bell2018 Histórico Cirurgia Ortognática

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75TH ANNIVERSARY CONTRIBUTION
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A History of Orthognathic Surgery in
North America
R. Bryan Bell, MD, DDS
This review highlights the contributions of American oral and maxillofacial surgeons to the field of orthog-
nathic surgery. The present state of the art and science of orthognathic surgery is the harvest of yesterday’s
innovation and research. An improved understanding of the biological and surgical principles and the
routine involvement of orthodontics have fueled widespread adoption of a coordinated approach to
the treatment of dentofacial problems. Technologic advances in rigid internal fixation, virtual surgical
planning with computer-aided manufacturing of occlusal splints and cutting guides, custom implants,
and worldwide interest in the correction of dentofacial and craniofacial deformities have resulted in highly
predictable, efficient, and safe treatment, which scarcely resembles the situation 70 years ago.
� 2018 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 76:2466-2481, 2018
I apologize for any omission and can only implore the reader for
nderstanding and forgiveness that any such oversight on my part
as unintentional.
On the occasion of the 100th anniversary of the found-
ing of the American Association of Oral and Maxillofa-
cial Surgeons and the 75th anniversary of the Journal
of Oral and Maxillofacial Surgery, I was asked to pro-
vide an authoritative history of orthognathic surgery in
the United States. Although I am neither the most qual-
ified nor the most knowledgeable on the subject, I
have, somewhat uniquely, been exposed to or known
intimately many of the transformative surgeons who
are credited with developing or refining modern
orthognathic procedures. My childhood was filled
with stories about courageous and innovative individ-
uals who inspired a generation of surgeons to reach
beyond the status quo: Names such as Gillies, Wass-
mund, Obwegeser, Luhr, Tessier, and many others
were often the subject of conversation at our family’s
dinner table. In addition to my father, William H.
Bell, I have been fortunate enough to count as mentors
some of the more contemporary luminaries in the
field, such as Tim Turvey, Ray White, and Myron
Tucker, who have helped shape not only my career
but the careers of an entire generation of oral and
maxillofacial surgeons in the United States and abroad.
l Director, Providence Head and Neck Cancer Program,
iate Member, Earle A. Chiles Research Institute, Robert
Cancer Center, Providence Cancer Institute Head and
tute, Portland, OR.
t of Interest Disclosures: The author has no relevant finan-
nship(s) with a commercial interest.
s correspondence and reprint requests to Dr Bell: Robert
Cancer Center, Providence Cancer Institute, 4805 NE
Ste 2N35, Portland, OR 97213; e-mail: richard.bell@
e.org
2466
My hope is that this personal account provides an ac-
curate tribute to the American pioneers who have
done so much on behalf of patients with dentofacial
or craniofacial deformities and, in doing so, contrib-
uted to the development of the modern specialty of
oral and maxillofacial surgery (OMS).*
When my father finished his oral (and maxillofacial)
surgery training in 1958 in Houston, Texas, a few years
before I was born, there were only a handful of surgical
procedures used to treat patients with dentofacial
deformities; these were primarily mandibular proced-
ures used for the correction of mandibular progna-
thism. Maxillary surgery was rarely, if ever, performed,
and transcranial facial surgery had not yet
been invented.
With an empirical basis for surgical techniques,
all done without orthodontics and virtually no
surgery in the maxilla, it is not surprising that most
patients with dentofacial deformities in 1958 received
*
u
w
Received September 6 2018
Accepted September 6 2018
� 2018 American Association of Oral and Maxillofacial Surgeons
0278-2391/18/31076-0
https://doi.org/10.1016/j.joms.2018.09.006
Delta:1_given name
mailto:richard.bell@providence.org
mailto:richard.bell@providence.org
https://doi.org/10.1016/j.joms.2018.09.006
http://crossmark.crossref.org/dialog/?doi=10.1016/j.joms.2018.09.006&domain=pdf
R. BRYAN BELL 2467
compromised or unsuccessful treatment. Key publica-
tions in the English-language literature by Trauner and
Obwegeser,1 K€ole,2 Murphey and Walker,3 and Moh-
nac4 at the time my father finished his training cata-
lyzed great interest in new methods of surgical-
orthodontic treatment, which in turn captivated an
entire generation of American oral and maxillofacial
surgeons and orthodontists; this led to the develop-
ment of novel surgical techniques founded on sound
biological principles and facilitated by rapid advances
in bioengineering technology.
Our present state of the art and science includes
many more surgical procedures performed not only
on the mandible and maxilla but also on the orbits and
anterior skull base. Most of these procedures are per-
formed intraorally and are stabilized with titanium or
biodegradable plates and screws, minimizing or elimi-
nating the need for intermaxillary fixation. An improved
understanding of the biological and surgical principles
and the routine involvement of orthodontics, virtual
surgical planning with computer-aided manufacturing
of occlusal splints and cutting guides, custom implants,
and worldwide interest in the correction of dentofacial
and craniofacial deformities have resulted in highly pre-
dictable, efficient, and safe treatment, which scarcely
resembles the situation 70 years ago. In the remainder
of this record of orthognathic surgery, I will attempt to
describe the contributions of American surgeons to
the development and refinement of orthognathic sur-
gery since the mid-20th century.
Pioneers in Europe and America, 1846-
1968
MANDIBULAR SURGERY
Mandibular Body Ostectomy and Osteotomy
Early orthognathic procedures were almost univer-
sally performed for the correction of mandibular prog-
nathism. In 1849, the American surgeon Simon P.
Hullihen,5 from Wheeling, West Virginia, described
the first mandibular osteotomy for the correction of a
skeletal anterior open bite, which resulted from scar
contractures associated with a facial burn. Hullihen,
who is considered the father of American OMS, per-
formed a wedge ostectomy in the premolar region
to reposition the mandible backward to correct the oc-
clusion. To stabilize the segments, a plaster cast was
made to construct a silver-plated occlusal splint; it
was cemented in place to allow bony consolidation.
In 1887, Vilray P. Blair performed a modification of
Hullihen’s operation by performing a segmental
mandibular body ostectomy for the correction of
mandibular prognathism. The procedure was initially
suggested by the pioneering orthodontist Edward
Angle,6 described independently by the treating ortho-
dontist J. W. Whipple7 in 1898 and later, by Blair,8 in
1906. Blair, Angle, and Whipple all practiced in St
Louis at the same time and were all very influential
in their day. Angle is recognized by many in the United
States as the father of modern orthodontics. Blair, a
general surgeon, is considered by some to be the father
of American plastic surgery and was almost certainly
the most dominant and active orthognathic surgeon
in the early 20th century. He provided detailed de-
scriptions of ‘‘operations on the jaw-bone and face’’
in 1907,9 which included his horizontal osteotomy of
the ramus, located between the sigmoid notch and
the mandibular foramen. Blair10 published one of the
first definitive textbooks on oral and facial surgery in
1912. He was also the first to emphasize the impor-
tance of cooperation with an orthodontist—a point
that was unfortunately lost on the field until the mid
1970s. Max Ballin,11 an American surgeon from De-
troit, seemsto have been an early adopter of Blair’s
technique and described its successful use in 1908,
again for the treatment of mandibular prognathism.
Meanwhile, across the Atlantic Ocean in Vienna,
Anton Freiherr von Eiselsberg,12 a student of Theodor
Billroth, described in 1906 a mandibular setback tech-
nique that used a step osteotomy designed to increase
the surface area of bony contact. William M. Har-
sha13,14 performed an extraoral mandibular body
ostectomy in 1912 but, unlike his predecessors,
appears to be the first to emphasize and document
preservation of the inferior alveolar nerve. The
following year, in 1913, Matthew H. Cryer,15 from
the University of Pennsylvania, modified this tech-
nique in a semicircular fashion near the angle of the
mandible, which permitted vertical rotation. In
1917, Thomas G. Aller16 described a wedge ostectomy
via a transoral approach, which was deemed quite
daring in the preantibiotic age. By the late 1920s, Var-
izad Kazanjian, the great Armenian-born, American
surgeon from Boston, seems to have had experience
with body ostectomies using a Gigli saw and an ortho-
dontic splint that was cemented onto the teeth after
surgery for the treatment of mandibular prognathism,
which he published in 1932.17
Mandibular Ramus and Condyle Osteotomies
Whereas the early body ostectomy approaches were
favored in America, alternative methods of reposition-
ing the mandible were simultaneously developed in Eu-
rope. In 1897, the Frenchman Paul Berger,18 from Paris,
described bilateral condylectomy for the correction of
mandibular prognathism, a technique that was per-
formed via a preauricular incision. The technique also
was described and used by fellow countrymen in
Lyon, Mathieu Jaboulay and L�eon B�erard,19 and was
widely used in France until the 1950s. However, this
technique often led to poor occlusal outcomes. An
alternative technique was developed in 1921 by L�eon
2468 HISTORY OF ORTHOGNATHIC SURGERY
Dufourmentel,20 who simply performed subcondylar
osteotomies without removing them. However, it was
the Czech surgeon Franti�sek Koste�cka,21 from Prague,
who in 1928 described and popularized a modification
of this technique that would become widely accepted,
which used a Gigli saw via an extraoral approach.22
The condylar operations were, of course, limited to
the treatment of mandibular prognathism and mandib-
ular asymmetry related to temporomandibular joint
pathology, which prompted surgeons to design alter-
native approaches. In 1905, Sir William Arbuthnot
Lane,23 from Guy’s Hospital in London, described a
horizontal ramus osteotomy for mandibular setback
that was placed just above the mandibular foramen
and lingua via an extraoral approach. A similar tech-
nique was described in 1907 by Blair,9 who used it
to successfully advance the mandible more than
9 mm. The procedure was performed in a ‘‘blind’’
fashion using a Gigli saw that was placed through
skin incisions. Subsequently, the procedure was used
and modified slightly by a number of pioneering sur-
geons in both America and Europe for either mandib-
ular advancement or setback, including W. Wayne
Babcock24 from Temple University in Philadelphia
(1909), Christian Bruhn25 from D€usseldorf (1921),
Gunther Perthes26 from T€ubingen (1922), and Kazan-
jian17 (1932), as well as Bruhn’s successor in
D€usseldorf, the pioneering surgeon August Linde-
mann,27,28 and Karl Schuchardt.29
In 1928, a Russian surgeon, Alexander Limberg,30
from Leningrad, described a posterior oblique vertical
ramus osteotomy performed via an external approach
for the correction of open-bite malocclusions. This
would be modified and documented over the years by
many surgeons, including the German Otto Hofer31 in
1936; the American Reed Dingman,32,33 from the
University of Michigan; the Swiss-born, American Kurt
H. Thoma,34 from Harvard School of Dental Medicine;
Marsh Robinson,35,36 from the University of Southern
California; and Edward C. Hinds,37 from the University
of Texas–Houston. It interesting to note that, in 1951,
an American surgeon from Texas, A. C. Sloan,38
described as a treatment for prognathism an intraoral
vertical ramus osteotomy, a technique that would be
modified and rediscovered a couple of decades later.
However, it is Colonel Jack C. Caldwell and Gordon
S. Letterman39 who are generally credited with docu-
menting the first true vertical ramus osteotomy, also
called a ‘‘vertical subsigmoid osteotomy.’’ Performed
via an extraoral approach, this procedure is differenti-
ated from the previous ramus osteotomies in that the
inferior bone cut extended to anterior of the gonial
angle. Hinds and colleagues40 later modified this by
performing an intraoral vertical ramus osteotomy.
What we know today as the ‘‘inverted-L osteotomy’’
appears to have been independently described by
Martin Wassmund41 in Berlin in 1927 and Hans
Pichler42 in Vienna in 1928.43 This approach to
advancing the mandible was performed via a transcer-
vical incision and involved interpositional bone graft-
ing. Caldwell et al44 later modified their vertical
osteotomy in a similar fashion to that of Wassmund
and Pichler, although it came to be known as a ‘‘C os-
teotomy.’’ Another American, Richard Topazian, from
the University of Connecticut, described the
inverted-L osteotomy using an intraoral approach.45
Despite these periodic innovations on either side of
the Atlantic Ocean, 2 primary schools in Europe are
often thought to be the cradle of modern orthognathic
surgery: the Vienna school of maxillofacial surgery,
founded by Hans Pichler (also famous for being Freud’s
oral cancer surgeon) and the German school, founded
in Berlin by Martin Wassmund. Pichler was succeeded
by his pupil Richard Trauner in 1955, who later moved
to Graz. Trauner was an innovative surgeon in his own
right and made numerous contributions to maxillofa-
cial surgery. He is also well known for having trained
Heinz K€ole and Hugo Obwegeser, two individuals
who would ignite interest in orthognathic surgery
around the globe. Although this Eurocentric view is
certainly understandable, one cannot underestimate
the contributions of American surgeons returning
from the First and Second World Wars in the first half
of the 20th century.
K€ole,2 who succeeded Trauner as chief in Graz,
described several new procedures for altering the po-
sition of the alveolar process (subapical osteotomies)
and probably described the first bimaxillary surgical
procedure, including the treatment of bimaxillary pro-
trusion by performing subapical osteotomies with or
without premolar extractions. K€ole made numerous
contributions to the literature and published the first
textbook on ‘‘surgical orthodontics’’ in 1964, along
with Reichenbach and Bruckl.
Obwegeser left Graz in 1956 to become chair of
OMS in Zurich, quickly making that Swiss city the
epicenter of orthognathic surgery in the world and
Mecca for a generation of interested surgeons. What
became known as the ‘‘bilateral sagittal split osteot-
omy’’ (BSSO) was first described in German by Obwe-
geser and Trauner,46 his mentor, in 1955 and in English
with Trauner in 19571; it would eventually become the
preferred technique for the correction of mandibular
deformities, primarily owing to its versatility, predict-
ability, and functional and esthetic results. Because
of this, the inverted-L osteotomy never really gained
popularity, likely owing to the requirement for an
extraoral incision, the related risk of marginal mandib-
ular nerve injury, and the additional time and
morbidity associated with bone graft harvest, as well
as fixation requirements. Obwegeser’s ‘‘sagittal split-
ting osteotomy’’ was modified by the Italian surgeon
R. BRYAN BELL 2469
Giorgio Dal Pont47 in 1958, who had visited Zurich
and after observing the master at work, conceived
the anterior extension of Obwegeser’s lateral osteot-
omy, allowing for greater advancements.Dal Pont ap-
pears not to have actually performed the procedure
prior to his description in the literature, but his
prescient refinement substantially improved the versa-
tility of the procedure. In 1968, the American military
oral and maxillofacial surgeon Ervin E. Hunsuck,48
from Walter Reed Army Medical Center, modified Ob-
wegeser’s sagittal split procedure by limiting the
extent of the medial horizontal osteotomy. Bruce
Epker49 and Larry Wolford,50 both from Texas, would
subsequently make additional refinements that will be
discussed in greater detail later.
Also in 1955, Obwegeser and Trauner46 published
the first intraoral horizontal osteotomy of the inferior
border, or ‘‘genioplasty,’’ in which the mobilized genial
segment remained pedicled to the tongue
musculature. Although this technique had been
described and illustrated using a cadaver by the
German surgeon Hofer51 in 1942, the circumstances
behind the cadaveric surgery were suspect and doubts
have been raised as to whether Hofer ever performed
the operation on a living patient. John Converse,52 an
American plastic surgeon from New York University,
also had described a genioplasty technique in 1964,
in which a free bone graft was placed transorally to
aid in chin projection; however, this techniquewas un-
reliable and rapidly lost favor in the wake of Obweges-
er’s innovative approach.
MAXILLARY SURGERY
Maxillary surgery was much slower than mandib-
ular surgery to be widely adopted. Although various
techniques for mobilizing the maxilla as a whole or
in smaller segments had been described decades
before 1958, maxillary osteotomies were rarely per-
formed because of the fear of devitalizing dento-
osseous structures. Bernard Von Langenbeck,53 the
great German surgeon, is credited with describing
the first maxillary osteotomy in 1859, which was per-
formed unilaterally and for tumor access. Similarly, the
equally prominent German surgeon Theodor Bill-
roth—father of the total laryngectomy—performed a
maxillary access procedure around the same time.
The American surgeon David W. Cheever,54 from Bos-
ton City Hospital, modified this approach in 1867 by
performing what appears to be the first recorded
maxillary down-fracture at the Le Fort I level, again
for the purpose of tumor access. Although these pro-
cedures were not performed for the correction of den-
tofacial deformities, they are remarkable feats given
the fact that they were accomplished in the preanes-
thetic era.
G€unther Cohn-Stock,55 a German surgeon from Ber-
lin, is considered by many to be the father of maxillary
surgery for the purposes of dentofacial correction,
publishing on segmental maxillary osteotomies in
1921. In 1935, a student of Cohn-Stock, Martin Wass-
mund,56 described the first true anterior maxillary os-
teotomy, which was a 2-stage procedure used
primarily for the closure of anterior open bites. Wass-
mund’s procedure was later modified in 1954 by Ivo
�Cupar57 from Zagreb (1-stage, palatal pedicle) and in
1962 by Sigfried Wunderer58 (1-stage, labial
pedicle). In the mid-1950s, posterior maxillary osteot-
omies began to be used after Karl Schuchardt,59,60 a
former student of Wassmund’s who practiced in
Hamburg, described a 2-stage posterior maxillary os-
teotomy for closure of an anterior open bite in 1955.
This was later modified to a 1-stage procedure by the
Czech surgeon Josef Kufner61 in 1960 and would
remain the mainstay of maxillary surgery until
the 1980s.
Martin Wassmund62 also described in 1927 what
could be considered a precursor of the modern Le
Fort I osteotomy for the correction of a post-
traumatic malocclusion, although he did not release
the pterygoid plates and relied on orthopedic traction
for forward movement. George Axhausen63 in 1934
was the first to describe mobilization of the Le Fort I
level osteotomy (for treatment of a malunited frac-
ture). Subsequent reports by A. Immenkamp,64 Schu-
chardt,29 Converse and Shapiro,65 Harold Gillies and
Norman Rowe,66 Joseph Kufner,67,68 and Hugo
Obwegeser69 showed that segmental or even total
mobilization of the maxilla was feasible, but again,
because of technologic limitations and concerns about
viability of the mobilized segments, the procedures
were rarely used, even in Europe.
Further contributing to the nascent state of the art in
the United States was that orthodontists in the mid-
20th century had virtually no interest in surgery and
surgeons had very little interest in orthodontics. Ex-
ceptions to this rule were present, of course, most
notably collaborations between Edward Angle, the fa-
ther of modern orthodontics, and his surgical col-
leagues from St Louis, Henry Mudd and Vilray Blair.
Although Angle and Blair never published together,
both wrote books that documented their experience
in orthognathic surgery.
By the mid-1950s, surgeons in the United States had
largely abandoned the body ostectomy procedures
that were originally described in the 19th and early
20th century by Hullihen, Angle, Blair, Kazanjian,
and Dingman. Most corrections were accomplished
in the mandible as a subcondylar osteotomy or extrao-
ral vertical ramus osteotomy, and virtually all of these
were performed via an extraoral approach with or
without a Gigli saw.
Silvana Cunha Costa
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Silvana Cunha Costa
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2470 HISTORY OF ORTHOGNATHIC SURGERY
So, by the start of 1959—as my father began his first
year in practice in Houston, Texas—American surgeons
were hungry for new techniques and innovative ap-
proaches toward managing complex jaw problems. In
Europe, Obwegeser appears to have already recognized
the importance of separating the pterygoid plates to
completely mobilize the maxilla at the Le Fort I level;
he had described interpositional bone grafts for added
stability; and he had begun to refine his intraoral sagittal
splitting technique by taking the vertical cut more ante-
riorly to allow for greater advancement. None of these
procedures, however, were common in the United
States or anywhere else for that matter. Furthermore,
maxillary surgery was virtually never performed
because of concerns about dento-osseous viability.
Thus, the stage was set for Obwegeser’s fateful visit to
America in 1966.70 In what can only be considered a
watershed moment in American OMS history, at the
invitation of General Robert Shira toWalter ReedHospi-
tal, Obwegeser mesmerized a room full of US surgeons
with his description of orthognathic surgical tech-
niques, and it is here that the real story of American
innovation begins as it relates to orthognathic surgery.
During his lectures, Obwegeser not only demon-
strated his sagittal split osteotomy for both mandibular
advancement and setback but also demonstrated
segmental maxillary and mandibular osteotomies, as
well as the Le Fort I osteotomy, which included separa-
tion of the pterygoid plates. Obwegeser’s presentation
to more than 500 American oral and maxillofacial sur-
geons inspired a new generation of leaders who, in the
following years, helped to catapult the specialty into
unprecedented success and relevance to health care.
One individual who was particularly influenced by
the possibilities of this nascent field was a young,
inquisitive surgeon from Houston, Texas, named Wil-
liam H. Bell.
Developing a Biological Basis for
Orthognathic Surgery and the
Contributions of William H. Bell
William H. Bell grew up in St Louis, where he grad-
uated from college and dental school after serving in
the Navy during World War II. In 1954, he completed
an internship in oral surgery at Metropolitan City Hos-
pital in New York City, where he recalls that ‘‘in any
given week, I would literally see hundreds of patients
who are candidates for either orthognathic surgery or
orthodontics. Unfortunately, none of them received
any treatment.’’ In 1955, he went on to complete his
resident training in oral surgery at JeffersonDavis Hos-
pital/University of Texas–Dental Branch in Houston
under the tutelage of Edward C. Hinds, who at
the time was considered one of the country’s finest
orthognathic surgeons. Hinds had refined and clini-
cally applied the extraoral vertical ramus osteotomy
technique for the correction of mandibular progna-
thism. Bell recalls that ‘‘Dr Hinds and the other Amer-
ican oral surgeons in Houston were aware of
descriptions of both anterior and posterior maxillary
osteotomies, but none were performed for orthog-
nathic problems at that time.’’ He stated, ‘‘My initial
response to these procedures was an insatiable inter-
est and curiosity but fear of the unknown clinical con-
sequences.’’ This same fear was shared by virtually
everyone in the oral (and maxillofacial) surgery and
basic science departments at the time. Bell searched
the available literature for relevant studies but found
none that supported a biological foundation for these
procedures. Having no research training or back-
ground, he sought the help of colleagues and was
heavily influenced by Bernard Levy and Sumpter Ar-
nim at the University of Texas–Dental Branch, both
of whom were described by Bell as ‘‘very fascinating
and inquisitive individuals with a great thirst for life
and desire to do the right thing.’’ Arnim encouraged
Bell to investigate the biology of facial osteotomies
and to show the patency of the vasculature and the ef-
fect that the operation had on the viability of the dental
pulp and bone. Arnim offered Bell 6 rabbits to use for
pilot investigations. The revascularization and histo-
logic techniques of F. W. Rhinelander, an orthopedic
surgeon, seemed promising, and Bell visited Rhine-
lander’s laboratory in Cleveland, Ohio, to observe his
ongoing orthopedic revascularization studies. On re-
turning to Houston, Bell performed preliminary pilot
studies in rabbits to work out the details of microangio-
graphic and histologic laboratory techniques. The
initial study animal was a sham control; the second
was an experimental animal killed humanely 3 weeks
after anterior maxillary osteotomy. When the animal
was killed, the findings of the angiographic and histo-
logic studies appeared very similar to those of the con-
trol unoperated animal—as if no surgery had been
done: Revascularization in the experimental animal ap-
peared similar to that in the control unoperated ani-
mal. After several more animals were studied, a
different animal model was needed and the surgical
and laboratory techniques were then refined in dogs.
These canine studies provided the data necessary to
apply for and receive grant support from the National
Institutes of Health (NIH) to studywound healing after
orthognathic surgery in primates. Bell stated, ‘‘Despite
numerous clinical successes and occasional failures,
the rationale for using various surgical techniques
(for maxillary and mandibular osteotomies) remains
virtually empiric. Basic questions concerned with
the healing of the surgical wound produced by maxil-
lary osteotomies and the vessels necessary to maintain
Silvana Cunha Costa
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R. BRYAN BELL 2471
blood supply to the bone segments and viability of the
teeth have not been investigated.’’
At this time in the mid-1960s, the only procedures
that were occasionally used to correct skeletal maloc-
clusion were the anterior maxillary osteotomy
described previously by Wassmund, Wunderer, and
�Cupar, as well as the posterior maxillary osteotomy
of Schuchardt and Kufner. In 1966, at a meeting of
the Houston Society of Oral Surgeons, Bell became
inspired by a conversation with Alex Mohnac and de-
signed an experiment to determine the biology of ante-
rior maxillary osteotomy wound healing. As Bell had
done previously in rabbits and dogs, standard anterior
maxillary osteotomies (labial vs palatal pedicle) were
completed in rhesus monkeys and the animals were
killed humanely at 1, 3, and 6 weeks after
surgery. Before death, the common carotid arteries
were exposed, cannulated, heparinized, and perfused
with a suspension of contrast dye injection
medium. Each maxilla was then dissected from the
specimens, and radiographs were taken. The 1-week
specimens confirmed a ‘‘blood clot in the center of
the osteotomized fragments bounded by proliferating
young granulation tissue.’’ The 3-week specimens
‘‘showed early callus formation between the bone frag-
ments. Considerable subperiosteal new bone forma-
tion was present in some of the sections.’’ The 6-
week specimens ‘‘showed osseous union of the osteo-
tomized bone fragmentswith no evidence of necrosis.’’
Bell concluded: ‘‘The results indicated that no single
blood vessel, such as the incisive canal or greater pal-
atine arteries, is essential tomaintenance of circulation
to the anterior maxillary fragment. Interosseous and
soft tissue collateral circulation and the freely anasto-
mosing gingival, palatal, floor of the nose and peri-
odontal plexuses permit many variations of the
anterior maxillary osteotomy technique (labial vs
palatal pedicles) without detriment to the integrity
of the blood supply to the anterior maxillary
segment.’’ This work was published in 196971 and
1970,72 and in its wake, in 1971, R. V. Walker recruited
Bell to the University of Texas Southwestern Medical
Center/Parkland Memorial Hospital in Dallas to
develop a research laboratory focused on the vascu-
larity and wound healing associated with maxillary
and mandibular osteotomies. In 9 subsequent NIH-
funded experiments, Bell would use a similar
approach to define the biological basis for virtually
every other type of facial osteotomy at the time,
including posterior maxillary osteotomy,73 maxillary
corticotomy,74 Le Fort I osteotomy down-fracture,75
vertical ramus osteotomy of the mandible,76 BSSO,77
1-tooth dento-osseous segmental osteotomies,78 gen-
ioplasty,79 and segmental Le Fort I osteotomy.80 Before
this work, none of these operations were commonly
performed, mostly because of fear over the viability
of the osteotomized segments and teeth. However,
once the safety and predictability of the techniques
were firmly established in Bell’s laboratory, surgeons
became emboldened to apply these findings in their
own practice.
The resulting body of work on the subject of orthog-
nathic surgery during Bell’s 20 years at Parkland
included more than 150 publications in peer-
reviewed journals and 6 textbooks. Furthermore, he
instituted so-called surgical safaris, which were
hands-on courses open to surgeons and orthodontists
around the globe, and thus helped to train a generation
of clinicians well beyond the confines of Dallas, Texas.
The now classic textbook Surgical Correction of Den-
tofacial Deformities, co-edited by Bell, William Proffit,
and Raymond White, the latter two from the Univer-
sity of North Carolina in Chapel Hill, was published
in 1980.81 Proffit was an orthodontist who, for more
than 30 years, held continuous NIH funding to study
the outcomes of the surgical-orthodontic treatment
of dentofacial deformities. White, a Virginia-trained
oral and maxillofacial surgeon, was an early adopter
of orthognathic surgery and applied his considerable
intellect toward systematic study of clinical problems.
Their treatise was and still is one of the most focused
and comprehensive textbooks ever published on the
subject of orthognathic surgery. The thorough descrip-
tion of the diagnosis and management of dentofacial
deformities, surgical technique, and detailed figures,
painstakingly hand drawn by Bill Winn, illustrated
the operations in breathtaking detail and would pro-
vide generations of surgeons the necessary informa-
tion from which to apply a surgical-orthodontic
approach to the problem of skeletal malocclusions.
The resulting propagation of orthognathic surgical
skills among North American oral and maxillofacial
surgeons and orthodontists served to catapult the spe-
cialty into mainstreammaxillofacial surgery and
contributed to the name change at the associa-
tion level.
Propagation of Orthognathic Surgery in
America, 1960-1985
The late sixties and early seventies was a time of
innovation in American OMS, although with a few ex-
ceptions, most of it was occurring in the mandible. R.
Bruce MacIntosh was a particularly innovative and
very active orthognathic surgeon during this time.
He had spent time in Switzerland with Obwegeser
and thus was truly on the forefront of American
OMS. In 1975, MacIntosh82,83 described the ‘‘total
mandibular subapical osteotomy,’’ a procedure that,
although technically challenging, could achieve
excellent correction of complex skeletal Class II
problems. An eloquent writer and prolific surgeon,
2472 HISTORY OF ORTHOGNATHIC SURGERY
MacIntosh was instrumental in expanding the scope
and technical skill of a generation of oral and
maxillofacial surgeons. In 1976, Richard Topazian,
another American oral and maxillofacial surgeon and
early adopter of Obwegeser’s techniques, described
an intraoral inverted-L osteotomy.45 As mentioned pre-
viously, maxillary surgery was rarely performed before
the mid-1970s; however, after microangiographic
studies and favorable clinical experiences with Le
Fort I down-fracture were published by Bell et al75 in
1975, American surgeons took to these procedures
with gusto.
Critical to the propagation of these techniques at
that time was the continued maturation of the spe-
cialty of OMS and the development of excellent
training programs highlighted by a burgeoning interest
and experience in orthognathic surgery. Individuals
such as Fred Henny at Henry Ford Hospital in Detroit,
Robert V. Walker at Parkland Hospital in Dallas, Scott
McCallum at the University of Alabama–Birmingham,
Elmer Bear at Virginia Commonwealth University,
Jack Kent at Louisiana State University, and Ed Hinds
at the University of Texas–Houston not only had
robust orthognathic surgical practices but were partic-
ularly adept at cultivating and nurturing future acade-
micians. For example, Henny facilitated the academic
careers of such notable figures as Bruce Epker, Bruce
McIntosh, Ralph Merrill, and Guy Catone, all of
whom went on to develop their own programs in
Texas, Michigan, Oregon, and Pennsylvania,
respectively.
The program at Parkland Memorial Hospital de-
serves special mention. R. V. Walker was a practicing
general dentist inWaco, Texas, when he joined themil-
itary during the Korean War at Brooke Army Medical
Center in San Antonio. There, he gained substantial
experience in the management of maxillofacial
trauma, caring for patients with extensive injuries
who were flown from Korea to Japan and then to
Brooke, 1 of the 3 Army-designated maxillofacial
trauma centers during that war. This experience
would impact his decision to train in oral surgery
and helped to shape his opinion that the essential
core of every good OMS training program started
with trauma.Walker began his tenure as chief of the di-
vision of OMS at Parkland Hospital in 1956 and created
a program in Texas that later produced 2 dental school
deans, more than 28 department chairs, and dozens of
academic surgeons throughout North and South Amer-
ica. Among his first recruits were Jim Bertz, in 1964,
who developed an interest in the correction of
congenital malformation and Bruce Epker, in 1968,
who had been trained by Fred Henny in Detroit, as
well as William Bell, in 1971.
Walker, Bertz, Bell, and Epker went on to train an
immensely talented group of surgical residents who
would help develop and refine orthognathic surgery
over the ensuing decades: Roger West (Seattle, WA),
Larry Wolford (Dallas, TX), Tim Turvey (Chapel Hill,
NC), Douglas Sinn (Dallas, TX), Markell Kohn (Lexing-
ton, KY), Bob Alexander (Jacksonville, FL), Cesar
Guerrero (Caracas, Venezuela), Stephen Schendel
(Palo Alto, CA), Keith Kreitziger (Gainesville, FL),
Gene Ireland (Storrs, CT), Philip Freeman (Houston,
TX), Felice O’Ryan (Oakland, CA), Alan Herford
(Loma Linda, CA), Scott Boyd (Nashville, TN), Ghali
Ghali (Shreveport, LA), and many others contributed
greatly to the advancement of patient care and spe-
cialty development in American OMS in general and
orthognathic surgery in particular. They also estab-
lished the first structured training program for surgical
orthodontics and emphasized combined treatment.
Cooperation between surgeons and orthodontists
was not new—indeed, the father of modern orthodon-
tics, Edward Angle, was a noted collaborator with V. P.
Blair in St Louis, dating back to the beginning of the
20th century. The great plastic surgeon John Converse
and Sidney Horowitz, as well as Harry Shapiro, were
also early champions of a multidisciplinary approach
to the treatment of dentofacial deformity, as were
Reed Dingman and Gerald V. Barrow in Michigan.
However, it was not until US oral and maxillofacial sur-
geons and orthodontists began to publish together in
earnest that the approach took root. Notable
surgeon-orthodontist partnerships that advanced
care during this period included R. V. Walker and
Phelps Murphey, William Bell and Tom Creekmore,
William Ware and Don Poultan, Bruce Epker and
Chuck Fish, RaymondWhite andWilliam Proffit, Roger
West and Bill McNeill, Larry Wolford and Frank Hill-
iard, and Tim Turvey and H. David Hall.
Another important advancement during the 1970s
was in the development of ‘‘two-jaw surgery,’’ which
represents the simultaneous mobilization of the
maxilla, mandible, and chin. K€ole2 had introduced bi-
maxillary alveolar surgery in 1959, and Obwegeser84
published his experience with a combined Le Fort I
and BSSO in 1970; however, this procedure was rarely
performed. K€ole had previously performed and advo-
cated for simultaneous maxillary and mandibular
surgery, but he did not completely mobilize the
maxilla. Similarly, the American surgeon AlexMohnac4
reported his experience in 1965, but this did not
involve a maxillary down-fracture or separation of
the pterygoid plates. In 1978, two Americans, Bob
Gross and Randy James,85 reported their experiences
with simultaneous mobilization of the maxilla and
mandible, followed shortly thereafter by Helmut Lin-
dorf and Emil Steinhauser86 from Germany. Although
Americans were 10 years behind their European col-
leagues in 1970, they quickly adopted and refined
these techniques. Comprehensive textbooks were
R. BRYAN BELL 2473
published at the beginning of the next decade (Bell,
Proffit, and White, 198081; Epker and Wolford,
198087), and by the mid-1980s, the Americans had
clearly caught up.
Bruce Epker had a particularly important role to
play in developing the practice of orthognathic sur-
gery in the United States at this time. He trained with
Fred Henny at Henry Ford in Detroit, after which
Epker completed his work on a PhD in cell biology
and was recruited to Parkland, where he directed the
OMS research program and staffed patient care activ-
ities in Dallas. In 1972 he accepted a position at John
Peter Smith Hospital in FortWorth, Texas, as Chairman
of OMS. He also developed and directed the Fort
Worth Cleft Palate Program. During this time, he
described and popularized a modification of Obweges-
er’s sagittal split osteotomy that emphasized mainte-
nance of the masseter muscle attachments to the
mandibular ramus.49,88 A proponent of ‘‘surgery
first,’’ he developed a close working relationship with
a skilled orthodontist, Leward ‘‘Chuck’’ Fish, and
together, they were powerful advocates of a
multidisciplinary approach to the treatment of
dentofacial deformities as well as simultaneous
repositioning of the maxilla, mandible, and chin.89-91
Inspired by the work of Tessier and Converse in the
late 1960s, Epker was routinely performing and
writing about Le Fort III osteotomies and other
middle-third facial osteotomies by the mid 1970s,
well ahead of most surgeons of his day.92-94 Aprolific
surgeon and writer, he authored 6 textbooks that
dealt with the management of facial and craniofacial
deformities; he has contributed major chapters to
other textbooks and published over 100 peer-
reviewed articles. He wrote the first textbook on
cosmetic surgery authored by an American-trained
oral and maxillofacial surgeon and was one of the
earliest champions of combining soft tissue esthetic
procedures with orthognathic surgery.95,96
Larry Wolford was an early product of Parkland
training whose work complemented that of Epker.
An innovative and meticulous surgeon, Wolford
made important modifications to Obwegeser’s
BSSO50,97 and was the first American to provide a
clinical and biological rationale for occlusal plane
alteration in orthognathic surgery,98-100 a technique
that was made predictable by the development of
rigid internal fixation during the mid to late 1980s.
Wolford also developed and popularized techniques
for temporomandibular joint reconstruction in
combination with orthognathic surgery101,102 and
published his experience in more than 100 peer-
reviewed journal articles. Since 1985, he has been
the sponsor and director of the OMS fellowship pro-
gram at Baylor College of Dentistry and Baylor Univer-
sity Medical Center, the first fellowship program in the
country to specialize in orthognathic and temporo-
mandibular joint surgery, and he has trained 20 fellows
and more than 80 residents. He has been involved in
clinical and basic research, and his studies have led
to 3 Food and Drug Administration–approved devices,
including synthetic bone grafts for facial reconstruc-
tion, total joint prostheses for the jaw joints, and an
anchoring system for reconstruction of the temporo-
mandibular joint.
Timothy A. Turvey completed the Parkland program
in 1973 and joined a cadre of American surgeons as an
observer of craniofacial surgery with Paul Tessier in
France. During his year with Tessier, Turvey built on
the principles of upper- and middle-third facial osteot-
omies that were taught to him by Epker and returned
to the University of North Carolina in 1974 to begin an
illustrious 45-year career at that institution, which con-
tinues today. Turvey was part of the first wave of
Tessier-inspired pediatric craniofacial surgeons and
was probably the first American oral and maxillofacial
surgeon to perform a transcranial surgical procedure
for the correction of craniosynostosis as well as facial
bipartition for orbital hypertelorism.103 His textbook
on cleft and craniofacial synostosis, co-edited by Vig
and Fonseca, was the first of its kind published by an
American oral and maxillofacial surgeon.104 Turvey
developed a refined technique for simultaneous repo-
sitioning of the cleft maxilla in combination with cleft
bone grafting and described novel methods and
optimal timing of bone grafting the cleft maxilla.105
Whereas his technical skill, innovative techniques,
and erudite oration earned him a reputation as a
prolific operator and teacher of surgery, it is his
decades-long commitment to accurately recording
and studying orthognathic surgery outcomes that
may be his greatest contribution. His collaboration
with Bill Proffit, Ray White, and others in the OMS
and orthodontic departments at the University of
North Carolina has resulted in a treasure trove of
data from which has come the hierarchy of stability
and countless technical observations, which
span the decades before and after rigid internal
fixation.106-110
Parkland’s influence also extended well beyond the
American shores, an example of which is in the trans-
formational contributions of Cesar Guerrero. Guerrero
trained at Parkland and was heavily influenced by Wil-
liam Bell. After his training, he returned to his native
Venezuela, where he established himself as a master
of orthognathic surgery and in the reconstruction of
congenital, developmental, and acquired craniomaxil-
lofacial deformities. His numerous surgical innova-
tions include performing the first transoral
mandibular distraction osteogenesis (DO) procedure
to lengthen the upper and lower jaws in the world, a
procedure that he has developed and popularized
2474 HISTORY OF ORTHOGNATHIC SURGERY
around the globe.110-113 His textbooks, published in
English, Spanish, and Chinese, are standard reading
for surgical residents and clinicians interested in
orthognathic surgery and DO.114 He also has been
one of the most influential OMS leaders in South Amer-
ican history and has spearheaded the development of
consistent educational standards, not only in his native
Venezuela but across Latin America.
Other notable contributions to the development
and propagation of orthognathic surgery came from
individuals whose primary interest was in pediatric
craniofacial surgery. Leonard B. Kaban, former chief
of the OMS department at Massachusetts General Hos-
pital, was probably the first American oral and maxillo-
facial surgeon to focus his practice and research on
pediatric patients. He invested his department’s re-
sources in clinical research and the systematic descrip-
tion and management of craniofacial deformities. His
career-long interest in craniofacial (hemifacial) micro-
somia has resulted in almost universally accepted
classification schema, and his management protocols
using costochondral grafting, DO, and endoscopic-
assisted surgery for reconstruction of the condyle-
ramus unit are considered the gold standard by many
surgeons around the globe.115-121 A prolific writer
and operator, Kaban is author or co-author of over
270 scientific publications and 5 books, including
the first OMS textbook on pediatric OMS.122
There is an inexorable link between craniofacial and
orthognathic surgery. Gillies and Harrison123 are
credited with publishing the first attempt at a Le Fort
III osteotomy in 1950, although others also described
high-level midface osteotomies, including Burien and
Kufner in 1958.68 However, it was Paul Tessier who
almost single-handedly created the new subspecialty
of pediatric craniofacial surgery in 1967, when he pre-
sented his results of Le Fort III osteotomy for patients
with Crouzon and Apert syndrome.124-126 Between
1970 and 1980, a number of surgeons described
modifications of Tessier’s approach, including Joseph
Murray,127 John Converse,128,129 Milton Edgerton,130
Ian Jackson,131 and Herman Sailer.132
During the late 1960s and early 1970s, a number of
American oral and maxillofacial surgeons visited Tess-
ier in Paris, including Bill Terry, Victor Matukas, and
Scott McCallam, bringing their observations back
with them to their academic homes at the University
of North Carolina and the University of Alabama–Bir-
mingham. However, it was Roger West, from the Uni-
versity of Washington, Wolford, and Turvey who
really embraced Tessier’s techniques, wrote about
them, and passed them down to the next generation
of oral and maxillofacial surgeons. Stephen Schendell
was another Parkland-trained oral and maxillofacial
surgeon who, after training in plastic surgery, spent
a considerable amount of time with Tessier and
returned home to build the subspecialty of pediatric
craniofacial surgery in the United States.
Another transformational craniofacial surgeon who
was trained by Tessier and who has impacted the field
is Jeffery Posnick. Posnick trained in both OMS and
plastic surgery and recognized the connection be-
tween craniofacial surgery and orthognathic surgery
early in his career, which began as director of the
craniofacial program at the Hospital for Sick Children,
and later at Georgetown University. His classic text-
book Craniofacial and Maxillofacial Surgery in Chil-
dren and Young Adults is exquisitely illustrated and
remains one of the best and most thorough descrip-
tions of the optimal management of dentofacial and
craniofacial deformities.133 Posnick also instituted
the first formal fellowship in pediatriccraniofacial sur-
gery for oral and maxillofacial surgeons and trained a
generation of academics who have continued to prop-
agate the technique skill and clinical acumen that have
defined his career, including Ramon Ruiz, Bernard J.
Costello, Paul Tiwana, and Pat Ricalde.134
Bruce Epker,96 Louis Belinfante, Victor Matukas, Pe-
ter Waite,135 Doug Sinn,136 Joe Niamtu,137 John
Griffin,138 and Clark Taylor were among the first
American-trained oral and maxillofacial surgeons to
recognize, document, and study the synergy between
soft tissue esthetic procedures and orthognathic
surgery. Esthetic surgery fellowships were developed
in the 1990s, and since that time, rhinoplasty and
other adjunctive procedures have been widely used
either simultaneously or sequentially with orthog-
nathic surgery. In this regard, Peter Waite, long-time
chair of the department of OMS at the University of
Alabama–Birmingham, deserves special mention.
Waite not only established one of the first formal fel-
lowships in esthetic surgery open to oral and maxillo-
facial surgeons but also made major contributions
toward applying orthognathic surgical procedures in
the treatment of obstructive sleep apnea. Building
off of pioneering work from Stanford University col-
leagues Powell and Riley,139 his clinical investigations
into the outcome of patients with obstructive sleep ap-
nea dramatically influenced treatment considerations
for patients in whom continuous positive airway pres-
sure and/or soft tissue reduction surgery failed.140
Technologic Innovation, 1985 to Present
RIGID AND SEMI-RIGID INTERNAL FIXATION
The decade between 1985 and 1995 was high-
lighted by the development of miniaturized metallic
plates and screws to provide rigid and semi-rigid inter-
nal fixation to stabilize facial osteotomies. Pioneered
by Swiss orthopedic surgeons who would form the
Arbeitsgemeinschaft f€ur Osteosynthesefragen (AO;
Association for the Study of Internal Fixation [ASIF])
R. BRYAN BELL 2475
in the 1960s, plates and screws designed for extremity
work did not begin to be used in the craniomaxillofa-
cial skeleton until the 1970s. Bernd Spiessl,141 a native
Bavarian who spent most of his career in Switzerland,
is credited with being the first oral and maxillofacial
surgeon to apply rigid internal fixation to a sagittal
split osteotomy of the mandible. However, it was
Hans Luhr,142,143 also from Germany, who in 1968
described and developed improved miniplates
specifically for use in the craniomaxillofacial
skeleton, as well as Michelet, Maxime Champy,144
Emil Steinhauser,145 and Franz H€arle and Bill Terry146
who would popularize their use in orthognathic sur-
gery, as well as trauma. Initially made of overly rigid
stainless steel or metal alloys such as Vitallium, tita-
nium plates and screws would transform the practice
of craniomaxillofacial surgery around the globe.
In America, these techniques of rigid internal fixa-
tion were eagerly adopted and scientifically studied
by Joseph Van Sickels, then at the University of
Texas–San Antonio, Tom Jeter, Bill Terry, Myron
Tucker, and others.147-149 In addition to Van Sickles’
early experience in stabilizing BSSOs and Le Fort
osteotomies, Van Sickles et al150 were also the first to
describe rigid internal fixation in the inverted-L osteot-
omy. Furthermore, in a series of biomechanical
studies, Van Sickels and Richard Haug, from the Uni-
versity of Kentucky, showed the ideal configuration
and materials with which to stabilize maxillary and
mandibular osteotomies.151 Edward Ellis, long-time
program director at Parkland Memorial Hospital and
now chief at the University of Texas–San Antonio,
with Gaylord Throckmorton and Doug Sinn in Dallas,
made important morphologic and biomechanical ob-
servations about maximum bite forces that occur
before and after orthognathic surgery—studies that
continue to have considerable relevance to third-
party payment of surgical services being amedical pro-
cedure performed for functional purposes, not a
cosmetic operation.152-154 Subsequent stability
studies, mostly from the University of North Carolina
group, showed superior stability with plates and
screws compared with wire fixation and therefore
created a new standard of care for orthognathic
surgery at the time. Adoption of plate and screw
fixation by American oral-maxillofacial surgeons was
then accelerated by improved manufacturing and
rapid distribution by Walter Lorenz and other industry
partners.
Concerns about compatibility with future imaging
needs, interference with radiation therapy, migration
of the material, growth restriction, long-term palpa-
bility, and thermal sensitivity almost immediately
caused scientists and clinicians to search for alternative
fixation materials to titanium. Advances in polymer
chemistry and manufacturing technique during the
1990s facilitated commercialization of biodegradable
plates and screws by a number of craniomaxillofacial
fixation companies, initially for use in pediatric cranio-
facial surgery, then later applied in orthognathic
surgery. Rita Suuronen155 and Piet Haers156,157
pioneered their use in Europe, whereas Barry
Eppley158,159 and Tim Turvey110 documented their
use extensively in North America to good success.
Although biodegradable bone plates and screws have
now been in use for more than 3 decades, reliable
composition, strength, duration, presence of an inflam-
matory response, and proper design have remained
problematic, except in nonfunctional bones, such as
the calvaria. Most surgeons have abandoned their use
in orthognathic surgery; however, they are considered
standard of care for fixation of pediatric craniofacial
procedures and a preferred option for pediatric cranio-
maxillofacial surgery in general.
DISTRACTION OSTEOGENESIS
DO was applied extensively for the treatment of
war-related limb-length deformities by the Russian or-
thopedic surgeon Gabriel Ilizarov160 in the 1940s and
1950s and used by Snyder et al161 in the craniofacial
skeleton in 1973. However, it was not until the
mid-1990s that the technique gained traction, when
Joseph McCarthy,162 chief of plastic surgery at New
York University, as well as Cesar Guerrero, William
Bell, and others began promoting DO as an alternative
or adjunctive procedure to orthognathic surgery.163
Bell and Guerrero114 published a textbook on the sub-
ject that documented outstanding clinical results of
cases primarily operated on by Guerrero in his native
Venezuela. Meanwhile, Bell went back to work in
the laboratory investigating a biological basis for DO
and, while working with a talented young oral-
maxillofacial surgeon, Marianela Gonzalez, defined
experimentally the optimal latency, activation, and
consolidation periods for successful clinical
application.164 Other American oral-maxillofacial sur-
geons also made substantial and innovative contribu-
tions during this time, including David Walker,165
Suzanne McCormick,166,167 Martin Chin,168 Kevin
Smith,169 Leonard Kaban,120 and Stephen Schendel.170
Distraction devices, which were initially bulky and
placed externally, eventually became miniaturized,
internal, and anatomic.
COMPUTER-AIDED SURGERY, INTRAOPERATIVE
IMAGING, AND CUSTOMIZED IMPLANTS
The age of 3-dimensional (3D) imaging in medicine
began in 1971 when Sir Godfrey Hounsfield invented
the computed tomography (CT) scan, which allowed
for unprecedented visualization and analysis of the
complex anatomy associated with craniomaxillofacial
2476 HISTORY OF ORTHOGNATHIC SURGERY
surgery in general and orthognathic surgery in partic-
ular. Diagnostic imaging was enhanced substantially,
in 1983, when Chuck Hull developed 3D printing,
facilitating the first 3D milling of human anatomy in
Germany and the United States in 1985. During the
1990s, selectively sintered stereolithographic models
began to be produced for diagnostic and treatment
planning purposes in orthognathicsurgery, although
this was uncommon outside of academic medical cen-
ters. Intraoperative navigation as a form of ‘‘frameless
stereotaxy’’ also was developed in Germany and
quickly adopted in Europe by Rolf Ewers,171,172
Rainer Schmelzeisen,173,174 Nils Gellrich,175
and others.
Coinciding with these technologic advancements
was the development and commercialization of soft-
ware to analyze and manipulate 3D data sets and the
application of this technology to orthognathic treat-
ment planning. Companies such asMaterialise (Leuven,
Belgium), Dolphin Imaging (Chatsworth, CA), SAS Insti-
tute (Cary, NC), and Quintiles (Atlanta, GA) are exam-
ples of companies that have contributed to the
advancement of computer-assisted treatment planning,
data storage, and analysis. Although these systems
certainly impacted the field of both surgery and ortho-
dontics, their impact onpatient outcomeswas probably
minimal, as therewas initially noway to actually transfer
the virtual plan to the patient. Furthermore, the com-
paniesweremarketing to the enduser (surgeons and or-
thodontists), who often had neither the time nor
expertise to embrace the technology. Therefore, as
the 1990s came to a close and the new millennium
began, treatment planning for orthognathic surgery
was still done inmore or less the same fashion inwhich
it had always been done: by clinical examination, face-
bow transfer, and analytical model surgery using plaster
casts based on an estimation of the jaw movements to
achieve the desired esthetic and functional result, fol-
lowed by construction of intermediate and final
occlusal splints to assist in maxillary-mandibular reposi-
tioning. Edward Ellis showed significant and additive er-
rors at each stage of orthognathic treatment planning
with analyticalmodel surgery176; thus, therewas clearly
a need for a more predictable method of performing or-
thognathic surgery.
The paradigm shift in orthognathic surgery treat-
ment planning began when Gwen Swennen,177 from
Bruges, Belgium, and Jaime Gateno and James
Xia,178-181 from Houston, Texas, independently and
simultaneously developed the first clinically validated
systems for using 3D imaging to assist in virtual
surgical planning in combination with 3D printing of
interocclusal splints to transfer the virtual plans into
reality. Andrew Christensen, who had previously
founded Medical Modeling Corporation in Golden,
Colorado, quickly recognized that what surgeons
needed was not only a service provider to print the
splints but also a quick, reliable, and accurate
platform with which to perform the virtual surgical
planning itself. Christiansen hired Katie Weimer as
his first software engineer, who then worked with
Gateno and Xia,182 David Hirsch183 from New York,
and Bryan Bell184-186 from Portland, Oregon, to apply
and validate the accuracy of virtual orthognathic
surgical planning in a multi-institutional fashion.187
The original method described by Gateno and Xia
involved establishing natural head position using a gy-
roscope, medical-grade CT scans, and laser scanning of
plaster casts. Subsequent refinements described by
Brian Farrell and Myron Tucker,188,189 from
Charlotte, and Sam Bobek, their fellow who is now
in Seattle, Washington, replaced the gyroscope and
plaster casts with an all-digital workflow process that
usually only requires a cone beam CT data set. Virtual
surgical planning has since become the gold standard
for orthognathic surgical planning and largely replaced
conventional analytical model surgery using plaster
casts and hand-made splints in the United States. In
2010, the US Food and Drug Administration approved
the first 3D printed titanium implant, fueling innova-
tive solutions to complex dentofacial problems.
FELLOWSHIP TRAINING, PRESENT DAY
During the 1990s and into the newmillennium, OMS
experienced an unprecedented expansion in scope and
relevance that can be attributed to the development of
fellowship training programs in esthetic surgery, head
and neck oncologic surgery, pediatric craniofacial sur-
gery, and microvascular reconstructive surgery. These
fellowship programswere born out of the clinical activ-
ity and expertise of a number of transformational
leaders in North American OMS. Although discussion
of the impact of these fellowships on OMS practice is
largely beyond the scope of this article, it is fair to say
that fellowships have had an outsized influence on
the scope of practice in OMS and the integration of
these disciplines into the management of patients
with complex dentofacial deformities. In particular,
the synergy between esthetic surgery, pediatric cranio-
facial surgery, and orthognathic surgery is obvious.
It is a natural evolution then, as medicine and sur-
gery have become more and more specialized, that
fellowship training programs in orthognathic surgery
would be established. As mentioned previously, Larry
Wolford was the first to establish a fellowship in or-
thognathic surgery, which has produced a number of
prolific academic orthognathic surgeons, including
Pushkar Mehra, Pedro Franco, David Cottrell, and
others. Jeff Posnick has transitioned his fellowship to
one of primarily orthognathic surgery, and Myron
Tucker has continued his legacy of technical expertise,
R. BRYAN BELL 2477
innovation, and education in a fellowship that is now
directed by one of his former fellows, Brian Farrell.
Summary
During much of the second half of the 20th century,
most dentofacial deformities were managed by reposi-
tioning the mandible alone, regardless of the location
of the deformity (maxilla or mandible), via transcervi-
cal approaches, and using skeletal wires and long
periods of intermaxillary fixation to achieve bony heal-
ing. Maxillary and mandibular osteotomies were devel-
oped in Europe and the United States but were rarely
used. Hugo Obwegeser energized a generation of
American oral and maxillofacial surgeons who have
since contributed greatly to the evolution of orthog-
nathic surgery. However, as maxillary surgery became
more widespread, thanks in part to Bell’s research on
the biological basis of orthognathic procedures, treat-
ment before the mid to late 1980s was characterized
by unpredictable movements and skeletal instability
in both the short and long-term.
Advances in rigid internal fixation are primarily
responsible for the high level of predictability and skel-
etal stability that is associated with modern orthog-
nathic surgical procedures. Procedures of the
maxilla, mandible, and chin are often combined based
on the individual deformity, are performed on an
outpatient basis, and are virtually always performed
via a transoral approach. Postoperative recovery and
a rapid return to function are facilitated by avoiding
long periods of intermaxillary fixation.
Despite this, it became clear that after 6 decades of
success, persistent problems with long orthodontic
treatment times, difficulties with controlling tooth
movements, and inaccuracies in analytical model sur-
gery remained. American surgeons, working in collab-
oration with industry partners, have developed a new
paradigm in orthognathic surgical treatment planning
using 3D computer programs that allows for more
accurate diagnosis and treatment than ever
before. Today, the virtual plan is transferred to the pa-
tient using computer-aided design–computer-aided
manufacturing splints and guide stents, which have
completely replaced the plaster casts and analytical
model surgery used previously, and osteotomies are
stabilized with patient-specific implants to achieve
maximal predictability.
Although many individuals have taken a Eurocentric
view of the evolution of orthognathic surgery, I have
attempted to highlight some of the innovations, tech-
nologic advancements, and scientific research that
emanated from the United States. It is hoped that the
reader has come away with a renewed appreciation
of thecontributions of American surgeons to the treat-
ment of dentofacial deformities.
Acknowledgments
I would like to acknowledge Tim Turvey,190 Jeff Posnick191 and
Farhad Naini,192 whose prior works on the history of orthognathic
surgery were quite helpful in constructing this review.
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	A History of Orthognathic Surgery in North America
	Pioneers in Europe and America, 1846-1968
	Mandibular Surgery
	Mandibular Body Ostectomy and Osteotomy
	Mandibular Ramus and Condyle Osteotomies
	Maxillary Surgery
	Developing a Biological Basis for Orthognathic Surgery and the Contributions of William H. Bell
	Propagation of Orthognathic Surgery in America, 1960-1985
	Technologic Innovation, 1985 to Present
	Rigid and Semi-Rigid Internal Fixation
	Distraction Osteogenesis
	Computer-Aided Surgery, Intraoperative Imaging, and Customized Implants
	Fellowship Training, Present Day
	Summary
	Acknowledgments
	References