STIRGIC-4L l’REATMT3S’i- OF XASDTRT’T,XR PRO(:NATHTSW

V. II. KAZAN.JI.\N, (!.ilI.G.. D.3I.D.. M.l).. F.i\.C’.S., BoWor, Ar.W*.

0 RTHODOSTIC correction of mandibular prognathism has probably been one

of the most, disputed problems of ort,hodontia. I’ndouhtedly marry brilliant
successes have been accomplished by the use of’ the usual m&hod of regulation of
t,he teeth. In extreme cases of prognathism, hcJwf?ver, surgical interference seems
t,o he gaining more popularity. I believe it was Angle who, in X398! made the fol-
lowing statement : ” Several years ago the author became c*onvinc:c>dthat no q-
eration dependent, upon tooth movement illol~c coultl rstablish proper rcl:ltion oi
the teeth or materia.lll\- improve the facial lines in certain (:i\scs of ~)ronounc~ec!
overdevelopment of the mandible. ” Brt’orr~ this time Hulliherr, in 1~46 m&e :I
pioneer operation upon an ~?lO~l~i~tCti jaw wit,h prognathism. SincY then opera-
tions for shortening the mandible havr bct~u prrt’ormrtl with irrcreasilrg nurnbel
by Blair, Ballin, Babcock, Pichler, Willett and many others. J tk ~ent~ral these
operations have been accomplished by t,wo methods.
The first method is to remove a section of the body of the mandible on each
side, thus practically creatin,, e a double mandibular I'rilCtllW and to innnobiiizt~
the segments until union is romplete (Blair, Ballin),
The second method is to cut the ramus on each side above the If:\-cl of’ the
mandibular canal, pushing the mandible back to thr desired position and irn-
mobilizing it until healing is caompleted (Pichler, Babcock I.
It is not 111s purpose to discuss the relative merits of these met,hods hut to W-
port a series of five cnsw tllitt have bet>]\ opcl~ated upon by me Following the first
method and to present my olwwat iou alltl c~onc~lusionsII~OII them.
Four of the cases were similar, characterized by extreme protrusion OC thtL
mandible, while the fifth one had a pronounced open-bite. As the preoperative
preparation, as well as the ~J~~~~~~ltims thrmselres. has btlen similar in all these
cases. I shall give just a brief history (II’ tl;lch cast and then describe generai
methods of treatment,.
CASE l.-(IS. S.) -female, a.ged twenty-one years. (Fig, 1 ii and B.,! After
the age of ten, t,he mandible gradually began to show abnormal prot,rusion until
it assumed its present condition (Fig. 1 (’ 1. The family history was essentiall:
negative. Examination showed a healthy young woman. The mandible ~-ah
abnormally prominent ; teeth wrre in good condition, but exhibited poor ucc1u-
sion, especially on the right side. As a result. the mrclian line had shifted to the
right. An x-ray examination oC t,he skull was negative, as was also the physical
examination. The various measurements o F the models showed displacements as
follows: The space bet,wcen the rnaxillar\- and mandibular centrals W&S 8 mm.
anteroposteriorly, and the median line had shifted 14 IIlJll. to the right.
On the basis of these measurements the sections of the mandible to be re-
moved were calculated as follows : right side 5 mm. : left side 15 mm. (Fig. 2.)
l_l-
*A papr~- presented to the Second International Orthodontic Congress, TAXIdon, 1931.
l”“4
 The right and left first molars were missing, but it was necessary to remove
the right and left second premolars in order to provide sufficient space from
which to remove the segments. Bands were then made in preparation for the
splints and cemented before the operat,ion onto the second and third molars and
canines and first premolars on either side.

A B c

Fig. I.---A and B, photographs of patient, C, showing position of teeth before operation, Case 1.

Fig. 2.-Models of teeth, Case 1.

Operation, July 14, 1931. Ether anesthesia was administered rectally. A

small incision was made below the border of the mandible on each side. Through
this opening the periosteum was separated from the mandible, and special clamps
were fastened to the bone. With a Gigli saw, a section was removed from each
side, the left hand section being larger than the right to harmonize with measure-
ments made previously to the operat,ion. (Fig. 3.) No special difficulty was en-
countered during the operation. The patient took the anesthesia well and re-
 ./i-

Fig. 3.-Diagram of operation: position of clamp; use of Gigli saw.

Fig. 4.-A, result after operation. B, position of teeth after operation, (case I.)
 mained in good condition throughout the operation. As soon as t,he sections
were removed, the anterior fragment of the mandible was fastened to the distal
parts by means of the splints previously prepared. A small rubber dam drain
was inserted into the incisions to establish drainage. These drains were kept in
until July 21. The patient had very little reaction. She was discharged from
the hospital on July 27. The occlusion was good and the splint,s were holding
well.
I saw the patient in my office once a week following her discharge from the
hospital. On July 27, an x-ray picture was taken showing the jaw in good posi-
tion. On August 22, the maxilla was freed from the mandible to allow more mo-
tion, the patient being able to use the mandible moderately well. On October 23,
the splints were removed. There was complete consolidation of the mandible.
(Fig. 4A and B.)
CASE 2.-( L. B.) female, aged twenty years, (Fig. 5) was referred to me by
the Orthodontic Department of the Harvard Dental School. She had noticed

Fig. 6.-Photographs of patient, Case 2.

progressive enlargement of the mandible since the age of thirteen years. (Figs. 6
and 7.) Mastication was greatly impaired due to malalignment of the teeth. Her
family history was negative except that her father was confined to a state hospital
for the insane. The patient’s past history did not reveal illness, soreness or in-
jury. Her physical examination was essentially negative with the exception of
low blood pressure which was 70/50. An x-ray examination of the head did not
show any enlargement of the sella turcica.
Prior to the operation, measurements and other preparations were made from
the study models. It was necessary to construct splints and cement them over the
teeth as in the previous case (Fig. 8).
Operation, April 12, 1930. Rect,al ether was used. The same operative pro-
cedure as in the preceding case was followed. Small incisions were made on each
side of the jaw and a section of bone was removed with a Gigli saw. Each sec-
tion measured approximately 11 mm. in length. In addition to the dental splints
used in this case to hold the jaw in position, wire sutures were used along the
lower border of the mandible. This, I believe, later proved unnecessary and
somewhat complicated the recovery.
 The patier ht hat1 very lit,tlr l)ostoperativrl rrac*tion ant1 was disIcharged from
the hospital on May 5. with instrnctions to report to the Ontpatien t Department
for follow-up 1breatment. Sh:, was gi\.rii pt~rrnissioll to return to her work in
Nel K York.
When she report,rd a t’ew months later. there was a complete consolidation
 Fig. 8.-Patient with splints in position, Case 2.

Fig. 9.-Photographs of patient on discharge from hospital, Case 2.

Fig. lO.--Patient before operation, Case 3.

of the mandible, facial appearance was greatly improved, and the occlusion of the
teeth was fair. The anesthesia of the lower lip which was caused by the resection
of the mandibular nerves had disappeared. (Fig. 9.)
CASE 3.-(EL. B.) female, aged sixteen years. (Fig. 10.) This patient had
also observed a gradual protrusion of the mandible since the age of ten years.
The personal and family histor?- was negative. except that her father had a
prominent mandible, although not so marked as that of the daughter. Physical
examination as well as x-ray, etc., was negative. Local examination showed ab-
normal prominence of the mandible; so much so! in fact, that there was very little
contact between the maxillary and mandibular teeth. The measurements of the
models showed the following displacements: The space between the maxillary
and mandibular centrals was 6 mm. anteroposteriorly, while the median line was
distorted 2 mm. to the right. The right mandibular first molar and the left sec-
. .
ond molar were mlssmg. (Figs. 11 and 12.) Previous to the operation, t,he

Fig. 15.-Patient before operation, Case 4.

Fig. 16.-Showing position of teeth, Case 4.

right second and left first molars were removed, and appliances were constructed
and cemented onto the teeth for the same reason as before.
Operation, July 9, 1930. Rectal ether was used. The same procedure was
followed as in the previous cases with the exception that drainage was not
established. It was necessary, however, to open the wound later to allow dis-
organized blood to drain out, thus making the patient more comfortable. X-ray
pictures taken on July 21 showed t.he fragments in good position. She was dis-
charged from the hospital on July 26. On October 4, the splints were removed.
The patient was finally discharged on November 29. There was complete consoli-
dation of the fragments. (Figs. 13 and 14.)
CASE 4.-(&f. I).) female, aged nineteen years. (Fig. 1Ti.) This patient
has had a deformity of the mandible all her life. It has caused no discomfort
with the exception of difficulty in chewing. She gives a history of a fa.11 -from a
swing at the age of eight years. Her brother has a similar condition oP Ihe jaw.
but it was corrected by orthodontia. She had vonsultetl a well known orthodon-
tist who did not consider her (*ase suitable for regulating. E’amily and personai
history was negative. Examination showed considerable prominence of ihr chin
and poor occlusion of the t,eetli (Fig. 16 ) . l’rcvious to the operationl the rnatl-
dibular first molars on each side of thr jaw wPre removed b>- her clrnt,ist. a&
the sockets were well healed bei’orc she was admitted to I he hospital. .\s in t,he
previous cases, the splints were constructed altd trementetl river i he I-ccth ire-
fore the operation.
Operation, June 12, 1931. Rectal ether was used. The same procedure was
followed in this operation as in the others.
This patient is still under treatment. S-ray pictures taken on June 2.5
showed the fragments in good position with a callus formation on the lert. while

on the right the contact of the bone was not as good, there being a V-shaped space
on the lower border. (Fig. 17.)
CASE Yj.- (P.) male! aged sixteen years. This case was a patienf with an
abnormal open-bite (Fig. 18). His chief complaint was an iuabilit~p to masticate
or to speak distinctly; hc had been obliged to take speech lessons in order to be
understood. He was also sensitive of the facial dePormit,y.
The family history was essentially nepat,ivr, with no traces of tuberculosis,
cancer, or malformations. Kit11 the exct@ion of iln illness at the age of two
years which the patient thinks caused the “open mouth.” his own history was
negative. As in the previous cases a complete physical examination showed nega-
tive findings. Repeated questioning failed to reveal any habits of thumb sucking
or tongue biting. There was JIO history of stomach troubles as a result of poor
mastication, no soreness or J)ain in the jaws at any time, and no history of injury
to the jaw. Local examination showed an cstreme open-bite with prominent
mandible. The space Mwren maxillary and mandibular teeth was 11 mm., and
the only point of int-ermaxillary contact was betwctxn the last. molars. The
tongue was abnormally large. Speech was poor, being more or less throaty.
 Suryical Treatment of Mnndib~tlar Prognathism 1233

Mouth hygiene was poor. Close examination of the mouth revealed the fact that
the condition was due to deformities of both the maxilla and the mandible, and
the alveolar processes were abnormally high. For obvious reasons it was de-

Fig. l8.-Models of teeth, Case 5.

Fig. lg.-Diagram of operation, using surgical burr for cutting the mandible, Case 5.

tided to cut through the mandible at t,he molar region on each side and elevate
the anterior segment to meet the maxillary t,eeth.
Previous to the operation the first molars on each side of the mandible were
removed. teeth were put in good condition. splints c~nstr~~tt~tl and cemented into
position. This preliminary work was done at the Harvard Dmtal School.
Operation, February 10. 1!X<l. Rectal t4 her was used. ‘1%~ iwuai i1lcaisiolr5
were mode along the lowers borcicr 01’ the rnaritl ible. anal the twtlj~ 01’ the belie wax
exposed. A4 semicircular ineisiou was attempted. 011 tile rig&t sii1.Ca S[)CCiili

semicircular trephine was used, while on t,hc IrI’t side thr cutting w:is ciotlt~ with
a. surgical burr. (Fig. 19.) The trephine cutting was rather disappointing arid
t,hc result, not what 1 ant,icip;rttd, hut tlrr srlrgical burr ~cenr~tl tar ~+~ot~li \cr.\
satist’actoril\-. After cutting t,hrough the mandible, the jaws were in~mobilizrcl
by w-irinK the maxillary and mandibular teeth togrthrr in the I~st possible
position.

The patient made an uneventful recover: ant1 was discharged t’rom the
hospital on March 3 with instructions to return to t,hc Outpatient Department
for follow-up treatment. The t&h were in i’air alignment (Fig. 20).
On February 25 the x-ra.v picture showec1 that 1he left, side of the mandihle
had already consolidated, but the union on ihe right side was delayed, due to
the invoIvement of the right molar tooth whicdh wa.s in the line of fracture. This
tooth was removed immediately and union obtained.
As all the cases received approximately the same treatment, I shall describe
the general method of procrtlurca with occasional tmphasis on variations in
technic.
PJIEI,IMIK;~I<YDIAGNOSIS .\NJ) PROGNOSW
On the study models the (axact location of’ the operation was determined as
about the mandibular first rIlolar region. ‘i’wo of t,he cases (2 and 3 I had no
molars, while in Cases 1 and 4 the first molars WWP sacrificed. The measure-
ments determining the exact size of the piecr of bontl to be removed were also
made on the models. The following method oi’ measuring was adopted. Study
models were placed in the existing rondit,ion and marked with perpendicular
lines over the last molar region. Then the masiliary models were carried forward
to assume the position which would result in the most satisfactory occlusion.
The marking of the maxillary model was extended down to the mandibular
model, and the distance between the first and second lines on the mandibular
model determined the amount of bone to be removed on each side. Owing to the
deviation of t,he median line, these measurements on the right and left sides dif-
fered in all cases. (Fig. 21. j

Fig. 21.-Diagram showing method of measuring the size of section of bone to be removed.

OPERATIVE PREPARATION

In addition to the preliminary work with models, described above, we had to

remove specific mandibular teeth at least a month before operation. If this step
is left until a later date, the healing process will undoubtedly be considerably
delayed. The next step is to construct splints. In all cases approximately the
same type of splint was used. Realizing the fact that it would not be possible to
remove a section of bone with absolute accuracy as to measurement, I attempted
to make splints in an adjustable form so as to allow for effective immobilization
of the parts.
The splints in the diagram (Fig. 22) are (A) a retention splint fastened to
the maxillary teeth and (B) a mandibular splint in three sections.
Bands were fitted over the posterior teeth and a round tube was soldered to
the buccal surface. At least two anterior teeth were utilized on each side and
then fastened together with a stout wire. A vertical slot was soldered into the
buccal side of these bands. After the operation the anterior and posterior bands
were connected with a stout wire threaded on one end and hooked on the other.
The advantage of this procedure is that it. allows for a read,justment to new posi-
tions as healing of the parts progresses.

In all cases colonie ether was given, and it proved to be very satisfactory
inasmuch as it gave the surgeon free access of the operative fieltl. .!n incisiori

Fig. 22.-Diagram of splint.

about 1 inch long was made along the lower borders of the mandible. The bone
was exposed and separated from its periosteum on the buccal as well as on the
lingual side. The operative exposure was extended to t,he buecal cavity, and
sectioning of the bone was made with a Gigli saw. In order to have good control
of the direction of the saw, a curved serrated hemostat, bent approximately to
the contour of the mandible, was clamped to the bone and the Gigli saw was in-
troduced distally to the clamp. AS one line was cut, the clamp was shifted for-
ward according to the measurements and the sectioning was repeated (Fig. 23).
 In all the eases there was no troublesome hemorrhage from mandibular
vessels.
As soon as the sectioning was completed, the hooked wire was introduced
and the parts were fastened together. In addition intermaxillary elastics were
applied to the maxillary and mandibular splints. In the first case wire suturing
was done at the lower border of the mandible, but in subsequent cases t,his prac-
tice was discarded as it seemed unnecessary and undoubtedly caused irritation.

POSTOPERATIVE CONVALESCENCE

Temperature charts indicated slight elevation of temperature in the first

two days, not over 100 degrees. There was a slight postoperative swelling or
edema. External drainage was necessary in all the cases for a time. After the
second week the mandibular splint was sufficient to hold the parts in position ef-
fectively, so that the interdental elastics were discarded, and the patients were
able to use the mandible quite effectively. There was naturally complete anes-

Fig. 23.-Special clamp used to act as a guide to Gigli saw.

thesia of the lower lip from the beginning, but this was a temporary condition
and within six months the first three cases were perfectly normal. Union was
complete in all these cases when last examined-Case 4 is still under treatment
(July, 1931), the operation being on June 12,1931.
In all cases there was a marked improvement in facial appearance. The oc-
clusion of the teeth was fair in the first and third cases, and excellent in the
second and fourth.
During the healing of the bone, it was necessary from time to time to make
adjustment of the splint in order to improve the occlusion of the teeth. Not in-
frequently I was obliged to push the mandibular molars medially in order to im-
prove the alignment. This was d8ne simply by rotating the connecting wires
slightly outward. In the meantime a vertical slot fastened to the mandibular
premolars allowed plenty of room to effect this adjustment. In the same man-
ner a backward swing of the anterior section of the mandible was resorted to at
times by changing the position of the screws holding the slotted wire firmly in
position. For this purpose I found the splints used in my cases superior to
unattachable types.
One of the arguments advanced against this type of operation is that sound
teeth are sacrificed. This, of course, is apparent, leaving aside the fact that the
 tCEFEXE:h (‘I.:‘-

Giln~el,, 1~. 1‘. : Kesectiorr of the Ilow for I’rotrusion of t& &l:lnll il,lp, sut g, (;yue(#. a (Jbit., lrttY,
191.7.
KI:lir. \‘. P. : Instances of Oprrat,irv Correction of >I;IIw]:]tj()n of the .J:l,vs. 1 ~‘rb:a~\‘~, J. ()~r[+,,
(kit, EURO. & RADIOG. 1 : 3%?, 1!)1,7.
Br~ln~, f’hristian: The Surgical Orthopedic (‘orrcctioll of I)efornlities of the .J;~\w, ‘rr:lns, St,\-.
cwth International Dental Congress 2 : 1568, I 9%.
Hallin, &fax: Double R,esrrtion for the Treatment of M\II:~ndibul;tr J’rotrusion, Ttrms ,,f Interest
30: 4““'d) 1908
. .
Babcock, W. U’ayne: The P’ieId of Osteoplastir Oljer:ltions for tlie (“orrwtion of l)pformjtiw of
the Jaws, Items of Interest 32 : 339, 1910.
Angle: Malocclusion of the Teeth, Philadelphia., 1907, page 572, S. S. White C!o.
Willett. R. C‘. : A Case Report, Traw. First Intrmation:~l Orthodontic (‘ongress. St. 1,ouis. I!)?;.
p. 1~~8, The C. V. Mosby Co.
Pichlrr, Hans : Double Resection of the hi:tndil,le in (‘axe of Very 51:lrkctl I’rogc&:l, lirit. Itent.
J. 41: 163, 1920.
Kostecka, F. : 11~1 Chirurgisehr ‘l’hrrapie 11u progenie, Zahnarztliche Rundschau, April, 1931.
Angle: Double Resection for the Treatment of Jlandihular Protrusion, I)entnl Cosmos, 1903.
Sle&srr : Behandlung der Okklusionsallomaliell tier %hnr. T)ent:\I C’osmos, 1 X9%99. ?;r. h.
\-. Auffenberg, Langcnbecks A. LXXIX.
Bergrr : Trnitmrnt chir. du Prognathisme, Lyon, 189i.
Brophy : Oral Surgery, Ilondon, 1916, P. Blakiston ‘s Son & (‘0.
Bruhn : iiber chirurgische und zahnRrztlicborthop%dische Massnahmrn zum Ausgleieh der
Mnkrognathie (Progenie) und Mikrognathir ties Unterkiefers, Deutsche Monatschr. f.
Znhnh. duli 1931. t!ber die Beseitigung drr Progenie durch chirurgisehe Massnahmen:
I)eutsche Monatschr. f. Zahnh. 1920; Deutsche Monatwhr. f. Zahnh. 1921.
Dufourmental: J,e traitment rhirurgieal du pognathism, Prrsse mhd. 29: 23.5, 1921.
Hullihen : Dental Cosmos, So. 3, 1900, Am. a. Dent. Sri. 1849.
Jab&q and Berard: Traitment ehirurginnl du Tnvgnathisme inferirur. ~‘WRSP III&~. Sr. 30.
1898; ref. hildebrands Jahrrslser. 1899.
KlaT,1,, Bange, and T%nst : T)ic T?rkrankungen des (;t,8ichtsskclrts, Ref. I)ie (:hirurgie Hand
rV. 1 Teil.
Im(‘USsION

Mr. &J&O& \ris]led to know whether acromegaly was the cause of the enlarged jaw in
any of or. Kazanjian’s cases. Ilc also wished to know whether 1~~ controlled the lmsterior
segments in paws where t,lirre w’rv no molar teeth.
Dr. Singer asked whether T)r. Kazanjian had observed cases of mandibular resection
where t,here had been an ahscu~e of sensory nerw regeneration in the anterior part Of the
mandible, following operation.
~[r. &le-AJfutthez&~ after congratulating Dr. Kazanjian on tlw wonderful results he had
obtained, pointed out that the operation was practically unknown in this country for the ear-
rection of mandibular prominenrc. He said that while he was at King’s College Hospital he
had a, patient on v,-llom hfr. \\7akeley performed l.his Oper:ltiOn With COIllpit~te SUCCBSS. hl this

particular bask the prognathism was not of very great importance because the patient was an
epileptic and a mental deficient, but the deformity was SO extraordinary that eren in her case
there might hare been a possibility of the inferiorit,y complex being improved.
 Mr. Piffs said it seems very evident that when we take these cases and the long series of
cases recorded by Dufourmental of Paris, the surgical treatment of prognathism has got beyond
the experimental stage. Tt is only within the last decade that the surgeon has obtained such a
degree of control over the rather refractory substance on which he works as to justify such
cases. He imagined that the number of cases suitable for an operation of this kind would
always be limited, but severe cases of prognathism were so very distressing to the individual
that he could not help feeling that we should hear very much mote of this operation in the
future.
He would like to ask Dr. Kazanjian whether he had contemplated or tested the procedure
of elongating the jaw in cases of mandibular retrusion. From time to time one saw cases of
so severe a degree that the deformity was hideous in the extreme, now that the procedure of
bone grafting had become an assured operation and a method of treatment became feasible.
Dr. Kazanjiun, in reply to Mr. Badcock’s question, said there was exclusion of any kind
of ncromegaly in his patients who were all young adults. We know that acromegaly shows
protrusion of the mandible and also brings about changes in the skull as well as in the hands
and so on. If such cases came to us, it would be unwise to operate because we cannot control
further changes in the jaw.
If the teeth are absent in the back of the jaw he did not see any contraindications for
wiring the segment of the bone together and eventually removing the wires.
The absence of regeneration of the sensory nerve was possible. He c.ould not remember
any of his cases who had developed permanent absence of sensation of the lower lip, but in any
case he had not heard any complaint even from absence of sensations. Patients usually got
reconciled to it and forgot that they had a numb lip.
Operations for mandibular retrusion were very successful and he had three cases in the
exhibition room showing elongation of the mandible by surgical means. The cases he operated
on were done, not by bone grafts, but by making a complete incision along the mandible and
elongating it. However, bone grafts in some cases were very successful.