Historical development of orthognathic surgery

Orthognathic surgery

1. Journal of Cranio-Maxillofacial Surgery (1996) 24, 195-204
© 1996 European Association for Cranio-Maxinofacial Surgery
Historical development of orthognathic surgery
E. W. Steinh~tuser
Department of Oral and Maxillofacial Surgery, (Professor Emeritus: Emil W. Steinhiiuser, DDS, MD),
University Erlangen, Nuremberg, Germany
Undoubtedly, the origin of orthognathic surgery,
which was at that time limited to mandibular surgery,
was in the United States of America. The first oper-
ation for the correction of malocclusion was
Hullihen's procedure which was carried out in 1849.
He, like most surgeons who operated on the jaw
bones and who performed a remarkable variety of
operative procedures, was basically a general surgeon,
but he had also had a dental training (Fig. 1). Other
examples of general surgeons of the 19th century who
reported on different maxillofacial operations were:
von Langenbeck, Cheever, Billroth, Dufourmentel
and others. The cradle of early orthognathic surgery,
however, was in St. Louis where the orthodontist
Edward Angle (1898) and the surgeon Vilray Blair
(1906) worked together. Both were involved in the
first described ostectomy of the horizontal ramus for
the correction of a case of mandibular prognathism,
which was reported in the literature by
Whipple
(1898). After several complications, an acceptable
result was finally achieved. The result of this so-called
'St Louis operation', which was carried out in 1897,
was questioned by another American surgeon,
Dr
Talbot (1907)
from Chicago. He even claimed priority
for suggesting this type of operation many years
earlier, but finally the St. Louis group of Angle, Blair
and Whipple succeeded in the 'Battle of Priority'.
The background to this scientific dispute is elaborated
upon in the interesting publication by
Biederman
(1956) who called it 'The strange story of the Angle
operation'.
There is no question, however, that Blair was the
dominant figure in early orthognathic surgery
~';..Z~ 2: < ,
'~,z~,. k,.
Fig. 1 - (a) Photograph of S. R. Hullihan, the first surgeon who
performed orthognathic surgery (courtesy Anthony Wolfe).
(b) Hullihan's operation in a case of distortion of the face with
protrusion of the mandibular alveolar segment caused by a burn.
1This paper is based on the Converse Lecture presented at the
63rd Annual Scientific Meeting of the American Society of Plastic
and Reconstructive Surgeons, San Diego 1994.
195
Fig. 2 - (a) Photograph of V. P. Blair who was the first to describe
several operative techniques for the correction of maxillofacial
deformities (courtesy Anthony Wolfe), (b) Ostectomy of the
mandibular body as performed by Blair in 1897 in the so-called 'St
Louis operation'.

2. 196 Journal of Cranio-Maxillofacial Surgery
(Fig. 2a). Before he published his first textbook in
1912, he described several methods for the correction
of maxillofacial deformities in an excellent article on
'Operations on the Jaw-Bone and Face' in 1907. Blair
emphasized how important it is to consider racial
differences also in treatment planning, in order to
achieve a harmonious face. He was also the first to
divide jaw deformities into five classes: mandibular
prognathism, mandibular retrognathism, alveolar
mandibular and maxillary protrusion and open bite.
He advocated several operations for corrective jaw
surgery, the ostectomy of the mandibular body
(Fig. 2b), the horizontal osteotomy of the ramus and
the v-shaped osteotomy for open bite closure. He
also made a clear statement when he wrote: 'An
approximately ideal occlusion would rarely be
accompanied with the best facial result.' This sen-
tence, which is so true, is still not understood by
many of our dental colleagues. Blair was also the
first to realize the benefits of the cooperation between
orthodontists and surgeons. A citation of the last
sentence of his article published in 1907 is a distinct
recommendation for such cooperation. He wrote:
'Treating of skeletal deformities is really surgical
work, but the earlier a competent, congenial ortho-
dontist is associated with the case, the better it will
be for both the surgeon and the patient.'
During WW I, Blair was chief consultant of the
American Military Forces and after the war he estab-
lished, together with Robert Ivy who was the first
professor of plastic surgery at an American univeristy,
a number of military hospital centres for the treat-
ment of face and jaw injuries. Thus, the first period
of orthognathic surgery in the USA came to an end
and it would take a long time before the speciality
was rediscovered in this country again.
There is not much to report on orthognathic surgi-
cal procedures which were carried out in Europe in
the 19th century. An exception is a report by Berger
(1897) from Lyon, France who described a condylar
osteotomy for the correction of prognathism (Fig. 3).
This method had been practiced in France until 1950,
when Dufourmontel and Mouly (1959) reported good
results with this technique. Babcock (1909) in the
USA, and several years later, Bruhn and Lindemann
(1921) in Germany, described an almost identical
method to the one introduced by Blair in 1907: a
horizontal osteotomy just between the sigmoid notch
and the mandibular foramen (Fig. 4). This operative
technique was amended a few years later by Kostecka
(1931) who worked in Prague. He described his
technique as a 'blind procedure', with the osteotomy
Fig. 3 - The technique of condylectomy for the correction of
mandibular prognathism as described by Berger, from France, in
1897.
a
-<,,, I l
Fig. 4 - (a) Horizontal osteotomy of the ramus which was
described by Blair in 1907, by Babcock in 1909 and later by Bruhn
in 1921, (b) blind technique of horizontal osteotomy of the ramus
according to Bruhn-Lindemann.
t
a

0 J
Fig. 5 - Horizontal osteotomy with a Gigli saw as described by Kostecka in 1931.

3. Historical development of orthognathic surgery 197
being carried out with a Gigli saw through a stab
incision (Fig. 5). The horizontal osteotomy of the
ramus, as well as the condylar osteotomy were rather
easy procedures, but the results were not satisfactory.
Too much relapse and open bite problems occurred
due to the small bony contact areas and the fragment
dislocations which resulted from the pull of the
inserted muscles. This was the reason why many
proposals for the improvement of mandibular oste-
otomies were published between 1920 and 1940.
Several renowned maxillofacial surgeons invented
new methods and new bone cuts for the correction
of skeletal mandibular deformities. In Austria and
Germany these were:
Perthes (1922) from Tt~bingen,
Pichler (1928) from Vienna, Wassmund (1935) from
Berlin and
Hofer (1936) from Linz. During this
period not much progress in orthognathic surgery
was reported from the USA or from other European
countries. Only
Kazanjian (1932) and Dingman (1944)
from the US must be mentioned, because both
described new techniques or improvements for the
correction of mandibular deformities. Also,
Limberg
(1928) from Russia, who had had part of his training
with Ivy in the United States, added some new
operative procedures to the treatment of jaw deform-
ities. Most of these maxillofacial surgeons from the
'early days' are listed in the chapter on 'Dramatis
personae' in Anthony Wolfe's book on
Plastic
Surgery of the Facial Skeleton (Wolfe
and Berkowitz,
1989). It is really a delight to read these highly
interesting comments on the pioneers of our specialty.
Again, there was a halt in the development of
orthognathic surgery during WW II. The few maxillo-
facial surgeons who were able to perform corrective
surgery on the jaw bones were totally committed to
the treatment of facial injuries and later on over-
loaded with reconstructive procedures. It was thus
until the beginning of the 1950s, when orthognathic
surgery as a true specialty had its origins, which led
to tremendous success all over the world.
The cradle of modern orthognathic surgery was
now central Europe, in particular Vienna and Graz,
and further north Berlin and Hamburg. The founder
of the 'Vienna School' of maxillofacial surgery was
Pichler, succeeded by his pupil
Trauner (1955) who
later moved on to Graz (Fig. 6). Trauner was the
inaugurator of several orthognathic surgical pro-
cedures, but his main claim to fame was that he
trained Heinz K61e and Hugo Obwegeser, who really
gave the decisive boost to orthognathic surgery. In
Berlin, Martin Wassmund who started the 'German
Fig. 6 - (a) Photograph of R. Trauner who was a pupil of Pichler,
the founder of the 'Vienna School' of maxillofacial surgery Fig. 7 - (a) Photograph of M. Wassmund, the founder of the
(courtesy Heinz K61e), (b) Inverted L osteotomy of the ramus for 'German School' of maxillofacial surgery, (b) Wassmund's
the correction of mandibular prognathism advocated by Trauner procedure for the correction of maxillary protrusion which was
in 1955. published in 1935.

4. 198 Journal of Cranio-Maxillofacial Surgery
School' was an important figure in maxillofacial
surgery. It was he who developed the anterior maxil-
lary osteotomy.(Fig. 7) which is still utilized today,
in addition to other corrective procedures on the
facial skeleton. His famous pupil was Karl
Schuchhardt (Fig. 8) who developed the posterior
maxillary osteotomy
(Schuchhardt, 1955), as well as
an oblique sagittal osteotomy of the mandibular
ramus. However, the main input to orthognathic
surgery came from the two associates of Trauner,
Heinz Krte (who succeeded Trauner in Graz) and
Hugo Obwegeser who was appointed to the chair of
oral and maxillofacial surgery in Zurich in 1956.
The main innovations which came from
Krle
(1959) were several new methods for changing the
position of the alveolar process. To the best of our
knowledge, he was the first to describe bimaxillary
alveolar surgery for the correction of protrusion
(Fig. 9), but also for deep bite or short face deformit-
ies. He also produced a new technique for open bite
closure and for genioplasty. His particular genioplasty
procedure proved to be very successful, because the
chin could be advanced and shortened in height at
Fig. 8 - (a) Photograph of K. Schuchhardt who was a pupil of
Wassmund (courtesy Gerhard Pfeifer), (b) Outline of the posterior
maxillary osteotomy which was described by Schuchhardt in 1955
as a two-stage procedure.
C ~7 -I
b
Fig. 9 - (a) Photograph of H. K61e who was a pupil of R. Trauner
(courtesy Heinz Krle), (b) Bimaxillary alveolar osteotomy for the
correction of protrusion or open bite which was introduced by
K61e in 1959, (c) Genioplasty with ostectomy and advancement of
the lower border as recommended by KOle in 1968.

5. Historical development of orthognathic surgery 199
the same time
(KOle, 1968). K61e contributed numer-
ous articles to the literature and in 1964 published,
together with Reichenbach and Br~ickl (1964), the
first textbook in the literature on 'Surgical
Orthodontics'. This book is still a standard work
today
(Reichenbach et al., 1964). The other famous
pupil of Trauner, Hugo Obwegeser, started his career
i!•' 't
Fig. 10 - (a) Photograph of H. Obwegeser who trained together
with H, K61e in Graz in Austria; their common teacher was
R. Trauner (courtesy H, Obwegeser), (b) Original drawing of the
sagittal splitting technique which was first published by Obwegeser
in 1955.
as an assistant in Graz and in 1955 published the
world-reknowned method of the 'intraoral sagittal
split of the mandible' (Fig. 10) This method which
was improved by the Italian surgeon Dal-Pont in
1958, opening new dimensions in mandibular surgery.
In particular, for the advancement of the mandible
this technique was ideal as no bone grafting was
necessary (Fig. 11). But in addition to the sagittal
split operation, Obwegeser started on maxillary sur-
gery in 1960. He was the first to present a large series
of Le Fort I osteotomies
(Obwegeser, 1969), at the
beginning in non-cleft patients, but a short time later
also in cleft patients (Fig. 12). Prior to this, maxillary
surgery for the correction of deformities was done
only in a limited number of cases.
Cohn-Stock (1921)
in Berlin started with anterior maxillary osteotomies,
followed by
Wassmund (1935) who described this
technique as a one-stage procedure. Wassmund was
probably also the first to perform a total maxillary
osteotomy in a patient with an open bite, in 1927.
Axhausen (1939) who also worked at that time in
Berlin, was the first to mobilize and advance a
malunited maxillary fracture by a Le Fort I osteotomy
and an additional vertical osteotomy (Fig. 13). In
the 1960s,
Hogeman and Wilmar (1967) from Sweden
demonstrated Le Fort I osteotomies in cleft patients,
but the real boost to maxillary surgery came from
Obwegeser's unit in Switzerland. In the 1960s and
Pig. 12 - Total maxillary advancement by a Le Fort I osteotomy in
a cleft palate patient as published by Obwegeser in 1969.
. • I ~ a b
Fig. 11 - Modification of the sagjttal splitting of the mandible by Fig. 13 - Le Fort I osteotomy with additional vertical bone cut for
Dal Pont in 1958. (a) the bone cut on the lingual, (b) on the buccal the correction of a malunited fracture; this technique was first
side. described by Axhausen in 1934.

6. 200 Journal of Cranio-Maxillofacial Surgery
1970s oral and maxillofacial surgeons from all over
the world, in particular from the USA, travelled to
Zurich to observe the 'Master' performing ortho-
gnathic and other types of maxillofacial surgery.
On the other side of the Atlantic, in the United
States, where orthognathic surgery originally started,
there was, as yet, not much interest in this particular
field. John Marquis Converse was the exception; at
that time he published several methods for corrections
of jaw deformities and together with the orthodontist
Horowitz (1969) he stressed the importance of close
collaboration between surgeon and orthodontist
(Fig. 14). Converse was also one of the first in the
plastic surgery community who was interested in
facial skeletal surgery in connection with recon-
structive procedures on the soft tissues.
Another input to orthognathic surgery came from
the American oral surgeons. This group, which had
separated from the plastic surgeons shortly after
World War II, moved slowly in the direction of
orthognathic surgery in the 1950s. The military oral
surgeons
CaldwelI and Letterman (1954) and several
other oral surgeons, such as
Robinson (1956), Hinds
(1958) and Thorna (1961) came up with different
methods for the correction of mandibular deformities
(Fig. 15). The military oral surgeon
Hunsuck (1968)
should also be mentioned, as he modified Obwegeser's
sagittal split procedure with his technique. However,
it took quite a while until the American oral-maxillo-
facial and plastic surgeons discovered the Le Fort I
and other maxillary and midfacial osteotomies. In
the meantime, their European colleagues were 10
years ahead, it was not until the late 1970s and into
the 1980s that the USA caught up, with many excel-
lent text books on orthognathic surgery being pub-
lished at this time
(Bell, 1980; Bell, 1985, Epker and
Fish, 1986; Profitt and White, 1991). In all these
books, written by surgeons and orthodontists, the
close cooperation between these two specialties was
always emphasized.
Another important progress in orthognathic sur-
gery was 'two-jaw surgery' which represents the simul-
taneous mobilization of the total maxilla and
mandible. K61e had already introduced bimaxillary
alveolar surgery in 1959, but it took some time to be
universally accepted. Obwegeser published his experi-
ence in 1970 as the first to perform total maxillary
and mandibular osteotomies. This was in 1970 when
the Le Fort I osteotomy was already a 'routine
procedure' in Zurich. Obwegeser alluded already at
that time to the main advantages of this rather
extensive surgical procedure; less relapse because of
better skeletal stability and major aesthetic improve-
ment due to the harmonization of the bony facial
structures. With the improvement of surgical tech-
niques, progress in anaesthesia and better stabiliz-
ation of the osteotomized segments, two-jaw surgery
b e
Fig. 14 - (a) Photograph of J. M. Converse (courtesy Anthony
Wolfe), (b,c) step osteotomy of the mandibular body for the
correction of mandibular prognathism as described by Converse
and Shapiro in 1952.
a b
Fig. 15 - (a,b) Technique of Caldwell and Letterman, published in
1954, for the correction of mandibular prognathism.
" ~ Z ~ ;
Fig. 16 - Stabilization of the bony segments with screws and plates
in two~aw surgery.

7. Historical development of orthognathic surgery 201
is nowadays a widely used procedure in orthognathic
surgery (Fig. 16).
Meanwhile, craniofacial surgery was developed in
Europe, primarily in France by Paul Tessier (Fig. 17).
It should be mentioned, however, that according to
Wolfe (1995) the first Le Fort III osteotomy was
performed by Gillies and Harrison in London in 1942
(Fig. 18). Another case of Le Fort III osteotomy on
a cleft patient was reported by Gillies and Rowe in
1954 (Fig. 19). But these were probably single cases,
because it took several more years until Tessier dem-
onstrated for the first time the spectacular results of
cranio-maxillofacial surgery at the plastic surgery
meeting in Rome in 1967
(Tessier, 1967). Also, ortho-
gnathic surgery was involved in the procedures which
he demonstrated but most of his cases were difficult
corrections of severe orbito-craniofacial deformities.
Paul Tessier was also the person who reinterested
American plastic surgeons in facial bone structures
and thereby in orthognathic surgery.
The latest aspect in the development of ortho-
gnathic surgery is the application of rigid or semi-
rigid fixation of the bony segments with plates and
screws. This technique has its origin in traumatology,
and orthopaedic surgeons utilized this system first. It
is interesting to learn that the first bone plating in
the maxillofacial region was carried out by the
German general surgeon Soerensen in 1917. He used
a wedding ring which was transformed into a small
gold plate for the stabilization of a comminuted
mandibular fracture (Fig. 20). It took over 50 years
until this method was rediscovered again, and at the
end of the 1960s the Swiss osteosynthesis group AO
developed, for the first time, smaller bone plates for
the mandible besides a large collection of plates and
screws for the extremities. However, it took another
/
Fig. 17 - (a) Photograph of P. Tessier the founder of craniofacial surgery (courtesy Paul Tessier), (b,c) illustration of transorbital Le
Fort III type osteotomy as described by Tessier in 1967.
a b
Fig. 18 - (a,b) Illustration of the first Le Fort III type osteotomy as carried out by Gillies and Harrison in 1942.

8. 202 Journal of Cranio-Maxillofacial Surgery
10 years until the principles of rigid osteosynthesis
were applied in orthognathic surgery.
Bernd Spiessl, a native Bavarian who later moved
to Switzerland, must be given credit for being the
first maxillofacial surgeon to apply the AO principles
to the fixation of a sagittal split osteotomy of the
mandible (Fig. 21). In 1974 he published an article
in which he described the technique of compression
screw application in the mandible. He also claimed
that with this technique the relapse, which was always
a danger in mandibular set-back or advancement
cases, was literally impossible. Many of his colleagues
did not believe that this meant progress in the treat-
ment of trauma, as well as in orthognathic surgery.
Obwegeser, too, was one of the 'non-believers' and
there were serious disputes between the two in several
conferences of the German and European Societies.
Another maxillofacial surgeon, who did a great
deal of work on the development of rigid osteosynth-
esis in trauma cases and in orthognathic surgery is
Fig. 19 - (a) Photograph of H. Gillies (courtesy British Association
of Plastic Surgeons), (b) N. Rowe (courtesy Mrs C. Rowe) who
reported the first Le Fort III osteotomy on a cleft patient in 1954.
Fig. 20 - First bone plating procedure in the mandible which was
described by Soerensen and Warnekros in 1917. A golden wedding
ring was made into a bone plate for the fixation of a comminuted
fracture of the mandible.
b
Fig. 21 - (a) Photograph of B. Spiessl who was the first to apply
rigid fixation in orthognathic surgery in 1974 (courtesy Bernd
Spiessl), (b) Screw fixation of a sagittal split osteotomy according
to Spiessl.

9. Historical development of orthognathic surgery 203
Fig. 22 - (a) Photograph of H. Luhr who introduced the principle
of mini bone plates in orthognathic surgery of the midfacial bone
structures in 1979 (courtesy Hans Luhr), (b) the first set of Luhr
miniplates which was designed for the application of compression
osteosynthesis and which was utilized in orthognathic surgery.
Hans Luhr from Germany (Fig. 22). He improved
the miniplates, which were originally developed in
France by
Michelet and Festal (1972) and Peri et al.
(1973) in the early 1970s, and in 1979 introduced his
own first miniplate set which was very helpful in the
treatment of trauma, and also for the stabilization of
the small and delicate midfacial skeleton. At that
time Luhr, as well as Spiessl, insisted on the principles
of compression osteosynthesis and again a heated
discussion started about the necessity and the value
of compression for better stabilization and bone
healing.
Champy and Lodde (1976) and also
Steinhi~user (1982), who developed their own minipl-
ate sets in 1976 and in 1979 respectively, felt that the
application of compression screws and plates was
more difficult and more hazardous for the adjustment
of the occlusion. Thus, they denied that compression-
osteosynthesis was necessary, and nowadays it is
generally accepted that compression is not so import-
ant for bone healing, at least not in maxillofacial and
orthognathic surgery.
What are the advantages of plate and screw appli-
cation for orthognathic surgery? The answer is clear:
the application of plates and screws is more rapid
and easier. The stabilization of the bone segments is
better and much more reliable. The convenience for
the patient is greater, because intermaxillary fixation
is no longer necessary and, most importantly, there
is less danger for the patient, because in the critical
postoperative phase after extubation the mouth can
be opened and cleaned and the airway can be easily
controlled.
There is no doubt that rigid fixation brought
tremendous progress in the treatment of trauma, and
also in orthognathic surgery. Many operations would
not be possible today, if this method of fixation and
stabilization was not available.
The latest development in orthognathic surgery is
the growing interest of plastic surgeons in this particu-
lar field. Within the last 10-15 years maxillofacial
surgeons, who are associated in the US with plastic
and reconstructive surgery, have made remarkable
contributions to this important part of corrective
facial surgery. The main input which has come from
this group was the addition of typical facial plastic
surgical procedures to the already well-established
osteotomies of the facial skeleton. The adjunct of
blepharoplasty, rhinoplasty, rhitidectomy, liposuc-
tion and lip corrections, just to name a few of these
procedures, has led again to a tremendous boost and
progress. In addition to soft tissue procedures, which
have always been the focus of interest for plastic
surgeons, a variety of corrections on the facial skel-
eton have been introduced. In this regard, aug-
mentation or reduction of the mandibular angle, the
malar bones, the supraorbital rim and the forehead
should be mentioned. And now we have probably
reached the culmination of this work, the combi-
nation of orthognathic and craniofacial surgery. It
was Paul Tessier who laid the foundations of this
fascinating part of reconstructive surgery, but the
refinements were carried out by his pupils and dis-
ciples including
Wolfe (1989), Salyer (1989) and
Ousterhout (1991) who have all written excellent
textbooks on Plastic and Aesthetic Surgery of the
Craniofacial skeleton. In these books, and in many
other publications, the importance of the combination
of facial or craniofacial plastic surgery with tra-
ditional orthognathic surgical procedures is con-
stantly emphasized.
The pendulum of progress and development has
now swung back to the US where orthognathic
surgery started about 100 years ago. Most of these
combinations of aesthetic and orthognathic surgical
procedures have originated there within the last few
years. On the other hand, in Europe as well, mainly
due to the development of better techniques and
materials in osteosynthesis, a lot of progress in ortho-

10. 204 Journal of Cranio-Maxillofacial Surgery
gnathic surgery has been achieved within the past
few years. All this leads to the conclusion that ortho-
gnathic surgery is now a grown-up specialty and an
important part of oral, maxillofacial and facial plas-
tic surgery.
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E. W. Steinh/iuser, DDS, MD
University Erlangen--Nttrnberg
Klinik ft~r Mund-, Kiefer-, Gesichtschirurgie
Gltickstr. 11
91054 Erlangen, Germany
Paper received 2 May 1995
Paper accepted 7 May 1996