REPAIR OF PROGNATHIC AND RETRUDED JAWS

JULIUS NEWMAN, M.D.

NEWARK, NEW JERSEY

W HILE the less severe types of not onIy by cosmetic considerations, but prognathism are treated by the aIso by the interference with mastication orthodontist, the more marked de- which necessariIy resuIts from marked

A B

FIG. I. A and B, prognathic jaw, before operation.

FIG. 2. A and B, pro& biIatera1 osteotomy.

formities (Figs. IA and IB) sooner or maIoccIusion. Prognathism can be success- Iater come to the attention of the pIastic fuIIy corrected by suitabIe pIastic surgery, surgeon. (Figs. 2~ and ZB) or in miIder cases, by

Repair of a prognathic jaw is demanded appropriate orthodontic procedures.

35

36 American Journal of Surgery Newman-Prognathism OCTOBER, 1+&?

PROGNATHISM

The two chief methods for the pIastic correction of prognathism are ostectomy

ramus. The tip of the ligature carrier hugs the bone and is passed in front of the anterior border of the ramus, unti1 the tip of the instrument can be feIt under the

FIG. 3. Photodiagram showing skin incision and GigIi saw in place.

and osteotomy. In the former (the technic formuIated by BIair’), a segment of bone is removed from each mandibIe, while in osteotomy, first suggested by Babcock,2 the mandibIe is cut, and the dista1 segment pushed backward and immobilized in the overIapped position. Since BIair’s method requires the pIastic surgeon to invade the ora cavity, thus opening the channe1 to possibIe infection, I have preferred to avoid ostectomy and to repair prognathism by the simpIer Babcock technic, nameIy, biIatera1 osteotomy.

OnIy IocaI anesthesia shouId be used in this procedure. Under genera1 anesthesia, the patient may vomit whiIe his jaws are wired. The resuIting insuffIation of vomitus may cause serious complications. An inci- sion 2 cm. in Iength is made aIong the posterior border of the ascending ramus. (Figs. 3 and 4.) The parotid grand is retracted and the masseter muScIe puIIed forward. The posterior border of the mandi- bIe is now exposed. A Iarge Iigature carrier, with a heavy bIack siIk suture, is passed between the parotid gIand and the ramus and then around the posterior border of the

FIG. 4,. Schema of jaw bone showing site of osteotomy.

skin. An incision is then made into the skin over the point at which the Iigature carrier can be feIt. The suture is then drawn through this new opening and a GigIi saw is attached to it. The GigIi saw is puIIed back through this second opening and out through the origina incision. The ramus is then cut through with the saw, above the entrance of the inferior aIveoIar nerve into its cana1. The entire procedure is then repeated on the opposite jaw. The mandibIe is next pushed back into the desire position with the upper teeth as a guide. By means of orthodontic bands (Fig. 5) and stainIess stee1 Iigatures, the mandibuIar fragment is immobiIized in its new position and wired to the maxiHa. (Fig. 6.)

At the end of four weeks, smaI1 vertica1 eIastic bands connecting maxiIIa and man- dibIe repIace the wires. The patient is then aIIowed sIight movements of the jaws. For the next few months, the patient shouId be under reguIar orthodontic observation.

RETRUDED CHIN

Another common mandibuIar deformity is retruded chin. This condition (Figs. 7 and 8) may be due to maIoccIusion, ankyIosis of the jaw, OsteomyeIitis of the jaw or trauma.

Many procedures have been recom- mended for the treatment of retruded chin. One is biIatera1 osteotomy of the rami with

NEW SERIES VOL.. LVIII, No. I Newman-Prognathism American Journal of Surgery 37

advancement of the mandibIe with or I have used both bone and cartiIage without bone grafts. A second method grafts and find them satisfactory in minor depends on the use of cartiIage or bone deformities, but the amount of materia1 grafts. needed to buiId up an extensive defect with

FIG. 5. Orthodontic bands in place before operation.

FIG. 6. Teeth wired after operation.

FIG. 7. ProfiIe of retruded chin; FIG. 8. FulI face view of retruded chin; before operation. before operation.

Mention may also be made of GiIIies’ method. This entaiIs Thiersch-grafting of a pocket in the chin, foIIowed by the use of a prosthetic appIiance on the Iower teeth. I have had some persona1 experience with this method, working with Sir HaroId GiIIies, and found that patients occa- sionaIIy compIained of irritation caused by food faIIing into the pocket. This method is aIso objectionabIe because it requires an excessive amount of sanitary attention on the part of the patient.

cartiIage or bone makes the method im- practica1 in Iarge deformities. Ivory is mentioned onIy to be condemned; it is a foreign body, surgicaIIy objectionabIe for admission to the permanent human struc- ture. A combined fat-and-derma1 graft is preferabIe. The Iiterature on fat as a graft materia1 in retruded chin is very scanty, but my experience with it has been uni- formIy satisfactory. The fat-derma1 com- bination is desirabIe because the amount avaiIabIe for a defect of any size is prac-

38 American Journal of Surgery Newman-Prognathism

ticaIly unIimited. Patients report that they tus in removing the graft and serve to hoId find it more “natural” to have the fee1 of it in the chin pocket. fat-and-skin than of some hard substance in The epidermis of the abdomina1 waI1 is the chin. sutured back in pIace with a continuous

suture. PROCEDURE The combined fat-and-derma1 graft is

The first step in this procedure is to make immediately transferred to the pocket in a mouIage of the face. The required chin the chin. This is heId in pIace by the various

FIG. 9. ProfiIe, retruded chin cor- FIG. 10. Full face view, retruded chin rected by operation. corrected by operation.

height is modeIIed on top of the mouIage and measurements are taken from this modeI, using gauze or linen as a pattern. The pattern is autocIaved and kept in the operating kit as a mode1 for the graft. This pattern is pIaced on the chin and outIined on the skin in briIIiant green, thus de- marcating the extent of the undermining necessary. Incision is made on the lower surface of the chin, from which the under- mining is done. ScrupuIousIy carefu1 hemo- stasis is necessary. This is best achieved by hot packs rather than by catgut ties. WhiIe an assistant controIs the bIeeding in the chin, the pattern is now transferred to the anterior abdomina1 waI1 and again outIined in brilliant green. The upper Iayer of skin is dissected off aIong three sides but not com- pIeteIy detached. The fat with the dermis on top of it is then removed from the tissue. Mattress sutures which are appIied to the corners of the graft, act as traction appara-

mattress sutures which were originaIIy used as traction sutures. The skin is carefuIIy sutured. Drainage shouId not be used. A compressive dressing is applied. Fresh mechanic’s waste, which has been washed and autocIaved, makes an exceIIent com- pressive dressing. The dressing shouId not be disturbed for at Ieast five days. (Figs. 9 and IQ.) Fat, when transpIanted with the dermis attached, does not undergo atrophy nearIy as readiIy as does simpIe fat graft. Whenever fat is transpIanted for a skin defect, it is essentia1 to overcorrect, to aIIow for shrinkage.

Chief bars to successfu1 procedure are trauma, infection and bIeeding. For this reason, exceptiona care must be taken with regard to asepsis, hemostasis and gentIe- ness in handIing.

SUMMARY AND CONCLUSIONS

I. Marked prognathism is a probIem for the pIastic surgeon and can be corrected by

New SERIES VOL. LVIII, No. 1 Newman-Prognathism American Journd of Surgery 39

ostectomy or by osteotomy. In ostectomy, a segment of bone is removed from each mandibIe. T’his requires the surgeon to open the oraI cavity, thus inviting possibie infection. BiIateraI osteotomy is safer and simpIer. The procedure consists in cutting the mandibIe and pushing the dista1 seg- ment back, immobilizing it in the over- Iapped position. To prevent vomiting, which might be hazardous, IocaI anesthesia shouId be used.

2. Retruded chin can be treated by the use of a combined fat-and-derm graft. The fat does not atrophy as readiIy when transpIanted with dermis as it does when

used aIone. It produces a more natura1 “fee”” to the patient than does bone, cartiIage or ivory.

3. The operative steps in both proce- dures are described and iIIustrated.

Thanks are due to Benjamin Weiss, D.D.S.

for his skiIfu1 work in appIying the orthodontic bands and for administering the orthodontic postoperative care.

REFERENCES

I. BLAIR, V. P. Operations on jaw bones and face. Sura., Gynec. Ed Obst., 4: 67, r9o7.

2. BABCOCK, W. W. Surgical treatment of certain jaw deformities. J. A. M. A., 53: 833, 1909.

WITH an injured limb entirely immobihzed in correct Iength and posi-

tion, the onIy indications for disturbing the limb or patient are those

familiar to every surgeon-sweIIing, rise of temperature, increased white

bIood ceI1 count, and IocaI symptoms which point to the sea1 of surgical

compIications, if they occur. From “Wounds and Fractures” by H. Winnett Orr (CharIes C. Thomas).