Orthognathic surgery for mentally retarded patients Alfred G. Becking, DDS,a and Dirk B. Tuinzing, DDS, PhD,b Amsterdam, Netherlands
The
DEPARTMENT
FREE
OF ORAL
AND
MAXILLOFACIAL
SURGERY,
TEACHING
HOSPITAL,
UNIVERSITY The surgical treatment of mentally retarded children for esthetic reasons is discussed. In mentally retarded adults a facial deformity can give rise to functional problems; in some cases a facial deformity can stigmatize the mental state. In selected cases orthognathic surgery may offer a solution for either problem. Two cases are reported. (ORAL SURC ORAL MED ORAL PATHOL
1991;72:162-4)
T
he surgical treatment of facial deformities is now routinely done almost worldwide. In the last two decades progress of the technical aspects of various corrective surgical treatment has been made. As these treatments have become safer and more available, indications for surgery have increased. Recently, ethical aspects of indications for corrective facial surgery for mentally retarded children was extensively discussed in the literature. Elective surgery for mentally retarded persons is always hazardous; however, the age of the patients might be an important factor. The following two case reports and discussion discuss this subject. CASE REPORTS Case 1
A 19-year-old woman with Down syndrome was referred to our clinic becauseof mastication problems resulting from mandibular prognathism (Fig. 1). Previous orthodontic treatment had been unsuccessful. The characteristic features of Down syndrome, such as a large, fissured tongue and hypoplasia of the nasal bridge with epicanthic folds at the inner anglesof the upper eyelids, were present. Her main complaint was the inability to chew adequately. She was well aware of her facial appearance and asked for correction of her prominent chin. Treatment consisted of 2 years of presurgical orthodontic therapy and an intraoral vertical ramus osteotomy. No tongue reduction was performed. The result 1 year postoperatively was good (Fig. 2); however, a slight tendency to an open bite was noticed. This was probably the result of the large volume of the tongue. Mas*Registrar,Oral
and Maxillofacial bOral and Maxillofacial Surgeon. 7/12/23834
162
Surgery.
Fig. 1. Case 1. A 19-year-old woman with Down syndrome and typical facial features, with mandibular prognathism causing functional and esthetic problems.
tication was normal. The patient was pleased with the reduction of her chin and with her ability to chew. During all sessionsshe never complained of the other facial characteristics of Down syndrome.
Volume Number
72 2
Orthognathicsurgeryfor the mentally retarded 163
Fig. 2. Case 1. Result 3 years after surgical and orthodontic treatment of prognathic mandible by intraoral vertical ramus osteotomy.
Fig. 3. Case 2. A 29-year-old mentally retarded man with mandibular prognathism and open bite, stigmatizing his mental state.
Case
deformities stigmatize a person with regard to his or her mental state. In some countries facial plastic surgery for children with Down syndrome is routinely done at the age of about 5 years. There are a number of standard operations, such as tongue reduction; augmentation of the nasal bridge, chin, or malar bones; lateral canthoplasty; and lower lip reduction.s-9 Some author& 9 are claiming a positive effect of this corrective surgery on social behavior and mental development; other& * have reservations concerning long-term psychologic effects. The criticism of this kind of treatment is whether it is ethical to change the facial appearance of mentally retarded children who are not aware of their facial deformity. The age of the child, 4 to 6 years, is, according to some psychologic theories, one in which surgical intervention might be experienced as an assault.3 Without prospective studies there is a lack of strong evidence that this group of patients will achieve significant increases in intelligence and social acceptance. Therefore unrealistic expectations after surgery are conceivable.4 Corrective surgery in mentally retarded adults is less controversial. The degree of mental retardation
2
A 29-year-old man (Fig. 3) with posttraumatic mental retardation was referred to our clinic because of mastication, speech, and esthetic problems. According to psychologic reports, his prominent lower jaw exaggerated his mental state. There was mandibular prognathism and a reversed overbite of 15 mm. Surgical treatment consisted of an intraoral vertical ramus osteotomy and a Le Fort I
osteotomy. No presurgical orthodontic treatment was carried out. Postoperatively, the patient’s facial appearance no longer stigmatized his mental state (Fig. 4). This aspect was endorsed by the patient, who believed that he did not appear “funny” anymore. Mastication was improved, and, for the most part, speech problems were resolved. DISCUSSION
Surgical treatment of facial deformities in mentally retarded children has been subject of discussion for many years. l-4 Previously, mentally retarded children rarely lived to the age of 20 years, but because of advances in medicine, longer life may now be expected. New issues include job training, social integration, and sexual maturation,5v ’ for which formal and functional demands of society are essential. In general, facial
164
ORAL
Becking and Tuinzing
SURG ORAL
MED ORAL PATHOL August 1991
disturbances such as mastication, speech, and drooling might also require correction. Orthognathic surgery is now done to correct a spectrum of craniofacial deformities in young adults. In our opinion orthognathic surgery may also offer a solution for functional and esthetic problems of mentally retarded young adults in carefully selected cases. Surgery at this age offers the opportunity to select patients with regard to functional disturbances, the patient’s awareness of the anomaly, and motivation. The two case reports illustrate this statement.
Fig. 4. Case 2. Result 2 years after surgical correction by intraoralvertical ramus osteotomy and Le Fort I osteotomy.
can play a role of importance; sometimes patients themselves ask for changes of their facial appearance. Stigmatizing facial features may emphasize or exaggerate the mental state. Psychologic changes can be better predicted in adults than in children. Functional
REFERENCES 1. Plastic surgery and Down’s syndrome [Editorial]. Lancet 1983;2:1314. 2. Bouman FG. Esthetische operaties bij kinderen met het syndroom van Down. Ned Tijdschr Geneeskd 1983;51:2338-9. 3. Belfer M. Facial plastic surgery in children with Down’s syndrome [Discussion]. Plast Reconstr Surg 1980;6:343-4. 4. Ebbin AJ. Facial plastic surgery in children with Down’s syndrome [Discussion]. Plast Reconstr Surg 1980;6:345. 5. Lemperle G, Radu D. Facial plastic surgery in children with Down’s svndrome. Plast Reconstr Sura 1980:6:337-42. 6. Olbrisch -RR. Plastic surgical management of children with Down’s syndrome: indications and results. Br J Plast Surg 1982;35:195-200. I. Hiihler H. Changes in facial expression as a result of plastic surgery in mongoloid children. Aesthetic Plast Surg 1977; 1:245-9. 8. Rozner L. Facial plastic surgery for Down’s syndrome. Lancet 1983;2:1320-3. 9. Wexler MR, Peled IJ, Rand Y, Mintzker Y, Feuerstein R. Rehabilitation of the face in patients with Down’s syndrome. Plast Reconstr Surg 1986;77:383-93. Reprint
requests:
A. G. Becking, DDS Department of Oral and Maxillofacial Surgery Teaching Hospital, Free University De Boelelaan I 117 1007 MB Amsterdam, The Netherlands
The
DEPARTMENT
FREE
OF ORAL
AND
MAXILLOFACIAL
SURGERY,
TEACHING
HOSPITAL,
UNIVERSITY The surgical treatment of mentally retarded children for esthetic reasons is discussed. In mentally retarded adults a facial deformity can give rise to functional problems; in some cases a facial deformity can stigmatize the mental state. In selected cases orthognathic surgery may offer a solution for either problem. Two cases are reported. (ORAL SURC ORAL MED ORAL PATHOL
1991;72:162-4)
T
he surgical treatment of facial deformities is now routinely done almost worldwide. In the last two decades progress of the technical aspects of various corrective surgical treatment has been made. As these treatments have become safer and more available, indications for surgery have increased. Recently, ethical aspects of indications for corrective facial surgery for mentally retarded children was extensively discussed in the literature. Elective surgery for mentally retarded persons is always hazardous; however, the age of the patients might be an important factor. The following two case reports and discussion discuss this subject. CASE REPORTS Case 1
A 19-year-old woman with Down syndrome was referred to our clinic becauseof mastication problems resulting from mandibular prognathism (Fig. 1). Previous orthodontic treatment had been unsuccessful. The characteristic features of Down syndrome, such as a large, fissured tongue and hypoplasia of the nasal bridge with epicanthic folds at the inner anglesof the upper eyelids, were present. Her main complaint was the inability to chew adequately. She was well aware of her facial appearance and asked for correction of her prominent chin. Treatment consisted of 2 years of presurgical orthodontic therapy and an intraoral vertical ramus osteotomy. No tongue reduction was performed. The result 1 year postoperatively was good (Fig. 2); however, a slight tendency to an open bite was noticed. This was probably the result of the large volume of the tongue. Mas*Registrar,Oral
and Maxillofacial bOral and Maxillofacial Surgeon. 7/12/23834
162
Surgery.
Fig. 1. Case 1. A 19-year-old woman with Down syndrome and typical facial features, with mandibular prognathism causing functional and esthetic problems.
tication was normal. The patient was pleased with the reduction of her chin and with her ability to chew. During all sessionsshe never complained of the other facial characteristics of Down syndrome.
Volume Number
72 2
Orthognathicsurgeryfor the mentally retarded 163
Fig. 2. Case 1. Result 3 years after surgical and orthodontic treatment of prognathic mandible by intraoral vertical ramus osteotomy.
Fig. 3. Case 2. A 29-year-old mentally retarded man with mandibular prognathism and open bite, stigmatizing his mental state.
Case
deformities stigmatize a person with regard to his or her mental state. In some countries facial plastic surgery for children with Down syndrome is routinely done at the age of about 5 years. There are a number of standard operations, such as tongue reduction; augmentation of the nasal bridge, chin, or malar bones; lateral canthoplasty; and lower lip reduction.s-9 Some author& 9 are claiming a positive effect of this corrective surgery on social behavior and mental development; other& * have reservations concerning long-term psychologic effects. The criticism of this kind of treatment is whether it is ethical to change the facial appearance of mentally retarded children who are not aware of their facial deformity. The age of the child, 4 to 6 years, is, according to some psychologic theories, one in which surgical intervention might be experienced as an assault.3 Without prospective studies there is a lack of strong evidence that this group of patients will achieve significant increases in intelligence and social acceptance. Therefore unrealistic expectations after surgery are conceivable.4 Corrective surgery in mentally retarded adults is less controversial. The degree of mental retardation
2
A 29-year-old man (Fig. 3) with posttraumatic mental retardation was referred to our clinic because of mastication, speech, and esthetic problems. According to psychologic reports, his prominent lower jaw exaggerated his mental state. There was mandibular prognathism and a reversed overbite of 15 mm. Surgical treatment consisted of an intraoral vertical ramus osteotomy and a Le Fort I
osteotomy. No presurgical orthodontic treatment was carried out. Postoperatively, the patient’s facial appearance no longer stigmatized his mental state (Fig. 4). This aspect was endorsed by the patient, who believed that he did not appear “funny” anymore. Mastication was improved, and, for the most part, speech problems were resolved. DISCUSSION
Surgical treatment of facial deformities in mentally retarded children has been subject of discussion for many years. l-4 Previously, mentally retarded children rarely lived to the age of 20 years, but because of advances in medicine, longer life may now be expected. New issues include job training, social integration, and sexual maturation,5v ’ for which formal and functional demands of society are essential. In general, facial
164
ORAL
Becking and Tuinzing
SURG ORAL
MED ORAL PATHOL August 1991
disturbances such as mastication, speech, and drooling might also require correction. Orthognathic surgery is now done to correct a spectrum of craniofacial deformities in young adults. In our opinion orthognathic surgery may also offer a solution for functional and esthetic problems of mentally retarded young adults in carefully selected cases. Surgery at this age offers the opportunity to select patients with regard to functional disturbances, the patient’s awareness of the anomaly, and motivation. The two case reports illustrate this statement.
Fig. 4. Case 2. Result 2 years after surgical correction by intraoralvertical ramus osteotomy and Le Fort I osteotomy.
can play a role of importance; sometimes patients themselves ask for changes of their facial appearance. Stigmatizing facial features may emphasize or exaggerate the mental state. Psychologic changes can be better predicted in adults than in children. Functional
REFERENCES 1. Plastic surgery and Down’s syndrome [Editorial]. Lancet 1983;2:1314. 2. Bouman FG. Esthetische operaties bij kinderen met het syndroom van Down. Ned Tijdschr Geneeskd 1983;51:2338-9. 3. Belfer M. Facial plastic surgery in children with Down’s syndrome [Discussion]. Plast Reconstr Surg 1980;6:343-4. 4. Ebbin AJ. Facial plastic surgery in children with Down’s syndrome [Discussion]. Plast Reconstr Surg 1980;6:345. 5. Lemperle G, Radu D. Facial plastic surgery in children with Down’s svndrome. Plast Reconstr Sura 1980:6:337-42. 6. Olbrisch -RR. Plastic surgical management of children with Down’s syndrome: indications and results. Br J Plast Surg 1982;35:195-200. I. Hiihler H. Changes in facial expression as a result of plastic surgery in mongoloid children. Aesthetic Plast Surg 1977; 1:245-9. 8. Rozner L. Facial plastic surgery for Down’s syndrome. Lancet 1983;2:1320-3. 9. Wexler MR, Peled IJ, Rand Y, Mintzker Y, Feuerstein R. Rehabilitation of the face in patients with Down’s syndrome. Plast Reconstr Surg 1986;77:383-93. Reprint
requests:
A. G. Becking, DDS Department of Oral and Maxillofacial Surgery Teaching Hospital, Free University De Boelelaan I 117 1007 MB Amsterdam, The Netherlands
