• Pediatric

Antegonial Notching of the Mandible: An Often Radiology

Overlooked Mandibular Deformity in Congenital and

Acquired Disorders 1
Melvin H. Becker, M.D., Peter J. Coccaro, D.D.S., and John Marquis
Converse, M.D.

Mandibular antegonial notching is a concavity of the undersurface of the body just anterior
to the angular process (gonion) seen in congenital and acquired disorders. The notch tends
to be longer in the congenital than in the acquired state, and the ascending ramus is at a more
obtuse angle to the body.

INDEX TERMS: Jaws, diseases. (Mandible, anatomic detail, 2 [43].920). (Mandible, hy-
poplastic congenital abnormality, 2 [43] .142)

Radiology 121:149-151, October 1976

•
of the inferior border of the man-
U PWARD CURVING
dible anterior to the angular process (gonion) is
known as antegonial notching. This deformity has been
seen with both congenital and acquired abnormalities of
the mandible (Fig. 1). These patients were seen at the
Center for Craniofacial Anomalies at the Institute of Re-
constructive Plastic Surgery, New York University Medical
Center; their evaluation included frontal and lateral ce-
phalometric studies and panoramic radiographs of the
mandible.
The congenital disorders in which antegonial notching
of the mandible were seen included Treacher-Collins (1)
mandibulofacial dysostosis (Fig. 2), Campomelic dwarfism,
Moebius disease, familial congenital anomaly of the
mandibular condyles (Fig. 3), hemifacial microsomia, bi-
lateral facial microsomia, congenital deformities of the
ascending ramus of the mandible, and neurofibromatosis.
Among the acquired states in which this mandibular de-
formity has been seen were juvenile rheumatoid arthritis
(Fig. 4), following trauma to the mandible in early childhood,
following infection in the vicinity of the temporomandibular
joint during infancy or early childhood, and in a hemophilic
patient in whom ankylosis of one temporomandibular joint
had developed following a mastoidectomy at the age of 3
years (Fig. 5). It has also been seen in children with various
as yet unnamed syndromes, and has been described in
Pierre Robin syndrome (1), frontometaphyseal dysplasia
(2), and mandibuloacral dysplasia (3).
When antegonial notching was seen in patients with
congenital disorders, the curve was a long arc extending
from the gonion to the menton; the angle between the
ascending ramus and the horizontal body was more obtuse
than the angle normally seen. In acquired antegonial
notching, the curve is closer to the angular process (gon-
ion); in some of these cases there was additional build-up
of bone on the angular process. Some degree of abnor-
mality of the condyle was present in all patients. Limitation
of protrusive and lateral motion was also noted.

congenita I

normal

Fig. 1. The mandibular shape in normal, acquired, and a congenital antegonial notching. Note the directions of muscle pull. C = condyle; CO
= coronoid; g =gonion; m = menton.

1 From the Departments of Radiology (M.H.B., P.J.C.) and Surgery (J.M.C.), New York University Medical Center, New York, N. Y. Presented
at the Pediatric Radiology Section of the Sixty-First Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago,
111., Nov. 30-Dec. 5, 1975.
This work was supported by grants from the Billy Rose Foundation and the Reader's Digest Training Fund, and N.I.H. grant DEO 3568. S5

149
150 MELVIN H. BECKER AND OTHERS October 1976

Fig. 2. Treacher-Collins syndrome: the body of the mandible

shows a marked concave curve on its inferior border (extending
from the gonion to the menton); the ascending ranmus is short
and joins the body at a more obtuse angle than normally.

DISCUSSION

Juvenile rheumatoid arthritis has been recognized as
an underlying factor in this mandibular deformity (4). The
temporomandibular joint may be the first symptomatic
area, and may be the only joint involved. The condylar area,
an important growth site, is injured by the inflammatory
reaction. This results in decreased growth of the mandible
Fig. 4. A. and B. Juvenile rheumatoid arthritis (Still's dis-
ease): the condyle is short and flattened. The antegonial notch
is a shorter curve than that seen in the congenital disorders, and
there is a build-up of bone on the angular process.
and a muscular imbalance, which leads to the growth
changes that produce the antegonial notching.

Fig. 3. A. and B. Familial congenital condyle abnormality: father and son with flattened short mandibular condyles
and antegonial notching.

Vol. 121 ANTEGONIAL NOTCHING OF THE MANDIBLE
The normal growth of the mandible depends upon having
all of its parts develop from the embryonic anlage. Its
shape is then dependent upon its environment, especially
the attached muscles and the direction of the muscle pull
(5). When the growth of the mandibular condyle fails to
contribute to the lowering of the mandible, the masseter
and medial pterygoid, by their continued growth, cause the
bone in the region of the angle to grow downward, pro-
ducing antegonial notching (5). There is a variable amount
of abnormality present in patients with hemifacial micro-
somia. When the mandible is the most affected structure
by the hypoplasia, the form of the mandible is similar to
that occurring with a localized condylar growth dysplasia,
showing an antegonial notch. However, when the under-
development of the mandible and its soft tissue environ-
ment are equal in degree, the antegonial notch does not
form (5). Animal studies show that the presence of the
superficial masseter and/or the medial pterygoid muscle
are necessary for the development of the angular process
of the mandible (6).
Department of Radiology
New York University Medical Center
560 First Ave.
New York, N. Y. 10016
REFERENCES
1. Pruzansky S: Not all dwarfed mandibles are alike. [In]: Birth
Defects: Original Article Series 5. New York, March of Dimes, 1969,
pp 120-129
Pediatric
151 Radiology
Fig. 5. Unilateral ankylosis of the temperomandibular joint:
this hemophilic patient had a mastoidectomy at age 3 yrs. and
was unable to move the mandible since that time. Now, at 30
yrs., note the obliteration of the left temperomandiblular joint
and the bilateral antegonial notching, more marked on the in-
volved side. The authors wish to thank Dr. Valmore F. Cross, St.
Peter's Hospital, Albany, N.Y., for permission to publish this
figure.
2. Holt JF, Thompson GR, Arenberg IK: Frontometaphyseal dys-
plasia. Radiol Clin North Am 10:225-243, Aug 1972
3. Young LW, Radebaugh JF, RubinP: New syndrome manifested
by mandibular hypoplasia, aero-osteolysis, stiff joints and cutaneous
atrophy (mandibulo-acral dysplasia) in two unrelated boys. [In]: Birth
Defects: Original Article Series 7. New York, March of Dimes, 1971,
pp 291-297
4. Engel MB, Richmond JB, Brodie AGA: Mandibular growth dis-
turbance in rheumatoid arthritis of childhood. Am J Dis Child 78:
728-743, Nov 1949
5. Hovell JH: Variations in mandibular form. Ann Roy Coli Surg
37:1-18, Jul1965
6. Avis V: The significance of the angle of the mandible: an ex-
perimental and comparative study. Am J Phys Antrop 19:55-61, Mar
1961