75TH ANNIVERSARY CONTRIBUTION

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.
Ó 2018 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 76:2466-2481, 2018

On the occasion of the 100th anniversary of the found- My hope is that this personal account provides an ac-
ing of the American Association of Oral and Maxillofa- curate tribute to the American pioneers who have
cial Surgeons and the 75th anniversary of the Journal done so much on behalf of patients with dentofacial
of Oral and Maxillofacial Surgery, I was asked to pro- or craniofacial deformities and, in doing so, contrib-
vide an authoritative history of orthognathic surgery in uted to the development of the modern specialty of
the United States. Although I am neither the most qual- oral and maxillofacial surgery (OMS).*
ified nor the most knowledgeable on the subject, I When my father finished his oral (and maxillofacial)
have, somewhat uniquely, been exposed to or known surgery training in 1958 in Houston, Texas, a few years
intimately many of the transformative surgeons who before I was born, there were only a handful of surgical
are credited with developing or refining modern procedures used to treat patients with dentofacial
orthognathic procedures. My childhood was filled deformities; these were primarily mandibular proced-
with stories about courageous and innovative individ- ures used for the correction of mandibular progna-
uals who inspired a generation of surgeons to reach thism. Maxillary surgery was rarely, if ever, performed,
beyond the status quo: Names such as Gillies, Wass- and transcranial facial surgery had not yet
mund, Obwegeser, Luhr, Tessier, and many others been invented.
were often the subject of conversation at our family’s With an empirical basis for surgical techniques,
dinner table. In addition to my father, William H. all done without orthodontics and virtually no
Bell, I have been fortunate enough to count as mentors surgery in the maxilla, it is not surprising that most
some of the more contemporary luminaries in the patients with dentofacial deformities in 1958 received
field, such as Tim Turvey, Ray White, and Myron
Tucker, who have helped shape not only my career * I apologize for any omission and can only implore the reader for
but the careers of an entire generation of oral and understanding and forgiveness that any such oversight on my part
maxillofacial surgeons in the United States and abroad. was unintentional.

Medical Director, Providence Head and Neck Cancer Program, Received September 6 2018
and Associate Member, Earle A. Chiles Research Institute, Robert Accepted September 6 2018
W. Franz Cancer Center, Providence Cancer Institute Head and Ó 2018 American Association of Oral and Maxillofacial Surgeons
Neck Institute, Portland, OR. 0278-2391/18/31076-0
Conflict of Interest Disclosures: The author has no relevant finan- https://doi.org/10.1016/j.joms.2018.09.006
cial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Bell: Robert
W. Franz Cancer Center, Providence Cancer Institute, 4805 NE
Glisan St, Ste 2N35, Portland, OR 97213; e-mail: richard.bell@
providence.org

2466
R. BRYAN BELL 2467

compromised or unsuccessful treatment. Key publica- 1906. Blair, Angle, and Whipple all practiced in St
tions in the English-language literature by Trauner and Louis at the same time and were all very influential
Obwegeser,1 K€ ole,2 Murphey and Walker,3 and Moh- in their day. Angle is recognized by many in the United
4
nac at the time my father finished his training cata- States as the father of modern orthodontics. Blair, a
lyzed great interest in new methods of surgical- general surgeon, is considered by some to be the father
orthodontic treatment, which in turn captivated an of American plastic surgery and was almost certainly
entire generation of American oral and maxillofacial the most dominant and active orthognathic surgeon
surgeons and orthodontists; this led to the develop- in the early 20th century. He provided detailed de-
ment of novel surgical techniques founded on sound scriptions of ‘‘operations on the jaw-bone and face’’
biological principles and facilitated by rapid advances in 1907,9 which included his horizontal osteotomy of
in bioengineering technology. the ramus, located between the sigmoid notch and
Our present state of the art and science includes the mandibular foramen. Blair10 published one of the
many more surgical procedures performed not only first definitive textbooks on oral and facial surgery in
on the mandible and maxilla but also on the orbits and 1912. He was also the first to emphasize the impor-
anterior skull base. Most of these procedures are per- tance of cooperation with an orthodontist—a point
formed intraorally and are stabilized with titanium or that was unfortunately lost on the field until the mid
biodegradable plates and screws, minimizing or elimi- 1970s. Max Ballin,11 an American surgeon from De-
nating the need for intermaxillary fixation. An improved troit, seems to have been an early adopter of Blair’s
understanding of the biological and surgical principles technique and described its successful use in 1908,
and the routine involvement of orthodontics, virtual again for the treatment of mandibular prognathism.
surgical planning with computer-aided manufacturing Meanwhile, across the Atlantic Ocean in Vienna,
of occlusal splints and cutting guides, custom implants, Anton Freiherr von Eiselsberg,12 a student of Theodor
and worldwide interest in the correction of dentofacial Billroth, described in 1906 a mandibular setback tech-
and craniofacial deformities have resulted in highly pre- nique that used a step osteotomy designed to increase
dictable, efficient, and safe treatment, which scarcely the surface area of bony contact. William M. Har-
resembles the situation 70 years ago. In the remainder sha13,14 performed an extraoral mandibular body
of this record of orthognathic surgery, I will attempt to ostectomy in 1912 but, unlike his predecessors,
describe the contributions of American surgeons to appears to be the first to emphasize and document
the development and refinement of orthognathic sur- preservation of the inferior alveolar nerve. The
gery since the mid-20th century. following year, in 1913, Matthew H. Cryer,15 from
the University of Pennsylvania, modified this tech-
Pioneers in Europe and America, 1846- nique in a semicircular fashion near the angle of the
1968 mandible, which permitted vertical rotation. In
1917, Thomas G. Aller16 described a wedge ostectomy
MANDIBULAR SURGERY via a transoral approach, which was deemed quite
Mandibular Body Ostectomy and Osteotomy daring in the preantibiotic age. By the late 1920s, Var-
Early orthognathic procedures were almost univer- izad Kazanjian, the great Armenian-born, American
sally performed for the correction of mandibular prog- surgeon from Boston, seems to have had experience
nathism. In 1849, the American surgeon Simon P. with body ostectomies using a Gigli saw and an ortho-
Hullihen,5 from Wheeling, West Virginia, described dontic splint that was cemented onto the teeth after
the first mandibular osteotomy for the correction of a surgery for the treatment of mandibular prognathism,
skeletal anterior open bite, which resulted from scar which he published in 1932.17
contractures associated with a facial burn. Hullihen,
who is considered the father of American OMS, per- Mandibular Ramus and Condyle Osteotomies
formed a wedge ostectomy in the premolar region Whereas the early body ostectomy approaches were
to reposition the mandible backward to correct the oc- favored in America, alternative methods of reposition-
clusion. To stabilize the segments, a plaster cast was ing the mandible were simultaneously developed in Eu-
made to construct a silver-plated occlusal splint; it rope. In 1897, the Frenchman Paul Berger,18 from Paris,
was cemented in place to allow bony consolidation. described bilateral condylectomy for the correction of
In 1887, Vilray P. Blair performed a modification of mandibular prognathism, a technique that was per-
Hullihen’s operation by performing a segmental formed via a preauricular incision. The technique also
mandibular body ostectomy for the correction of was described and used by fellow countrymen in
mandibular prognathism. The procedure was initially Lyon, Mathieu Jaboulay and Leon Berard,19 and was
suggested by the pioneering orthodontist Edward widely used in France until the 1950s. However, this
Angle,6 described independently by the treating ortho- technique often led to poor occlusal outcomes. An
dontist J. W. Whipple7 in 1898 and later, by Blair,8 in alternative technique was developed in 1921 by Leon
2468 HISTORY OF ORTHOGNATHIC SURGERY

Dufourmentel,20 who simply performed subcondylar Martin Wassmund41 in Berlin in 1927 and Hans
osteotomies without removing them. However, it was Pichler42 in Vienna in 1928.43 This approach to
the Czech surgeon Frantisek Kostecka,21 from Prague, advancing the mandible was performed via a transcer-
who in 1928 described and popularized a modification vical incision and involved interpositional bone graft-
of this technique that would become widely accepted, ing. Caldwell et al44 later modified their vertical
which used a Gigli saw via an extraoral approach.22 osteotomy in a similar fashion to that of Wassmund
The condylar operations were, of course, limited to and Pichler, although it came to be known as a ‘‘C os-
the treatment of mandibular prognathism and mandib- teotomy.’’ Another American, Richard Topazian, from
ular asymmetry related to temporomandibular joint the University of Connecticut, described the
pathology, which prompted surgeons to design alter- inverted-L osteotomy using an intraoral approach.45
native approaches. In 1905, Sir William Arbuthnot Despite these periodic innovations on either side of
Lane,23 from Guy’s Hospital in London, described a the Atlantic Ocean, 2 primary schools in Europe are
horizontal ramus osteotomy for mandibular setback often thought to be the cradle of modern orthognathic
that was placed just above the mandibular foramen surgery: the Vienna school of maxillofacial surgery,
and lingua via an extraoral approach. A similar tech- founded by Hans Pichler (also famous for being Freud’s
nique was described in 1907 by Blair,9 who used it oral cancer surgeon) and the German school, founded
to successfully advance the mandible more than in Berlin by Martin Wassmund. Pichler was succeeded
9 mm. The procedure was performed in a ‘‘blind’’ by his pupil Richard Trauner in 1955, who later moved
fashion using a Gigli saw that was placed through to Graz. Trauner was an innovative surgeon in his own
skin incisions. Subsequently, the procedure was used right and made numerous contributions to maxillofa-
and modified slightly by a number of pioneering sur- cial surgery. He is also well known for having trained
geons in both America and Europe for either mandib- Heinz K€ ole and Hugo Obwegeser, two individuals
ular advancement or setback, including W. Wayne who would ignite interest in orthognathic surgery
Babcock24 from Temple University in Philadelphia around the globe. Although this Eurocentric view is
(1909), Christian Bruhn25 from D€ usseldorf (1921), certainly understandable, one cannot underestimate
Gunther Perthes26 from T€ ubingen (1922), and Kazan- the contributions of American surgeons returning
jian17 (1932), as well as Bruhn’s successor in from the First and Second World Wars in the first half
D€usseldorf, the pioneering surgeon August Linde- of the 20th century.
mann,27,28 and Karl Schuchardt.29 K€ole,2 who succeeded Trauner as chief in Graz,
In 1928, a Russian surgeon, Alexander Limberg,30 described several new procedures for altering the po-
from Leningrad, described a posterior oblique vertical sition of the alveolar process (subapical osteotomies)
ramus osteotomy performed via an external approach and probably described the first bimaxillary surgical
for the correction of open-bite malocclusions. This procedure, including the treatment of bimaxillary pro-
would be modified and documented over the years by trusion by performing subapical osteotomies with or
many surgeons, including the German Otto Hofer31 in without premolar extractions. K€ ole made numerous
1936; the American Reed Dingman,32,33 from the contributions to the literature and published the first
University of Michigan; the Swiss-born, American Kurt textbook on ‘‘surgical orthodontics’’ in 1964, along
H. Thoma,34 from Harvard School of Dental Medicine; with Reichenbach and Bruckl.
Marsh Robinson,35,36 from the University of Southern Obwegeser left Graz in 1956 to become chair of
California; and Edward C. Hinds,37 from the University OMS in Zurich, quickly making that Swiss city the
of Texas–Houston. It interesting to note that, in 1951, epicenter of orthognathic surgery in the world and
an American surgeon from Texas, A. C. Sloan,38 Mecca for a generation of interested surgeons. What
described as a treatment for prognathism an intraoral became known as the ‘‘bilateral sagittal split osteot-
vertical ramus osteotomy, a technique that would be omy’’ (BSSO) was first described in German by Obwe-
modified and rediscovered a couple of decades later. geser and Trauner,46 his mentor, in 1955 and in English
However, it is Colonel Jack C. Caldwell and Gordon with Trauner in 19571; it would eventually become the
S. Letterman39 who are generally credited with docu- preferred technique for the correction of mandibular
menting the first true vertical ramus osteotomy, also deformities, primarily owing to its versatility, predict-
called a ‘‘vertical subsigmoid osteotomy.’’ Performed ability, and functional and esthetic results. Because
via an extraoral approach, this procedure is differenti- of this, the inverted-L osteotomy never really gained
ated from the previous ramus osteotomies in that the popularity, likely owing to the requirement for an
inferior bone cut extended to anterior of the gonial extraoral incision, the related risk of marginal mandib-
angle. Hinds and colleagues40 later modified this by ular nerve injury, and the additional time and
performing an intraoral vertical ramus osteotomy. morbidity associated with bone graft harvest, as well
What we know today as the ‘‘inverted-L osteotomy’’ as fixation requirements. Obwegeser’s ‘‘sagittal split-
appears to have been independently described by ting osteotomy’’ was modified by the Italian surgeon
R. BRYAN BELL 2469

Giorgio Dal Pont47 in 1958, who had visited Zurich G€ unther Cohn-Stock,55 a German surgeon from Ber-
and after observing the master at work, conceived lin, is considered by many to be the father of maxillary
the anterior extension of Obwegeser’s lateral osteot- surgery for the purposes of dentofacial correction,
omy, allowing for greater advancements. Dal Pont ap- publishing on segmental maxillary osteotomies in
pears not to have actually performed the procedure 1921. In 1935, a student of Cohn-Stock, Martin Wass-
prior to his description in the literature, but his mund,56 described the first true anterior maxillary os-
prescient refinement substantially improved the versa- teotomy, which was a 2-stage procedure used
tility of the procedure. In 1968, the American military primarily for the closure of anterior open bites. Wass-
oral and maxillofacial surgeon Ervin E. Hunsuck,48 mund’s procedure was later modified in 1954 by Ivo
from Walter Reed Army Medical Center, modified Ob-  upar57 from Zagreb (1-stage, palatal pedicle) and in
C
wegeser’s sagittal split procedure by limiting the 1962 by Sigfried Wunderer58 (1-stage, labial
extent of the medial horizontal osteotomy. Bruce pedicle). In the mid-1950s, posterior maxillary osteot-
Epker49 and Larry Wolford,50 both from Texas, would omies began to be used after Karl Schuchardt,59,60 a
subsequently make additional refinements that will be former student of Wassmund’s who practiced in
discussed in greater detail later. Hamburg, described a 2-stage posterior maxillary os-
Also in 1955, Obwegeser and Trauner46 published teotomy for closure of an anterior open bite in 1955.
the first intraoral horizontal osteotomy of the inferior This was later modified to a 1-stage procedure by the
border, or ‘‘genioplasty,’’ in which the mobilized genial Czech surgeon Josef Kufner61 in 1960 and would
segment remained pedicled to the tongue remain the mainstay of maxillary surgery until
musculature. Although this technique had been the 1980s.
described and illustrated using a cadaver by the Martin Wassmund62 also described in 1927 what
German surgeon Hofer51 in 1942, the circumstances could be considered a precursor of the modern Le
behind the cadaveric surgery were suspect and doubts Fort I osteotomy for the correction of a post-
have been raised as to whether Hofer ever performed traumatic malocclusion, although he did not release
the operation on a living patient. John Converse,52 an the pterygoid plates and relied on orthopedic traction
American plastic surgeon from New York University, for forward movement. George Axhausen63 in 1934
also had described a genioplasty technique in 1964, was the first to describe mobilization of the Le Fort I
in which a free bone graft was placed transorally to level osteotomy (for treatment of a malunited frac-
aid in chin projection; however, this technique was un- ture). Subsequent reports by A. Immenkamp,64 Schu-
reliable and rapidly lost favor in the wake of Obweges- chardt,29 Converse and Shapiro,65 Harold Gillies and
er’s innovative approach. Norman Rowe,66 Joseph Kufner,67,68 and Hugo
Obwegeser69 showed that segmental or even total
mobilization of the maxilla was feasible, but again,
MAXILLARY SURGERY because of technologic limitations and concerns about
Maxillary surgery was much slower than mandib- viability of the mobilized segments, the procedures
ular surgery to be widely adopted. Although various were rarely used, even in Europe.
techniques for mobilizing the maxilla as a whole or Further contributing to the nascent state of the art in
in smaller segments had been described decades the United States was that orthodontists in the mid-
before 1958, maxillary osteotomies were rarely per- 20th century had virtually no interest in surgery and
formed because of the fear of devitalizing dento- surgeons had very little interest in orthodontics. Ex-
osseous structures. Bernard Von Langenbeck,53 the ceptions to this rule were present, of course, most
great German surgeon, is credited with describing notably collaborations between Edward Angle, the fa-
the first maxillary osteotomy in 1859, which was per- ther of modern orthodontics, and his surgical col-
formed unilaterally and for tumor access. Similarly, the leagues from St Louis, Henry Mudd and Vilray Blair.
equally prominent German surgeon Theodor Bill- Although Angle and Blair never published together,
roth—father of the total laryngectomy—performed a both wrote books that documented their experience
maxillary access procedure around the same time. in orthognathic surgery.
The American surgeon David W. Cheever,54 from Bos- By the mid-1950s, surgeons in the United States had
ton City Hospital, modified this approach in 1867 by largely abandoned the body ostectomy procedures
performing what appears to be the first recorded that were originally described in the 19th and early
maxillary down-fracture at the Le Fort I level, again 20th century by Hullihen, Angle, Blair, Kazanjian,
for the purpose of tumor access. Although these pro- and Dingman. Most corrections were accomplished
cedures were not performed for the correction of den- in the mandible as a subcondylar osteotomy or extrao-
tofacial deformities, they are remarkable feats given ral vertical ramus osteotomy, and virtually all of these
the fact that they were accomplished in the preanes- were performed via an extraoral approach with or
thetic era. without a Gigli saw.
2470 HISTORY OF ORTHOGNATHIC SURGERY

So, by the start of 1959—as my father began his first orthognathic surgeons. Hinds had refined and clini-
year in practice in Houston, Texas—American surgeons cally applied the extraoral vertical ramus osteotomy
were hungry for new techniques and innovative ap- technique for the correction of mandibular progna-
proaches toward managing complex jaw problems. In thism. Bell recalls that ‘‘Dr Hinds and the other Amer-
Europe, Obwegeser appears to have already recognized ican oral surgeons in Houston were aware of
the importance of separating the pterygoid plates to descriptions of both anterior and posterior maxillary
completely mobilize the maxilla at the Le Fort I level; osteotomies, but none were performed for orthog-
he had described interpositional bone grafts for added nathic problems at that time.’’ He stated, ‘‘My initial
stability; and he had begun to refine his intraoral sagittal response to these procedures was an insatiable inter-
splitting technique by taking the vertical cut more ante- est and curiosity but fear of the unknown clinical con-
riorly to allow for greater advancement. None of these sequences.’’ This same fear was shared by virtually
procedures, however, were common in the United everyone in the oral (and maxillofacial) surgery and
States or anywhere else for that matter. Furthermore, basic science departments at the time. Bell searched
maxillary surgery was virtually never performed the available literature for relevant studies but found
because of concerns about dento-osseous viability. none that supported a biological foundation for these
Thus, the stage was set for Obwegeser’s fateful visit to procedures. Having no research training or back-
America in 1966.70 In what can only be considered a ground, he sought the help of colleagues and was
watershed moment in American OMS history, at the heavily influenced by Bernard Levy and Sumpter Ar-
invitation of General Robert Shira to Walter Reed Hospi- nim at the University of Texas–Dental Branch, both
tal, Obwegeser mesmerized a room full of US surgeons of whom were described by Bell as ‘‘very fascinating
with his description of orthognathic surgical tech- and inquisitive individuals with a great thirst for life
niques, and it is here that the real story of American and desire to do the right thing.’’ Arnim encouraged
innovation begins as it relates to orthognathic surgery. Bell to investigate the biology of facial osteotomies
During his lectures, Obwegeser not only demon- and to show the patency of the vasculature and the ef-
strated his sagittal split osteotomy for both mandibular fect that the operation had on the viability of the dental
advancement and setback but also demonstrated pulp and bone. Arnim offered Bell 6 rabbits to use for
segmental maxillary and mandibular osteotomies, as pilot investigations. The revascularization and histo-
well as the Le Fort I osteotomy, which included separa- logic techniques of F. W. Rhinelander, an orthopedic
tion of the pterygoid plates. Obwegeser’s presentation surgeon, seemed promising, and Bell visited Rhine-
to more than 500 American oral and maxillofacial sur- lander’s laboratory in Cleveland, Ohio, to observe his
geons inspired a new generation of leaders who, in the ongoing orthopedic revascularization studies. On re-
following years, helped to catapult the specialty into turning to Houston, Bell performed preliminary pilot
unprecedented success and relevance to health care. studies in rabbits to work out the details of microangio-
One individual who was particularly influenced by graphic and histologic laboratory techniques. The
the possibilities of this nascent field was a young, initial study animal was a sham control; the second
inquisitive surgeon from Houston, Texas, named Wil- was an experimental animal killed humanely 3 weeks
liam H. Bell. after anterior maxillary osteotomy. When the animal
was killed, the findings of the angiographic and histo-
Developing a Biological Basis for logic studies appeared very similar to those of the con-
trol unoperated animal—as if no surgery had been
Orthognathic Surgery and the
done: Revascularization in the experimental animal ap-
Contributions of William H. Bell
peared similar to that in the control unoperated ani-
William H. Bell grew up in St Louis, where he grad- mal. After several more animals were studied, a
uated from college and dental school after serving in different animal model was needed and the surgical
the Navy during World War II. In 1954, he completed and laboratory techniques were then refined in dogs.
an internship in oral surgery at Metropolitan City Hos- These canine studies provided the data necessary to
pital in New York City, where he recalls that ‘‘in any apply for and receive grant support from the National
given week, I would literally see hundreds of patients Institutes of Health (NIH) to study wound healing after
who are candidates for either orthognathic surgery or orthognathic surgery in primates. Bell stated, ‘‘Despite
orthodontics. Unfortunately, none of them received numerous clinical successes and occasional failures,
any treatment.’’ In 1955, he went on to complete his the rationale for using various surgical techniques
resident training in oral surgery at Jefferson Davis Hos- (for maxillary and mandibular osteotomies) remains
pital/University of Texas–Dental Branch in Houston virtually empiric. Basic questions concerned with
under the tutelage of Edward C. Hinds, who at the healing of the surgical wound produced by maxil-
the time was considered one of the country’s finest lary osteotomies and the vessels necessary to maintain
R. BRYAN BELL 2471

blood supply to the bone segments and viability of the of the osteotomized segments and teeth. However,
teeth have not been investigated.’’ once the safety and predictability of the techniques
At this time in the mid-1960s, the only procedures were firmly established in Bell’s laboratory, surgeons
that were occasionally used to correct skeletal maloc- became emboldened to apply these findings in their
clusion were the anterior maxillary osteotomy own practice.
described previously by Wassmund, Wunderer, and The resulting body of work on the subject of orthog-
C upar, as well as the posterior maxillary osteotomy nathic surgery during Bell’s 20 years at Parkland
of Schuchardt and Kufner. In 1966, at a meeting of included more than 150 publications in peer-
the Houston Society of Oral Surgeons, Bell became reviewed journals and 6 textbooks. Furthermore, he
inspired by a conversation with Alex Mohnac and de- instituted so-called surgical safaris, which were
signed an experiment to determine the biology of ante- hands-on courses open to surgeons and orthodontists
rior maxillary osteotomy wound healing. As Bell had around the globe, and thus helped to train a generation
done previously in rabbits and dogs, standard anterior of clinicians well beyond the confines of Dallas, Texas.
maxillary osteotomies (labial vs palatal pedicle) were The now classic textbook Surgical Correction of Den-
completed in rhesus monkeys and the animals were tofacial Deformities, co-edited by Bell, William Proffit,
killed humanely at 1, 3, and 6 weeks after and Raymond White, the latter two from the Univer-
surgery. Before death, the common carotid arteries sity of North Carolina in Chapel Hill, was published
were exposed, cannulated, heparinized, and perfused in 1980.81 Proffit was an orthodontist who, for more
with a suspension of contrast dye injection than 30 years, held continuous NIH funding to study
medium. Each maxilla was then dissected from the the outcomes of the surgical-orthodontic treatment
specimens, and radiographs were taken. The 1-week of dentofacial deformities. White, a Virginia-trained
specimens confirmed a ‘‘blood clot in the center of oral and maxillofacial surgeon, was an early adopter
the osteotomized fragments bounded by proliferating of orthognathic surgery and applied his considerable
young granulation tissue.’’ The 3-week specimens intellect toward systematic study of clinical problems.
‘‘showed early callus formation between the bone frag- Their treatise was and still is one of the most focused
ments. Considerable subperiosteal new bone forma- and comprehensive textbooks ever published on the
tion was present in some of the sections.’’ The 6- subject of orthognathic surgery. The thorough descrip-
week specimens ‘‘showed osseous union of the osteo- tion of the diagnosis and management of dentofacial
tomized bone fragments with no evidence of necrosis.’’ deformities, surgical technique, and detailed figures,
Bell concluded: ‘‘The results indicated that no single painstakingly hand drawn by Bill Winn, illustrated
blood vessel, such as the incisive canal or greater pal- the operations in breathtaking detail and would pro-
atine arteries, is essential to maintenance of circulation vide generations of surgeons the necessary informa-
to the anterior maxillary fragment. Interosseous and tion from which to apply a surgical-orthodontic
soft tissue collateral circulation and the freely anasto- approach to the problem of skeletal malocclusions.
mosing gingival, palatal, floor of the nose and peri- The resulting propagation of orthognathic surgical
odontal plexuses permit many variations of the skills among North American oral and maxillofacial
anterior maxillary osteotomy technique (labial vs surgeons and orthodontists served to catapult the spe-
palatal pedicles) without detriment to the integrity cialty into mainstream maxillofacial surgery and
of the blood supply to the anterior maxillary contributed to the name change at the associa-
segment.’’ This work was published in 196971 and tion level.
1970,72 and in its wake, in 1971, R. V. Walker recruited
Bell to the University of Texas Southwestern Medical
Propagation of Orthognathic Surgery in
Center/Parkland Memorial Hospital in Dallas to
America, 1960-1985
develop a research laboratory focused on the vascu-
larity and wound healing associated with maxillary The late sixties and early seventies was a time of
and mandibular osteotomies. In 9 subsequent NIH- innovation in American OMS, although with a few ex-
funded experiments, Bell would use a similar ceptions, most of it was occurring in the mandible. R.
approach to define the biological basis for virtually Bruce MacIntosh was a particularly innovative and
every other type of facial osteotomy at the time, very active orthognathic surgeon during this time.
including posterior maxillary osteotomy,73 maxillary He had spent time in Switzerland with Obwegeser
corticotomy,74 Le Fort I osteotomy down-fracture,75 and thus was truly on the forefront of American
vertical ramus osteotomy of the mandible,76 BSSO,77 OMS. In 1975, MacIntosh82,83 described the ‘‘total
1-tooth dento-osseous segmental osteotomies,78 gen- mandibular subapical osteotomy,’’ a procedure that,
ioplasty,79 and segmental Le Fort I osteotomy.80 Before although technically challenging, could achieve
this work, none of these operations were commonly excellent correction of complex skeletal Class II
performed, mostly because of fear over the viability problems. An eloquent writer and prolific surgeon,
2472 HISTORY OF ORTHOGNATHIC SURGERY

MacIntosh was instrumental in expanding the scope would help develop and refine orthognathic surgery
and technical skill of a generation of oral and over the ensuing decades: Roger West (Seattle, WA),
maxillofacial surgeons. In 1976, Richard Topazian, Larry Wolford (Dallas, TX), Tim Turvey (Chapel Hill,
another American oral and maxillofacial surgeon and NC), Douglas Sinn (Dallas, TX), Markell Kohn (Lexing-
early adopter of Obwegeser’s techniques, described ton, KY), Bob Alexander (Jacksonville, FL), Cesar
an intraoral inverted-L osteotomy.45 As mentioned pre- Guerrero (Caracas, Venezuela), Stephen Schendel
viously, maxillary surgery was rarely performed before (Palo Alto, CA), Keith Kreitziger (Gainesville, FL),
the mid-1970s; however, after microangiographic Gene Ireland (Storrs, CT), Philip Freeman (Houston,
studies and favorable clinical experiences with Le TX), Felice O’Ryan (Oakland, CA), Alan Herford
Fort I down-fracture were published by Bell et al75 in (Loma Linda, CA), Scott Boyd (Nashville, TN), Ghali
1975, American surgeons took to these procedures Ghali (Shreveport, LA), and many others contributed
with gusto. greatly to the advancement of patient care and spe-
Critical to the propagation of these techniques at cialty development in American OMS in general and
that time was the continued maturation of the spe- orthognathic surgery in particular. They also estab-
cialty of OMS and the development of excellent lished the first structured training program for surgical
training programs highlighted by a burgeoning interest orthodontics and emphasized combined treatment.
and experience in orthognathic surgery. Individuals Cooperation between surgeons and orthodontists
such as Fred Henny at Henry Ford Hospital in Detroit, was not new—indeed, the father of modern orthodon-
Robert V. Walker at Parkland Hospital in Dallas, Scott tics, Edward Angle, was a noted collaborator with V. P.
McCallum at the University of Alabama–Birmingham, Blair in St Louis, dating back to the beginning of the
Elmer Bear at Virginia Commonwealth University, 20th century. The great plastic surgeon John Converse
Jack Kent at Louisiana State University, and Ed Hinds and Sidney Horowitz, as well as Harry Shapiro, were
at the University of Texas–Houston not only had also early champions of a multidisciplinary approach
robust orthognathic surgical practices but were partic- to the treatment of dentofacial deformity, as were
ularly adept at cultivating and nurturing future acade- Reed Dingman and Gerald V. Barrow in Michigan.
micians. For example, Henny facilitated the academic However, it was not until US oral and maxillofacial sur-
careers of such notable figures as Bruce Epker, Bruce geons and orthodontists began to publish together in
McIntosh, Ralph Merrill, and Guy Catone, all of earnest that the approach took root. Notable
whom went on to develop their own programs in surgeon-orthodontist partnerships that advanced
Texas, Michigan, Oregon, and Pennsylvania, care during this period included R. V. Walker and
respectively. Phelps Murphey, William Bell and Tom Creekmore,
The program at Parkland Memorial Hospital de- William Ware and Don Poultan, Bruce Epker and
serves special mention. R. V. Walker was a practicing Chuck Fish, Raymond White and William Proffit, Roger
general dentist in Waco, Texas, when he joined the mil- West and Bill McNeill, Larry Wolford and Frank Hill-
itary during the Korean War at Brooke Army Medical iard, and Tim Turvey and H. David Hall.
Center in San Antonio. There, he gained substantial Another important advancement during the 1970s
experience in the management of maxillofacial was in the development of ‘‘two-jaw surgery,’’ which
trauma, caring for patients with extensive injuries represents the simultaneous mobilization of the
who were flown from Korea to Japan and then to maxilla, mandible, and chin. K€ ole2 had introduced bi-
Brooke, 1 of the 3 Army-designated maxillofacial maxillary alveolar surgery in 1959, and Obwegeser84
trauma centers during that war. This experience published his experience with a combined Le Fort I
would impact his decision to train in oral surgery and BSSO in 1970; however, this procedure was rarely
and helped to shape his opinion that the essential performed. K€ ole had previously performed and advo-
core of every good OMS training program started cated for simultaneous maxillary and mandibular
with trauma. Walker began his tenure as chief of the di- surgery, but he did not completely mobilize the
vision of OMS at Parkland Hospital in 1956 and created maxilla. Similarly, the American surgeon Alex Mohnac4
a program in Texas that later produced 2 dental school reported his experience in 1965, but this did not
deans, more than 28 department chairs, and dozens of involve a maxillary down-fracture or separation of
academic surgeons throughout North and South Amer- the pterygoid plates. In 1978, two Americans, Bob
ica. Among his first recruits were Jim Bertz, in 1964, Gross and Randy James,85 reported their experiences
who developed an interest in the correction of with simultaneous mobilization of the maxilla and
congenital malformation and Bruce Epker, in 1968, mandible, followed shortly thereafter by Helmut Lin-
who had been trained by Fred Henny in Detroit, as dorf and Emil Steinhauser86 from Germany. Although
well as William Bell, in 1971. Americans were 10 years behind their European col-
Walker, Bertz, Bell, and Epker went on to train an leagues in 1970, they quickly adopted and refined
immensely talented group of surgical residents who these techniques. Comprehensive textbooks were
R. BRYAN BELL 2473

published at the beginning of the next decade (Bell, country to specialize in orthognathic and temporo-
Proffit, and White, 198081; Epker and Wolford, mandibular joint surgery, and he has trained 20 fellows
198087), and by the mid-1980s, the Americans had and more than 80 residents. He has been involved in
clearly caught up. clinical and basic research, and his studies have led
Bruce Epker had a particularly important role to to 3 Food and Drug Administration–approved devices,
play in developing the practice of orthognathic sur- including synthetic bone grafts for facial reconstruc-
gery in the United States at this time. He trained with tion, total joint prostheses for the jaw joints, and an
Fred Henny at Henry Ford in Detroit, after which anchoring system for reconstruction of the temporo-
Epker completed his work on a PhD in cell biology mandibular joint.
and was recruited to Parkland, where he directed the Timothy A. Turvey completed the Parkland program
OMS research program and staffed patient care activ- in 1973 and joined a cadre of American surgeons as an
ities in Dallas. In 1972 he accepted a position at John observer of craniofacial surgery with Paul Tessier in
Peter Smith Hospital in Fort Worth, Texas, as Chairman France. During his year with Tessier, Turvey built on
of OMS. He also developed and directed the Fort the principles of upper- and middle-third facial osteot-
Worth Cleft Palate Program. During this time, he omies that were taught to him by Epker and returned
described and popularized a modification of Obweges- to the University of North Carolina in 1974 to begin an
er’s sagittal split osteotomy that emphasized mainte- illustrious 45-year career at that institution, which con-
nance of the masseter muscle attachments to the tinues today. Turvey was part of the first wave of
mandibular ramus.49,88 A proponent of ‘‘surgery Tessier-inspired pediatric craniofacial surgeons and
first,’’ he developed a close working relationship with was probably the first American oral and maxillofacial
a skilled orthodontist, Leward ‘‘Chuck’’ Fish, and surgeon to perform a transcranial surgical procedure
together, they were powerful advocates of a for the correction of craniosynostosis as well as facial
multidisciplinary approach to the treatment of bipartition for orbital hypertelorism.103 His textbook
dentofacial deformities as well as simultaneous on cleft and craniofacial synostosis, co-edited by Vig
repositioning of the maxilla, mandible, and chin.89-91 and Fonseca, was the first of its kind published by an
Inspired by the work of Tessier and Converse in the American oral and maxillofacial surgeon.104 Turvey
late 1960s, Epker was routinely performing and developed a refined technique for simultaneous repo-
writing about Le Fort III osteotomies and other sitioning of the cleft maxilla in combination with cleft
middle-third facial osteotomies by the mid 1970s, bone grafting and described novel methods and
well ahead of most surgeons of his day.92-94 A prolific optimal timing of bone grafting the cleft maxilla.105
surgeon and writer, he authored 6 textbooks that Whereas his technical skill, innovative techniques,
dealt with the management of facial and craniofacial and erudite oration earned him a reputation as a
deformities; he has contributed major chapters to prolific operator and teacher of surgery, it is his
other textbooks and published over 100 peer- decades-long commitment to accurately recording
reviewed articles. He wrote the first textbook on and studying orthognathic surgery outcomes that
cosmetic surgery authored by an American-trained may be his greatest contribution. His collaboration
oral and maxillofacial surgeon and was one of the with Bill Proffit, Ray White, and others in the OMS
earliest champions of combining soft tissue esthetic and orthodontic departments at the University of
procedures with orthognathic surgery.95,96 North Carolina has resulted in a treasure trove of
Larry Wolford was an early product of Parkland data from which has come the hierarchy of stability
training whose work complemented that of Epker. and countless technical observations, which
An innovative and meticulous surgeon, Wolford span the decades before and after rigid internal
made important modifications to Obwegeser’s fixation.106-110
BSSO50,97 and was the first American to provide a Parkland’s influence also extended well beyond the
clinical and biological rationale for occlusal plane American shores, an example of which is in the trans-
alteration in orthognathic surgery,98-100 a technique formational contributions of Cesar Guerrero. Guerrero
that was made predictable by the development of trained at Parkland and was heavily influenced by Wil-
rigid internal fixation during the mid to late 1980s. liam Bell. After his training, he returned to his native
Wolford also developed and popularized techniques Venezuela, where he established himself as a master
for temporomandibular joint reconstruction in of orthognathic surgery and in the reconstruction of
combination with orthognathic surgery101,102 and congenital, developmental, and acquired craniomaxil-
published his experience in more than 100 peer- lofacial deformities. His numerous surgical innova-
reviewed journal articles. Since 1985, he has been tions include performing the first transoral
the sponsor and director of the OMS fellowship pro- mandibular distraction osteogenesis (DO) procedure
gram at Baylor College of Dentistry and Baylor Univer- to lengthen the upper and lower jaws in the world, a
sity Medical Center, the first fellowship program in the procedure that he has developed and popularized
2474 HISTORY OF ORTHOGNATHIC SURGERY

around the globe.110-113 His textbooks, published in returned home to build the subspecialty of pediatric
English, Spanish, and Chinese, are standard reading craniofacial surgery in the United States.
for surgical residents and clinicians interested in Another transformational craniofacial surgeon who
orthognathic surgery and DO.114 He also has been was trained by Tessier and who has impacted the field
one of the most influential OMS leaders in South Amer- is Jeffery Posnick. Posnick trained in both OMS and
ican history and has spearheaded the development of plastic surgery and recognized the connection be-
consistent educational standards, not only in his native tween craniofacial surgery and orthognathic surgery
Venezuela but across Latin America. early in his career, which began as director of the
Other notable contributions to the development craniofacial program at the Hospital for Sick Children,
and propagation of orthognathic surgery came from and later at Georgetown University. His classic text-
individuals whose primary interest was in pediatric book Craniofacial and Maxillofacial Surgery in Chil-
craniofacial surgery. Leonard B. Kaban, former chief dren and Young Adults is exquisitely illustrated and
of the OMS department at Massachusetts General Hos- remains one of the best and most thorough descrip-
pital, was probably the first American oral and maxillo- tions of the optimal management of dentofacial and
facial surgeon to focus his practice and research on craniofacial deformities.133 Posnick also instituted
pediatric patients. He invested his department’s re- the first formal fellowship in pediatric craniofacial sur-
sources in clinical research and the systematic descrip- gery for oral and maxillofacial surgeons and trained a
tion and management of craniofacial deformities. His generation of academics who have continued to prop-
career-long interest in craniofacial (hemifacial) micro- agate the technique skill and clinical acumen that have
somia has resulted in almost universally accepted defined his career, including Ramon Ruiz, Bernard J.
classification schema, and his management protocols Costello, Paul Tiwana, and Pat Ricalde.134
using costochondral grafting, DO, and endoscopic- Bruce Epker,96 Louis Belinfante, Victor Matukas, Pe-
assisted surgery for reconstruction of the condyle- ter Waite,135 Doug Sinn,136 Joe Niamtu,137 John
ramus unit are considered the gold standard by many Griffin,138 and Clark Taylor were among the first
surgeons around the globe.115-121 A prolific writer American-trained oral and maxillofacial surgeons to
and operator, Kaban is author or co-author of over recognize, document, and study the synergy between
270 scientific publications and 5 books, including soft tissue esthetic procedures and orthognathic
the first OMS textbook on pediatric OMS.122 surgery. Esthetic surgery fellowships were developed
There is an inexorable link between craniofacial and in the 1990s, and since that time, rhinoplasty and
orthognathic surgery. Gillies and Harrison123 are other adjunctive procedures have been widely used
credited with publishing the first attempt at a Le Fort either simultaneously or sequentially with orthog-
III osteotomy in 1950, although others also described nathic surgery. In this regard, Peter Waite, long-time
high-level midface osteotomies, including Burien and chair of the department of OMS at the University of
Kufner in 1958.68 However, it was Paul Tessier who Alabama–Birmingham, deserves special mention.
almost single-handedly created the new subspecialty Waite not only established one of the first formal fel-
of pediatric craniofacial surgery in 1967, when he pre- lowships in esthetic surgery open to oral and maxillo-
sented his results of Le Fort III osteotomy for patients facial surgeons but also made major contributions
with Crouzon and Apert syndrome.124-126 Between toward applying orthognathic surgical procedures in
1970 and 1980, a number of surgeons described the treatment of obstructive sleep apnea. Building
modifications of Tessier’s approach, including Joseph off of pioneering work from Stanford University col-
Murray,127 John Converse,128,129 Milton Edgerton,130 leagues Powell and Riley,139 his clinical investigations
Ian Jackson,131 and Herman Sailer.132 into the outcome of patients with obstructive sleep ap-
During the late 1960s and early 1970s, a number of nea dramatically influenced treatment considerations
American oral and maxillofacial surgeons visited Tess- for patients in whom continuous positive airway pres-
ier in Paris, including Bill Terry, Victor Matukas, and sure and/or soft tissue reduction surgery failed.140
Scott McCallam, bringing their observations back
with them to their academic homes at the University Technologic Innovation, 1985 to Present
of North Carolina and the University of Alabama–Bir-
mingham. However, it was Roger West, from the Uni- RIGID AND SEMI-RIGID INTERNAL FIXATION
versity of Washington, Wolford, and Turvey who The decade between 1985 and 1995 was high-
really embraced Tessier’s techniques, wrote about lighted by the development of miniaturized metallic
them, and passed them down to the next generation plates and screws to provide rigid and semi-rigid inter-
of oral and maxillofacial surgeons. Stephen Schendell nal fixation to stabilize facial osteotomies. Pioneered
was another Parkland-trained oral and maxillofacial by Swiss orthopedic surgeons who would form the
surgeon who, after training in plastic surgery, spent Arbeitsgemeinschaft f€ ur Osteosynthesefragen (AO;
a considerable amount of time with Tessier and Association for the Study of Internal Fixation [ASIF])
R. BRYAN BELL 2475

in the 1960s, plates and screws designed for extremity 1990s facilitated commercialization of biodegradable
work did not begin to be used in the craniomaxillofa- plates and screws by a number of craniomaxillofacial
cial skeleton until the 1970s. Bernd Spiessl,141 a native fixation companies, initially for use in pediatric cranio-
Bavarian who spent most of his career in Switzerland, facial surgery, then later applied in orthognathic
is credited with being the first oral and maxillofacial surgery. Rita Suuronen155 and Piet Haers156,157
surgeon to apply rigid internal fixation to a sagittal pioneered their use in Europe, whereas Barry
split osteotomy of the mandible. However, it was Eppley158,159 and Tim Turvey110 documented their
Hans Luhr,142,143 also from Germany, who in 1968 use extensively in North America to good success.
described and developed improved miniplates Although biodegradable bone plates and screws have
specifically for use in the craniomaxillofacial now been in use for more than 3 decades, reliable
skeleton, as well as Michelet, Maxime Champy,144 composition, strength, duration, presence of an inflam-
Emil Steinhauser,145 and Franz H€arle and Bill Terry146 matory response, and proper design have remained
who would popularize their use in orthognathic sur- problematic, except in nonfunctional bones, such as
gery, as well as trauma. Initially made of overly rigid the calvaria. Most surgeons have abandoned their use
stainless steel or metal alloys such as Vitallium, tita- in orthognathic surgery; however, they are considered
nium plates and screws would transform the practice standard of care for fixation of pediatric craniofacial
of craniomaxillofacial surgery around the globe. procedures and a preferred option for pediatric cranio-
In America, these techniques of rigid internal fixa- maxillofacial surgery in general.
tion were eagerly adopted and scientifically studied
by Joseph Van Sickels, then at the University of DISTRACTION OSTEOGENESIS
Texas–San Antonio, Tom Jeter, Bill Terry, Myron
DO was applied extensively for the treatment of
Tucker, and others.147-149 In addition to Van Sickles’
war-related limb-length deformities by the Russian or-
early experience in stabilizing BSSOs and Le Fort
thopedic surgeon Gabriel Ilizarov160 in the 1940s and
osteotomies, Van Sickles et al150 were also the first to
1950s and used by Snyder et al161 in the craniofacial
describe rigid internal fixation in the inverted-L osteot-
skeleton in 1973. However, it was not until the
omy. Furthermore, in a series of biomechanical
mid-1990s that the technique gained traction, when
studies, Van Sickels and Richard Haug, from the Uni-
Joseph McCarthy,162 chief of plastic surgery at New
versity of Kentucky, showed the ideal configuration
York University, as well as Cesar Guerrero, William
and materials with which to stabilize maxillary and
Bell, and others began promoting DO as an alternative
mandibular osteotomies.151 Edward Ellis, long-time
or adjunctive procedure to orthognathic surgery.163
program director at Parkland Memorial Hospital and
Bell and Guerrero114 published a textbook on the sub-
now chief at the University of Texas–San Antonio,
ject that documented outstanding clinical results of
with Gaylord Throckmorton and Doug Sinn in Dallas,
cases primarily operated on by Guerrero in his native
made important morphologic and biomechanical ob-
Venezuela. Meanwhile, Bell went back to work in
servations about maximum bite forces that occur
the laboratory investigating a biological basis for DO
before and after orthognathic surgery—studies that
and, while working with a talented young oral-
continue to have considerable relevance to third-
maxillofacial surgeon, Marianela Gonzalez, defined
party payment of surgical services being a medical pro-
experimentally the optimal latency, activation, and
cedure performed for functional purposes, not a
consolidation periods for successful clinical
cosmetic operation.152-154 Subsequent stability
application.164 Other American oral-maxillofacial sur-
studies, mostly from the University of North Carolina
geons also made substantial and innovative contribu-
group, showed superior stability with plates and
tions during this time, including David Walker,165
screws compared with wire fixation and therefore
Suzanne McCormick,166,167 Martin Chin,168 Kevin
created a new standard of care for orthognathic
Smith,169 Leonard Kaban,120 and Stephen Schendel.170
surgery at the time. Adoption of plate and screw
Distraction devices, which were initially bulky and
fixation by American oral-maxillofacial surgeons was
placed externally, eventually became miniaturized,
then accelerated by improved manufacturing and
internal, and anatomic.
rapid distribution by Walter Lorenz and other industry
partners.
Concerns about compatibility with future imaging COMPUTER-AIDED SURGERY, INTRAOPERATIVE
needs, interference with radiation therapy, migration IMAGING, AND CUSTOMIZED IMPLANTS
of the material, growth restriction, long-term palpa- The age of 3-dimensional (3D) imaging in medicine
bility, and thermal sensitivity almost immediately began in 1971 when Sir Godfrey Hounsfield invented
caused scientists and clinicians to search for alternative the computed tomography (CT) scan, which allowed
fixation materials to titanium. Advances in polymer for unprecedented visualization and analysis of the
chemistry and manufacturing technique during the complex anatomy associated with craniomaxillofacial
2476 HISTORY OF ORTHOGNATHIC SURGERY

surgery in general and orthognathic surgery in partic- needed was not only a service provider to print the
ular. Diagnostic imaging was enhanced substantially, splints but also a quick, reliable, and accurate
in 1983, when Chuck Hull developed 3D printing, platform with which to perform the virtual surgical
facilitating the first 3D milling of human anatomy in planning itself. Christiansen hired Katie Weimer as
Germany and the United States in 1985. During the his first software engineer, who then worked with
1990s, selectively sintered stereolithographic models Gateno and Xia,182 David Hirsch183 from New York,
began to be produced for diagnostic and treatment and Bryan Bell184-186 from Portland, Oregon, to apply
planning purposes in orthognathic surgery, although and validate the accuracy of virtual orthognathic
this was uncommon outside of academic medical cen- surgical planning in a multi-institutional fashion.187
ters. Intraoperative navigation as a form of ‘‘frameless The original method described by Gateno and Xia
stereotaxy’’ also was developed in Germany and involved establishing natural head position using a gy-
quickly adopted in Europe by Rolf Ewers,171,172 roscope, medical-grade CT scans, and laser scanning of
Rainer Schmelzeisen,173,174 Nils Gellrich,175 plaster casts. Subsequent refinements described by
and others. Brian Farrell and Myron Tucker,188,189 from
Coinciding with these technologic advancements Charlotte, and Sam Bobek, their fellow who is now
was the development and commercialization of soft- in Seattle, Washington, replaced the gyroscope and
ware to analyze and manipulate 3D data sets and the plaster casts with an all-digital workflow process that
application of this technology to orthognathic treat- usually only requires a cone beam CT data set. Virtual
ment planning. Companies such as Materialise (Leuven, surgical planning has since become the gold standard
Belgium), Dolphin Imaging (Chatsworth, CA), SAS Insti- for orthognathic surgical planning and largely replaced
tute (Cary, NC), and Quintiles (Atlanta, GA) are exam- conventional analytical model surgery using plaster
ples of companies that have contributed to the casts and hand-made splints in the United States. In
advancement of computer-assisted treatment planning, 2010, the US Food and Drug Administration approved
data storage, and analysis. Although these systems the first 3D printed titanium implant, fueling innova-
certainly impacted the field of both surgery and ortho- tive solutions to complex dentofacial problems.
dontics, their impact on patient outcomes was probably
minimal, as there was initially no way to actually transfer
the virtual plan to the patient. Furthermore, the com- FELLOWSHIP TRAINING, PRESENT DAY
panies were marketing to the end user (surgeons and or- During the 1990s and into the new millennium, OMS
thodontists), who often had neither the time nor experienced an unprecedented expansion in scope and
expertise to embrace the technology. Therefore, as relevance that can be attributed to the development of
the 1990s came to a close and the new millennium fellowship training programs in esthetic surgery, head
began, treatment planning for orthognathic surgery and neck oncologic surgery, pediatric craniofacial sur-
was still done in more or less the same fashion in which gery, and microvascular reconstructive surgery. These
it had always been done: by clinical examination, face- fellowship programs were born out of the clinical activ-
bow transfer, and analytical model surgery using plaster ity and expertise of a number of transformational
casts based on an estimation of the jaw movements to leaders in North American OMS. Although discussion
achieve the desired esthetic and functional result, fol- of the impact of these fellowships on OMS practice is
lowed by construction of intermediate and final largely beyond the scope of this article, it is fair to say
occlusal splints to assist in maxillary-mandibular reposi- that fellowships have had an outsized influence on
tioning. Edward Ellis showed significant and additive er- the scope of practice in OMS and the integration of
rors at each stage of orthognathic treatment planning these disciplines into the management of patients
with analytical model surgery176; thus, there was clearly with complex dentofacial deformities. In particular,
a need for a more predictable method of performing or- the synergy between esthetic surgery, pediatric cranio-
thognathic surgery. facial surgery, and orthognathic surgery is obvious.
The paradigm shift in orthognathic surgery treat- It is a natural evolution then, as medicine and sur-
ment planning began when Gwen Swennen,177 from gery have become more and more specialized, that
Bruges, Belgium, and Jaime Gateno and James fellowship training programs in orthognathic surgery
Xia,178-181 from Houston, Texas, independently and would be established. As mentioned previously, Larry
simultaneously developed the first clinically validated Wolford was the first to establish a fellowship in or-
systems for using 3D imaging to assist in virtual thognathic surgery, which has produced a number of
surgical planning in combination with 3D printing of prolific academic orthognathic surgeons, including
interocclusal splints to transfer the virtual plans into Pushkar Mehra, Pedro Franco, David Cottrell, and
reality. Andrew Christensen, who had previously others. Jeff Posnick has transitioned his fellowship to
founded Medical Modeling Corporation in Golden, one of primarily orthognathic surgery, and Myron
Colorado, quickly recognized that what surgeons Tucker has continued his legacy of technical expertise,
R. BRYAN BELL 2477

innovation, and education in a fellowship that is now Acknowledgments

directed by one of his former fellows, Brian Farrell.
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.
Summary
During much of the second half of the 20th century,
most dentofacial deformities were managed by reposi-
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