International Journal of Clinical and Developmental Anatomy
2015; 1(3): 64-69
Published online July 25, 2015 (http://www.sciencepublishinggroup.com/j/ijcda)
doi: 10.11648/j.ijcda.20150103.12
Overview on the Anatomical and Clinical Aspects of
Mandibular Prognathism
Ahmed M. S. Hegazy1, *, Bakr Ahmed Bakr2
1
2
Anatomy Department, Benha Faculty of Medicine, Benha University, Benha City, Egypt
Laser in Dentistry, Dental Consultant, Ministry of Health, Giza City, Egypt
Email address:
ahmed0562301954@yahoo.com (A. M. S. Hegazy)
To cite this article:
Ahmed M. S. Hegazy, Bakr Ahmed Bakr. Overview on the Anatomical and Clinical Aspects of Mandibular Prognathism. International
Journal of Clinical and Developmental Anatomy. Vol. 1, No. 3, 2015, pp. 64-69. doi: 10.11648/j.ijcda.20150103.12
Abstract: The form and size of the human mandible is subject to considerable variation from the accepted normal. One of
the more interesting and rewarding aspects of oral surgery is the operative correction of the Mandibular abnormalities, the
category of malformation into which the mandibular deformity falls. In this study we reviewed more than 30 articles to clarify
the mandibular prognathism with its effects. Conclusion: Awareness of the normal and abnormal variations of the mandibular
anatomy with their causes, deferential diagnosis, prognosis and complications especially mandibular prognathism is very
important for the maxillo-facial surgeon to achieve a suitable decision during treatment.
Keywords: Prognathism, Mandible, Deformity, Acromegaly, Maxillo-Facial Surgery
1. Introduction
The form and size of the human mandible is subject to
considerable variation from the accepted normal. One of the
more interesting and rewarding aspects of oral surgery is the
operative correction of these abnormalities.
It is therefore necessary to devise a classification based
upon immediate causes and upon which a rationale of
treatment for these cases can be established. A classification
upon which both the timing and nature of treatment can be
based is as follows:
1. Extreme degrees of normal variation.
Increased size leading to mandibular prognathism.
Reduced size leading to mandibular retrognathism.
2. Abnormalities of shape or size occurring as part of a
more extensive syndrome.
3. Decrease in size due to localized defect in the
mandibular growth center.
Unilateral.
Bilateral.
4. Increase in size as a result of over activity of the
condylar growth center.
Unilateral.
Bilateral.
Bilateral mandibular prognathism often represents the first
and most striking physical characteristic of acromegaly;
usually, it is also the main reason why patients seek help
from orthodontists or maxillo-facial surgeons(1).
2. Prognathism
Prognathism is a deformity characterized by an abnormal
protrusion of the mandible. The broader part of the lower
dental arch lies opposite the narrower portion of the upper
arch, causing a malocclusion varying with the degree of the
deformity. The protruding chin, with the massive jaw and
heavy lips, often results in a very displeasing appearance,
which primarily causes the patient to come for surgical aid. It
may be due to actual hypertrophy of the bone; errors in the
eruption of the teeth; premature extraction of deciduous
molars; or to fractures or contracting scars of the face and
neck (Figure 1).
Lateral cephalometric radiograph examination (Figure 2)
showed massive mandibular prognathism, prominent
supraorbital ridges and an enlarged sella turcica. Additionally,
magnetic resonance imaging (MRI) scans confirmed the
expansively growing tumour mass within and above the sella
turcica. Furthermore; the entire calvarian bone was thickened,
thus confirming the provisional diagnosis of acromegaly.
Endocrinological examination showed increased levels of the
insulin-like growth factor-I (IGF-I) (627.0 ng/ml; norm:
117.0 to 329.2 ng/ml), increased prolactin (63.69 µg/l; norm:
2.10 to 17.7 µg/l) and depressed testosterone levels (0.84 µg/l;
norm: 2.41 to 8.30 µg/l). Ultrasonography showed
65
Ahmed M. S. Hegazy and Bakr Ahmed Bakr: Overview on the Anatomical and Clinical Aspects of Mandibular Prognathism
hepatosplenomegaly and an enlarged left kidney. In addition,
colonoscopy showed dilatation of the colonic lumen.
Ophthalomological screening showed a large bi-temporal
visual field defect due to tumor compression of the optic
chiasm. The patient underwent transsphenoidal surgery with
complete tumor resection(2).
usually exhibit enlargement of all parts of the neurocranium
and orofacial bones except the maxilla. The mandible usually
shows the biggest enlargement, and the ramus is more
affected than the body of the mandible (6, 7). The enlargement
of the sella turcica caused by the tumor expansion of the
pituitary gland is a striking manifestation that is detectable
on lateral cephalometric radiographs in almost every patient
with acromegaly (8).
2.1. Acromegaly
Figure 1. Initial facial photographs (1a: frontal and 1b: lateral view)(37).
Figure 2. Lateral cephalometric radiograph. (37)
Acromegaly and mandibular prognathism were the main
reasons for the patient to seek orthodontic treatment.
Enlargement of the lips and the tongue, may impair
swallowing, chewing and speaking. Frontal bossing,
prognathism, macroglossia and an increased size of hands
and feet have often been described in the literature as
cosmetic changes associated with GH adenomas (3,4,5).
Lateral cephalometric radiograph examination showed
massive mandibular prognathism, prominent supraorbital
ridges and an enlarged sella turcica. Patients with acromegaly
Acromegaly (derived from the Greek words "akros",
extremities, and "megas", big). This term was proposed by
Pierre Marie, a famous French neurologist working in La
Salpetrière Hospital, in Paris, who published the first
description of the disease and its pathology in 1886. It is used
when the disease begins in adulthood(9).
Acromegaly is a rare, insidious, and potentially lifethreatening condition for which there is good, albeit
incomplete, treatment that can give the patient additional
years of high-quality life(10).
Acromegaly is a rare disease that is responsible for
bilateral mandibular prognathism in adults. Excess of growth
hormone and local tumor growth of the pituitary gland affect
the entire body and increase mortality. In most patients, this
disease is diagnosed far too late. Orthodontic and maxillofacial surgeons dealing with orthognatic surgery should be
well aware of this disease as patients usually present with
them first because of striking mandibular growth. In case of
mandibular prognathism in combination with enlargement of
lips, nose, tongue, hands and feet followed by visual field
defects, sleep apnea, decreased energy and osteoarthritis,
every clinician should consider the diagnosis of acromegaly.
Although acromegaly is a rare disease, its symptoms are
striking and can hardly be misconstrued(11).
Mandibular prognathism normally is the result of an
imbalance between the nasomaxillary complex and a
prominent mandible. The accompanying dental condition
reveals a Class III malocclusion with an anterior cross bite. A
compensated inter-dental relationship can be found with
labial tipping of the maxillary anterior teeth in conjunction
with lingual tipping of the mandibular anterior teeth.
However, the vertical dental relationship with either over or
open bite conditions varies among patients with mandibular
prognathism. Overall, the discrepancies can easily be noticed
in the sagittal dental and facial appearance with the
prominent vertical feature of greater lower anterior facial
height(12).
Researchers have identified a gene on the X
chromosome, GPR101, which was overexpressed 1000-fold
more than normal in a genetic study of 43 patients affected
by sporadic or inherited gigantism that manifested during
childhood or adolescence. This duplication was not evident
in patients who began abnormal growth at age 9 or 10, but
only in those who started to grow excessively before the age
of 3. In a separate analysis of 248 patients with sporadic
acromegaly, a mutation in the GPR101 gene was found in
about 4% of cases. Nainggolan L. Gene Discovery in Giants
International Journal of Clinical and Developmental Anatomy 2015; 1(3): 64-69
Could Shed Light on Human Growth(13).
Acromegaly is an acquired disorder related to excessive
production of growth hormone (GH) and characterized by
progressive somatic disfigurement (mainly involving the face
and extremities) and systemic manifestations. The prevalence
is estimated at 1:140,000–250,000. It is most often diagnosed
in middle-aged adults (average age 40 years, men and
women equally affected). Due to insidious onset and slow
progression, acromegaly is often diagnosed four to more than
ten years after its onset. The main clinical features are
broadened extremities (hands and feet), widened thickened
and stubby fingers, and thickened soft tissue. The facial
aspect is characteristic and includes a widened and thickened
nose, prominent cheekbones, forehead bulges, thick lips and
marked facial lines. The forehead and overlying skin is
thickened, sometimes leading to frontal bossing. There is a
tendency towards mandibular overgrowth with prognathism,
maxillary widening, tooth separation and jaw malocclusion.
The disease also has rheumatologic, cardiovascular,
respiratory and metabolic consequences which determine its
prognosis. In the majority of cases, acromegaly is related to a
pituitary adenoma, either purely GH-secreting (60%) or
mixed. In very rare cases, acromegaly is due to ectopic
secretion of growth-hormone-releasing hormone (GHRH)
responsible for pituitary hyperplasia. The clinical diagnosis is
confirmed biochemically by an increased serum GH
concentration following an oral glucose tolerance test
(OGTT) and by detection of increased levels of insulin-like
growth factor-I (IGF-I).
Assessment of tumor volume and extension is based on
imaging studies. Echocardiography and sleep apnea testing
are used to determine the clinical impact of acromegaly(11).
Diagnosis of acromegaly as one of the responsible causes
of bilateral mandibular prognathism in adults Laboratory
studies used in the diagnosis of growth hormone (GH)/IGF-I
excess include the following:
Oral glucose: To determine the extent to which the patient
can suppress GH concentration after the consumption of oral
glucose.
GH: Clearly elevated GH levels (>10 ng/mL) after oral
glucose, combined with the clinical picture, secure the
diagnosis of acromegaly.
IGF-I: Elevated IGF-I values in a patient whose symptoms
prompt appropriate clinical suspicion almost always indicate
GH excess.
Imaging studies include the following:
Magnetic resonance imaging (MRI): To image pituitary
adenomas.
Computed tomography (CT) scanning: To evaluate the
patient for pancreatic, adrenal, and ovarian tumors secreting
GH/GHRH; use chest CT scans to evaluate for bronchogenic
carcinoma secreting GH/GHRH.
Radiography: To demonstrate skeletal manifestations of
GH/IGF-I excess(14).
2.1.1. Prognosis
Because of the small number of people with gigantism,
mortality and morbidity rates for this disease during
66
childhood are unknown.
In acromegaly, a severe disease that is often diagnosed late,
morbidity and mortality rates are high, particularly as a result
of associated cardiovascular, cerebrovascular, and respiratory
disorders and malignancies.[1]
Because IGF-I is a general growth factor, somatic
hypertrophy in acromegaly occurs across all organ systems.
Associated complications include the following:(15)
Acromegalic heart
Increased muscle and soft tissue mass
Increased kidney size
Articular overgrowth of synovial tissue and
hypertrophic arthropathy
Joint symptoms, back pain, and kyphosis: Common
presenting features
Thick skin
Hyperhidrosis (often malodorous)
Carpal tunnel syndrome and other entrapment
syndromes
Macroglossia: May result in sleep apnea
Cerebral aneurysm and increased risk of cerebrovascular
accident: Less common.(16)
2.2. Effect of Mandibular Prognathism on Masticatory
Muscles Volume
Several investigators have reported significant associations
between masticatory muscle size and skeletal craniofacial
form (17, 18, 19, 20) while others have found very few
correlations between the size of jaw-closing muscles and
craniofacial morphology. (21)
Strictly speaking, even when the differences in measuring
methods are taken into account, there has been no agreement
on the association between craniofacial form and the size of
related muscular structures(22)
To understand biomechanical relationships between hardand soft tissue structures, we believe that it is indispensable
to examine the structural association between muscles and
the adjacent local skeletal sites on which muscle forces are
exerted, rather than examining correlations between the
overall craniofacial skeletal structure and the size of
masticatory muscles within a traditional cephalometric
paradigm. Mandibular prognathism, a gross skeletal
deformity of the craniofacial area often requires orthognathic
surgery. Because the surgical approach necessitates invasion
into the mandibular ramus and gonial region, an
understanding of the association between the morphology of
the skeletal and muscular components of craniomandibular
structures is indispensable in achieving successful treatment
and post-treatment stability. In addition, such an
understanding will provide meaningful insight into the
principles that account for relationships between form and
function of the craniomandibular apparatus(23)
To study relationships between form and function of the
craniomandibular apparatus we use:
1) Examine computerized Tomography (CT) images of the
craniofacial structure in adult patients with mandibular
prognathism;
67
Ahmed M. S. Hegazy and Bakr Ahmed Bakr:
Ba
Overview on the Anatomical and Clinical Aspects
spects of Mandibular
M
Prognathism
2) Based on CT's three-dimensionalit
imensionality, investigate
whether the temporal and masseter muscle
m
volumes
correlate with transverse head
ad dimension
dimensions;
3) Investigate whether the masseter m
muscle volume
correlates with the size of the zygomat
zygomatico-mandibular
skeletal sites, the form of the antegonial
antegon region, and
orientation of the masseter muscle;
4) Investigate whether the masseter
asseter muscle
mus
orientation
has influence on the inclination
inclinati
of the
zygomaticomandibular skeletal sites (24).
Kitai et al (24) found in theirr study significant
signi
positive
correlations were found among
mong tem
temporal muscle
crosssectional area, masseter muscle
uscle cross
cross-sectional area,
temporal muscle volume, and masseter
sseter muscle volume. Only
the volume data on the temporall and massete
masseter muscle were
used for subsequent analyses, because the volume data
correlated highly with the cross-sectional
ectional area data.
The temporal and masseter muscle volume
vo
showed
significant positive correlation with the widths of the
bizygomatic arch and the temporal
poral fossa but not with
cranium width.
There were significant positive
ve correlatio
correlations among the
zygomatic arch cross-sectional area, the mandibular
ma
ramus
cross-sectional area, and masseter muscle
uscle volume.
volu
Masseter muscle volume did not significantly
signific
correlate
with the gonial angle and the masseter
asseter anterior
anter
orientation.
The masseter zygomatic angle was
as 95.1 + 6.2
6 degrees, and
the masseter antegonial angle wass 87.8 + 8.3 degrees.
d
A significant positive correlation
ion was found
foun between the
zygomatic arch angle and the antegonial
egonial angle.
angle
The temporal and masseter muscle volumes
vo
showed
significant positive correlation with
ith bizygoma
bizygomatic arch width.
This finding is consistent withh the genera
general consensus in
previous reports that subjects withh strong or thick
th
mandibular
(25 .26,
elevator muscles have wider transverse
sverse head dimensions
d
27, 28.29, 30)
The temporal and masseterr muscle volumes were
significantly correlated with the temporal
emporal fossa
foss width but not
with the cranium width. These results
sults suggest that the greater
bizygomatic arch width for those
se individual
individuals having large
temporal and masseter muscless is not due
du to the wide
cranium but rather to the wide temporal
mporal fossa, which is filled
primarily with the temporal muscle
uscle and partly
p
with the
masseter muscle.
Significant positive correlation
ion was found
f
between
masseter volume and the cross-sectional
sectional areas of the
zygomatic arch and the mandibular ramus.
In patients with mandibular prognathism,
prognathism the bilateral
difference in muscle volume would
uld reflect the
th difference in
the spatial anatomy of a skeletal
tal structure and could not
predict mandibular skeletal asymmetry(24)
2.3. Effect of Prognathism on the Tongue
ongue Vo
Volume (Figure 3)
The morphological relationship
ip between
betwee the tongue and
maxillo-mandibular structures is an essential element in our
understanding of the growth andd developme
development of orofacial
structures, the etiology of specific
fic types of malocclusions,
and occlusal stability after orthod
orthodontic or surgical correction
of malocclusions. It was
as hypothes
hypothesized that the size and form
of dental arches were determined bby the tongue size(31).
Figure 3. Initial intraoral photograph
graph showing
sho
Angle class III malocclusion.
(37)
Macroglossia is defined
efined as to
tongue enlargement due to
muscle hypertrophy, tumor or an endocrine disturbance.
Pseudo macroglossia,, or relative macroglossia, is defined as
the tongue being normal
mal in size, but appearing large due to
its anatomical reciprocation.
cation. The tongue locates forward and
is larger than normal in prognathism,
prognath
and this macroglossia
may cause problems such as Cla
Class III malocclusion and an
open bite(32).
It has also been suggested
ggested that an increase in the volume
of soft tissues inducess the osteogenic
osteog
reaction at the growth
site of the bone. (33)
A large tongue hass been regarded
regar
as a possible cause of
mandibular prognathism (34). A relative
r
increase in tongue
volume after the mandibular
dibular set
set-back surgery in patients with
mandibular prognathism
ism was als
also suggested as a possible
cause of relapse, i.e., decrease in over
o
jet and overbite during
the retention period. Although this has formed a basis for the
validation of the glossectomy
sectomy as one
o of the effective choices
for the acquisition of post-treatm
treatment occlusal stability the
lack of accurate quantitative
tive information
info
on tongue volume
has hampered us in giving a de
definite answer to a simple
question of whether mandibular
andibular prognathism
p
is accompanied
by a large tongue.. Indeed, the
t
deciding criteria for
glossectomy in adult patients wit
with mandibular prognathism
have been based only on subjectiv
subjective visual judgment. (35)
Yoo et al. (36) found
nd that the subjects with mandibular
prognathism showed tongue volumes
volu
similar to those of the
control subjects. Hence,
ce, it would be logical to assume that a
possible increase in relative tongue
tongu volume is anticipated in
patients with mandibular
dibular prognathism
pro
who undergo
mandibular set-back surgery. The resulting narrowness of the
oral cavity may be compensated
compensate for by the short-term
positional adaptation of the tongue,
tongu which was characterized
by the simultaneous downward movement of the hyoid bone
after mandibular set-back
back surgery the results obtained in the
current study do not support the cclinical surmise that patients
with mandibular prognathism
nathism have
hav larger tongues. Logically,
this leads to a possible
le increase in relative tongue volume in
these patients who undergo mandibular
ma
set-back surgery.
International Journal of Clinical and Developmental Anatomy 2015; 1(3): 64-69
Based on the results of the current correlation analysis, it can
be speculated that this relative increase in size of the tongue
is attuned by a lowering of the mandible to the demands of
airway maintenance.
3. Conclusion
Awareness of the normal and abnormal variations of the
mandibular anatomy with their causes, deferential diagnosis,
prognosis and complications especially mandibular
prognathism is very important for the maxillo-facial surgeon
to achieve a suitable decision during treatment.
References
[1]
[2]
Martin Gosau, Corinna Vogel, Antonios Moralis1, Peter Proff,
Johannes Kleinheinz and Oliver Driemel; Mandibular
prognathism caused by acromegaly – a surgical orthodontic
case: Head & Face Medicine 2009, 5:16.
Martin Gosau, Corinna Vogel, Antonios Moralis1, Peter Proff,
Johannes Kleinheinz and Oliver Driemel Head & Face
Medicine 2009, 5:16.
[3]
Vitral RW, Tanaka OM, Fraga MR, Rosa EA: Acromegaly in
an orthodontic patient. Am J Orthod Dentofacial Orthop 2006,
130:388-90.
[4]
Jane JR, Laws ER Jr: Surgical management of pituitary
adenomas Singapore Med J 2002, 6:318-23.
[5]
Chanson P, Salenave S: Acromegaly. Review. Orphanet J Rare
Dis 2008, 3:1-17.
[6]
Dostalova S, Sonka K, Smahel Z, Weiss V, Marek J:
Cephalometric assessment of cranial abnormalities in patients
with acromegaly. J Craniomaxillofac Surg 2003, 31(2):80-7.
[7]
Chung KC, Buchman SR, Aly HM, Trotman CA: Use of
modern craniofacial techniques for comprehensive
reconstruction of the acromegalic face. Ann Plast Surg 1996,
36(4):403-8.
[8]
[9]
Sugata T, Myoken Y, Tanaka S: Acromegaly identified in a
patient with a complaint of malocclusion. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 1998, 85(1):44-6.
Daly AF, Rixhon M, Adam C, Dempegioti A, Tichomirowa
MA, Beckers A: High prevalence of pituitary adenomas: a
cross-sectional study in the province of Liege, Belgium. J Clin
Endocrinol Metab 2006, 91:4769-75.
[10] Giustina A, Chanson P, Bronstein MD, Klibanski A, Lamberts
S, Casanueva FF, et al. A consensus on criteria for cure of
acromegaly. J Clin Endocrinol Metab. Jul 2010;95(7):3141-8.
[11] Philippe Chanson and Sylvie Salenave Orphanet Journal of
Rare Diseases 2008, 3:17
[12] Baik HS, Han HK, Kim DJ, Proffit WR. Cephalometric
characteristics of Korean Class III surgical patients and their
relationship to plans for surgical treatment. Int J Adult
Orthodon Orthognath Surg 2000;15:119-28.
[13] Nainggolan L. Gene Discovery in Giants Could Shed Light on
Human Growth Trivellin G, Daly AF, Faucz FR, Yuan B,
Rostomyan L, Larco DO, et al. Gigantism and acromegaly
due to Xq26 microduplications and GPR101 mutation. N Engl
J Med. Dec 18 2014;371(25):2363-74.
68
[14] Alicia Diaz-Thomas, MD, MPH; Chief Editor: Stephen Kemp,
MD, PhD: Gigantism and Acromegaly. medscape jan 6, 2015.
[15] Melmed S, Casanueva FF, Klibanski A, Bronstein MD,
Chanson P, Lamberts SW, et al. A consensus on the diagnosis
and treatment of acromegaly complications. Pituitary. Sep
2013;16(3):294-302.
[16] Oshino S, Nishino A, Suzuki T, et al. Prevalence of cerebral
aneurysm in patients with acromegaly.Pituitary. Jun
2013;16(2):195-201.
[17] Weijs WA, Hillen B (1984). Relationships between
masticatory muscle cross-section and skull shape. J Dent Res
63:1154-1157.
[18] Weijs WA, Hillen B (1986). Correlations between the crosssectional area of the jaw muscles and craniofacial size and
shape. Am J PhysAnthropol 70:423-431.
[19] Gionhaku N, Lowe AA (1989). Relationship between jaw
muscle volume and craniofacial form. J Dent Res 68:805-809.
[20] Benington PC, Gardener JE, Hunt NP (1999). Masseter
muscle volume measured using ultrasonography and its
relationship with facial morphology. Eur J Orthod 21:659-670.
[21] Hannam AG, Wood WW (1989). Relationships between the
size and spatial morphology of human masseter and medial
pterygoid muscles, the craniofacial skeleton, and jaw
biomechanics. Am JPhys Anthropol 80:429-445.
[22] Shiratsuchi Y, Kouno K, Tashiro H (1991). Evaluation of
masticatory function following orthognathic surgical
correction of mandibular prognathism. J Craniomaxillofac
Surg 19:299-303.
[23] Takada K, Petdachai S, Sakuda M (1993). Changes in
dentofacial morphology in skeletal Class III children treated
by a modified maxillary protraction headgear and a chin cup:
a longitudinal cephalometric appraisal. Eur J Orthod 15:211221.
[24] N. Kitai, Y. Fujii, S. Murakami,S. Furukawa, S. Kreiborg,and
K. Takada1 J Dent Res 81(11):752-756, 2002.
[25] Ringqvist M (1973). Isometric bite force and its relation to
dimensions of the facial skeleton. Acta Odontol Scand 31:3542.
[26] Hannam AG, Wood WW (1989). Relationships between the
size and spatial morphology of human masseter and medial
pterygoid muscles, the craniofacial skeleton, and jaw
biomechanics. Am J Phys Anthropol 80:429-445.
[27] Kiliaridis S, Kalebo P (1991). Masseter muscle thickness
measured by ultrasonography and its relation to facial
morphology. J Dent Res 70:1262-1265.
[28] van Spronsen PH, Weijs WA, Valk J, Prahl Andersen B, van
Ginkel FC (1991). Relationships between jaw muscle crosssections and craniofacial morphology in normal adults,
studied with magnetic resonance imaging. Eur J Orthod
13:351-361.
[29] Bakke M, Tuxen A, Vilmann P, Jensen BR, Vilmann A, Toft M
(1992). Ultrasound image of human masseter muscle related
to bite force, electromyography, facial morphology, and
occlusal factors. Scand J Dent Res 100:164-171.
[30] Kiliaridis S (1995). Masticatory muscle influence on
craniofacial growth. Acta Odontol Scand 53:196-202.
69
Ahmed M. S. Hegazy and Bakr Ahmed Bakr: Overview on the Anatomical and Clinical Aspects of Mandibular Prognathism
[31] Brodie AG (1953). Muscular factors in the diagnosis and
treatment of malocclusions. Angle Orthod 23:71-77.
[32] Karamese, M., Akdağ, O., Selimoglu, M.N., Abacı, M.,
Akatekin, A. and Tosun, Z. Combined Therapy for
Mandibular Prognathism: Sagittal Split Osteotomy with
Excision of Tongue. Modern Plastic Surgery, 2014, 4, 53-57.
[33] Frankel R, Frankel C (1989). Orofacial orthopedics with the
functional regulator. Basel: Karger, pp. 12-18.
[34] Kole H (1965). Results, experience, and problems in the
operative treatment of anomalies with reverse overbite
(mandibular protrusion). Oral Surg Oral Med Oral Pathol
19:427-450.
[35] (Swanson LT, Murray JE (1969). Partial glossectomy to
stabilize occlusion following surgical correction of
prognathism. Oral Surg Oral Med Oral Pathol 27:707-715.
[36] E. Yoo, S. Murakamil, K. Takada, H. Fuchihatal, and M.
Sakuda. Tongue Volume in Human Female Adults with
Mandibular Prognathism. J Dent Res 75(12): 1957-1962,
December, 1996.
[37] Martin Gosau,Corinna Vogel, Antonios Moralis, Peter Proff,
Johannes Kleinheinz, and Oliver Driemel: Mandibular
prognathism caused by acromegaly – a surgical orthodontic
case; Head Face Med. 2009; 5: 16.Published online 2009 Aug
6. doi: 10.1186/1746-160X-5-16 PMCID: PMC2741435.