a marked foreshortening of the lower third of the face. Intermaxillary opening was limited to 17 mm. Both mandibular condylar heads were palpable during function. Opening was limited to a vertical direction. No lateral or protrusive movement was possible. Intraorally, the soft tissues were of normal contour and devoid of pathosis. The dentition, which was in fair repair, was intact except for the mandibular second molars and the maxillary right second molar, which were missing. The anterior teeth exhibited a moderate amount of spacing and flaring in a labial direction. The molars were in an Angle Class II or distoclusal relationship (Figs. 2 and 3). Radiographic examination revealed a foreshortened mandible with pronounced bilateral antegonial notching. The head of the left condyle appeared blunted and foreshortened. Preoperative
evaluation
The preoperative maxillofacial evaluation included analysis of a facial moulage and photographs, articulated dental models, extra- and intraoral radiographs, cephalometric tracings, and cut-outs. On the basis of this evaluation, it was determined that the patient had a marked skeletal deficiency in the body and symphyseal portions of the mandible.
Volume 29 Number 2
Surgical
Pigs. 2 rind 3. Preoperative
Angle
correction
Class
Treatment
a,nd microgenia
165
II malocclusion.
Pigs. 4 and 5. Predetermined postoperative rotational advancement of mandible.
Furthermore, it was thought corrected separately.
0,” microglrathio
that the deficiencies
occlusion
illustrating
amount
were of such magnitude
of anterior
and
that each should lrll
plan
The planned treatment consisted of bilateral vertical oblique osteotomies with an advanccment of the anterior fragment (Fig. 6). It was determined that, to obtain the best possible occlusion, the right side of the mandibular body required a greater lengthening than the left side (Figs. 4 and 5). This anterior and rotational advancement would create bony defects of approximately 1.5 cm. on the right side and 0.5 cm. on the left side. Since the defect on the right side would be significant, it would be bridged by a bone graft. The defect on the left side would be minimal and would not require a graft. An autogenous onlay graft was contemplated for the symphysis (Fig. 6), since the ramus procedure would necessitate the taking of a graft. Treatment
and
course
On Aug. 6, 1967, the patient was admitted to the hospital. It was arranged to have the Orthopedic Service remove a portion of the iliac crest to be used as a free graft. On Aug. 9, 1967, the patient was taken to the operating room where, following induction of nasoendotracheal anesthesia, bilateral vertical oblique osteotomies were performed via submandibular incisions. The disarticulated mandible was mobilized and moved anteriorly to its
166
Goldberg and Hinmelfarb
Fig. 6. Bilateral symphysis.
Fig.
7. Postoperative
preoperativ around the Workir section of perforation graft then
vertical
oblique
cephalogram
Oral Surg. February, 1970
osteotomies
with
with
superimposition
onlay
grafts
in right
of soft-tissue
ramus
and
profile.
rely predetermined position and fixed to the maxilla by intermaxillary wires p: previously placed mandibular and maxillary Erich arch bars. lg concomitantly, members of the Orthopedic Service obtained a 5 by 2.5 cm. the iliac crest. The graft was sectioned and contoured into two pieces. Mm itiple 1s were made in the cortex of one portion which measured 3 by 2.5 by 0.5 em. The was wired to the distal segment of bone on the right side, where the d#efect
Volume 29 Number 2
Fig. 8. Postoperative
Xurgical
cowcctio?b of miwog~~uthia a,ld microgenia
167
profile.
measured 1.5 cm. It bridged the defect and rested passively over the proximal segment. Roth submandibular wounds were then closed in layers. Next, the lower lip was reflected downward. A double envelope flap in the lip and periosteum was developed to expose the mentum. The second piece of bone, measuring 2.5 by 2 by 2 cm., was decorticated and wired to the symphysis. These flaps were then closc~l primarily. The postoperative course was relatively uneventful, except for a dehiscence over the symphyseal graft. This defect was packed open, irrigated daily with 1 per cent neomycin, and allowed to heal secondarily. After 11 weeks of immobilization, intermaxillary fixation was removed and the patient was allowed to return to function. Subsequent exercises restored preoperative intermaxillary opening. Approximately 7 months postoperatively, a draining fistula developed in the anterior mandibular mueobuccal fold and a 1 by 0.5 cm. sequestrum was removed from the anterior portion of the graft. The wound has subsequently closed uneventfully. It is now approximately 14 months since the operation, and the patient’s facial contour and occlusion are st,allle (Figs. 7 and 8).
COMMENT
The foregoing ease illustrates an approach to the treatment of a major facial deformity. Since many facial and functional deformities require several surgical procedures, one must begin to appreciate the costs of correction. Preoperatively, the patient exhibited four areas of deformity : (1) restricted intermaxillary opening, (2) inadequate length of the mandible, (3) a deficient mentum, and (4) a marked Angle Class II malocclusion or distoclusion. In all of the preoperative discussions serious consideration was given to improving the intermaxillary opening. However, it was decided that, in view of the ext-ensive amount of surgical intervention minimally required to correct the basic deformities, we would accept a restricted but apparently adequate intermaxillary opening. The authors would like to express their thanks for the cooperation of Dr. John Manly, Director of Orthopedics, for obtaining the iliac crest graft, and Mr. Floyd Jackson for his care and interest in preparing the illustrations.
168
GoUberg
aud Himmelfarb
Oral Surg. February,1970
REFERENCES 1. Caldwell,
2. 3. 4. 5. 6. 7.
J., Hayward, J., and Lister, R.: Corrections of Mandibular Retrognathia by Vertical L Osteotomy: A New Technique, J. Oral Surg. 26: 259, 1968. Plastic Surgery, Philadelphia, 1964, W. B. Saunders Company, Converse, J. : Reconstructive chap. 23, pp. 869-947. Millard, D.: Chin Implants, Plast. & Reconstruct. Surg. 13: 70, 1954. Corrected by Vertical Oblique Osteotomies of Ascending Robinson, M. : Micrognathism Ramus and Iliac Bone Graft, ORAL SURG., ORAL MED. & ORAL PATH. 10: 1125, 1957. Corrected by Vertical Osteotomies of the Robinson, M., and Lytle, J.: Micrognathism Rami Without Bone Graft, ORAL SURG., ORAL MED. & ORAL PATH. 15: 641, 1962. Trauner, R., and Obwegeser, H.: The Surgical Correction of Mandibular Prognathism With Consideration of Genioplasty, ORAL Sum., ORAL MED. & ORAL PATH. 10: 899, 1957. Trauner, R., and Obwegeser, H.: Operating Methods in Cases of Microgenia and Distoocclusion, ORAL SURG.,ORAL MED. &ORAL PATH.~~: 787,1957.
AND ord
VOLUME
29
NUMBER
2
FEBRUARY,
1970
Operative oral surgery Surgical correction of micrognathia and microgenia Report
of a case
Stuart M. Goldberg, D.D.S.,’ Jamaica, N. Y. DEPARTMENT HOSPITAL
OF DENTISTRY, CENTER
and Robert L. Himmelfarb, LONG
ISLAND
D.D.X.,“’
JEWISH-QUEENS
AFFILIATION
T
he deformities of micrognathia and microgenia produce a significant disproportionate relationship between the hard and soft tissues of the lower and middle thirds of the face. Usually accompanying this is a severe malocclusion, which creates a functional disability of the stomatognathic system with respect to mastication and speech. The basic concern in the correction of these deformities is the achievement of satisfactory function and stability of the hard tissues and a balanced harmony of the overlying soft tissues. Although cosmetics is not our primary concern, facial appearance is extremely important since disfiguring deformities have the potentiality of producing serious social handicaps with psychic overtones. The surgical approach to micrognathia and microgenia are many, and each must be carefully designed to meet the requirements of the individual patient. Attempts at lengthening the mandible to correct micrognathia include various *Formerly **Attending
Chief Resident in Oral Surgery. Oral Surgeon.
At present
Assistant
Attending
Oral Surgeon.
163
164
Goldberg and Himmelfarb
Oral Surg. February,
Fig.
1. Preoperative
1970
profile.
types of sliding osteotomies of both the body and the ramus of the mandible, with and without interposed bone grafts. 1p2*4l ~-17 In a like manner, a deficiency of the mentum, or microgenia, has been corrected by a sliding osteotomy or by the insertion of autogenous, heterogenous, or alloplastic onlay grafts.2y 3, 6 CASE REPORT A 17-year-old boy was referred by an orthodontist to the oral surgery clinic and possible correction of his severe micrognathia and microgenia (Fig. 1). Past
for evaluation
history
The patient’s mother related that the facial deformity did not manifest itself until the child was recuperating from a prolonged hospitalization for the treatment of body burns sustained at the age of 7. She attributed the facial deformity to the “prolonged use of body bandages which extended up to and around t.he lower portion of the face.” All other elements of the past medical history and the review of systems were essentially negative. Regional
examination
Extraoral examination of the head and neck was essentially negative except for a marked foreshortening of the lower third of the face. Intermaxillary opening was limited to 17 mm. Both mandibular condylar heads were palpable during function. Opening was limited to a vertical direction. No lateral or protrusive movement was possible. Intraorally, the soft tissues were of normal contour and devoid of pathosis. The dentition, which was in fair repair, was intact except for the mandibular second molars and the maxillary right second molar, which were missing. The anterior teeth exhibited a moderate amount of spacing and flaring in a labial direction. The molars were in an Angle Class II or distoclusal relationship (Figs. 2 and 3). Radiographic examination revealed a foreshortened mandible with pronounced bilateral antegonial notching. The head of the left condyle appeared blunted and foreshortened. Preoperative
evaluation
The preoperative maxillofacial evaluation included analysis of a facial moulage and photographs, articulated dental models, extra- and intraoral radiographs, cephalometric tracings, and cut-outs. On the basis of this evaluation, it was determined that the patient had a marked skeletal deficiency in the body and symphyseal portions of the mandible.
Volume 29 Number 2
Surgical
Pigs. 2 rind 3. Preoperative
Angle
correction
Class
Treatment
a,nd microgenia
165
II malocclusion.
Pigs. 4 and 5. Predetermined postoperative rotational advancement of mandible.
Furthermore, it was thought corrected separately.
0,” microglrathio
that the deficiencies
occlusion
illustrating
amount
were of such magnitude
of anterior
and
that each should lrll
plan
The planned treatment consisted of bilateral vertical oblique osteotomies with an advanccment of the anterior fragment (Fig. 6). It was determined that, to obtain the best possible occlusion, the right side of the mandibular body required a greater lengthening than the left side (Figs. 4 and 5). This anterior and rotational advancement would create bony defects of approximately 1.5 cm. on the right side and 0.5 cm. on the left side. Since the defect on the right side would be significant, it would be bridged by a bone graft. The defect on the left side would be minimal and would not require a graft. An autogenous onlay graft was contemplated for the symphysis (Fig. 6), since the ramus procedure would necessitate the taking of a graft. Treatment
and
course
On Aug. 6, 1967, the patient was admitted to the hospital. It was arranged to have the Orthopedic Service remove a portion of the iliac crest to be used as a free graft. On Aug. 9, 1967, the patient was taken to the operating room where, following induction of nasoendotracheal anesthesia, bilateral vertical oblique osteotomies were performed via submandibular incisions. The disarticulated mandible was mobilized and moved anteriorly to its
166
Goldberg and Hinmelfarb
Fig. 6. Bilateral symphysis.
Fig.
7. Postoperative
preoperativ around the Workir section of perforation graft then
vertical
oblique
cephalogram
Oral Surg. February, 1970
osteotomies
with
with
superimposition
onlay
grafts
in right
of soft-tissue
ramus
and
profile.
rely predetermined position and fixed to the maxilla by intermaxillary wires p: previously placed mandibular and maxillary Erich arch bars. lg concomitantly, members of the Orthopedic Service obtained a 5 by 2.5 cm. the iliac crest. The graft was sectioned and contoured into two pieces. Mm itiple 1s were made in the cortex of one portion which measured 3 by 2.5 by 0.5 em. The was wired to the distal segment of bone on the right side, where the d#efect
Volume 29 Number 2
Fig. 8. Postoperative
Xurgical
cowcctio?b of miwog~~uthia a,ld microgenia
167
profile.
measured 1.5 cm. It bridged the defect and rested passively over the proximal segment. Roth submandibular wounds were then closed in layers. Next, the lower lip was reflected downward. A double envelope flap in the lip and periosteum was developed to expose the mentum. The second piece of bone, measuring 2.5 by 2 by 2 cm., was decorticated and wired to the symphysis. These flaps were then closc~l primarily. The postoperative course was relatively uneventful, except for a dehiscence over the symphyseal graft. This defect was packed open, irrigated daily with 1 per cent neomycin, and allowed to heal secondarily. After 11 weeks of immobilization, intermaxillary fixation was removed and the patient was allowed to return to function. Subsequent exercises restored preoperative intermaxillary opening. Approximately 7 months postoperatively, a draining fistula developed in the anterior mandibular mueobuccal fold and a 1 by 0.5 cm. sequestrum was removed from the anterior portion of the graft. The wound has subsequently closed uneventfully. It is now approximately 14 months since the operation, and the patient’s facial contour and occlusion are st,allle (Figs. 7 and 8).
COMMENT
The foregoing ease illustrates an approach to the treatment of a major facial deformity. Since many facial and functional deformities require several surgical procedures, one must begin to appreciate the costs of correction. Preoperatively, the patient exhibited four areas of deformity : (1) restricted intermaxillary opening, (2) inadequate length of the mandible, (3) a deficient mentum, and (4) a marked Angle Class II malocclusion or distoclusion. In all of the preoperative discussions serious consideration was given to improving the intermaxillary opening. However, it was decided that, in view of the ext-ensive amount of surgical intervention minimally required to correct the basic deformities, we would accept a restricted but apparently adequate intermaxillary opening. The authors would like to express their thanks for the cooperation of Dr. John Manly, Director of Orthopedics, for obtaining the iliac crest graft, and Mr. Floyd Jackson for his care and interest in preparing the illustrations.
168
GoUberg
aud Himmelfarb
Oral Surg. February,1970
REFERENCES 1. Caldwell,
2. 3. 4. 5. 6. 7.
J., Hayward, J., and Lister, R.: Corrections of Mandibular Retrognathia by Vertical L Osteotomy: A New Technique, J. Oral Surg. 26: 259, 1968. Plastic Surgery, Philadelphia, 1964, W. B. Saunders Company, Converse, J. : Reconstructive chap. 23, pp. 869-947. Millard, D.: Chin Implants, Plast. & Reconstruct. Surg. 13: 70, 1954. Corrected by Vertical Oblique Osteotomies of Ascending Robinson, M. : Micrognathism Ramus and Iliac Bone Graft, ORAL SURG., ORAL MED. & ORAL PATH. 10: 1125, 1957. Corrected by Vertical Osteotomies of the Robinson, M., and Lytle, J.: Micrognathism Rami Without Bone Graft, ORAL SURG., ORAL MED. & ORAL PATH. 15: 641, 1962. Trauner, R., and Obwegeser, H.: The Surgical Correction of Mandibular Prognathism With Consideration of Genioplasty, ORAL Sum., ORAL MED. & ORAL PATH. 10: 899, 1957. Trauner, R., and Obwegeser, H.: Operating Methods in Cases of Microgenia and Distoocclusion, ORAL SURG.,ORAL MED. &ORAL PATH.~~: 787,1957.