A CASE OF MANDIBULAR PROGNATHISM CORRECTED BY … · gro1l'Sly derangeu and this factor had no doubt contribured 10 the severe paradontal disease and extensive carit:s which was revealed

177

A CASE OF MANDIBULAR PROGNATHISM CORRECTED BY KOSTECKA'S OPERATION

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D. T . H . PAINE, F.R.C.S., Major D. V. TAYLOR. F .D.S., H .D.D., R.A.D.C. , Captain P . FELIX, F.D.S., R.A.D.C.

R eiC",..:tmt Tlislory.-P-Le. J. A. F .. aged 21. was first seen at B.M.H. \Vuppcrral where he: a ttcnrlc:rl for den ta l treatmen t and iT was nvticetl [h at his UlauJibk \\M disp mportionatdy large: in com par ison to the other facia l bon es. Ht:' stalro that ·his lower jaw had become progrcs~ivel y cnJarg-ed from the tim e of ad ulescence. but had remained as now seen ( li g:.~. A I, BI. Cl) for some years. Ile now fillds il cli lli l:lI lr to eat Army rations and is <H .. urcly (Unst:iu 1I5 o r h is appearance.

Family history reveals tha t mother and brother arc normal but that fa lher b(ls .~im i lar

appeanlnce.

:fIG. Al FIG. E l.

FIG. Al.-Position or teeth i n occlus ion pre -operatively.

F rG . Rt.- P rofil e pre'Clp~ra t ively.

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1i8 A Case of l'101ldibular PrognrlthiMH.

FIG. Cl.-l'ul1-facc prc-opera tively.

Ou 'F.xamiJlatioJl. A tall thiu yuung .LUall, rather poorly nourished , normally proportioned except for ::l severely prognathous H1<lnrliblc. ]nstead of the normal 18 inch "overjet" there wail a Sp <1CC of nearly I inch antcro-posreriorly hetween the incisal edges of upper a nd lower incisor teeth when closed lO);tLitcr (fig. AI). The occlusion was gro1l'Sly dera ngeu and this factor had no doubt contribu red 10 the severe paradontal disease and extensive carit:s which was revealed on examination of [he leech and gums. Ibcre was no signs of soft tissue thickening o[ the face. o r ovcrg rowth of the extremities.

Radiugraphic Exami1wtioll.-Sh owcd no nbnormal ir y in hOllY stl'uclure, but of course groliS ('nhlrgelllem of the manriiblc (fig. n T).

CUflsiclemlioll.-As th is patienr c:Jrnestl y re(luc~t\!d any lreaunenl possible to improve his condition , it was decided [0 perfo rm Kostecka's operation. preceded by nt:<.:el'sary consen fll ive and paradontal treatment to the teeth. This operflti c)1l consins of a bilateral section of [he ascending rami of the nl(lndilJle al $lIch a level and plane that inj ury to the infer_ior dental nCHes and arteri(~s a'l'e avoided . Th C' hodv of the mandible is then nlovt:d Jl t)sler iorly ro a predetermined posil io n. immo.uil i7cci. n~d bony IInion nllowed to

tilkt: place.

Tre.lIlmenl. - (a) Pre1iminaT'V: All GlriClIlS <"lv ili e:; were treated and the gingi \'al condition improved as much as~ possible by appropriate measures.

(b) Pre-operative: Upper and lower impres~iomi we-re taken and dental cap splints constrllctcd on the models so obtained. 'Vith the splin ts in position the models were then pbccd in a position of normal occlusion and the locking phltes , already soldered on to 1he splint:. of the bllccal surfaces in ('41,4~ regions, were localized and lucking plat es

54 'I ;:. constrllcted. The splints were then cem ented on to th e teeul.

(c) Operation 25. 10.50: Allxsthetic: Pentothal induction j'ollowe!l by oxygen-<.:yclopropane administered by mearrs of an cndo-tracheal lube.- -Captain H. A :\:l illar, RAJ\-'f.C.


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D. T. H . PaiHe, n. 11, Tay/Of, P. Feli.T

FIG, D.- Splints in position after oper:ltion !'=howing locking de\'ice in .)~14~ regions. 544.)

F IG, B2.

Ft(;. ~\2 ,-Po~i ti on of leell l ill occlusion post ~uperati vdy.

Fi t;. H2.- Proftle post-opcrath·cly.

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180 A Case of lvlallllibular Prognathis1I1

FIe. C2.-Full-face post-opera tively .

RI. B1.-Lateral dew prc -operativcl~·.


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D. T. ll . Paille, n . r". Taylor, P. Fc:l£" ISI

R2, B2.- Latcral view post .operatively.

R3. A2 .-Postero~allterior \'iel\ I>ost~operatj vel y.


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182 A Case of Mandibular Prognathism

To. detel'mine the plane ofsectiDn, a Kingsley splint was inserted into. the mDuth, with, the external aTms carefully adjusted to. fDllow the Dcclusal plane and the teeth then clDsed Dn the intra-OTal sectiDn. A line was marked o.n the skin, paTallel to the external arm,. and higher up Dver the ascending ramus at a level judged to be above the lingual but. below the lowest point of the sigmoid notch. Available radiDgraphs and manual palpatiDn were employed to. assist in the determination of this: level. The division Df the bones. was carried Dut with a Gigli saw inserted by means of a curved seeker through two. small external incisio.ns. During insertion, the seeker was maintained in direct contact with the internal surface of the bone until it emerged through the second skin incision. The' main segment of the mandible so mobilized was then pushed backwards until the teeth, came into. the new pre-arranged position Df normal Dcclusio.n and were fixed thus by applicatiDn of the locking plates Dn the dental splints. Penicillin cover was maintained. pre- and Po&t-operatively.

Result.---'Smooth post-Dperative recovery, and no evidence of nerve or vascular trauma .. RadiDgraphs showed good apposition of bone ends at lines Df sectiDn.

FixatiDn was maintained fDr eleven weeks, during which the patient actually gained a. !few lb. in weight. Release of the locking plates then revealed firm bony uniDn, and all. mandibular mDvements were normal after a few days, and normal food could be taken. Splints were remo.ved and the bite was adjusted by "spot-grinding" teeth where necessary' io improve the new occlusion. The patient was discharged and re-examined in five weeks; when the condition was found to be unchanged. He was then referred fOT completion IOf dental treatment to. his Unit Dental Officer.

It was noticed that since discharge from hDspital a great improvement in mental out-· look had taken place. The imprDvement in appearance was accDmpanied by a distinct change in manner and bearing.

SUMMARY

(I) A case of mandibular prognathism treated by Kostecka's operation IS:

described.

(2) Special attention is drawn to the valuable psychological effect, which can:. be achieved by a successful operation of this type.

Photographs and radiographs presented herewith demonstrate the condition before and after operation and show the lines of section. '

. ACKNOWLEDGMENTS

Thanks are due to Lieut.-Colonel W. F. L.Fava, R.A.M.C., Officer Commanding B.M.H. Iserlohn, fot I?ermission to submit this case for publication.


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Documents

A CASE OF MANDIBULAR PROGNATHISM CORRECTED BY … · gro1l'Sly derangeu and this factor had no doubt contribured 10 the severe paradontal disease and extensive carit:s which was revealed