Download THE SURGICAL CORRECTION OF MANDIBULAR PROTRUSION

THE
SURGICAL
CORRECTION
OF
AND
T.
The
surgical
absorbing
ramus.
of election,
The
the
fact
method
that
operation
To-day
this
LONDON,
of mandibular
ENGLAND
protrusion
and
retrusion
the
instrumentation
results
the
and
diversity
in an
who
editorial
were
analysis
describing
in relation
cases
the
In this
by
the
to
To
in
my
be
mind
Britain
it
the
and
other
take
place.
methods
of
should
is the
procedure
use
be
rigid,
are
best
of antibiotics
in procedures
has
hand,
to
choose
an
certain
advantages
jaws
short
have
hold
by
(1951)
performed
in the
for operative
paper
to review
rendered
fragments
used
and
cast
except,
for
of several
operation
will
At
which
should
make
and
results
of which
absolute
technique
the literature.
-is
be simple
in
dental
cap
obvious
reasons,
fulfil
is involved,
provided
criteria
is a matter
all
the same time,
it is my belief
(1934)
is as nearly
applicable
it the
splint,
in
figure
the incidence
of
oral cavity.
There
should
techniques
that
all
have
and
materially
and
should
metal
for
Kazanjian
in so far as they
immobilisation
been
fast
the
time
one method.
Thoma
(1951)
technique
of the
should
fulfilled
and is not in my experience
practicable.
based
on the method
devised
by Kosteka
it offers
by
was
reduced
to a negligible
involve
opening
into the
to the patient
if one
already
mentioned.
any
the diversity
of operative
which
are described
in
commonly
that
with
recently,
except
adequate
apposition
However,
fixation
most
in this
deformities,
surgery,
on the
a reasonable
qualifications
be to-day
no real hazard
is made
of those
advances
On
of the two
of aseptic
procedures
if given
effective,
these
edentulous
jaws.
In addition,
the
post-operative
infection
difficulty
operation
operative
that,
union
should
the
variety
of
Immobilisation,
design.
respect
knowledge
immobilisation,
matched
by
and
for the correction
the
introduction
of
of immobilisation.
optimum
articles
their
a subject
of the horizontal
regard
to the site
the
osteotomy
gave
,
safer
and
to three
in which
ascending
ramus,
and by Scougall
and Colvin
(1 95 1) who
procedures
on the horizontal
ramus.
Therefore,
it would
palpably
serve
no useful
purpose
the separate
techniques
been
influenced
by
been
the mechanics
of approach
so variable
points
only to a universal
dissatisfaction
is singularly
little
changed
and, comparatively
(1951),
antibiotics.
has
in 1849, described
a case of osteotomy
surgeons
have
developed
techniques
in
published
problem
Skaloud
HENRY,
of approach,
in the
have been
the situation
discussed
and
correction
PROTRUSION
RETRUSION
CRADOCK
interest
since
Hullihen,
Since
that
time
many
MANDIBULAR
operation
of choice
in the
use
of
that the
as most
majority
of cases.
This
( 1946)
operation,
and
of section
the
others,
being
Technique
above
of
technique
consists
essentially
the
lingula
Kosteka’s
of
and
a blind
below
dental
that
cast
study
Pre-operatively,
of penicillin,
Operation-At
62
casts
a horizontal
dental
cap
are
push
splints
taken
back
are
and
the
sigmoid
Preliminary
operation.
are taken
together
with
profile
photographs,
and any slight variation
in the line of section
articulated
have
been
osteotomy
by Bowdier
ascending
ramus,
procedures-Lateral
optimum
the
skull
amount
determined.
splints
are cemented
as the most suitable
is usually
performed
line
position,
radiographs
of displacement
Pre-operative
on
the
assumption
or pull forward
is to be effected.
To this predetermined
made
with
the appropriate
method
of intermaxillary
cast metal
cap
this being
regarded
operation,
which
Henry
the
notch.
so that
clinically
can be approximately
in the
described
of the
position
fixation.
and the patient
is placed
on a course
antibiotic.
under
endotracheal
anaesthesia
with
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
THE
the
SURGiCAL
possible
CORRECTION
addition
of one
OF
of the
MANDIBULAR
hypotensive
PROTRUSION
drugs,
AND
a point
63
RETRUSION
is marked
midway
between
the tragus
of the ear and the angle of the mandible.
Next a line is drawn
to the inner canthus
of the eye.
A stab incision
down to the posterior
border
of the ascending
ramus
is made,
and
a special
seeker,
which
is a modified
Reverdin’s
needle,
is introduced.
Since the operation
is
blind
it is important
contact
with
handle
internal
is depressed
and
; a small
drawn
A Gigli
saw
2).
The
place
the
mandible
the
ramus
at
closed
one
time
or
delivered
release
to
two
on
should
until
until
the
and
needle
the
position
it is important
to stop
the
skin
below
and
and
effect
it
the
by
avoid
seeker
the
in
saw.
unnecessary
atraumatic
chin
damage
sutures.
to
A stitch
the
surface.
is divided
be
possible
fixation
being
by
skin.
is placed
already
skin
has
to
(Fig.
been
3).
achieved
2
Gigli
saw
is supported
and
Patient’s
line
the
then
this
in
The
the
mandible
intermaxillary
immediately
position
remain
border.
on
should
FIG.
Special
and
anterior
it to protrude
side
sawing
bone
the
is withdrawn
and
the
reaches
allow
opposite
predetermined
strike
it
it bulges
point
1), the
(Fig.
operatlon.
being
divided
same
tile
by
needle
ramus
1
FIG.
and
the
the
is repeated
in its
l-Kosteka’s
Ramus
of
of
then
is attached
the
point
point
will
procedure
dividing
Figure
the
surface
incision
(Fig.
Wilen
that
the
The
through
attached.
assistant.
an
puncture
the
2--
Figure
wounds
tongue
for
are
traction,
if required.
Post-operative
tube
be
is
management-The
removed
Ilot
associated
occurs
The
with
from
nurse
by
in
should
of
the
be
ever
the
of
my
is
mandible
it
has
he
to
and
watchful
is
the
that
maintained
no
and
that
for
for
fifteen
which
being
and
any
endotracheal
of
structures
as
the
prognathism,
obstruction
consciousness
Immobilisation
been
In
attached
full
same
watched
regained.
see
its
until
fixation.
cases
is carefully
to
important
treatment
intermaxillarv
most
recovery
is about
it
back
charge
Thereafter
immobilised
least;
patient’s
consciousness
macroglossia,
dropping
in
regained.
until
is maintained
of
for
may
airway
carried
tongue
case
the
back.
control
are
fractured
three
jaw
months
at
weeks.
DISCUSSION
The
it does
inferior
VOL.
operation
not
dental
36 B,
has
produce
NO.
nerve,
1,
several
advantages.
a noticeable
and
FEBRUARY
it
scar,
does
1954
not
It is expeditious,
it should
open
into
not
the
involve
oral
it does
damage
cavity.
not
sacrifice
to the
facial
Moreover,
any
nerve
teeth,
or the
it is a one-stage
64
T. C.
procedure
and
which,
Its
a
with
functional
slide
weeks,
planning,
can
nearly
always
produce
an
acceptable
cosmetic
result.
disadvantage,
simple
and
This
adequate
HENRY
other
in
since
latter
one
than
plane,
it is a blind
hazard
has
in exceptional
is
that
procedure
not
cases
where
the
must
be
immobilisation
there
occurred
in
is a slight
the
risk
author’s
I,
#{149}
‘
S
.
,.
-
-
.
:
might
either
#{149}
thinness
of
the
the
for
of
imperfect
true
that
calls’
to
valid,
often
every
the
to favour
the
osseous
union
despite
of
make
\Vhile
are
apposition
and
structure
criticisms
case,
because
region
union.
these
region,
upper
or
cortical
in practice
in
action
of
osseous
both
occur
in of thisthe
fragments,
bone
preponderance
region
are so
and
‘
isibilit
that
almost
remains.
is that
non-union
muscular
of
any
colleagues.
in this
operations
operations
of control
allowing
separation
in
his
procedures
be open
in
lack
twelve
be damaged.
knowledge,
by
of access
hazard
criticism
occur
from
segment,
his
favour
least
may
upon
de oid
particular
Another
--
:-
-
,
to
not
at
vessel
or,
operated
often
this
‘
.__i_
does
for
a large
Moreover
other
hich
claim
to
!i
‘
that
experience
cases
‘
articulation
retained
fact
hone
is
appears
the
the
it
theoretithat
fragments
is minimal.
,
F
.
( ase
1-Metal
maxillary
splints
fixation
#{149}
#{149}
in
poSltlon
precision
by
.
with
lock.
of patients-The
the
at
age
inter-
cases
that
treatment
would
seem
have
already
when
surgical
has
that
been
mandibular
protrusion
delay
a matter
of
concern
her
impressionable
orthodontics
can
Certain
teens,
cases
and
error
of
should
judged
to
reported
The
author
two
and
As
a further
the
patient
is in late
not
is
likely
to
age.
But
parent.
In
as to whether
in both
unless
retrusion,
the
in
age
it
they
especially
protrusion,
so in
is
orthodontic
appliances,
superior
is this
it
prognathism,
conditions
Particularly
or
benefit
in
mandibular
of
others,
not
and
certainly
orthodontic
degree
will
treatment
and,
succeed.
a
treatment
but
of abnormality
treatment,
A decision
teens
further
with
a later
seeking
hope.
will
.
conservative
early
to
sooften,
and
been
reported
assumed
that
produced
be
postponed
ceased.
now
criterion,
will
years
to patient
been
years
adolescence
of fourteen
are
it
most
either
retrusion
.
in
great
with
or
and
of
effe
at
a young
ctive
operation
girl
is
who
is at
age.
the
has
a half
in the
continued
have
have
relapse,
age
as
has
growth
operation
is
it
the
be
the
made
be
of case
matters
children
to orthodontic
of the
degree
,
offers
often
effective,
combined,
most
can
after
is
it
correction
failed
are
Many
by
these
choice
operation
importance.
respond
because
‘3
10.
.
cap
Selection
receive
in the
that
the
disability.
until
after
However,
degree
upon
and
it does
the
or early
the
four
appear
greatest
adult
that
is
that
years
psychological
a
operation
its
before
ago,
right
reason
it
has
possibility
eighteenth
and
in none
and
essential
advocated
in
any
this
benefit,
cases
the
last
case
occurred.
operation
this
of
inadequate.
relapse
and
that
growth
those
been
birthday,
has
in the
the
mandibular
both
perform
physical
been
that,
have
the
to
of
when
duration
time
performed
continuation
birthday,
a strong
and
the
after
to
twentieth
cases
five
due
For
the
there
first
of relapse
was
of immobilisation
operated
ago,
past
this
is when
undeniably
life.
THE
JOURNAL
OF
BONE
ANI)
JOINT
SURGERY
THE
SURGICAL
CORRECTION
OF
MANDIBULAR
CASE
Case
1-Girl
The
ai
aged
patient
opinion
Some
seventeen
first
as
to
the
orthodontic
controlled
wait
jaw
for
continued,
not,
alignment
of
could
be
desirability
had
relationship
operation
obtained
after
was
correction
surgical
4
of
an
but
it had
was
still
she
had
left.
At
the
same
to
correcting
age
was
quite
been
of
when
started
time
she
was
inferior
school
late
and
sent
for
protrusion.
and
it was
orthodontic
deformity
performed,
major
the
years,
established
at
the
were
of the
at
FIG.
of fifteen
girl
displacement
mandible
age
undertaken
if osteotomy
The
the
The
undertaken
described.
of
a view
that,
65
RETRUSION
protrusion.
at
4).
with
teeth
Mandibular
observation
been
AND
REPORTS
(Fig.
until
however,
the
Operation
already
under
treatment
the
should
years.
came
PROTRUSION
it had
felt
not
that
she
treatment
but
to
was
obtain
a satisfactory
such
dental
an
occlusion
fragment.
seventeen
easily
years
according
reduced
to
its
to
the
technique
predetermined
position,
44
1.
Case
Figure
FIG.
4-Appearance
of
patient
age
hf teen,
before
at age
seventeen.
at
result
intermaxillary
and
lower
The
wires
splints.
girl,
weeks,
retaining
period
she
and
who
lost
inability
and
was
without
a student
the
intermaxillary
a little
weight
to open
although
the
occurred
on
removed
the
photographs
36B,
applied,
was
Radiographs
VOL.
were
Recovery
upper
both
sides
1,
did
and
not
until
feel
operation.
fifteen
unduly
plate
patient
to her
was
was
after
or
Post-operative
fixed
to
in hospital
employment
weeks
tired
5-
Figure
locking
the
returned
fixation
but
at
the
upper
ten
end
operation.
embarrassed
the
for
days.
of three
During
by
this
her
appliance
of the
fragments
mouth.
this
period
of immobilisation
were
and
when
desired
4 to 9) show,
FEBRUARY
a precision
incident
pharmacist,
fragments
occlusion
(Figs.
NO.
the
during
later
5
1954
slightly
the
was
showed
tilted
intermaxillary
obtained.
a satisfactory
fair
outwards
fixation
No
after-
cosmetic
and
was
treatment
result
apposition
forwards.
released
was
and
Osseous
sound
and
required
functional
the
and,
union
splints
as
occlusion
the
66
T.
were
achieved.
maintained
Case
Two
and
the
2-Woman
The
and
aged
patient
was
a
slight
half
years
operative
thirty
HENRY
later
scars
years.
referred
C.
have
no
relapse
faded
into
Mandibular
has
retrusion
at a comparatively
late
age
occurred,
the
occlusion
is
insignificance.
with
for
maxillary
correction
overjet.
of her
facial
deformity,
r-
-
:i_
-
I.‘&:*
FIG.
(‘ase
I.
Figure
/-
#{149}-
(4
Fio.
6-Pre-operative
studs’
study
FIG.
Case
1-Composite
which
was
incisor
teeth
not
be given
the
functional
diagrams
by
10).
casts
showing
showing
the
the
new
articulation
at the
articulation
time.
7
Figure
9
FIG.
taken
of
from
profile
of the
a severe
In a preliminary
dealing
with
occlusion.
It
the
was
photographs
ascending
mandibular
study
maxillary
decided
x-ray
retrusion
with
overjet
that
and
ramus.
the
models,
alone,
most
tracings,
with
to
nor
the
line
of
obvious
would
JOURNAL
show
a protrusion
it became
effective
THE
7--Post-operative
obtained.
8
a combination
(Fig.
casts
such
method
OF
that
BONE
the
upper
relief
would
a procedure
would
AND
be
of section
improve
to advance
JOINT
SURGERY
THE
the
mandible
and
provide
brought
SURGICAL
by
a bilateral
a partial
forward
to
Immobilisation
had
CORRECTION
OF
osteotomy
denture.
A
a predetermined
was
MANDIBULAR
and,
at a later
bilateral
osteotomy
position.
maintained
for
PROTRUSION
sixteen
date,
An
advance
when
the
maxillary
performed
of nearly
it
was
67
RETRUSION
to reduce
was
weeks,
AND
and
half
an
judged
overjet
the
inch
that
mandible
was
made.
clinical
union
occurred.
‘-t-...t
V
-‘ -
I
10
FIG.
Case
2.
Figure
overjet.
11
FIG.
photographs
lO-pre-operative
Figure
1 1-Post-operative
showing
result
mandibular
man(llbular
of
with
retrusion
osteotomv
and
corresponding
forward
displacement.
maxillary
#{149}.4
- .‘
.-
F
FIG.
Case
2.
Figure
12
12-Final
FIG.
photograph
after
Figure
Post-operative
higher
than
process
had
become
of function
as
demonstrable
VOL.
36 B,
radiographs
anticipated,
detached
a result
from
of this,
1,
FEBRUARY
1954
alveolectomv
13-Dental
showed
being
radiographically.
No.
maxillary
at
occlusion
that
the
the
and
rest
bony
the
level
of
of the
union
and
13
provision
of
partial
denture.
obtained.
line
of section
on
the
sigmoid
notch,
fragment.
of the
However,
condylar
the
left
so
there
neck
side
that
was
to
was
the
slightly
coronoid
no disturbance
ramus
was
later
68
T.
A material
the
improvement
osteotom’
maxillary
Six
(Fig.
overjet
months
11)
and
after
in
but
the
the
both
masticatory
patient
could
shortness
the
first
C. HENRY
ability
still
not
of the
upper
lip.
the
upper
alveolus
operation
and
freely
appearance
oppose
was
was
the
trimmed
obtained
lips
from
by
because
canine
of the
to canine
0
14
FIG.
Case
2.
Figure
FIG.
l4-Pre-operative
study
Figure
casts.
1-Post-operative
15
studs’
casts
with
in
dentures
position.
16
FIG.
Case
2-Composite
diagrams
and
a partial
was
satisfactory
according
her
life
denture
to the
(Figs.
to
with
from
profile
section
of
replace
a marked
patient,
13 to
17
FIG.
taken
had
the
photographs
the
ascending
extracted
improvement
given
her
and
radiograph
ramus.
teeth
was
in the
the
ability
fitted.
functional
to
tracings,
masticate
The
to
final
show
the
result
occlusion
of the
properly
for
the
line
(Fig.
teeth
first
JOURNAL
OF
BONE
AND
JOINT
12)
which,
time
17).
THE
of
SURGERY
in
THE
5URGICAL
CORRECTION
OF
MANDIBULAR
PROTRUSION
AND
69
RETRUSION
SUMMARY
The
1.
technique
the
rami
2.
The
are
discussed.
3.
Illustrative
of correction
of the
best
mandible
age
for
I wish to record
for Sick Children.
for their
excellent
is described
the
cases
of mandibular
and
operation,
are
protrusion
and
retrusion
by osteotomies
through
illustrated.
and
the
factors
that
might
favour
or
prevent
relapse,
described.
my thanks
to
Great
Ormond
illustrations.
Mr Derek
Street,
Martin,
London,
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of the
Photographic
P. Cull,
the medical
Department,
artist
at the
The
same
Hospital
hospital,
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