Micrognathia* A Suggested Treatment for Correction in Early Infancy Auzert D. Davis, D.DS., MD. and Rosert Dunn, D.DS. San Francisco (Reprinted from the American Journal of Diseases of Children, April, 1933, Volume 45, No. 4.) A search of the literature on micrognathia reveals few suggestions for correction of this deformity other than appliances that have the disadvan- tages of being cumbersome, difficult of retention, insanitary and requiring a closed mouth. (1). As dyspnea is an ever present symptom, any appara- tus that causes pressure and decrease in size of the airways seems illogical. Considerable study has evolved the form of treatment suggested in the case report that follows, Early recognition and treatment over a long period of time (two years as a minimum) are imperative. Report of Case A boy, aged 3 weeks, was brought to the Stanford Children’s Clinic for closure of a cleft palate, form 6, Brophy classification. (1d). Figure 1 Figure 2 Fig. 1. Right profile at the age of 3 weeks 2) Left profile at the age of 3 weeks On examination, the child was found to be normal in all respects except for the cleft involving the soft tissues of the palate and a marked distal relation of the mandible. The history was irrelevant, neither parent ot ancestors having had either type of deformity. ‘The parents were well de- veloped, normal, middle class people. The prenatal history gave no clue as to any interference in normal development; the child was born at term. Oral examination showed the tongue placed far distal to normal, and ap- *From the Department of Surgery, Stanford University Medical School, THE ANGLE ORTHODONTIST 247parently much smaller than usual, Difficulty in swallowing and some slight postural dyspnea were noted, but the presence of the cleft was no doubt responsible for the alleviation of the marked dyspnea so often present in these cases, Fig. 3. Roentgenograms taken at the ages of 6 weeks and 11 months, respectively. Figures 1 and 2 reveal the characteristic birdlike type of profile, and figure 3 permits a study of the relationship of the soft structures to the bony development beneath. As will be noted, the mandible was the typical form of brachygnathia, with the incisor region meeting the maxillae very near the tuberosities. The chin, while distinctly formed, was markedly retruded, and the lower lip was formed into a distinct pout in its effort to reach the upper lip. ‘The angle of the jaw varied considerably from the normal type, in that the body met the ramus at almost a right angle instead of an obtuse one. The marked shortness of the mandible gave the maxillae the appearance of protrusion, but careful study showed the abnormality to exist entirely in the mandible, Comment Embryologically, the deformity is due to imperfections in development of the first branchial arch and cleft, and the most commonly associated mal- formation is a cleft palate. It must be remembered that the mandible develops from two ossific centers and unites at the symphysis, the alveolar ridge of the mandible meeting the inclined planes forming the upper arch, and aiding in the normal approximation. The lower jaw, being formed and united in advance of the upper, acts as a matrix on which the upper jaw is formed. Considering the position of the child in utero, where the weight of the entire fetal body may be readily thrown on the vertex, it is easy to conceive how pressure of the 248 THE GLE ORTHODONTISTsternal region in contact with the mandible might force the forming jaws to- gether. If this undue force occurred at a time when the lower jaw was united and the upper jaw ununited, it is easy to understand how pressure on the chin could force the partly calcified lower jaw backward, straighten the Figure 4 Figure 5 Fig. 4. Position of the lip guard used at the age of 6 weeks. Fig. 5. Position of the lip guard used a few weeks later. Note the improvement, in the profile obtuse angle to almost a right angle and prevent union of the horizontal plates, causing a cleft in the soft tissues of the palate without involvement of the alveolar ridge or lip. It would also account for the backward dis- placement and small size of the tongue. According to Mall, (1g) the mandible reaches its characteristic shape by the middle of the third’ month of fetal life, At this time the lips project about equally, Later the upper lip of the embryo grows more rapidly, so that in the fourth and fifth months it projects markedly beyond the lower lip. Normally, by a greater growth of the lower jaw and lip this difference is overcome. If, how- ever, some inhibitory factor, such as that mentioned, occurred, the early fetal arrangement might be retained and deformity result. Experiments recently carried out on embryos of Amniota prove con- clusively that many deformities cannot be produced by the same factors— pressure of amniotic bands or deficiencies of the amniotic fluid—in Anam- niota since no amnion is present in these animals. Yet, while the casual factor formerly attributed to disturbances in the amnion may vary, the same developmental defects may occur in both. Probably the better known, forms of brachygnathia, affecting both jaws, are seen in dogs, such as the Abacus type of Pekinese and the pug. Another form of shortening of the mandible occurs in sheep. ‘The defect is known among the shepherds as “hog-jaw,” and the animal so affected is unable to suckle or graze, THE ANGLE ORTHODONTIST 249The lower jaw, imperfectly developed, falls short of the normal by about 1 inch (2.5 cm.) or more. Nicholas and Prenant, in 1888, reported a specimen in a lamb in which the mandible was completely absent. A speci Figure 6 Figure 7 Fig. 6. Forced protrusion in nursing at the age of 944 months. The jaw must be protruded in order to suckle. Fig. 7. The right and left profiles at the age of 10 months, showing the changes in the profile. Note the droop of the lower lip on the right, showing the necessity for further bony development. men in the museum of the Royal College of Surgeons (no. 186) shows a com- plete absence of the right half of the mandible, right palate and malar bones, with a wide median cleft through the posterior half of the palate. Extreme forms of this type of deformity result in a conjoined eyeball with a corres- ponding cyclops eye behind the fused maxillary processes. This is shown in a pronounced case of agnathia in a human subject in the museum of the Royal College of Surgeons (no. 261). Other forms might be noted, but the similarity of the resultant defect leads one to the conclusion that some inhibitory factor in development has occurred, the pressure theory being the most logical one. In the case reported, operation for closure of the cleft was postponed until the child should reach the age of from 16 to 20 months. On examination and study of the portraits and roentgenograms, the following conclusions were reached: 250 THE ANGLE ORTHODONTIST1, The apparent excessive overdevelopment in the maxilla was normal. 2. ‘The body of the mandible, including the mental protuberances, was apparently normal, but the ramus was markedly at right angles to the body, which is not a normal condition at this age. Figure & Fig, 8. The profile at the age of 1154 months. 3. The deformity was actually due to the extreme distal position of the mandible, and had it been possible to obtain clearly defined roentgeno- grams of the temperomandibular articulation, an abnormal condition would have been revealed. 4, Experience in treating older children with the same deformity led us to apply a remedy before eruption of the teeth occurred, in order to obtain a normal chin and jaw. (2). 5. The conclusion was reached that as the mandible of the new-born babe is normally distal in relationship in a certain degree to the position it will occupy a little later and as it is nature’s plan to bring about this forward position through natural feeding (which is the upper lip and nose pressed against the mother’s breast, and the bringing forward of the mandible in the act of sucking the nipple), if we could imitate this natural process with some exaggeration through mechanical means, it might aid in overcoming the de- formity. THE ANGLE ORTHODONTIST 251re 9 Figure 10 Fig, 9. The attachment made for the ordinary nursing bottle. ‘The cap sleeve with the solid perpendicular rod and lip guard is fastened to the bottle by means of the set-screw. It was made for us by C. O. Edwards, D.DS., Oakland, C: Fig. 10. The assembled apparatus, showing two positions of extension. Apparatus A metal form was made to fit the upper lip and was connected to the nursing bottle through an easily adjustable attachment permitting length- ening by degrees the distance between the rubber nipple and the infant’s mouth, It was then presented to the mother with the instruction to lengthen the distance every few days between the infant’s mouth and the nipple, with the result shown in figure 8 after eleven months’ use. ‘The mother has been advised to continue with the nursing bottle and appliance as long as possible and to give all liquids to the infant in this manner. Literature 1. (a) Eley, R. C., and Farber, Sidney; Hypoplasia of the Mandible (Micro- gnathy), Am, J. Dis, Child. 39:1167 (June) 1930. (b) Dolamore: Inferior Re- trusion, Internat, J. Orthodontia 9:50, 1925. (c) von Ertl, Johann: Chirurgie der Gesichis—und Kieferdefekte, Berlin, Urban & Schwarzenberg, 1918. (d) Brophy, T. W.: Cleft Lip and Palate, Philadelphia, P. Blakiston’s Son & Co, 1923) (©) Wakeley: Defective Division of Mandibular Arch, J. Anat. 57:140” (Jan.) 1923. (f) Lenstrup, E.: Hypoplasia of Mandible as Cause of Choking Fits in Infants, Acta paediat. $:154, 1925. (g) Keibel, Franz, and Mall, F. P.: Manual of Human Embryology, Philadelphia, J. B. Lippincott Company, 1910, vol. 1, P. 865 vol. 2, p. 440. 252 THE ANGLE ORTHODON